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train · 26.9k rows

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18,986	199,388	24572+24405	Discharge summary	report+report	Admission Date: Discharge Date: [2155-5-28] Date of Birth: [2155-5-22] Sex: F Service: NB DICTATED BY:[Last Name (NamePattern4) 62062] DISCHARGE DIAGNOSES: Airway obstruction, resolved. [Known lastname ] [Known lastname 62063] is a 3600 gram little girl born at term (EDC [2155-5-27]) to a 32 year old G2, P1, now 2, female. Prenatal screen: O+, antibody negative, RPR nonreactive, rubella- immune, hepatitis B surface antigen negative, GBS negative. Pregnancy was complicated by maternal bipolar disease treated with 300 mg of lithium once a day. Father of the baby has a history of aortic stenosis, status post repair in childhood. He also has non-active hepatitis B. The patient's first baby is healthy. During this pregnancy, she had mild polyhydramnios and diabetes insipidus precipitated by lithium ingestion. [Known lastname ] was born by normal spontaneous vaginal delivery with Apgar scores of 8 at one minute and 9 at five minutes. She was given bulb suction and some blow-by O2 in the delivery, otherwise the resuscitation was unremarkable. Initially she was sent to the Newborn Nursery. She was noted to have two episodes of central cyanosis; one was in the context of feeding and the other one was while asleep. The NICU team was called to evaluate infant. She was brought to the NICU. While on the warmer, she was noted to have several seconds of rhythmic eye movement with eyes moving up and to the right. At the same time, she desaturated to 70. Because of concern for seizures, she was admitted to the NICU for further observation. EXAMINATION ON ADMISSION: GENERAL: In no obvious distress. Weight 3600 grams. Head circumference 35 cm, length 20 inches, temperature 99.3, heart rate 114, BP 68/40, mean 40, glucose stick 91. HEENT: Normocephalic, atraumatic. Inferior fontanel flat, open. Palate intact. Red reflex present bilaterally Neck supple. Lungs clear bilaterally. CARDIOVASCULAR: Regular rhythm with normal rate, no murmur. Femoral pulses 2+ bilaterally. ABDOMEN: Abdomen soft without bowel sounds. No masses or distension. EXTREMITIES: Warm, well-perfused, with brisk capillary refill. GU: Normal female external genitalia, by midline, with no sacral dimple. ANUS: Patent. NEURO: DTRs bilateral. [Name2 (NI) 35632] 2+. Normal tone. Normal suck and gag. HOSPITAL COURSE BY SYSTEM: CARDIOVASCULAR: Given paternal history of congenital heart disease, she received a cardiac evaluation including four extremity blood pressures. Normal hyperoxia test with a pO2 of 277 on 100 percent oxygen. She did not have a murmur. RESPIRATORY: She remained stable on room air. She experienced one to two episodes of desaturations per day, the last one on [2155-5-25]. These episodes of desaturations were in the context of sucking on pacifier. Since then she has not had any further desaturations or apneic episodes. FEN: [Known lastname ] has been orally feeding ad lib. Due to mom's prescription for lithium, she is receiving Similac formula. Her electrolytes initially were within normal limits. Given concern for diabetes insipidus precipitated by maternal lithium use, she received a second set of electrolytes that were within normal limits. Her urine output remained within normal limits. I.D.: Secondary to concern for seizure activity, she received an LP with 5 whites and 7 reds. She received 48 hours of antibiotics until all cultures remained negative. CBC showed a white count of 21 with 57 polys, no bands. HEMATOLOGY: Initial hematocrit was 50.3 with 278,000 platelets. NEURO: [Known lastname ] was seen by the Neurology Consult Service. Her EEG showed a pattern not indicative of seizure activity. They recommended that she be watched for 48 hours after last episode before returning home without seizure medication. At this time, she will not require neurologic followup. ROUTINE HEALTHCARE MANAGEMENT: [Known lastname ] passed her BAERs. She received hepatitis B vaccine. Given history of desaturations, we recommend that [Known lastname ] be seen at 2 weeks of life, in addition to her 1 month routine healthcare visit. [First Name11 (Name Pattern1) 449] [Last Name (NamePattern1) ], [MD Number(1) 54604] Dictated By:[Last Name (NamePattern1) 56160] MEDQUIST36 D: [2155-5-26] 16:33:46 T: [2155-5-27] 20:58:50 Job#: [Job Number 62064] Admission Date: [2155-5-22] Discharge Date: [2155-6-4] Date of Birth: [2155-5-22] Sex: F Service: NB ADDENDUM TO PREVIOUS DICTATION ON [2155-5-28]: CONTINUED HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: Secondary to an oxygen desaturation that had occurred on [2155-5-27] [Known lastname 48192] discharge date was moved so that she would be spell free for five days. She has had had no further apneic or desaturation episodes. Her last episode was on [2155-5-27], a week before discharge. Her car seat test was repeated and she had no difficulty passing on the second test on [6-2]. CARDIOVASCULAR: Secondary to some high blood pressures with systolics in the 80s to 90s [Known lastname ] received a renal ultrasound to confirm kidney flow and structure. Her renal ultrasound was normal. Blood pressures currently are stable with [Initials (NamePattern4) ] [Last Name (NamePattern4) 1131] on the day before discharge of 77/42 with a mean of 54. She does not have a murmur at time of discharge. GASTROINTESTINAL: On day of life 10 [Known lastname ] passed a grossly bloody stool. At that time she had no abdominal distention or feeding intolerance. The decision was made to change her formula to Nutramigen at which time her bloody stools stopped. She has had no other abdominal issues since that time. At time of discharge examination was notable for improved extremity tone with a continued head lag. Early intervention services had been arranged. [First Name11 (Name Pattern1) 449] [Last Name (NamePattern1) ], [MD Number(1) 54604] Dictated By:[Last Name (NamePattern4) 61793] MEDQUIST36 D: [2155-6-3] 16:30:45 T: [2155-6-3] 17:24:42 Job#: [Job Number 61794]	[ "781.3", "V05.3", "V19.5", "770.82", "796.2", "770.83", "V30.00", "V29.1", "V29.0", "792.1" ]	icd9cm	[ [ [] ] ]	[ "99.55", "93.96", "03.31" ]	icd9pcs	[ [ [] ] ]								201, 1638											2411, 4669	4698, 6262																																															1653, 2383
44,071	153,383	36175	Discharge summary	report	Admission Date: [2157-8-9] Discharge Date: [2157-8-10] Date of Birth: [2097-11-14] Sex: M Service: MEDICINE Allergies: Indomethacin Attending:[First Name3 (LF) 7333] Chief Complaint: Nausea, acute cardiac tamponade s/p atrial flutter ablation Major Surgical or Invasive Procedure: 1) Atrial flutter ablation 2) Pericardiocentesis with drain History of Present Illness: 59yo male with h/o atrial fib, atrial flutter, sick sinus syndrome, s/p DDD pacemaker placed in [2147] who presents now s/p aflutter ablation earlier today which was complicated by acute cardiac tamponade requiring pericardiocentesis and placement of pericardial drain. Patient underwent ablation procedure for a flutter which appeared to be successful. At the end of procedure, patient c/o nausea and had apparent vagal episode in which he syncopized. His HR decreased, BP decreased, and he had a brief episode of apnea. His pacemaker began pacing. He was given epinephrine, IVF, and dopamine for pressure support. An echo revealed acute cardiac tamponade, and the patient underwent a pericardiocentesis with placement of a pericardial drain. 350cc of blood initially drained, with normalization of patient's hemodynamic status. An echo post-pericardiocentesis revealed a small, loculated effusion subtending the right atrial free wall; no tamponade. The patient was transferred to the CCU for further monitoring and treament. On arrival to the CCU, VS were T 97.3, HR 70, BP 112/77, RR 23, O2 sat 100% on 3L NC. The patient was no longer requiring pressors. He c/o sharp substernal chest pain, non-radiating, and worse with inspiration. He does not have clear SOB, but is unable to take a deep breath secondary to pain. He c/o headache, but denies any lightheadedness, diaphoresis, chills, abdominal pain, N/V, or right groin pain. Patient was seen by Dr. [Last Name (STitle) ] for pacemaker evaluation on [2157-6-16], and was noted to have an increase in the number of episodes of SVT/a fib (20% of the day) lasting from seconds up to 22 minutes at a time. The patient was started on flecanaide. Leading up to the procedure over the past several weeks, the patient reported 5 episodes of symptomatic atrial flutter. His symptoms included lightheadedness, diaphoresis, and palpitations. Most of his episodes would last for approximately one hour, and he did not have any syncopal events. He did have one episode for which he presented to the ED after 2 hours of symptoms. In the ED his BP decreased to 60s. He was in symptomatic a flutter for approximately 4 hours, with the flutter resovled internally though his pacemaker. He has a 5-month history of bilateral lower extremity edema, thought to be an adverse effect of Procardia. Procardia was d/c'd and patient was started on Flecainide. Per patient's history, episodes of a flutter have increased since changing from Procardia to Flecainide. . On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, or bleeding at the time of surgery. He denies recent fevers, chills or rigors. All of the other review of systems were negative. . Cardiac review of systems is notable for sharp chest pain at present, and episodes of palpitations, lightheadedness, diaphoresis, and SOB during episodes of atrial flutter as above. He denies any history of dyspnea on exertion, paroxysmal nocturnal dyspnea, or orthopnea. Past Medical History: 1. Paroxysmal atrial fibrillation 2. Sick sinus syndrome s/p DDD pacemaker ([2147]), generator change [1-/2156] 3. HTN 4. Hyperlipidemia 5. Idiopathic scoliosis (s/p 4 surgeries and spinal fusions [2113]-[2144]) 6. Sleep apnea 7. Arthritis 8. s/p squamous cell cancer removal from arm, face, back 9. s/p tonsillectomy as child 10. h/o H. pylori 11. Diverticulitis s/p colectomy [2148] Social History: Lives with wife. [Name (NI) 1403] as president of non-profit organization (scoliosis foundation). Tobacco history: denies. ETOH: [7-28] drinks per week. Illicit drugs: denies. Family History: Maternal grandfather deceased secondary to CAD. No family history of arrhythmias. Physical Exam: VS: T=97.3 BP=112/77 HR=70 RR=23 O2 sat=100% on 3L NC GENERAL: WDWN male in NAD. Alert, oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink. MMM. NECK: Supple. No appreciable JVD. CARDIAC: Normal S1, S2. No R/M/G appreciated. Pericardial drain in place, dressing C/D/I, approximately 350cc blood in drain. Chest non-tender to palpation in area of drain. LUNGS: Respirations unlabored. CTAB without any wheezes, crackles, or rhonchi. ABDOMEN: Bowel sounds present. Soft, NTND. RIGHT GROIN: dressing C/D/I, no evidence of hematoma, no femoral bruit, non-tender to palpation EXTREMITIES: Warm, well-perfused. No clubbing or cyanosis. 1+ edema of lower extremities bilaterally. SKIN: No rashes. PULSES: DP pulses 2+ bilaterally Pertinent Results: [2157-8-10] 05:35AM BLOOD WBC-11.6# RBC-4.16 Hgb-13.4* Hct-39.2* MCV-94 MCH-32.2* MCHC-34.2 RDW-12.6 Plt Ct-264 [2157-8-9] 11:30AM BLOOD WBC-7.7 RBC-4.59* Hgb-14.7 Hct-42.5 MCV-93 MCH-32.1* MCHC-34.7 RDW-12.6 Plt Ct-265 [2157-8-9] 11:30AM BLOOD PT-11.3 PTT-22.0 INR(PT)-0.9 [2157-8-10] 05:35AM BLOOD Glucose-124* UreaN-15 Creat-0.7 Na-136 K-3.8 Cl-97 HCO3-26 AnGap-17 [2157-8-9] 11:30AM BLOOD Glucose-98 UreaN-17 Creat-0.8 Na-137 K-4.1 Cl-97 HCO3-28 AnGap-16 [2157-8-10] 05:35AM BLOOD Calcium-9.1 Phos-3.0 Mg-2.1 TTE [2157-8-9]: Pre-pericardiocentesis: There is a large pericardial effusion abutting the right ventricular and right atrial free wall. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. There is compression of both right heart [Doctor Last Name 1754]. Post-pericardiocentesis: small, loculated effusion subtending the right atrial free wall; no tamponade. TTE [2157-8-9]: Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). 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 located posterior to the atria. Compared with the prior study (images reviewed) of [2157-8-9], the pericardial effusion has mostly resolved. There is no evidence of cardiac tamponade. TTE [2157-8-10]: The mitral valve leaflets are structurally normal. There is a very small pericardial effusion adjacent to the inferior wall of the left ventricle and around the atria. Compared with the prior study (images reviewed) of [2157-8-9], the very small pericardial effusion adjacent to the left ventricualr is now better visualized. Brief Hospital Course: 59yo male with h/o a fib/flutter, sick sinus syndrome s/p DDD pacemaker placed [2147], HTN, and hyperlipidemia, admitted after pericardiocentesis and placement of a pericardial drain for acute cardiac tamponade occurring in setting of elective atrial flutter ablation. Tamponade resolved after pericardiocentesis and placement of pericardial drain, with 350cc blood drained. Patient temporarily required epinephrine, IVF, and dopamine for pressure support, but was hemodynamically stable off pressors at time of transfer to CCU. No further drainage was noted, and echo after pericardiocentesis revealed a small, loculated effusion subtending the right atrial free wall; no tamponade. A repeat echo several hours later did not reveal any reaccumulation of fluid. The pericardial drain was left in place overnight, with an additional 100cc of serosanguinous fluid draining. The patient c/o sharp, pleuritic chest pain, likely secondary to pericardial irritation from the pericardiocentesis and drain placement. He was initially given toradol, then morphine for pain control, but was later transitioned to PO hydromorphone with IV hydromorphone for breakthrough pain, as pain remained a [7-30] overnight. ECG did not reveal any ST or T wave changes concerning for cardiac ischemia. The pericardial drain was removed the morning after the procedure ([2157-8-10]), and a repeat echo after the drain had been removed revealed a very small pericardial effusion adjacent to the inferior wall of the left ventricle and around the atria. The patient's pain improved after the drain was removed, but sharp substernal chest pain was still present. A repeat ECG revealed bigeminy, but no changes concerning for cardiac ischemia or recurrent atrial flutter/a fib. The patient was hemodynamically stable, and was discharged home. He was instructed to take ibuprofen 800mg PO TID, as he is allergic to indomethacin. He was also given hydromorphone to take 1-2mg PO Q4 hours as needed for pain. In addition to pain medications, he was given prescriptions for colace and senna to protect against constipation while he is taking hydromorphone. Regarding his atrial flutter ablation, the procedure appeared to be successful at the end of the ablation. He remained in normal sinus rhythm overnight, and was monitored on telemetry. His verapamil was stopped, and he was continued on flecainide. He will follow up with Dr. [Last Name (STitle) ] two days following discharge. Medications on Admission: 1. Flecainide 100mg PO Q12 2. Hydrochlorothiazide 25mg PO dailu 3. Lisinopril 10mg PO daily 4. Modafinil 200mg PO daily 5. Rosuvastatin 20mg PO daily 6. Verapamil 180mg tab PO daily 7. ASA 325mg PO daily 8. Omega-3 Fatty Acids-Fish Oil 300mg-1000mg capsule PO daily Discharge Medications: 1. Flecainide 50 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours). Disp:180 Tablet(s) Refills:2 2. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:90 Tablet(s) Refills:2 3. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:30 Tablet(s) Refills:0 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. 5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 6. Modafinil 200 mg Tablet Sig: One (1) Tablet PO once a day. 7. Omega-3 Fatty Acids-Fish Oil 300-1,000 mg Capsule Sig: One (1) Capsule PO once a day. 8. Ibuprofen 800 mg Tablet Sig: One (1) Tablet PO three times a day for 2 weeks. Disp:42 Tablet(s) Refills:0 9. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 11. Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Discharge Disposition: Home Discharge Diagnosis: 1) Atrial flutter 2) Hypotension 3) Pericardial tamponade 4) Pericarditis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for an ablation or repair of your atrial flutter or abnormal heart rhythm. Unfortunately, you developed a complication after the procedure called pericardial tamponade which is caused by fluid (in this case blood) compressing your heart and causing it not to pump effectively. Fortunately, we were able to quickly detect this and we drained the fluid with a needle. Several repeat ultrasounds of your heart showed that the fluid had disappeared. Your chest pain will now be a result of the irritation in the lining of your heart caused by the blood. The best way to treat this is with 2 weeks of ibuprofen 800mg by mouth three times daily to cure the inflammation. We will also start you on dilaudid 1-2mg by mouth every 4 hours as needed for breakthrough pain. - START ibuprofen 800mg by mouth three times daily - START dilaudid 1-2mg by mouth every four hours as needed for pain - START docusate 100mg by mouth twice daily to protect against constipation as dilaudid can cause constipation. - STOP taking verapamil - START senna 8.6mg by mouth twice daily as needed for constipation - Take all the rest of your medications as prescribed including flecainide If you experience worsening chest pain, shortness of breath, fevers, chills please call your doctor or come to the emergency department. Followup Instructions: Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 62] Date/Time:[2157-9-12] 9:20	[ "427.81", "716.90", "401.9", "V45.01", "423.3", "E879.8", "272.4", "998.89", "756.19", "427.32", "423.9", "427.31", "327.23", "458.9" ]	icd9cm	[ [ [] ] ]	[ "37.34", "37.0" ]	icd9pcs	[ [ [] ] ]	10645, 10651	6872, 9356	333, 395	10769, 10769	4987, 6849	12260, 12407	4097, 4180		9673, 10622		10672, 10748		9382, 9650			10920, 12237									4195, 4968																									234, 295									423, 3449										10784, 10896							3471, 3878	3894, 4081
49,508	162,410	44575	Discharge summary	report	Admission Date: [2150-4-16] Discharge Date: [2150-4-21] Service: MEDICINE Allergies: Nsaids / Bactrim Attending:[First Name3 (LF) 358] Chief Complaint: Angioedema Major Surgical or Invasive Procedure: Intubation History of Present Illness: Pt is an 85 y/o F with a h/o GAVE s/p Argon treatment last on [2150-3-11], iron deficiency anemia, Cirrhosis [1-19] HepC, portal HTN/grade 1 varices but no hx of bleeding varices, CRI (baseline Cr = 1.2-1.5) who is transfered from [Hospital3 ] intubated s/p angioedema. By report the pt has some mild abdominal pain and some irritation in her throat a day prior to admission to [Hospital3 ]. The following morning she called her son with complaints of oral swelling; son states that her speach was garbled. The son reports that the patient denies having had any SOB, no wheezing, no hives. He called an abmulance who transported the pt to [Hospital3 ]. . Per OMR, the patient present to [Hospital1 18] pheresis unit on [2150-4-10] for blood transfusion for chronic slow upper GI bleeding. She had no pretreatment medications given and no adverse events; vitals on leaving the unit were 97.4 - 67 - 119/55. She has also been recently treated for a UTI with bactrim started on [2150-4-3]. . At St Elizabeths', she was HD stable but had a large, edematous tongue. She recevied decadron, epinephrine, benadryl, famotidine and hydroxazine in the ED. The ED was unable to intubate and she was taken to the OR. Laryngeal edema was noted, but the ET tube was passed successfully. She was then transfered to the CCU. She received hydroxazine TID and her tongue swelling improved. SBT was attempted early on but failed likely secondary to sedation. Per report, pt did have a cuff leak. Family requested transfer to [Hospital1 18] as pt receives all her care here. . On arrival in the MICU she passed an SBT and was successfully extubated. She did well throughout the day but continued to have an O2 requirement. By the time of transfer to the floor she was on 2L of NC O2 satting 94%. On the floor she is alert and oriented. She does not know what caused her swelling. She denies new pills, new medications, or new foods. She feels well and has no SOB, itching, or complaints. . Past Medical History: # GAVE - s/p Argon treatment, last on last on [2150-3-11] # Hepatitis C # Cirrhosis - Child's class A, portal HTN, grade 1 varices - no h/o ascites, encephalopathy, variceal bleeding, synthetic function intact # DM type II # HTN # iron deficiency anemia # s/p R radial nephrectomy for renal cell Ca [55] yrs ago # hypercholesterolemia # osteopenia # insomnia # Angioedema [3-26] possibly due to Bactrim but as yet not proven Social History: Lives alone in [Location (un) 583] in [Hospital3 4634] complex. Is widowed. Has 2 sons who live nearby. No tob in >45 yrs, occ EtOH (at holidays). Worked in food business in sales. Family History: No family history of allergic diseases Physical Exam: GEN: Pleasant elderly lady in NAD, speaking comfortably, no cyanosis, jaundice, or dyspnea VS: 99.4 124/58 82 18 94% on 2L NC HEENT: MMM, no OP lesions, tongue NL size, neck supple, no LAD or thyromegaly CV: RR, NL S1 S2 no S3 S4 MRG PULM: Roncherous breath sounds with scattered wheezes and crackles 1/4 up the lung fields ABD: BS+, NT, ventral hernia, gas on percussion, no masses or HSM, no fluid wave, + collaterals and angiomata LIMSB: No LE edema, + clubbing NEURO: PERRLA, EOMI, moving all limbs, reflexes 2+ of the biceps and petellar tendons. Pertinent Results: Admission labs: [2150-4-17] 05:15AM BLOOD WBC-7.4 RBC-3.41* Hgb-10.2* Hct-31.4* MCV-92 MCH-29.9 MCHC-32.5 RDW-16.7* Plt Ct-139* [2150-4-17] 05:15AM BLOOD Glucose-132* UreaN-27* Creat-1.1 Na-143 K-4.3 Cl-112* HCO3-24 AnGap-11 [2150-4-18] 08:30AM BLOOD ALT-112* AST-59* LD(LDH)-203 AlkPhos-99 TotBili-1.7* [2150-4-17] 05:15AM BLOOD Calcium-8.6 Phos-2.8 Mg-2.4 . Discharge labs: [2150-4-21] 05:50AM BLOOD WBC-5.0 RBC-3.13* Hgb-9.6* Hct-28.4* MCV-91 MCH-30.7 MCHC-33.8 RDW-16.9* Plt Ct-200 [2150-4-21] 05:50AM BLOOD Glucose-91 UreaN-34* Creat-1.4* Na-137 K-3.9 Cl-103 HCO3-24 AnGap-14 [2150-4-20] 05:40AM BLOOD ALT-55* AST-34 LD(LDH)-182 AlkPhos-83 TotBili-1.3 [2150-4-20] 05:40AM BLOOD Albumin-2.6* Calcium-8.3* Phos-3.5 Mg-2.0 Brief Hospital Course: 85F with a h/o GAVE s/p argon laser treatment last on [2150-3-11], iron deficiency anemia due to chronic UGIB, cirrhosis [1-19] HCV, portal HTN with grade 1 varices but no history variceal bleeding, CRI (baseline Cr = 1.2-1.5) who is s/p prolonged intubatation for angioedema of unknown etiology - possibly due to Bactrim. She is doing very well on s/p extubation at this point. All antihistamines have been discontinued at this point. She was progressively be restarted on her home meds. . # Angioedema: Resoved. Lack of hives, bronchospasm or hypotension suggests that this was not allergic angioedema but rather bradykinin related. C3 and C4 were low. C1 esterase inhibitor pending, [Doctor First Name ] neg. Per allergy consult at [Hospital 7302] prior to transfer, non-allergic angioedema is due to complement depletion (either hereditary or CA related) or complement activation (infection or transfusion). The patient did have a transfusion recently which may be related. Medications would also be high on the list of etiologies. Common offenders are NSAIDS and ACEIs, but ARBs have also been implicated. It was discovered that the Pt was taking Bactrim when the reaction leading to her admission. This is a possible offender and has been added to her allergy list. Restarted home meds one by one. All but felodipine have been restarted. Had hives and itching the day prior to discharge which did not generalize and seemed more of a contact dermatitis on the L arm. No new medications were started so it is unclear what initiated this. Responded to hydroxyzine x1. Also of note, the patient refused to shower or be washed down this admission which may contribute to her itchiness. . # Chronic UGIB: Received regular blood transfusions as an outpatient for any HCT < 30. In the past she only needed them infrequently but her transfusion requirements have increased lately. Transfused prior to discharge. [Month (only) 116] need outpatient follow up with GI (Dr [First Name8 (NamePattern2) 1158] [Last Name (NamePattern1) 679] has been recommended by her outpatient gastroenterologist [First Name4 (NamePattern1) 2127] [Last Name (NamePattern1) 10113]). . # Wheezes and ronchi: Related to angioedema and volume overload most likely. Resolved with diuresis and nebulizers. . # Hx HCV complicated by cirrhosis. No evidence of encephalopathy now, but is at risk. Continued lactulose. Continued SPIRONOLACTONE [ALDACTONE] - 50 mg daily. Continue FUROSEMIDE [LASIX] - 40 mg daily. Continue NADOLOL - 80 mg daily as PPx against variceal bleeding. . # HTN: Holding home CCB as normotensive. On Nadolol as above. . # CRI: baseline 1.5, was elevated on admission to [Hospital3 5097] to 1.7. At baseline on discharge. . # Diabetes: ISS in house. Discharged on metformin. Medications on Admission: Home Medications: FELODIPINE - 10 mg QAM and 5 mg QPM FOLIC ACID - 1 mg daily FUROSEMIDE [LASIX] - 40 mg daily HYDROCORTISONE ACETATE [ANUSOL-HC] - 25 mg daily LACTULOSE 10 gram/15 mL daily METFORMIN - 1000 mg QAM and 500 mg QPM MUPIROCIN - 2 % Ointment [Hospital1 ] NADOLOL - 80 mg daily PANTOPRAZOLE - 40 mg [Hospital1 ] SPIRONOLACTONE [ALDACTONE] - 50 mg daily SUCRALFATE - 1 g TID ZOLPIDEM - 5 mg Tablet - [12-21] QHS PRN CALCIUM CARBONATE-VITAMIN D2 - 500 mg-375 unit [Hospital1 ] CYANOCOBALAMIN - 500 mcg daily FERROUS GLUCONATE - 325 mg 5 times a day SARNA ULTRA [Hospital1 ] Discharge Medications: 1. Calcium 500 With D 500 mg(1,250mg) -400 unit Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:11 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:11 3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:5 4. Anusol-HC 25 mg Suppository Sig: One (1) suppository Rectal once a day. Disp:30 suppositories Refills:6 5. Lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO once a day. Disp:450 ML(s) Refills:11 6. Metformin 500 mg Tablet Sig: Two (2) Tablet PO QAM. Disp:60 Tablet(s) Refills:5 7. Metformin 500 mg Tablet Sig: One (1) Tablet PO QPM. Disp:30 Tablet(s) Refills:5 8. Nadolol 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:5 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:5 10. Spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:5 11. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. Disp:30 Tablet(s) Refills:0 12. B-12 DOTS 500 mcg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:11 13. Ferrous Gluconate 325 mg Tablet Sig: One (1) Tablet PO five times a day. Disp:150 Tablet(s) Refills:11 Discharge Disposition: Home Discharge Diagnosis: Angioedema Discharge Condition: Stable vital signs, at baseline Discharge Instructions: You were admitted at [First Name8 (NamePattern2) 1495] [Hospital ] Hospital with angioedema, or swelling in your mouth and throat. You had a breathing tube placed for this. You were then transfered to [Hospital1 771] where you had the breathing tube taken out. You improved clinically and were discharged to home. . Please continue to take your medications as ordered. Because you had a likely medication reaction that led to your angioedema you should throw out your old medications. Do not take any supplements. Here is your updated medication list list: 1. STOP taking felodipine for now 2. Calcium + vitamin D twice daily 3. Vitamin B12 daily 4. Folic acid daily 5. Furosimide 40mg daily 6. Anusol daily as needed for hemorrhoids 7. Metformin 1000mg (2 pills) in the morining and 500mg (1 pill) in the evening 8. Lactulose 15mL daily to 3 bowel movements per day 9. Nadolol 80mg daily 10. Pantoprazole (Protonix) 40mg twice daily 11. Spironolactone 50mg daily 12. Zolpidem (Ambien) 5mg at night as needed for insomnia 13. Iron 5 times daily . Please attend your follow up appointments. . Please call your doctor or come to the emergency room if you experience swelling of you face or tongue, chest pain, palpitations, shortness of breath, wheezing, bleeding, or other concerning symptoms. Followup Instructions: MD: [Name6 (MD) 10160] [Name8 (MD) 10161], NP Specialty: Priamry Care Date and time: [Last Name (LF) 766], [5-4] at 4pm Location: [Hospital3 ] Phone number: [Telephone/Fax (1) 250] Special instructions if applicable: booked with Russain interpreter Completed by:[2150-4-22]	[ "995.1", "428.0", "733.90", "250.00", "537.83", "403.90", "780.52", "456.21", "E928.9", "280.0", "572.3", "571.5", "428.43", "272.0", "070.70", "553.1", "585.3" ]	icd9cm	[ [ [] ] ]	[ "96.71" ]	icd9pcs	[ [ [] ] ]	9263, 9269	4375, 7182	234, 246	9323, 9356	3594, 3594	10709, 11012	2966, 3006		7836, 9240		9290, 9302		7208, 7208			9380, 10686	3986, 4352								3021, 3575					7226, 7813																				184, 196									274, 2282						3610, 3970											2304, 2742	2758, 2950
12,008	187,452	24620	Discharge summary	report	Admission Date: [2172-9-8] Discharge Date: [2172-9-24] Date of Birth: [2111-5-16] Sex: F Service: MEDICINE Allergies: Penicillins / Colchicine / Bactrim Attending:[First Name3 (LF) 3556] Chief Complaint: altered mental status, GI bleed Major Surgical or Invasive Procedure: Right internal jugular central venous catheter, left subclavian central venous catheter History of Present Illness: 61yo female with history of neurofibromatosis, HTN, hyperlipidemia, and recent hospitalization for complicated pna, pancreatitis, c-diff colitis and adrenal insufficiency who presents with GI bleed, hypotension and hypoxia. . The patient was in her usual state of health when she was found to have decreased responsiveness at her nursing home. She had a similar presentation about 1 month ago and was found to be septic. Given this concern, she was brought to the ED for further evaluation. . On arrival to the ED, the patient was thought to be hypoxic however she had clear lung sounds and was breathing comfortably. She was initially placed on NRB but was quickly weaned to NC and sats remained stable. Her mental status, however, did not improve. Patient was also found to be hypotensive in the ED and was briefly started on levophed with improvement in her BP. She received vancomycin and ceftriaxone given concern for sepsis and got 4L IV fluids. She had melanotic stool in the ED so she was started on protonix gtt and received 2U pRBCs in the ED. GI aware of the patient. Labs pertinent for [Last Name (un) ], elevated potassium, elevated lactate and troponin. UA positive for UTI. WBC of 31.4. . The patients mental status improved so she was not intubated. Triple lumen and arterial lines were placed. She denied any localizing symptoms. EKG showed deep anterior t-wave inversions. She remained afebrile in the ED. . On arrival to the MICU, T: 95.4 BP: 128/57 P: 77 R: 16 O2: 100% on NC. Patient was oriented and had no acute complaints. Past Medical History: 1. Coronary artery disease s/p revascularization, with STEMI [3-19], BMS x 2 in [2165], [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] 2, in [2165] and [2170] (RCA) 2. Congestive heart failure with LVEF 30% 3. Moderate COPD on home oxygen 4. Pulmonary embolism [2158] 5. Neurofibromatosis Type 1 6. Malignant nerve sheath tumor (s/p removal from left anterior chest wall [6-18] and radiation [2172]) 7. Depression 8. Hypothyroidism 9. Adrenal insuficiency [12-18] chronic steroid use for COPD exacerbation 10. Hypercalcemia 11. Alcoholism per omr (patient denies current ETOH abuse) 12. Schizoaffective disorder 13. Gout 14. C. diff colitis [1-/2172], recurred [3-/2172] Social History: Ms. [Known lastname 805] lives with her boyfriend in a trailer in [Name (NI) 3146], MA. Boyfriend has MR secondary to seizures. She is on disability, used to work as a nursing aide. Is visited 2x/week by VNA. Tobacco: Quit smoking in past 2.5 weeks. Smoked for >30 years. ETOH: Reports <1 drink a week. Drugs: Denies IVDU. Family History: Mother/sister/nephew/son with Neurofibromatosis, Type I. Father w/COPD. Sister w/COPD. Mother w/asthma. Mother died of MI at age 72. Father died of MI at age 86. Physical Exam: Vitals: T: 95.4 BP: 128/57 P: 77 R: 16 O2: 100% on NC General: Alert, oriented, sleeping HEENT: Sclera anicteric, MMM, EOMI Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation anterolaterally, good respiratory effort Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, grossly intact, normal sensation, gait deferred Pertinent Results: [2172-9-8] 12:20PM [Month/Day/Year 3143] WBC-31.4# RBC-3.73 Hgb-10.7* Hct-35.9* MCV-96 MCH-28.8 MCHC-29.9* RDW-16.8* Plt Ct-606* [2172-9-8] 12:20PM [Month/Day/Year 3143] Neuts-89* Bands-2 Lymphs-8* Monos-0 Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0 [2172-9-8] 12:20PM [Month/Day/Year 3143] PT-13.3 PTT-21.8* INR(PT)-1.1 [2172-9-8] 12:20PM [Month/Day/Year 3143] Glucose-90 UreaN-101* Creat-7.7# Na-130 K-7.5* Cl-96 HCO3-11* AnGap-31* [2172-9-8] 12:20PM [Month/Day/Year 3143] ALT-9 AST-5 AlkPhos-158* TotBili-0.1 [2172-9-8] 12:20PM [Month/Day/Year 3143] Lipase-71* [2172-9-8] 12:20PM [Month/Day/Year 3143] cTropnT-0.11* [2172-9-8] 08:32PM [Month/Day/Year 3143] Calcium-8.2* Phos-6.2# Mg-1.8 Brief Hospital Course: 61yo female with history of HTN, hyperlipidemia, and recent hospitalization for complicated pna, pancreatitis, c-diff colitis and adrenal insufficiency who presents with GI bleed, hypotension and hypoxia. #1: Anemia, GI bleed. Patient presented to the emergency department with symptoms of a GI bleed. The patient required multiple transfusions of packed red [Month/Day/Year ] cells. Her hematocrit stabilized. There is no source of bleeding visualized on the CT of the abdomen and pelvis upon admission. Laboratory evaluation was not significant for hemolysis. GI consultation felt that she was mostly suffering from a GI bleed however did not feel that an EGD or colonoscopy was indicated due too severe to clinical status. The patient had a second episode of melena with a drop in her hematocrit 2 days prior to death. Patient was transfused with 3 more units of packed red [Month/Day/Year ] cells, 2 platelet transfusions, one fresh frozen plasma. #2: Sepsis patient presented with leukocytosis as well as elevated lactate and hypotension. Patient does have a history of known C. difficile infection. Her [Month/Day/Year ] cultures that were initially drawn in the emergency were positive. Patient was treated with linezolid, IV vancomycin, meropenem. Eventually the IV vancomycin was discontinued as well as her meropenem. This course was complicated by continued elevations of her lactate as well as white [Month/Day/Year ] cell count after initial improvement. Repeat [Month/Day/Year ] culture showed gram-negative rods. The patient was restarted on meropenem. The patient's pressure support requirements increased prior to that. As for source of her sepsis it was not initially clear. Patient has possibly an intra-abdominal infection although there was no source of infection found on CT of the abdomen. Patient was treated for questionable ventilator associated pneumonia. #3: Altered mental status the patient's mental status was altered throughout her stay. Although the patient was on sedatives for her intubation status we eventually were able to discontinue sodas it without return of patient's normal baseline mental status. She does have underlying dementia however per her family her mental status is worse. And neurologic consultation was obtained and they were unable to give a clear etiology as she has multiple medical problems currently. [Name2 (NI) 6] EEG was performed showing diffuse lower legs but no specific evidence of nonconvulsive status epilepticus. #4: Direct hyperbilirubinemia. Throughout her stay her bilirubin as well as LFTs alkaline phosphatase became elevated. Was suggestive of obstructive or cholestatic process. Right upper quadrant ultrasound was obtained and did not show any intrahepatic obstruction but the CBD was not visualized. Possibly secondary to the mass effect of her pseudocyst. Surgery evaluated the patient and stated that a HIDA scan would most likely not be useful due to her severe clinical condition that would prevent any surgical intervention. He discontinued all about toxic medications to help improve her liver function. #5: coagulopathy The patient will coagulopathy as her liver function deteriorated. Her INR was increased to above 2. After her second episode of GI bleed the patient was given fresh frozen plasma to improve her coagulation status. Her INR did improve to 1.7. #6: C. difficile colitis. Patient has a known history of C. difficile colitis. She had a negative toxin by PCR was positive. The patient was treated with p.o. vancomycin as well as IV Flagyl. A KUB was obtained and did not show evidence of toxic megacolon. #7: Pancreatic pseudocyst on initial CT of the abdomen the patient was found to have a large pancreatic pseudocyst with questionable hemorrhage versus infection. Surgical consultation was obtained and they believe that the pseudocyst had hemorrhage. They did not perform any intervention secondary to her severe clinical status. #8 hypoxic respiratory failure the patient required intubation due to 2 persistent hypoxia. There were multiple times to wean the patient from ventilation however it was not successful. The patient's ventilation status was monitored with consistent arterial [Name2 (NI) ] gases. Respiratory failure is most likely secondary to pulmonary edema. There was some evidence later in her hospital course a ventilator associated pneumonia and she was treated for such. #9 hypothyroidism patient has a known history of hypothyroidism. A TSH was drawn and was elevated. A free T4 was pending at the time of the death. During her admission we continue her home dose of levothyroxine. There is little evidence that this was a myxedema coma. #10 adrenal insufficiency Patient has a known history of adrenal insufficiency. She received stress dose of steroids on her initial admission. We continued her home dosing of prednisone. #11 gout Known history of gout. We discontinued her allopurinol and colchicine in the setting of acute kidney injury. #12 acute kidney injury Patient was admitted with acute kidney injury. Her renal function improved after fluid resuscitation. #13 COPD Patient is on home oxygen 2 to significant COPD. She was intubated. #14 coronary artery disease Patient has no history of coronary artery disease. We discontinued her [Name2 (NI) ] secondary to GI bleed. A Holter beta blocker and ACE inhibitor in the setting of hypotension. We continued her aspirin regimen. After continued deterioration in the setting of the ICU a family meeting was held for goals care discussion. After lengthy discussion the family decided to make the patient comfort measures only. We discontinued pressor and ventilation support. The patient expired approximately 3-4 hours after the patient was made comfort measures only. Time of death was 01:00 on [2172-9-24]. Her primary care physician was notified. The family did not request autopsy. Medications on Admission: 1. rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY 2. furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY 3. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY 4. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY 5. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 6. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet PO DAILY (Daily). 7. allopurinol 100 mg Tablet Sig: Two (2) Tablet PO once a day. 8. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO once a day. 10. Advair Diskus 250-50 mcg/dose Disk with Device Sig: One (1) puff Inhalation twice a day. 11. metoprolol tartrate 50 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) neb Inhalation Q4H (every 4 hours) as needed for wheezing. 13. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: One (1) Tablet PO twice a day. 14. gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 15. dapsone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours) as needed for pain. 17. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY 18. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H 20. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 21. ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO once a day. 23. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for groin rash. 24. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Sepsis, bacteremia GI bleed with anemia Hemorrhagic pancreatitis Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3559] MD, [MD Number(3) 3560*]	[ "707.22", "496", "412", "V09.80", "038.0", "995.92", "518.81", "237.71", "401.9", "997.31", "576.2", "287.5", "533.40", "274.9", "244.9", "276.7", "349.82", "255.41", "577.2", "785.52", "428.22", "E935.3", "294.20", "574.20", "707.03", "286.7", "285.1", "E930.8", "295.70", "276.4", "428.0", "584.9", "008.45", "E932.0", "560.1", "E934.8", "577.0", "E879.8", "599.0" ]	icd9cm	[ [ [] ] ]	[ "96.6", "00.14", "96.04", "38.97", "96.72" ]	icd9pcs	[ [ [] ] ]	12354, 12363	4621, 10541	326, 415	12472, 12482	3843, 4598	12534, 12669	3120, 3283		12326, 12331		12384, 12451		10567, 12303			12506, 12511									3298, 3824																									255, 288									443, 2009																	2031, 2755	2771, 3104
29,080	181,664	33430	Discharge summary	report	Admission Date: [2163-2-21] Discharge Date: [2163-2-23] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3556] Chief Complaint: OSH transfer for GIB Major Surgical or Invasive Procedure: none History of Present Illness: 84 year old male with a PMH of colon CA s/p hemicolectomy [2151], chronic anemia (baseline HCT 30s), and CKD (Cr 1.8-2.2) who was transferred from an OSH having presented there on [2-21] with symptoms of anemia and two episodes of melena. One week ago, Mr. [Known lastname ] passed [Last Name (un) ] "black diarrhea." Subsequently, he began feeling light headed, fatigued, and dizzy. He was also not eating very much, but states he was able ot keep up with his fluid intake. His bowel habits returned to [Location 213] until 3 days ago when he had a further episode of black stool. Since then, his fatigue and dizziness have worsened. He felt short of breath with minimal exertion. He had no further black bowel movements, but when his wife began to experience similar symptoms, they presented to [Hospital3 ]. There, he was found to be guaiac positive with a HCT of 13. He received 1 unit PRBCs. He was transferred to [Hospital1 18] for further care. . In the [Hospital1 18] ED, vitals were 98.7, 110, 98/62, 22, 98%2L NC. A CXR showed a LLL opacity c/w evolving pneumonia. Blood cultures were sent and he received a dose of vancomycin and ceftriaxone. EKG showed lateral ST depressions c/w a strain pattern. Initial labs were notable for pancyopenia with WBC of 1.5 (ANC 1090, 74% PMNs with 2% bands), a HCT of 16.9, and platelets of 35. Potassium was 6.6 and lactate was 4.6. INR was 1.5. Troponin was elevated at 0.25 (was 0.15 at OSH with normal CKs). He was given protonix, ceftriaxone, azithromycin, vancomycin, and he was typed and cross-matched. . Currently he denies any epigastric pain, nausea or vomiting. He took an ibuprofen dose 2 days ago for his dizziness, but denies any other NSAID use. Past Medical History: # Colon CA - stage B, s/p resection in [2151], no evidence of disease recurrence, last CT abdomen was done in [10-17] # HTN # Macrocytic Anemia, on oral B12, HCT 33.6 in [10-18] # CKD (baseline Cr 1.8-2.2) # Increased IgM kappa monoclonal protein with polyclonal increase in IgA. He has declined bone marrow aspiration and biopsy. # Chronic elevation of alkaline phosphatase, no hepatic pathology # gout Social History: He drinks a 7 oz beer each day. Lifelong smoker until yesterday, [1-12] ppd x 70 years Lives with wife, is independent in function and ADLs. Family History: non-contributory Physical Exam: T: 96.5 BP: 135/63 P: 103 RR: 22 O2 sat: 98% 2L Gen: elderly, pleasant, NAD HEENT: NCAT, PERRL, EOMI Neck: JVP flat CV: RRR no MRG, nl S1, S2 Resp: CTAB Abd: NABS, soft, NTND, no guarding/rigidity/rebound Back: no CVA tenderness Rectal: Guaiac: positive per ED exam Ext: no CCE, 2+/4 symmetric pedal pulses Neuro: grossly non-focal Pertinent Results: [2163-2-21] 02:50PM BLOOD WBC-1.5* RBC-1.49* Hgb-5.6* Hct-16.9* MCV-114* MCH-37.5* MCHC-33.1 RDW-20.6* Plt Ct-35* [2163-2-21] 02:50PM BLOOD Neuts-74* Bands-2 Lymphs-18 Monos-4 Eos-0 Baso-0 Atyps-2* Metas-0 Myelos-0 [2163-2-21] 02:50PM BLOOD PT-16.5* PTT-26.7 INR(PT)-1.5* [2163-2-21] 02:50PM BLOOD Glucose-150* UreaN-87* Creat-3.1* Na-140 K-6.6* Cl-108 HCO3-15* AnGap-24* [2163-2-21] 02:50PM BLOOD ALT-27 AST-37 LD(LDH)-342* AlkPhos-123* TotBili-0.7 [2163-2-21] 02:50PM BLOOD cTropnT-0.25* [2163-2-21] 06:45PM BLOOD CK-MB-5 cTropnT-0.20* [2163-2-22] 03:46AM BLOOD CK-MB-6 cTropnT-0.22* [2163-2-22] 03:46AM BLOOD VitB12-1235* Folate-GREATER TH Hapto-340* [2163-2-21] 03:12PM BLOOD Lactate-4.6* . MICRO: [2163-2-22] 1:47 am Influenza A/B by DFA Source: Nasopharyngeal aspirate. FINAL REPORT [2163-2-22] DIRECT INFLUENZA A ANTIGEN TEST (Final [2163-2-22]): Negative for Influenza A viral antigen. DIRECT INFLUENZA B ANTIGEN TEST (Final [2163-2-22]): POSITIVE FOR INFLUENZA B VIRAL ANTIGEN. REPORTED BY PHONE TO DR. [Last Name (STitle) 16800] [2163-2-22] 3:15PM. . [2-21] CXR IMPRESSION: 1. Left lower lobe opacity likely representing atelectasis, however, early pneumonia cannot be excluded. Right pleural effusion noted. 2. If clinically feasible, dedicated PA and lateral views could be helpful for further evalution. . [2-22] CXR IMPRESSION: Marked interval progression with now massive bilateral pulmonary edema and moderate bilateral pleural effusions. Previously noted left lower lobe focal consolidation is discernable; however, difficult to characterize in the presence of diffuse background parenchymal changes. [2-22] ECHO The left atrium is normal in size. The estimated right atrial pressure is 10-20mmHg. The left ventricular cavity size is normal. There is moderate to severe global left ventricular hypokinesis with more severe mid to distal septal/anterior/inferior and apical hypokinesis/akinesis (LVEF = 30 %). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] Right ventricular chamber size is borderline dilated with depressed free wall contractility. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. 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. Brief Hospital Course: 84M with distant h/o colon CA now p/w GI bleed, found to have PNA and influenza. Pt presented to OSH with HCT of 13, bumped to 16 after 1 unit PRBCs. At [Hospital1 18] ICU, placed on IV PPI and transfused 2 units pRBCs. Also received 2 units of FFP to reverse mild coagulopathy and 1 unit of platelts for thrombocytopenia. Pt confirmed DNR/DNI status on admission. GI consulted and deferred endocscopy given pt's relative hemodynamic [Name2 (NI) 77558] and noted troponin leak with EKG changes c/w demand strain. Was also given CTX and azithro for CAP. A DFA was positive for influenza B. Shortly after transfusion of 2nd units of RBCs, pt noted to be hypoxic and in worsening respiratory distress and exam was c/w pulmonary edema. IV lasix and morphine were administered with mild improvement. Pt did not tolerate CPAP so was given supplemental O2 via face tent. Nebulized bronchodilators and IV solumedrol were given for possible COPD exacerbation given pt's smoking history. An echocardiogram showed moderate to severely depressed LVEF of 30%. Repeat CXR showed massive pulmonary edema. A large IV Lasix challenge was given with 200mg IV, and pt did put out urine to this, but continued to have worsening pulmonary edema. Pt's family was present throughout and requested only that the pt be kept as comfortable as possible. Liberal IV morphine was used to this effect with good results. On the morning of [2163-2-23], pt expired peacefully with family at bedside. Family declined autopsy. Medications on Admission: Lopressor 50 mg PO BID Allopurinol 300 mg PO daily Folic Acid 1 mg PO daily Vit B12 250 mcg PO daily Aleve 220 mg PRN Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: n/a Followup Instructions: n/a [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3559] MD, [MD Number(3) 3560]	[ "799.02", "428.0", "578.1", "284.1", "403.90", "486", "276.7", "V10.05", "410.71", "584.9", "491.21", "585.9", "286.9" ]	icd9cm	[ [ [] ] ]	[ "99.07", "99.05", "99.04" ]	icd9pcs	[ [ [] ] ]	7556, 7565	5853, 7359	283, 289	7616, 7625	3062, 5830	7677, 7812	2676, 2694		7528, 7533		7586, 7595		7385, 7505			7649, 7654									2709, 3043																									223, 245									317, 2057																	2079, 2497	2513, 2660
55,575	108,289	13355	Discharge summary	report	Admission Date: [2172-10-22] Discharge Date: [2172-11-4] Date of Birth: [2108-2-26] Sex: M Service: MEDICINE Allergies: Aspirin Attending:[First Name3 (LF) 2181] Chief Complaint: UGIB Major Surgical or Invasive Procedure: EGD History of Present Illness: 64 M with history of cirrhosis presumed due to EtOH, PUD s/p past Billroth [Hospital 40608] transfer from [Hospital3 ] with melena and BRBPR. Patient was admitted on [2172-10-16] with melena and BRBPR x 2 days. Also associated with crampy abdominal pain and nausea. Initial hematocrit 26.5, INR 1.8, developed thrombocytopenia to 60s as well. Had EGD in ED which showed no varices, obvious ulcers or tears. Source thought to be "dusky" patch in stomach. Stomach filled with blood and unable to visualize duodenum. Per HO report 6 units PRBCs given in addition to 2 units FFP (though nursing reports 10 units PRBCs, FFP and platelets). Per notes, repeat EGD performed [10-20]. Bright red blood in gastric reminant without ulceration seen. Also appears to have had bleeding scan performed with results unavailable currently. Continued to have evidence of bleeding during hospital course; HO reported cessation of bleeding and then restart, though not clear from notes. Patient has complained of epigastric area abdominal pain, but nothing out of ordinary from usual chronic abdominal pain. Denies hematemesis. No chest pain or shortness of breath. + occasional palps. Denies abdominal swelling/ascites. Patient also with Afib with RVR (to 160) on presentation requiring diltiazem gtt with eventual transition to dilt PO and digoxin PO. [Hospital1 ] notes some hypotension (as low as 84/50 seen in notes) but not requiring pressors at any time. Sodium 157 today; D5W with K started. Patient also noted to have leukocytosis to 24K on [10-19], also with slight amylase elevation, prompting CT (report not included with paperwork; per HO was normal with ?no ascites; progress notes suggest "air within thickened gastric remnant - air trapped in folds vs. contained perforation"). Given zosyn due to leukocytosis and ?concern for bowel ischemia since admission. . Vitals prior to transfer: 98.1, HR 87, 114/90, 23, 100% on 2L NC. . Past Medical History: - Cirrhosis [1-11] EtOH. Noted to have grade I varices on [2160] endoscopy report, none in [2166] (though did have gastric varices). - h/o Billroth II for PUD "many years ago" and about 5 abdominal surgeries (between age 20 and ~[2153]) - Recurrent UGIB with PUD as above. Reports last GI bleeding about 10 years ago, but OSH notes with melena and hematocrit drop (49 down to 24), found to have gastritis without ulcer or varices on EGD. - History of EtOH abuse, none since ~[2153]. - Chronic pain of bilateral arms (thought due to OA) and abdomen. - Atrial fibrillation. On coumadin in the past. - Depression, psychosis - history of DVT and s/p IVC filter placement - chronic pancreatitis, history of pseudocyst with resection. - HTN Social History: PhD in English, once worked at [Hospital3 1810]. Currently on disability. No tob, drug use. No EtOH in 10 years. Lives in [Hospital1 1501] x yrs Family History: Denies family history of liver disease. Mother with increased bleeding of unclear etiology. Physical Exam: VS: T: 97.9 BP: 140/72 HR: 74 Afib RR 16 100% on 2L nc GEN: NAD, chronically ill appearing, pleasant HEENT: NC/AT, EOMI, PERRL, no OP lesions, poor dentition CV: irregularly irregular, no mrg PULM: coarse breath sounds ABD: +bs, soft, NTND EXT: 2+ hand edema, 2+ LLS to knees NEURO: CN 2-12 intact, UE/LE strength 5/5 bilat, PSYCH: appropriate Pertinent Results: [2172-10-23] 03:13PM BLOOD WBC-11.1* RBC-3.85* Hgb-11.4* Hct-32.7* MCV-85 MCH-29.7 MCHC-35.0 RDW-17.0* Plt Ct-114* [2172-10-25] 04:52AM BLOOD WBC-11.1* RBC-3.73* Hgb-11.0* Hct-32.2* MCV-87 MCH-29.6 MCHC-34.2 RDW-17.5* Plt Ct-153 [2172-10-27] 10:39PM BLOOD WBC-19.5* RBC-3.02* Hgb-9.0* Hct-27.3* MCV-91 MCH-29.9 MCHC-33.0 RDW-17.4* Plt Ct-195 [2172-10-29] 12:59PM BLOOD WBC-10.0 RBC-2.99* Hgb-9.0* Hct-26.6* MCV-89 MCH-30.0 MCHC-33.6 RDW-18.1* Plt Ct-271 [2172-11-1] 05:20AM BLOOD WBC-8.5 RBC-3.05* Hgb-9.2* Hct-27.3* MCV-90 MCH-30.2 MCHC-33.6 RDW-17.6* Plt Ct-319 [2172-11-4] 05:16AM BLOOD WBC-6.1 RBC-3.04* Hgb-9.2* Hct-27.4* MCV-90 MCH-30.2 MCHC-33.5 RDW-17.0* Plt Ct-355 [2172-10-22] 03:17AM BLOOD Neuts-79.5* Lymphs-11.0* Monos-7.8 Eos-1.4 Baso-0.2 [2172-10-26] 06:00PM BLOOD Neuts-77.2* Lymphs-13.9* Monos-6.4 Eos-2.2 Baso-0.3 [2172-10-24] 03:09AM BLOOD PT-14.1* PTT-29.0 INR(PT)-1.2* [2172-10-28] 03:59AM BLOOD PT-14.8* PTT-28.9 INR(PT)-1.3* [2172-11-3] 05:33AM BLOOD PT-14.5* PTT-47.3* INR(PT)-1.3* [2172-11-3] 05:33AM BLOOD Plt Ct-363 [2172-10-22] 03:17AM BLOOD Ret Aut-2.4 [2172-10-23] 03:12AM BLOOD Glucose-156* UreaN-20 Creat-0.9 Na-142 K-3.9 Cl-109* HCO3-31 AnGap-6* [2172-10-25] 04:52AM BLOOD Glucose-113* UreaN-11 Creat-1.0 Na-145 K-3.5 Cl-110* HCO3-30 AnGap-9 [2172-10-29] 03:27AM BLOOD Glucose-85 UreaN-12 Creat-1.1 Na-139 K-3.2* Cl-108 HCO3-24 AnGap-10 [2172-11-2] 05:39AM BLOOD Glucose-94 UreaN-12 Creat-0.9 Na-140 K-3.9 Cl-108 HCO3-25 AnGap-11 [2172-11-4] 05:16AM BLOOD Glucose-93 UreaN-13 Creat-1.0 Na-139 K-4.1 Cl-107 HCO3-27 AnGap-9 [2172-10-22] 03:17AM BLOOD ALT-56* AST-45* LD(LDH)-282* CK(CPK)-141 AlkPhos-39 TotBili-0.8 [2172-10-25] 04:52AM BLOOD ALT-30 AST-30 LD(LDH)-304* AlkPhos-49 TotBili-0.9 [2172-10-31] 05:52AM BLOOD ALT-18 AST-27 LD(LDH)-335* AlkPhos-49 TotBili-0.4 [2172-10-24] 03:09AM BLOOD Lipase-22 [2172-10-23] 03:12AM BLOOD CK-MB-4 cTropnT-0.02* [2172-10-27] 11:22AM BLOOD CK-MB-NotDone cTropnT-0.04* [2172-10-27] 10:39PM BLOOD CK-MB-NotDone cTropnT-0.05* [2172-10-28] 03:59AM BLOOD CK-MB-NotDone cTropnT-0.05* [2172-10-23] 03:12AM BLOOD TotProt-4.0* Albumin-2.7* Globuln-1.3* Calcium-8.6 Phos-2.9 Mg-1.7 [2172-10-30] 02:29PM BLOOD Calcium-9.1 Phos-2.1* Mg-1.8 [2172-11-4] 05:16AM BLOOD Calcium-8.9 Phos-3.8 Mg-2.4 [2172-10-22] 03:17AM BLOOD calTIBC-234* VitB12-1205* Folate-15.9 Ferritn-23* TRF-180* [2172-10-23] 03:12AM BLOOD PEP-NO SPECIFI [2172-10-27] 05:20AM BLOOD Digoxin-1.0 [2172-10-31] 05:52AM BLOOD Digoxin-0.9 [2172-10-23] 09:00PM BLOOD Lactate-1.3 [2172-10-27] 09:47AM BLOOD Lactate-2.8* [2172-10-27] 11:34AM BLOOD Lactate-1.8 [2172-10-23] 09:00PM BLOOD freeCa-1.13 . . IMAGING STUDIES: ECHO [2172-10-22]: The left atrium is elongated. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Normal global biventricular systolic function. Limited study. . CXR [2172-10-22] AP SEMI-UPRIGHT CHEST: There is a right internal jugular central venous catheter whose tip extends into the right atrium. This could be pulled back approximately 3 cm for placement in the cavoatrial junction if desired. The lungs are hyperinflated. There is no evidence of pulmonary edema. The thoracic aorta is tortuous. The heart is enlarged. The osseous structures demonstrate bilateral abnormalities of the shoulders and proximal humerus, nonspecific, possibly relating to neuropathic joint or prior trauma. Please correlate with history and consider dedicated plain films. In the upper abdomen, note is made of multiple clips as well as a linear structure possibly represents an IVC filter. . CXR [2172-10-23] Since yesterday, right internal jugular catheter still ends in the very low right atrium, could be pulled back 5 cm to end in the cavoatrial junction. Tortuosity of the aorta and hyperinflation are unchanged. Old left rib fractures and bilateral humeral deformities are stable. Cardiomegaly is mild and unchanged. Volume overload increased. Small left pleural effusion increased. Clips are in the abdomen. An IVC filter is probably in place. There is no free air. . ABD Xray [2172-10-23] FINDINGS: Two supine views of the abdomen reviewed. An upright chest radiograph obtained one hour previously was also reviewed. There is a nonobstructive bowel gas pattern without dilated bowel loops or air-fluid levels. Scattered phleboliths are seen in the pelvis. No other soft tissue calcifications. There are surgical clips in the left upper quadrant. An IVC filter is in place. Patient is status post right hip fracture with surgical hardware present. On recent chest radiograph, there was no free air seen under the diaphragms. IMPRESSION: No free air. Non-obstructive bowel gas pattern without pneumatosis or bowel wall thickening. . CT ABD/PEL [2172-10-23] CT OF THE ABDOMEN WITHOUT IV CONTRAST: IMPRESSION: Limited study. 1. No evidence of small-bowel obstruction or ileus. 2. New, small amount of free air adjacent to small bowel loops in the left upper quadrant, in the abscence of a recent procedure this is concerning for local perforation. No extraluminal oral contrast is noted. 3. Anasarca. 4. New bilateral small pleural effusions with associated atelectasis. 5. Multiple compression fractures of the lower thoracic and lumbar spines ofunknown chronicity. . BIL UE US [2172-10-24]: BILATERAL UPPER EXTREMITY DOPPLER ULTRASOUND: [Doctor Last Name ]-scale and color Doppler son[Name (NI) 493] images were obtained that demonstrate an occlusive thrombus in the right subclavian vein. Acoustic windows were limited on this patient given his right internal jugular catheter and other, so the study was therefore limited. Flow is demonstrated in the distal right subclavian vein and axillary vein but one of two brachial veins demonstrates occlusive thrombus. On the right, the basilic and cephalic veins compressed and appear normal. The left internal jugular and axillary veins demonstrated normal compressibility and wall-to-wall flow, however, the left subclavian vein could not be imaged. A non-compressible thrombus was demonstrated in one left brachial vein. The left cephalic was visualized and appeared normal. IMPRESSION: Occlusive thrombus in the right subclavian vein and in one brachial vein on each side. . ECHO [2172-10-27]: Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. The tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. IMPRESSION: Suboptimal image quality. Focused views. Normal right ventricular size and function. Overall normal left ventricular function. Compared with the prior study (images reviewed) of [2172-10-22], right ventricular size and function are similar. The images are suboptimal for comparison. . CXR [2172-10-17] Since [2172-10-23], a right PICC was installed with its tip in the distal [Year (4 digits) 17911]. Right internal jugular catheter still ends in the low right atrium, should be pulled back 5 cm for optimal placement. In IVC filter and clips in the abdomen are unchanged. Tortuosity of the aorta and hyperinflation are stable. Old left rib fractures and deformity of both shoulders are also unchanged. . CTA-CHEST [2172-10-27] FINDINGS: Scattered bilateral small subsegmental pulmonary emboli (in right lower lobe 3:47, 60, 68 and left upper lobe in 3:44). No evidence of right heart strain. Scattered small peripheral parenchymal opacities, some patchy, some ground-glass (probably representing infection) and some nodular with wedge shape (probably representing infarction areas), most prominent in the right upper lobe. Peripheral atelectasis, septal thickening, bronchial wall thickening and peribronchial nodularity are seen in lung bases. Enlarged lymph nodes are seen in right hilum, AP window, bilateral lower paratracheal stations. Small bilateral pleural effusions with adjacent compressive atelectasis are more prominent on the left side. Prominent ascending aorta. At the level of the pulmonary artery bifurcation, ascending aorta measures 37 mm and descending aorta measures 22 mm. Limited visualization of abdominal organs reveal presence of small hypodense lesion in right kidney, likely cyst. Multiple anterior wedge compression fractures in the spine of indeterminate chronicity. Old bilateral rib fractures and old deformities of both shoulders. IMPRESSION: 1. Scattered bilateral small subsegmental pulmonary emboli, in right lower and left upper lobes.. 2. Multiple peripheral parenchymal opacities that could represent infection. The wedge-shaped consolidations probably represent infarction, in right upper lobe. . ECG [2172-10-22] Atrial fibrillation with mean ventricular rate 92. Marked precordial T wave inversion. No previous tracing available for comparison. . ECG:[2172-10-22] Atrial fibrillation. Extensive ST-T wave changes in the precordium and inferior leads may be due to myocardial ischemia. Compared to the previous tracing of [2172-10-22] the ST-T wave changes are actually somewhat improved. . Brief Hospital Course: In summary, Mr. [Known lastname ] is a 64 year old male with alcoholic cirrhosis cirrhosis and atrial fibrillation, and hx of DVTs, admitted with an upper GI bleed of unclear etiology. . #Upper GI bleed. Patient has history of alcoholic cirrhosis so was started on octreotide drip. However, EGD [2172-10-22] showed one cord of grade I varices and friabilitiy of anastamosis site from prior bilroth surgery which was initially thought to be the likely source of bleeding. He was initially on PPI drip, but this was transitioned to IV PPI [Hospital1 ]. He was evaluated by surgery for possible surgical resection of bleeding site, however, they felt him to be a poor surgical candidate given multiple surgeries in the past. Hematocrits remained stable after the initial 3 units of pRBCs transfused on [2178-10-22]/08. Etiology of the bleeding is not clear as repeat EGD on [2172-10-29] did not show any varices or bleeding or friability at the anasamosis site. Hepatology/GI recommended a colonoscopy both to look for source of bleeding and given pts apparent hypercoaguability given hx of DVTs and current bilaterally upper extremety DVTS. Colonoscopy was unremarkable. Hepatology recommended outpatient follow up with a capsule study and not restarting any coagulation until follow up given risk of re-bleeding. Pt was schedule to have follow up at the [Hospital1 18] Liver Center. . #Air in mesentery. Concern for microperforations, per surgery, perhaps related to scope trauma from OSH EGD. Initailly with abdomominal pain, though this has improved. Has been evaluated by surgery who wanted conservative management given multiple prior surgeries. He was made NPO and monitored with serial abdominal exams. He was started on fluconazole and zosyn per surgery. Pt completed an empiric 7 day course of antibiotics. His abdominal pain resolved, and he has remained afebrile and his WBC count has trended down. . #Pulmonary embolism. Pt was transferred back to the MICU after an episode of chest pain, hypoxia, and tachicardia to the 160s-170s with bigeminy. Pt had no acute ST-T changes on EKG, and CEs remained flat 0.05, down from 0.07 on admission. On CTA chest, patient noted to have bilateral subsegmental PEs. He had several episodes of A. fib with RVR likely secondary to PEs, possibly related to his bilateral upper extremity DVTs. Given patient's recent significant GI bleed, decision was made not to anticoagulate unless patient was stable for more than two weeks. An [Hospital1 17911] filter was placed. Patient had an IVC filter in place prior to admission. An echo was performed and shows normal right ventricular function. Since placement of [Name (NI) 17911] pt has had no furthe episodes of RVR, chestpain or hypoxia. His O2 sats have remained normal on room air. . # B/l upper extremity clots. Patient has significant clot burden, making line placement difficult. Unable to anticoagulate at present due to GIB. Cachexia, weight loss, and extensive clot burden concerning for malignancy. Anticoagulation was not initiated given ongoing GI bleed. An [Name (NI) 17911] filter was placed when patient was found to have PEs. Pt underwent colonoscopy which was normal. Patient will need outpatient age appropriate cancer screening. . # Abdominal pain. Patient has chronic abdominal pain secondary to pancreatitis, but with concern for microperforation as above. On methadone and percocet at home for pain, which was held due to microperforation. Abdominal pain resolved. . # Afib. Patient in A. fib. Initially managed at OSH on diltiazem drip. Patient had a few episodes of A. fib with RVR associated substernal chest pain and ST depressions on EKG, concerning for rate related demand ischemia. He was started on lopressor to improve HR control to avoid tachycardia. Patient is not anticoagulated due to GI bleed. Echo was performed during admission. . # Cirrhosis. Patient has well compensated alcoholic cirrhosis. He was followed by liver. He was noted to have one band of grade I varices on EGD on [2172-10-22], but none were noted on the repeat EGD, on [2172-10-29]. He will have follow up with Liver Center as an outpatient. . Medications on Admission: (upon transfer from OSH): diltiazem 120 mg daily Pantoprazole PO 40 mg daily methadone 5 mg Q8H lasix 20 daily digoxin 0.125 daily Zosyn 4.5 g Q12H ([10-18] planned through [10-23]) Oxycodone 10 mg Q6H prn morphine IV 2 mg prn zofran 4 mg IV prn. D5W with 40K at 70/hr Discharge Medications: 1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 4. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 6. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). 7. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 8. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for SSCP. Discharge Disposition: Extended Care Facility: [Hospital3 13990] Health Care Center Discharge Diagnosis: Gastrointestinal bleeding Deep vein thrombosis Discharge Condition: Stable for rehab/skilled nursing facility	[ "427.1", "456.1", "453.40", "276.0", "996.74", "415.19", "707.07", "577.1", "455.0", "998.11", "303.93", "280.9", "571.5", "E879.8", "571.2", "730.18", "427.31", "287.5", "E878.2", "707.21", "414.01", "E849.7" ]	icd9cm	[ [ [] ] ]	[ "99.07", "88.72", "99.04", "45.13", "99.15", "38.93", "44.43", "38.7", "45.23" ]	icd9pcs	[ [ [] ] ]	19032, 19099	13759, 17973	274, 279	19190, 19235	3717, 6487		3244, 3337		18300, 19009		19120, 19169		17999, 18277												3352, 3698																									230, 236									307, 2277																	2299, 3058	3074, 3228				6504, 13736
31,258	136,841	3481	Discharge summary	report	Admission Date: [2123-6-24] Discharge Date: [2123-6-30] Date of Birth: [2047-10-25] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5018] Chief Complaint: Found unresponsive by wife after aphasia 1 day prior Major Surgical or Invasive Procedure: NONE History of Present Illness: This 75 y/o man with history of Afib on warfarin presented after collapsing at home ~8pm. He was in his USOH earlier today, visiting Foxwoods resort when, on the way home ~1400h, he began mumbling. As per his wife, he was intelligible but his words were both slurred and his speech was hypophonic. He denied other symptoms including headache, visual changess or focal weakness. The mumbling speech persisted but the patient resisted his wife's request to be evaluated. At ~2000h, his wife heard a dull thud in an adjacent room and came upon the patient alert but mute and weak, leaning against the wall. There was no seizure activity noted or evident trauma. EMS was contact[Name (NI) ] and found RIGHT hemiplegia. FSBS 156, SBP 200/P. In the ER, the patient became briefly more alert, saying "yes" and "no" but not to appropriate questions. Past Medical History: 1. pituitary tumor 2. cardiomyopathy; last echo with EF 35-45%, 1+MR, [11-18]+AR in [4-/2121] 3. hypertension 4. diabetes type II 5. chronic obstructive pulmonary disease 6. CPPD Social History: Formerly smoked 2-3 packs per day for almost 50 years. He denies drugs or alcohol. He is married. He is retired, and used to own a smoke shop. Working on losing weight. Self employed, lives at home with wife. Former [Name2 (NI) 1818]. Social EtOH. Family History: Significant for breast cancer in his mother at age 82, stroke in his father at age 58, sister who died of leukemia, brothers with heart disease and another brother with liver cancer. Physical Exam: Gen: Obese elder man, lying comfortably in bed, NAD. Sclerae anicteric. MMM. No meningismus. No carotid bruits auscultated. Lungs clear bilaterally. Heart irregularly irregular in rate. Abd soft, nontender, nondistended. Bowel sounds heard throughout. Neuro: >>MS??????Alerts to voice. Minimal spontaneous speech. Will say "yes" or "no" to requests to lift arm, close eyes or state name. Follows some commands. Eyes midline, w/o apparent neglect. >>CN??????Fundi w/ sharp discs. PERRL. VFIC. No ptosis. EOMI w/ oculocephalics. Slight RIGHT facial droop. >>Motor?????? FROM Difficulty assessing strength secondary to comprehension and inability to follow all commands. Yet [3-22] strength noted in upper extremities when attempting to insert a NGT on prior days. >>Sensory?????? withdrawals to nox stim throughout except distally at Right foot. >>DTRs??????L/R: bic 2/0, br 1/0, tri 1/0, pat 2/0, Ach 0/0. Toes downgoing >>Coord/Gait??????Not tested. Pertinent Results: [2123-6-24] 09:00PM PLT COUNT-167 [2123-6-24] 09:00PM PT-32.1* PTT-34.7 INR(PT)-3.3* [2123-6-24] 09:00PM WBC-7.8 RBC-5.39 HGB-15.7 HCT-47.3 MCV-88 MCH-29.1 MCHC-33.1 RDW-14.0 [2123-6-24] 09:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2123-6-24] 09:00PM CK-MB-NotDone [2123-6-24] 09:00PM CK(CPK)-97 [2123-6-24] 09:00PM estGFR-Using this [2123-6-24] 09:00PM GLUCOSE-196* UREA N-42* CREAT-1.5* SODIUM-139 POTASSIUM-5.0 CHLORIDE-103 TOTAL CO2-26 ANION GAP-15 [2123-6-24] 10:40PM cTropnT-<0.01 [2123-6-30] Phos 2.4 replenished with Neutra Phos HCT - IMPRESSION: 1. Left temporal parenchymal hemorrhage. 2. Findings concerning for a pituitary mass. Further evaluation with MR is recommended. ECHO - WNL NO shunting noted. The left atrium is mildly dilated. No thrombus/mass is seen in the body of the left atrium. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. No masses or thrombi are seen in the left ventricle. Overall left ventricular systolic function is normal (LVEF>55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. 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. CXR - Since earlier today, ETT tip is 4.5 cm above the carina. Nasogastric tube is in the stomach. Moderate left pleural effusion with associated retrocardiac alveolar opacity increased suggesting aspiration or atelectasis. Vascular congestion decreased. No other change since earlier today. MRI- IMPRESSION: Left posterior hematoma without signs of underlying enhancement or abnormal vascular structures. Presence of chronic microhemorrhages may suggest amyloid angiopathy but follow up is recommended. Sellar abnormality noted HCT - IMPRESSION: 1. No significant change in the large left posterior temporal hemorrhage or debris of the mass effect. No new foci of hemorrhage. 2. Stable appearance of the sella abnormality compared to [2115-12-19]. [2123-6-28] ECG - Atrial fibrillation with rapid ventricular response. Diffuse non-specific ST-T wave changes. Compared to the previous tracing of [2123-6-25] atrial fibrillation is new. However, the deep T wave inversions in the lateral leads have partially normalized. Clinical correlation and repeat tracing are suggested. Brief Hospital Course: Pt was initially admitted and cared for in the ICU. Pt was intubated and extubated in the ICU. HCT, cardiac monitoring, MRI obtained significant for possible amyloid angiopathy. Pt was supertherapeutic on coumadin, INR 3.3 There seems to be no traumatic antecedent. No mass or AVM in MRI.The absence of edema makes me believe that there it is not a hemorhagic transformation of infarct. Pt was given FFP, Profilnine, and vitamin K. Pt placed on a nicardipine drip. After nicardipine drip and pt was extubated. Pt was transferred to the Step Down unit and observed. Lisinopril, Atenolol was started and coumadin was d/cd. On [2123-6-28], he was started on ASA 81 mg PO daily. NGT placement was attempted successfully. Overnight, SVT and afib noted and treated with Diltizem and Lopressor. On [2123-6-29], pt passed the speech and swallow eval and PO feeds restarted. Pt monitored on telemetry without tachyarrhytmias. Cardiology was consulted for eval for "mini-maze" procedure given the fact that he is at high risk for recurrent ICH if he were to resume coumadin. They felt that he was not a good candidate. Cognition, speech and sponateous movements improved. Medications on Admission: warfarin 1.25 mg daily, Atenolol 25mg daily, dostinex 0.5mg daily, glyburide 1.25mg daily, flonase Discharge Medications: 1. Cabergoline 0.5 mg Tablet Sig: [11-18] Tablet PO qday (). 2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 4. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 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. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Discharge Disposition: Extended Care Facility: [Hospital3 1107] [Hospital ] Hospital - [Location (un) 38] Discharge Diagnosis: Left Temporal Intracranial Hemorrhage Discharge Condition: Stable. Improving mentation. Able to follow some commands. Orally feeding. No tachyarrhythmias. Discharge Instructions: F/U with PCP and Neurologist as scheduled F/U with rehab therapy as instructed Pt is to NEVER take COUMADIN again. Followup Instructions: [Name6 (MD) 4267] [Last Name (NamePattern4) 4268], MD, PHD (Neuro/Stroke Division) Phone:[Telephone/Fax (1) 657] Date/Time:[2123-7-28] 2:00pm [Hospital Ward Name 23] Bldg [Location (un) 6749] Dr. [Last Name (STitle) 1274] (Autonomics) Phone:[Telephone/Fax (1) 44] Date/Time:[2123-9-29] 1:30 ECHOCARDIOGRAM Phone:[Telephone/Fax (1) 62] Date/Time:[2124-5-10] 11:00 [Name6 (MD) 4267] [Last Name (NamePattern4) 4268] MD, [MD Number(3) 5023]	[ "790.92", "427.31", "277.30", "431", "250.00", "427.32", "E934.2", "V58.61", "518.81", "401.9", "276.2", "425.4", "496" ]	icd9cm	[ [ [] ] ]	[ "96.6", "96.04", "99.07", "96.71" ]	icd9pcs	[ [ [] ] ]	8021, 8118	5923, 7096	370, 377	8200, 8298	2946, 5900	8461, 8986	1760, 1945		7246, 7998		8139, 8179		7122, 7223			8322, 8438									1960, 2927																									278, 332									405, 1261																	1283, 1473	1489, 1744
22,699	126,236	43936	Discharge summary	report	Admission Date: [2170-10-15] Discharge Date: [2170-10-20] Date of Birth: [2112-1-26] Sex: M Service: CARDIOTHORACIC Allergies: Ivp Dye, Iodine Containing Attending:[Last Name (NamePattern1) 1561] Chief Complaint: Progressive dyspnea and a chest CT which revealed interstitial disease. admitted for right VATS lung biopsy for definitive diagnosis. Major Surgical or Invasive Procedure: right VATs wedge biopsy History of Present Illness: The patient is a delightful 58- year-old gentleman with progressive dyspnea for several months over the last year, culminating an episode of pneumonia and he required admission with intravenous antibiotics and steroid therapy in [2170-2-20]. Since that time he has continued to be dyspneic at rest. This has been progressive over the past several months to the point where he gets short of breath just getting and in and out of a truck. Recent CT scan demonstrates air space disease suspicious for either nonspecific interstitial pneumonitis versus hypersensitivity pneumonitis and possibly desquamative interstitial pneumonitis. Because of the progressive nature of his disease and the severity of it and evidence of active lung disease and complications of steroid therapy, we have elected to proceed forward a lung biopsy. Past Medical History: HTN,GERD, Hyperchol, hernia repair- unbilical, inguinal Social History: current smoker, frequent alcohol use Family History: non contributory Physical Exam: General: obese male in NAD. A+OX3 HEENT; unremarkable. Chest: clear bilat COR: RRR S1, S2 Abd; obese, soft, NT, +BS extrem: no c/c/e Pertinent Results: [2170-10-15] Pathology Tissue: RT. UPPER LOBE WEDGE, RT. [2170-10-15] [Last Name (LF) ],[First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] Not Finalized Brief Hospital Course: Pt was admitted on [2170-10-15] and taken to the OR for right VATS lung biopsy. OR and Post op unvevntful. Chest tubes were d/c'd on POD#2. pt's pain was well controlled on po percocet, [Last Name (un) 1815] reg diet, ambulating well on room air. Medications on Admission: lisinopril, protonix Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:0 d for arthritis. 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:160 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: right VATS wedge biopsy HTN, GERD,hyperchol, Hernia repair- inguinal, unbilical Discharge Condition: good Discharge Instructions: Call Dr.[Name (NI) 1816] office if you experience chest pain, shortness of breath, fever, chills, nausea, vomiting or redness, drainage from your incision sites. You may shower on friday. After showeriing, cover your chest tube site with a claen bandaid daily. DO NOT RESUME YOUR lisinopril until after you have had your follow up appointment with Dr. [Last Name (STitle) 952]. At that time he will advise you regarding your lisinopril and a new medication lopressor which you are now taking. Followup Instructions: Call Dr.[Name (NI) 1816] office [Telephone/Fax (1) 170] for a follow up appointment in [10-5] days. Completed by:[2170-10-23]	[ "401.9", "V15.84", "515", "278.00", "560.1", "530.81", "272.0", "553.1" ]	icd9cm	[ [ [] ] ]	[ "34.21", "04.81", "33.28" ]	icd9pcs	[ [ [] ] ]	2752, 2758	1862, 2118	438, 464	2882, 2889	1658, 1839	3438, 3582	1472, 1490		2189, 2729		2779, 2861		2144, 2166			2913, 3415									1505, 1639																									264, 400									492, 1323																	1345, 1402	1418, 1456
57,158	100,697	41827	Discharge summary	report	Admission Date: [2127-10-15] Discharge Date: [2127-10-25] Date of Birth: [2083-10-2] Sex: M Service: NEUROLOGY Allergies: Penicillins / lisinopril Attending:[First Name3 (LF) 2569] Chief Complaint: Transferred from OSH, intubated/sedated, stroke care Major Surgical or Invasive Procedure: Angiographically guided clot retrieval procedure, insertion of central venous catheter, arterial line procedure History of Present Illness: The pt is a 44 year-old right-handed man with a past medical history significant for HLD, depression who presents as an OSH transfer with a basilar occlusion. History derived from wife who was at bedside. Patient noted the onset of nausea and vomiting on Monday. Wife thinks the patient woke up with this sensation. He denied any sensation of vertigo, he apparently had a mild headache. In addition to the severe nausea and vomiting he felt unsteady and kept veering to the right when he was walking. This sensation had been improving over the last two days but was still present so he made an appointment with his PCP. [Name10 (NameIs) ] was able to drive and get to his PCP on his own power this morning. Besides the above symptoms his wife stated that he didn't have any facial asymmetry, no obvious weakness, no problems with vision, no difficulty with language. At the PCP's office he was by report feeling worse and disoriented. We have not been able to contact the PCP [Name Initial (PRE) ]. He then reportedly collapsed at the office with a question of seizure like activity, and possible left eye deviation. EMS arrived and he was intubated and transferred to a local hospital then [Hospital1 ]. At the OSH they got a head CT which apparently was normal and then a CTA which showed an occlusion of the right vertebral artery, and an occlusion in the top of the basilar artery. There endovascular service was not available and he was transferred to [Hospital1 18] for endovascular intervention. Past Medical History: - HLD - Depression - Insomnia Social History: Lives at home with his wife and three children. He is a sales representative. No history of smoking. No drug use. Uses EtOH on social occasions. Family History: Both his mother and father had CAD, he had a grandmother with a stroke. Migraine history in his family but he does not have any headaches. No history that wife is aware of bleeding or clotting disorders. Physical Exam: Physical Exam on Admission: Vitals: T:98 P: 84 R: 16 BP:159/99 SaO2:100 intubated General: intubated, propofol off for about 2-3 minutes HEENT: NC/AT, intuabed, no scleral icterus noted, MMM Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally Cardiac: RRR, nl. S1S2 Abdomen: soft, NT/ND, normoactive bowel sounds Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Grimacing to pain, not opening eyes to pain. Not responding to commands. Withdraws right side purposefully away from pain. Not responding to any commands. -Cranial Nerves: I: Olfaction not tested. II: PERRL 2.5 to 2mm and brisk. Some roving eye movements, no clear ocular bobbing. Unable to test visual fields. III, IV, VI: has dolls eyes in horizontal and vertical directions V: corneals intact, ? of less on left VII: unclear but with grimace little less movement of left face IX, X: Gag intact -Motor: Normal bulk, tone throughout. With stimulation withdraws to pain on the right arm and leg purposefully, the left leg is externally rotated and withdraws less than the left, he extensor postures the left arm. -Sensory: Withdraws to pain as above -DTRs: [Name2 (NI) ] Tri [Last Name (un) 1035] Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response was flexor bilaterally. -Coordination: not assessed -Gait: not assessed Pertinent Results: Labs on Admission: [2127-10-15] 01:55PM BLOOD WBC-9.2 RBC-4.37* Hgb-15.1 Hct-41.6 MCV-95 MCH-34.5* MCHC-36.3* RDW-12.6 Plt Ct-203 [2127-10-15] 01:55PM BLOOD PT-12.7 PTT-22.2 INR(PT)-1.1 [2127-10-15] 01:55PM BLOOD Lupus-PND AT-101 ProtCFn-129* ProtSAg-113 ACA IgG-2.3 ACA IgM-3.2 [2127-10-15] 01:55PM BLOOD ESR-3 [2127-10-15] 01:55PM BLOOD Fibrino-302 [2127-10-16] 05:10AM BLOOD Glucose-129* UreaN-9 Creat-0.6 Na-139 K-3.7 Cl-105 HCO3-23 AnGap-15 [2127-10-16] 05:10AM BLOOD ALT-43* AST-23 [2127-10-16] 05:10AM BLOOD CK-MB-2 cTropnT-<0.01 [2127-10-16] 05:10AM BLOOD Calcium-8.1* Phos-3.8 Mg-2.1 Cholest-202* [2127-10-16] 05:10AM BLOOD Triglyc-102 HDL-48 CHOL/HD-4.2 LDLcalc-134* [2127-10-16] 05:10AM BLOOD %HbA1c-5.5 eAG-111 [2127-10-16] 05:10AM BLOOD TSH-0.60 [2127-10-15] 01:55PM BLOOD b2micro-1.3 [2127-10-15] 01:55PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2127-10-15] 05:54PM URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-MOD [2127-10-15] 05:54PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]->1.050* [2127-10-15] 05:54PM URINE RBC-6* WBC-29* Bacteri-FEW Yeast-NONE Epi-<1 [2127-10-15] 05:54PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG Cultures: MRSA Screen [2127-10-20]: Negative Sputum [2127-10-18]: Pneumococcus (Sensitivities pending) Urine culture [2127-10-18]: No growth C diff Toxin [2127-10-20], [2127-10-22]: Negative Stool O/P: pending Stool Cultures: pending EKG [2127-10-15]: Sinus bradycardia. Q-T interval prolongation. No previous tracing available for comparison. CXR [2127-10-15]: Appropriately positioned ET and NG tubes. Mild retrocardiac atelectasis. ECHO [2127-10-18]: The left atrium is normal in size. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast at rest. 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. Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. There is abnormal septal motion/position. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. MRI/MRA ([2127-10-16]): 1. Complete occlusion of the basilar artery with multiple acute infarcts in the right cerebellum, right vermis, and bilateral paramedian pons. Top of the basilar artery, including bilateral posterior cerebrals and superior cerebellar arteries appear patent. Complete occlusion of the right vertebral artery with intrinsic high T1 signal may represent occlusion secondary to dissection. MRI/MRA ([2127-10-19]): Extensive acute infarctions in the bilateral pons, right superior vermis, and right superior and inferior cerebellum, and small acute infarction in the inferior left cerebellar hemisphere, with expected temporal evolution. New small acute infarction more superiorly in the left cerebellar hemisphere. Minimal effacement of the right lateral wall of the superior fourth ventricle, new since the prior exam. Partially improved flow through the distal basilar artery, which was previously occluded. Persistent occlusion of the right superior cerebellar artery. Persistent abnormal irregularity and narrowing of the intracranial right vertebral artery. Persistent nonvisualization of the right posterior inferior cerebellar artery. Brief Hospital Course: For two days prior to seeking medical attention, he was experiencing symptoms of nausea, vomitting and headaches. He did not receive TPA at the outside hospital. Mr. [Known lastname ] was admitted to the ICU following an interventional procedure which recanalized occluded vessels in the posterior circulation (right vertebral artery and top of the basilar artery). He was intubated on arrival and remained intubated for this procedure. He was transferred to the ICU following this procedure. - He has remained hemodynamically stable during his course in the ICU and has not required IV pressors. He was initiated on IV anticoagulation with heparin and received his first dose of warfarin on [2127-10-22]. His heparin drip was discontinued on discharge and should receive his first dose of lovenox at his rehab facility. - He was plavix loaded in the interventional suite and while he was receiving both plavix and heparin, he was noted to have some oropharyngeal bleeding that was formally addressed by a bronchoscopic evaluation showing the presence of a traumatic lesion in the soft pharynx. This was treated with packing and has subsequently remained bleeding-free; additionally his plavix was discontinued. - On the days following his admission, we have noticed an improvement in his overall neurological examination. Today, he is able to move his eyes conjugately in all four directions as well as possesses significant neck movement. He has started to regain some chewing movements of his mouth but cannot volitionally open his mouth or protrude his tongue. He does have some very slight volitional movement of his upper extremities along the plane of gravity but this comes with a prolonged reaction time. - He received a tracheostomy and PEG tube on [2127-10-21] and has subsequently done well on trach collar. His tube feeds were reinitiated overnight, and they are currently at goal. He has remained on trach collar for >2 days. - He had a repeat MRI on [2127-10-19] which showed completion of his stroke with extensive areas of infarcts in the region of the midbrain and right cerebellum as well as partial recanalization of his right vertebral and basilar artery - His family has remained at his bedside throughout his stay. We had a family meeting on [2127-10-17] where we discussed his prognosis and likely prolonged rehabilitation. - He has been seen by and worked with speech therapy to develop a system of YES (looking up) and NO (looking down). In addition, his therapist provided some communication boards to help improve his communication skills. With PT's help, he has also been able to sit up in chair during much of the day time. - He did spike some fevers during his ICU course associated with a slight elevation in WBC and foul smelling sputum. Cultures have eventually grown out Coag positive staph aureus for which he is currently receiving IV vancomycin and ciprofloxacin. He is also receiving aztreonam so as to cover for coag negative staph bacteremia. - Prior to his discharge, he received a PICC line. His INR remained subtherapeutic in spite of three days of 5mg of warfarin QHS, and his dose was increased prior to discharge. Physical Examination on Discharge: Vitals: T 37.6-37.9, 59-65, 142-158/68-78, 16-24, 96-100%, 4.5L/2.8L GEN: Young, NAD, intermittently extends arms and legs, makes good eye contact, diaphoretic. CV: Regular heart sounds, without murmurs or rubs Pulm: Clear to auscultation bilaterally Abd: Soft without tenderness or distention Extremities: Without edema or clubbing Neurological Examination: Mental Status: Eyes are open at baseline. Can shake/nod head slowly. Intermittently will follow commands. Variably responds correctly by looking up/down. Cranial Nerves: PERRL, Able to provide conjugate gaze in all four directions but has difficulty tracking objects. There is no apparent facial droop or ptosis. There are no corneal reflexes, and no gag, although he does have a cough. There is no VOR. Cannot open his mouth and show his teeth or protrude tongue. Motor: Extensor posturing to pain in both upper extremities. Some right sided volitional movement along the plane of gravity but is slow. Lower extremities spontaneously extensor posture, also occasional triple flexion on painful stimulation of the lower extremities. He occasionally withdraws to pain. Reflexes are normal throughout, toes are up bilaterally Sensory: Difficult to assess Coordination/Gait: Not tested Transitional Issues: - Please keep Mr. [Known lastname ] [Last Name (Titles) 90846] on warfarin (he needs this for the indefinite future). He can be on a lovenox bridge to a goal INR of 2.0 to 3.0. Please check coags daily especially while his antibiotics are being discontinued. - Please have Mr. [Known lastname ] follow up with Dr. [Last Name (STitle) ] of the Division of Vascular Neurology on [Month (only) ] the 16th, [2127] at 10AM. - He requires a total of 14 days of IV antibiotics. His vancomycin, aztreonam and ciprofloxacin can be safely discontinued on [2127-11-3]. These are designed to treat a coag positive staph pneumonia and coag negative staph bacteremia. - Mr. [Known lastname ] is an extremely motivated individual with a highly supportive family. Please provide aggressive phyiscal therapy and occupational therapy for him. - Continue to titrate his antihypertensives to maintain his SBP<130 Medications on Admission: Citalopram 20mg qd Trazadone 50mg qd Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for fever, pain. 2. insulin regular human 100 unit/mL Solution Sig: As directed Injection every six (6) hours. 3. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 4. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day. 5. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. heparin (porcine) in D5W 25,000 unit/500 mL Parenteral Solution Sig: 1700U/hr Intravenous Continuous infusion: Until INR reaches a goal of 2.0-3.0. 7. aztreonam in dextrose(iso-osm) 2 gram/50 mL Piggyback Sig: One (1) Intravenous Q8H (every 8 hours) for Until [2127-11-3] days. 8. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. ciprofloxacin in D5W 400 mg/200 mL Piggyback Sig: One (1) Intravenous Q12H (every 12 hours) for Until [2127-11-3] days. 10. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) Intravenous Q 12H (Every 12 Hours) for Until [2127-11-3] days. 11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 13. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 15. labetalol 5 mg/mL Solution Sig: One (1) Intravenous Q4H (every 4 hours) as needed for SBP>160. 16. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Ischemic Stroke of the Posterior Circulation, Pontine/Midbrain infarct Hypercholesterolemia Depression Discharge Condition: Mental Status: Follows commands, responds by eye movements (Yes - look up, NO- look down) Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: Mr. [Known lastname ], you received treatment at the Intensive Care Unit of the [Hospital1 69] for a stroke in the back portion of your brain. This caused your symptoms of nausea and vomiting for two days, followed by your collapse at your physician's office. Our neurointerventional team were able to fix the blockage in the blood vessels of your brain, but there was still a large portion of tissue that did not receive oxygen and nutrients for a long period of time. The region of your brain infarcted is called the brainstem, which can control a variety of functions including swallowing, breathing and has passing through connections that control movement. - Initially, you were placed on a breathing machine to help maintain regular breathing. This was switched over to a "tracheostomy", which is an artificial breathing tube that connects directly to your trachea. This is a reversible procedure, that may be able to come out in the future. - Since you have significant swallowing dysfunction, you received a PEG tube that inserts directly into your stomach. You can receive tube feeds and water through this tube to provide you vital nutrients that you need to recover. - It is important that you try your best to participate as much as possible in rehabilitation exercises to help improve your strength over time. - We initiated you on a medication called IV heparin to keep your blood thin and [Hospital1 90846] and prevent future clots. This will be transitioned to a pill called WARFARIN or COUMADIN, which will do the same to your blood (blood thinner). - You will receive antibiotics for a limited period of time to treat a blood stream infection as well as a pneumonia that you developed while in the ICU. - We have scheduled an appointment for you to see one of our stroke specialists on the [10-24] at 1:00PM. Your day-to day care will be under the physician at your acute rehabilitation facility. - In addition to these, you will continue to take CITALOPRAM for depression WARFARIN for blood thinning LISINOPRIL for hypertension SIMVASTATIN for high cholesterol INSULIN as needed for high blood sugars FAMOTIDINE twice daily to prevent stress ulcers in your stomach Followup Instructions: [Hospital Ward Name 23] Building [Location (un) ] [Location (un) 830], [Location (un) ], [Numeric Identifier 718] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 640] [Last Name (NamePattern4) 3445], MD Phone:[Telephone/Fax (1) 2574] Date/Time:[2127-12-24] 1:00 [First Name8 (NamePattern2) ] [Name8 (MD) 162] MD [MD Number(2) 2575] Completed by:[2127-10-25]	[ "E879.8", "344.81", "790.7", "041.11", "518.81", "272.0", "997.31", "276.69", "344.00", "311", "780.52", "433.31", "443.24", "528.9" ]	icd9cm	[ [ [] ] ]	[ "33.24", "96.72", "43.11", "39.74", "96.6", "33.22", "00.41", "31.1", "88.41" ]	icd9pcs	[ [ [] ] ]	15148, 15218	7962, 11165	341, 454	15365, 15365	3949, 3954	17780, 18233	2254, 2463		13459, 15125		15239, 15344		13397, 13436			15555, 17757						3147, 3930			2478, 2492																	11179, 11539	12444, 13371							249, 303									482, 2018	11709, 12423							3968, 7939		15380, 15531							2040, 2072	2088, 2238
13,379	126,915	15196	Discharge summary	report	Admission Date: [2173-2-13] Discharge Date: [2173-2-19] Date of Birth: [2123-8-30] Sex: M Service: ACOVE HISTORY OF PRESENT ILLNESS: The patient is a 49 year old gentleman with a seizure disorder since a left middle cerebral artery stroke in [2167]. He was admitted on [2173-2-13] with grand mal tonic-clonic seizure times six after missed doses of Dilantin. The patient had missed his doses of Dilantin due to a late mail order of his medications. His serum level was 1.9 at admission. The patient's status epilepticus broke after Dilantin load on Ativan in the Emergency Room. However, he was intubated in the Emergency Room for airway protection. Patient was also initially hypertensive in the Emergency Room to 220/100 and then hypotensive upon arrival to the Intensive Care Unit with a blood pressure of 84/50 which responded to intravenous fluids. The patient was extubated the day after admission without complication and transferred to the Medicine floor on [2173-2-15]. Patient also had acute renal insufficiency which had resolved by the time of transfer to the Medicine floor, but also with rhabdomyolysis with peak creatinine kinase of 31,000 on [2173-2-16]. This was also trending down at the time of transfer. At the time of transfer, the patient denied any symptoms or complaints and review of systems was negative. PAST MEDICAL HISTORY: 1. Seizure disorder. 2. Left middle cerebral artery stroke in [2167] with residual right hemiparesis. 3. Expressive aphasia. 4. Hypertension. 5. Depression. MEDICATIONS AT HOME: 1. Vasotec 10 twice a day. 2. Norvasc 5. 3. Atenolol 50. 4. Celexa 20. 5. Dilantin 100 twice a day. 6. Aspirin 81. 7. Lipitor. ALLERGIES: Reportedly to Penicillin and Sulfa with a rash. SOCIAL HISTORY: The patient is married. He is originally from [Country 16573]. He has four children. He quit tobacco in [2163]. No alcohol use. Worked as a journalist before the stroke. FAMILY HISTORY: Non-contributory. PHYSICAL EXAMINATION ON ADMISSION: Pleasant African American gentleman in no apparent distress, lying in bed. Physical examination with a normal examination except notable for expressive aphasia with slurred verbalizations. The patient also has 1 out of 5 strength in the right upper and lower extremities, but otherwise neurologically intact. Physical examination also notable for a large 1 inch laceration in the left lateral aspect of the patient's tongue. LABS ON ADMISSION TO INTENSIVE CARE UNIT: BUN and creatinine 15/1.3; hematocrit 35; white blood count 23; Dilantin level 1.9; urinalysis with large blood, otherwise normal. HOSPITAL COURSE: This is a 49 year old gentleman with seizure disorder status post stroke in [2167], admitted with grand mal tonic-clonic seizure and status epilepticus which broke after the Dilantin load and Ativan. The patient was intubated and then managed in the Intensive Care Unit for one night. He was then extubated without event. Patient was also noted to have rhabdomyolysis. The patient was stable on transfer to the floor on [2173-2-15]. 1. Rhabdomyolysis: The patient's creatinine kinase peaked at 31,000 [2173-2-16] and continued to trend down. The patient's rhabdomyolysis was likely due to his status epilepticus on admission with resulting convulsions. Patient's liver function tests were also slightly elevated, but likely related to the rhabdo and muscle breakdown. Patient was continued with aggressive intravenous fluids and his electrolytes were monitored very carefully. The patient was started on bicarbonate in his intravenous fluids for two days to alkalinize his urine. The patient's creatinine kinase continued to trend down at the time of discharge. 2. Seizure disorder: The patient was without any further seizure disorder since the Emergency Room. Patient's status epilepticus was likely related to patient's missing multiple doses of his home Dilantin due to the mail order medication being late. I spoke with the patient's primary care taker who is his wife, and they have an adequate supply and were counseled on the importance of compliance. Patient stayed on Dilantin throughout his hospital stay. The albumin adjusted serum level was monitored. Planned outpatient follow-up on Dilantin levels and titration. 3. Blood pressure: The patient was initially hypotensive in the Intensive Care Unit, but responded to intravenous fluids after the Dilantin intravenous was stopped. The patient then became hypertensive which he has been known to be for many years. Patient's beta-blocker was titrated up as needed. 4. Infectious disease: The patient was febrile in the Intensive Care Unit which may have been a stress response, but also possibly related to him being intubated. His differential includes pneumonia pneumonitis, although there is no evidence of aspiration or process on chest x-ray. The patient's white blood count was initially elevated at admission, but trended down to within normal limits. The patient was continued on Levofloxacin and Flagyl which had been started in the Intensive Care Unit for coverage and was continued on this for a seven day course. Patient's blood cultures from admission had no growth to date. 5. Red urine: The patient's red urine was likely due to myoglobinuria, hematuria from Foley trauma given the greater than 1,000 red blood cells in the urinalysis. Patient's urine cleared and was yellow by the time of discharge. 6. Tongue laceration: This is from the seizure at admission. The patient's tongue was evaluated by Ear, Nose, and Throat consult who recommended conservative treatment. The patient had good granulation tissue there. Patient was continued on Peridex swish and spit which he was discharged on for use at home. 7. Anemia: The patient's iron study was most consistent with iron deficiency. He should consider starting iron supplements as an outpatient after rhabdomyolysis has resolved. Patient's hematocrit was stable throughout his hospital stay. 8. History of stroke: The patient was continued on aspirin and blood pressure control as above. 9. Mental status: The patient was minimally responsive at admission due to his status epilepticus, but his mental status was at baseline throughout the remainder of his hospital stay. 10. Fluids, Electrolytes and Nutrition: The patient was evaluated by Speech and Swallow after his Intensive Care Unit stay with intubation and was cleared for p.o. with pureed and thin liquids. The patient's electrolytes should be monitored closely given his rhabdomyolysis. 11. Communication: With patient and wife daily. Patient's code status is full. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: To home with services. DISCHARGE DIAGNOSIS: 1. Seizure disorder. 2. Status epilepticus. 3. Renal failure. 4. Rhabdomyolysis. MEDICATIONS ON DISCHARGE: 1. Peridex by mouth swish and spit times 10 days. 2. Colace liquid as needed. 3. Atenolol 100 once daily. 4. Aspirin 325 once daily. 5. Ranitidine 150 twice a day. 6. Celexa 20 once daily. 7. Levofloxacin 500 once daily, total of 7 day course. 8. Flagyl 500 three times a day, total of 7 day course. 9. Phenytoin 100 mg q12 hours. FOLLOW-UP PLANS: Patient is to follow-up with Dr. [Last Name (STitle) 1699] as scheduled. Patient is also to follow-up with Dr. [Last Name (STitle) ] of the [Hospital ] Clinic as scheduled. [First Name11 (Name Pattern1) 312] [Initials (NamePattern4) ] [Last Name (NamePattern4) 313], M.D. [MD Number(1) 314] Dictated By:[Name8 (MD) 6906] MEDQUIST36 D: [2173-5-14] 01:24 T: [2173-5-14] 18:53 JOB#: [Job Number 44248]	[ "507.0", "584.9", "518.81", "780.39", "276.2", "311", "728.89", "438.11", "438.89" ]	icd9cm	[ [ [] ] ]	[ "96.71", "38.93", "96.04" ]	icd9pcs	[ [ [] ] ]				6737, 6789			2011, 2051				6810, 6896	6922, 7263		2688, 6171							1597, 1793																							7281, 7763															163, 1387								2066, 2670		6187, 6715							1409, 1576	1810, 1994
51,670	112,085	37836	Discharge summary	report	Admission Date: [2148-2-28] Discharge Date: [2148-3-4] Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 3200] Chief Complaint: Abdominal right upper quadrant pain Major Surgical or Invasive Procedure: [2148-3-2] Laparoscopic cholecystectomy [2148-2-29] ERCP History of Present Illness: 88M hx of CAD s/p MI and [Name Prefix (Prefixes) ] [2147-1-20] off plavix, HTN, HLD, distant bladder Ca [2137]. On day of presentation out of his usual state of health noticed mid-epigastric and anterior chest pain that woke him up from his post lunch nap. He described as pressure-like, [8-28] starting in mid-epigastrium and radiating to anterior chest. He subsequently developed chills at home. He came to the ED as was concerned that pain was similar to previous MI. Had N w/ V x 1 in the ED waiting room NB/NB. Pain subsided after maalox and gingerail in the ED. Pnt denies diarrhea. Reports relative constipation over the past few weeks. Last BM 1 day prior to presentation. Passing gas normally since. His daughter notice that he has appeared yellow over the past week. He reports 30lb unintentional weightloss over the past 3 months. He denies any chronic abdominal pain, but does mention similar pain 3 weeks ago which resolved with vomiting. Denies feeling more tired than usual. Denies night sweats, fevers or chills except as above. No recent sick contacts or suspicious meals. No recent travel. Pain worse with inspiration. Of note, per his medical chart has ongoing leukocytosis (13-18) of unclear cause for the past several months. . In the ED Initial vitals were 98.6 HR 78 BP 173/73 RR 20 O2 97%, physical exam was notable for jaundice and distended abdomen with mild epigastric tenderness. EKG was unchanged from baseline and trop X1 was negative. Her other labs were notable for Alkp 1112, T.Bili 3.3, ALT/AST = 218/269, Lip =80, WBC = 15.8 with 79% neutrophils. Cr/BUN 1.3/35 was at the lower end of his baseline. RUQ US revealed stones in the gallbladder, a distended CBD 1.5cm with sludge, no ductal stone but distal end was not visualized. Patient was given IV Got IV cipro 400 + flagyl 500mg + IV NS 1000cc. He also ate in the ED w/o N or V. Pnt was seen in the ED by GI who recommended Abx coverage with Unacyn and doing ERCP tomorrow. Past Medical History: - Coronary artery disease s/p NSTEMI with DES to RCA in [1-29] at [Hospital1 18] (Dr. [Last Name (STitle) ] - Echo [4-/2147]: mod MR, Mod TR, Mod PHTN, LVEF = 45% - Hypertension - Hyperlipidemia - Macular Degeneration - Cataracts - Bladder cancer s/p BCG injection - Depression / anxiety - BPH on finasteride and tamsulosin - Diverticulosis with Hx of GIB [4-/2147] - On [8-/2147] was hospitalized for syncope and found to have Hct of 24 and guiac positive stools. Pnt refused in house colonoscopy. Was followed as outpatient with subsequent stable hematocrits. - Leukocytosis: per OMR WBC counts have been ranging from 11.8 to 18 since [4-/2147], unclear whether this was worked up. Social History: Patient lives with his wife. [Name (NI) ] has four daughters. [Name (NI) ] does not drink alcohol. He smoked from ages 19 to 23, approximately 1 PPD. He is independent and very active, does not use any ambulatory devices at baseline. Former Navy. Family History: - Father died of CHF - Mother died of breast cancer - Sister died of lung cancer - No family history of sudden death Physical Exam: Upon presentation to [Hospital1 18]: Temp:98.6 HR:78 BP:173/73 Resp:20 O(2)Sat:97 Normal Constitutional: Comfortable HEENT: Normocephalic, atraumatic, Extraocular muscles intact sclera anicteric. Surgical pupils bilat Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Nondistended, Soft epigastric tenderness with guarding no rebound mild right upper quadrant tenderness negative [Doctor Last Name ] sign GU/Flank: No costovertebral angle tenderness Extr/Back: No cyanosis, clubbing or edema Skin: Warm and dry, No rash Neuro: Speech fluent Pertinent Results: [2148-2-28] 09:30PM URINE RBC-[3-23]* WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0 [2148-2-28] 08:56PM LACTATE-1.2 [2148-2-28] 05:45PM GLUCOSE-147* UREA N-35* CREAT-1.3* SODIUM-136 POTASSIUM-3.8 CHLORIDE-96 TOTAL CO2-28 ANION GAP-16 [2148-2-28] 05:45PM ALT(SGPT)-218* AST(SGOT)-269* ALK PHOS-1125* TOT BILI-3.3* [2148-2-28] 05:45PM cTropnT-<0.01 [2148-2-28] 05:45PM WBC-15.8* RBC-4.00* HGB-11.7# HCT-35.6 MCV-89 MCH-29.2 MCHC-32.8 RDW-15.4 [2148-2-28] 05:45PM NEUTS-79.0* LYMPHS-17.3* MONOS-2.7 EOS-0.6 BASOS-0.4 [2148-2-28] 05:45PM PLT COUNT-227 [2148-2-28] 05:45PM PT-12.1 PTT-23.8 INR(PT)-1.0 [2148-2-28] Gallbladder Ultrasound IMPRESSION: 1. Marked intrahepatic biliary dilatation which is new since the previous study of [2147-1-21]. Common bile duct measures up to 1.5 cm, slightly increased in size since the previous study. In addition, echogenic material within the common bile duct likely represents sludge. No discrete duct stone is identified; however, the distal common bile duct is not visualized on this study due to overlying bowel gas. MRCP/ERCP could be performed for further evaluation. 2. Cholelithiasis. [2148-2-29] ERCP IMPRESSION: Severe bulging of the major papilla with an impacted stone partially protruding was noted. Pus was noted draining around the impacted stone. A single periampullary diverticulum with large opening was found at the major papilla Cannulation of the biliary duct was performed with a sphincterotome using a free-hand technique Multiple large stones ranging 1-1.5cm in size were noted in the CBD. The CBD was dilated to approximately 18mm diffusely. A sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. Given the large size of the biliary stones, a sphincteroplasty was performed with a balloon to 12mm. Five large brown stones were extracted successfully using a balloon catheter. No further large filling defects were noted in the CBD, however, given suspicion of smaller stone fragments, A 5cm by 10FR Double pigtail biliary stent was placed successfully. Excellent drainage of contrast and bile was noted Brief Hospital Course: 88M hx of CAD s/p MI and [Name Prefix (Prefixes) ] [2147-1-20] off plavix, HTN, HLD, distant bladder cancer who is admitted with picture concerning for acute cholangitis s/p ERCP with stone removal and sphincterotomy. Patient admitted to the Medicine Service initally; his hospital course as follows per dictation of Medical house staff: . # Ascending cholangitis: He initially presented with RUQ pain, new jaundice, but no fevers. Leukocytosis and CBD dilatation on RUQ U/S. ERCP was performed and several stones were removed, with evidence of purulence around a larged impacted stone. A double pigtail stent was placed and his abdominal pain subsided. He was started on Unasyn and will continue on antibiotics for a 14-day course. He was initially kept NPO for 24 hours, then his diet was advanced slowly, as tolerated. He did not have any recurrence of his epigastric pain. Of note, he has had chronic leukocytosis as of late, which will likely improve now that stones have been removed. Per surgery, the patient was transferred to their service for likely cholecystectomy during this admission. He will return in 6 weeks for an ERCP and stent evaluation. . #. Weight loss: He reported a 30lb weight loss over 3 months. He is otherwise active and feels well beyond the present illness. He did have an episode of gross GIB in [4-/2147] which was not investigated. These may warrant malignancy workup focusing on the GI tract if this should be relevant to the patient's wishes and goals of care as an outpatient. . # Coronary artery disease: He is s/p NSTEMI with DES to RCA in 1/[2147]. He is off Plaxix. Trop was neg x1 and EKG unchanged from baseline. Suspicion for ACS was low. Once he was no longer NPO, he was restarted on his home aspirin, statin, lisinopril and metoprolol post procedure. . # BPH: His home doses of finasteride and tamsulosin restarted after procedure. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ________________________________________________________________ [Hospital ] hospital course after care transferred to the Acute Care Surgery Service on [2148-3-1]: He underwent ERCP on [2148-2-29] with sphincterotomy where large brown stones were extracted successfully. His post-ERCP labs were followed and on [2148-3-2] he was taken to the operating room for laparoscopic cholecystectomy without any complications. On POD#1 his diet was advanced for which he is tolerating without any issues. His pain is controlled on oral medication and he is ambulating independedntly. He will follow up in [Hospital 2536] clinic in [2-22] weeks and with GI in 6 weeks for ERCP and possible stent removal. During her hospitalization the patient was cared for by the rotating acute care surgical service. Medications on Admission: FINASTERIDE - 5 mg Tablet - one Tablet(s) by mouth one daily - No Substitution LISINOPRIL - 5 mg Tablet - one Tablet(s) by mouth one daily - No Substitution METOPROLOL TARTRATE - 25 mg Tablet - one Tablet(s) by mouth twice daily - No Substitution PAROXETINE HCL - 10 mg Tablet - one Tablet(s) by mouth daily - No Substitution SIMVASTATIN - 40 mg Tablet - two Tablet(s) by mouth daily - No Substitution TERAZOSIN - 5 mg Capsule - one Capsule(s) by mouth one daily - No Substitution IRON - 325 mg (65 mg Iron) Capsule, Sustained Release - one Capsule(s) by mouth one daily - No Substitution Discharge Medications: 1. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 6. paroxetine HCl 10 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every 4-6 hours as needed for pain. 9. oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO every 4-6 hours as needed for pain. Disp:20 Tablet(s) Refills:0 10. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 11. senna 8.6 mg Tablet Sig: 1-2 Tablets PO once a day as needed for constipation. 12. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) ML's PO twice a day as needed for constipation. Discharge Disposition: Home Discharge Diagnosis: Cholelithiasis Discharge Condition: Mental Status: Clear and coherent. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital with gallstones and underwent an operation to remove your gallbladder. You may be 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. Please call your doctor or return to the emergency room if you have 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. * 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. Activity: No heavy lifting of items [11-2] 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: Follow up in [Hospital 2536] clinic in [2-22] weeks, call [Telephone/Fax (1) 600] for an appointment. Follow up with [Name6 (MD) ] [Name8 (MD) 84650], MD, Gastroenterology in 6 weeks for ERCP and for evaluation of removal of biliary stent and re-evaluate biliary tree. Call [Telephone/Fax (1) 13246] for an appointment. The following appointment was made prior to your hospital stay; if you are unable to keep this appointment you [First Name8 (NamePattern2) ] [Doctor First Name ] to contact the provider to cancel/reschedule: Provider: [First Name8 (NamePattern2) 3296] [Last Name (NamePattern1) 3297],[First Name7 (NamePattern1) 3295] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] IM (NHB) Date/Time:[2148-3-6] 2:30 Completed by:[2148-3-4]	[ "600.00", "038.9", "V45.82", "412", "V10.51", "V49.86", "995.91", "300.4", "401.9", "414.01", "574.71", "576.1" ]	icd9cm	[ [ [] ] ]	[ "51.85", "51.88", "51.84", "51.87", "51.23" ]	icd9pcs	[ [ [] ] ]	10754, 10760	6363, 9134	285, 352	10819, 10819	4158, 6340	12599, 13414	3384, 3503		9773, 10731		10781, 10798		9160, 9750			10922, 12229									3518, 4139																									210, 247							12241, 12576		380, 2360										10834, 10898							2382, 3096	3112, 3368
51,482	136,600	45693	Discharge summary	report	Admission Date: [2183-8-8] Discharge Date: [2183-8-11] Date of Birth: [2129-1-14] Sex: F Service: MEDICINE Allergies: Lisinopril / Atazanavir / fresh fruit / Cephalosporins / raltegravir / maraviroc Attending:[First Name3 (LF) 594] Chief Complaint: Bacteremia Major Surgical or Invasive Procedure: Femoral line placement [2183-8-8] Biopsy of skin [2183-8-11] Bronchoscopy [2183-8-11] History of Present Illness: 54F with HIV (off ART now) c/b OI, CKD, DM, Hepatitis C, recurrent UTI, and h/o cocaine/opiate abuse with recent cocaine relapse, presents from [Hospital ] Rehab with recurrent CoNS bacteremia, C. Diff. infection, and acute mental status changes. Patient recently presented to [Hospital1 18] ED on [7-11] with severe desquamating rash and was transferred to [Hospital1 112] burn unit with a question of [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Syndrome. Rash was determined to desquamating lichenoid hypersensitivity rxn likely related to ARVs, cephalosporins, and/or drugs of abuse, which was treated by stopping ART and cephalosporins and applying topical clobetasol. She had marked improvement of her skin lesions and was HD stable, so was transferred to the floor on [7-16] with aggressive wound care. She was noted to have a pruritic macular rash on [7-29] in setting of re-starting her ARVs on her torso, arms, and back with no mucosal involvement or desquamation, so ARVs were immediately stopped. She was seen by allergy that thought she may be experiencing drug-induced lupus secondary to increased hydralazine dose, which was also held. Notably, she also developed a CoNS line infection at [Hospital1 112] with positive blood cx w/GPC in clusters and subsequent Tx with vanco. She was transferred to [Hospital ] rehab on [7-31] and placed on PO vanco. At [Hospital1 ], notable events included: * She developed a second CoNS line infection in the setting of fevers and chills on [8-3] with positive cxs for GPC in clusters. She was started on IV vancomycin (they did not pull the line at that time) * They were planning on ECHO for concern of endocarditis, but have not done yet. * ?cushings from clobetasol withdrawal after DRV/r/ABC/3TC was started, so ART was again stopped * Multiple electrolyte abnormalities (low mg, K, PO4), corrected at time of transfer. * She was transfused at [Hospital1 ] for HCT down to 23 and now 30. * Developed fever and diarrhea - started on PO vancomycin in the setting of positive C Diff stool cxs * She is still having diarrhea despite ongoing PO vancomycin. * Developed chest pain early this week, better with SLNTG, trop 0.04. See by cardiology (Dr. [Last Name (STitle) 4610] who reportedly rec'd ETT and she was given an appointment to follow-up with Dr. [First Name (STitle) 437]. * She has developed delirium and hallucinations and pulled her own line (I think she has had similar episodes in the past, but needs to be evaluated) * Has has had pain in her hips thought be musculoskeletal. She was ultimately transferred to [Hospital1 ] for therapy of bactermia, c. diff, and altered mental status. On arrival to the floor, the patient was unable to recount her history or communicate as she was moaning in pain. Past Medical History: PAST MEDICAL / SURGICAL HISTORY: - HIV, diagnosed in [2158], on HAART (CD4 742, VL<20 [4-3]). - Castleman's Disease - Hepatitis C - no response to PEG-IFN/Ribavirin - Shingles - Migraines - HTN - DM II - History of MRSA - Recurrent UTI - Recurrent nephrolithiasis - HSV - Pancytopenia [1-23] HAART medications - CKD baseline creatinine 2.85-3.0, followed by Dr. [Last Name (STitle) 118] (nephrolithiasis, pyelonephritis & perinephric abscess c/b perinephric hematoma during stenting [8-/2182]) Social History: Lives at home in [Location (un) 745]. Has 3 children: one son [Name (NI) 2855] is her HCP, one daughter with hydrocephalus/seizure disorder is in a nursing home ([Location (un) 511] Pediatric Care), 3rd child (female) died in childhood from complications of HIV. - Worked as a counselor (no longer working) - Former heavy smoker, currently 1 pack q2 weeks. - Former ETOH abuse, none since [2174] - Former IVDU, none since [2174] - Recent cocaine use ([2182]) Family History: - Father died of MI - Mother with diabetes - Sister with lung cancer at age 38 and was a heavy smoker. - Brother with diabetes Physical Exam: Admission: VS T 97.7 (axillary), BP 153/?, HR 96, RR , O2 sat 100%RA GEN- In acute distress (moaning in pain), unable to speak due to pain HEENT- Eyes shut closed with purulent discharge, unable to assess EOM/sclera, diffuse labial desquamation, unable to assess OP NECK supple, no JVD, no LAD PULM CTA anteriorly, unable to assess posteriorly (pt could not sit up) CV RRR normal S1/S2, no mrg ABD soft NT ND EXT WWP 2+ pulses palpable bilaterally, no c/c/e NEURO CNs2-12 intact, motor function grossly normal SKIN Diffuse, desquamating rash over entire body. Numerous areas of blistering, broken skin. Discharge: AF Tm 100.4 BP 126/51 (70) HR 76 pOx 97 on PRVC FiO2 60 PEEP 10 PPeak 25 390 cc x 28 (ARDSNet ventilation) Gen: Intubated, sedated HEENT - Eye closed with purulent discharge Neck: supple, no JVD, no LAD Pulm: CTA anteriorly Abd: soft, non-tender, non-distended Ext: WWP 2+ pulses bilaterally, no c/c/e, left femoral line Neuro: sedated Skin: Diffuse, desquamating rash over entire body. Numerous areas of blistering, broken skin. + Erythroderma Pertinent Results: I. Labs A. Admission [2183-8-8] 11:58PM BLOOD WBC-8.3# RBC-3.45* Hgb-10.4* Hct-33.2* MCV-96 MCH-30.2 MCHC-31.4 RDW-17.7* Plt Ct-100# [2183-8-8] 11:58PM BLOOD Neuts-65 Bands-4 Lymphs-14 Monos-8 Eos-8* Baso-0 Atyps-1* Metas-0 Myelos-0 [2183-8-8] 11:58PM BLOOD Plt Smr-LOW Plt Ct-100# [2183-8-10] 04:54AM BLOOD WBC-7.5 Lymph-18 Abs [Last Name (un) ]-1350 CD3%-81 Abs CD3-1093 CD4%-35 Abs CD4-469 CD8%-45 Abs CD8-613 CD4/CD8-0.8 [2183-8-8] 11:58PM BLOOD Glucose-45* UreaN-44* Creat-2.3# Na-141 K-5.3 Cl-112* HCO3-19* AnGap-15 [2183-8-9] 06:29AM BLOOD ALT-26 AST-35 LD(LDH)-272* AlkPhos-82 TotBili-0.4 [2183-8-8] 11:58PM BLOOD Albumin-2.5* Calcium-8.1* Phos-3.6 Mg-2.0 [2183-8-9] 06:29AM BLOOD CRP-46.4* [2183-8-9] 06:29AM BLOOD Vanco-24.8* [2183-8-9] 12:13AM BLOOD Type-[Last Name (un) ] Temp-37.1 pO2-51* pCO2-34* pH-7.32* calTCO2-18* Base XS--7 [2183-8-9] 12:13AM BLOOD Lactate-2.0 [2183-8-9] 12:13AM BLOOD freeCa-1.18 B. Discharge [2183-8-11] 04:12AM BLOOD WBC-9.1 RBC-3.19* Hgb-9.6* Hct-31.4* MCV-98 MCH-30.1 MCHC-30.6* RDW-17.6* Plt Ct-101* [2183-8-11] 04:12AM BLOOD Neuts-89* Bands-1 Lymphs-7* Monos-2 Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 [2183-8-11] 04:12AM BLOOD Plt Ct-101* [2183-8-11] 06:53PM BLOOD Glucose-82 UreaN-49* Creat-3.1* Na-134 K-5.0 Cl-111* HCO3-15* AnGap-13 [2183-8-11] 06:53PM BLOOD Calcium-6.9* Phos-4.4 Mg-2.0 [2183-8-11] 07:37PM BLOOD Type-ART Temp-36.7 Rates-18/4 Tidal V-450 PEEP-5 FiO2-100 pO2-76* pCO2-33* pH-7.22* calTCO2-14* Base XS--13 AADO2-603 REQ O2-99 -ASSIST/CON Intubat-NOT INTUBA [2183-8-11] 04:45PM BLOOD Type-ART pO2-107* pCO2-35 pH-7.21* calTCO2-15* Base XS--13 [2183-8-9] 12:13AM BLOOD Type-[Last Name (un) ] Temp-37.1 pO2-51* pCO2-34* pH-7.32* calTCO2-18* Base XS--7 [2183-8-11] 07:37PM BLOOD Lactate-2.4* K-4.9 II. Microbiology [2183-8-11] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2183-8-11] URINE URINE CULTURE-PENDING INPATIENT [2183-8-11] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2183-8-10] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2183-8-9] SWAB GRAM STAIN-FINAL; WOUND CULTURE-PRELIMINARY {STAPH AUREUS COAG +}; ANAEROBIC CULTURE-FINAL [Last Name (LF) ],[First Name3 (LF) ] [2183-8-9] SWAB GRAM STAIN-FINAL; WOUND CULTURE-PRELIMINARY; ANAEROBIC CULTURE-FINAL [Last Name (LF) ],[First Name3 (LF) ] [2183-8-9] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2183-8-9] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2183-8-9] EYE GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL {STAPH AUREUS COAG +, ESCHERICHIA COLI} INPATIENT [2183-8-9] EYE GRAM STAIN-FINAL; RESPIRATORY CULTURE-PRELIMINARY {STAPH AUREUS COAG +, ESCHERICHIA COLI, PROTEUS MIRABILIS}; FUNGAL CULTURE-PRELIMINARY INPATIENT [2183-8-9] BLOOD CULTURE Blood Culture, Routine-PRELIMINARY {PROTEUS MIRABILIS, GRAM POSITIVE COCCUS(COCCI)}; Anaerobic Bottle Gram Stain-FINAL INPATIENT [2183-8-8] BLOOD CULTURE Blood Culture, Routine-PRELIMINARY {PROTEUS MIRABILIS, ESCHERICHIA COLI, GRAM POSITIVE COCCUS(COCCI), GRAM NEGATIVE ROD #3}; Anaerobic Bottle Gram Stain-FINAL; Aerobic Bottle Gram Stain-FINAL [2183-8-8] 11:58 pm BLOOD CULTURE Blood Culture, Routine (Preliminary): PROTEUS MIRABILIS. FINAL SENSITIVITIES. Piperacillin/Tazobactam sensitivity testing performed by [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060]. INTERMEDIATE TO AZTREONAM sensitivity testing performed by [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060]. ESCHERICHIA COLI. FINAL SENSITIVITIES. Piperacillin/Tazobactam sensitivity testing performed by [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060]. RESISTANT TO AZTREONAM sensitivity testing performed by [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060]. GRAM POSITIVE COCCUS(COCCI). Reported to and read back by J. RESKE-[Doctor Last Name ] #[Numeric Identifier 97383] [2183-8-10] 0915. GRAM NEGATIVE ROD #3. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PROTEUS MIRABILIS \| ESCHERICHIA COLI \| \| AMPICILLIN------------ <=2 S =>32 R AMPICILLIN/SULBACTAM-- <=2 S 16 I CEFAZOLIN------------- =>64 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S =>64 R CEFTRIAXONE----------- <=1 S =>64 R CIPROFLOXACIN--------- =>4 R =>4 R GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S =>16 R Anaerobic Bottle Gram Stain (Final [2183-8-9]): GRAM NEGATIVE ROD(S). Reported to and read back by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] #[Numeric Identifier 21399] [2183-8-9] 1157. Aerobic Bottle Gram Stain (Final [2183-8-9]): GRAM NEGATIVE ROD(S). III. Radiology [2183-8-11] CXR post-intubation after tube re-position Endotracheal tube tip projecting approximately 4 cm above the carina. Decreased density layering along the minor fissure, which may be projectional. [2183-8-11] CXR post-intubation Interval intubation with endotracheal tube tip projecting approximately 4.5 cm above the carina. Esophageal catheter with weighted tip projecting over the left upper quadrant likely within the stomach. Mild cardiomegaly, as noted previously. Small amount of density layering along the minor fissure, increased compared to prior. [2183-8-11] CT Head IMPRESSION: 1. No evidence of acute intracranial process. 2. Increased soft tissue density overlying the left frontal bone. Correlation with physical exam is recommended. [2183-8-9] TTE The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. Left ventricular systolic function is hyperdynamic (EF>75%). The right ventricular cavity is mildly dilated with borderline normal free wall function. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. There is no valvular aortic stenosis. The increased transaortic velocity is likely related to increased stroke volume due to aortic regurgitation. Moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. Mild to moderate ([12-23]+) mitral regurgitation is seen. Due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (Coanda effect). The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: near-hyperdynamic left ventricular systolic function. At least mild-to-moderate mitral regurgitation, directed posteriorly. Moderate aortic regurgitation. Moderate tricuspid regurgitation. Severe pulmonary hypertension. Compared with the prior study (images reviewed) of [2183-5-13], the degrees of mitral regurgitation, tricuspid regurgitation and pulmonary hypertension have increased. Brief Hospital Course: 54F with HIV (CD4 469 on [8-3], VL undetectable on [6-3], was on HAART since [2172] but discontinued due to recent hospitalization in [Hospital1 112] burn unit secondary to large desquamating lichenoid hypersensitivity reaction which could have been reaction to ? ART, cephalosporins, or cocaine) complicated by OI, CKD, DM, Hepatitis C, recurrent UTI, polysubstance abuse with recent cocaine relapse and history of cocaine/opiate abuse transferred from [Hospital ] rehab for recurrent CoNS bacteremia, C. Difficile infection, and acute encephalopathy. Her hospital course was complicated by acute toxic-metabolic encephalopathy with impaired airway protection resulting in endotracheal intubation for airway protection with suspected ARDS, GNR bacteremia likely from skin breakdown, acute oliguric renal failure, and erythroderma necessitating transfer to [Hospital6 13185] Burn Unit for further care. # Coagulase negative Staph, Proteus Mirabilis, and Escherichia Coli bacteremia Patient was noted to have two episode of Coagulase negative Staph bacteremias while at [Hospital ] rehab in setting of mid-line and central line placements given underlying skin conditions. She was hemodynamically stable throughout hospitalization. Blood cultures were obtained on admission showing also Proteus Mirabilis and Escherichia Coli bacteremia as well. Sensitivities were obtained from blood cultures as below: PROTEUS MIRABILIS \| ESCHERICHIA COLI \| \| AMPICILLIN------------ <=2 S =>32 R AMPICILLIN/SULBACTAM-- <=2 S 16 I CEFAZOLIN------------- =>64 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S =>64 R CEFTRIAXONE----------- <=1 S =>64 R CIPROFLOXACIN--------- =>4 R =>4 R GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S =>16 R ID consultation was obtained. The patient was initially on IV vancomycin, and IV aztrenonam ([2183-8-9] - [2183-8-11]) but switched to meropenem due to clinically worsening and above data. Cephalosporins were avoided given concern for lichenoid reaction. An ECHO did not suggest endocarditis. Surveillance cultures on [8-10] and [8-11] are no growth to date suggestive of clearance. For drug monitoring, her last vancomycin trough (24.8) was on [2183-8-9]. Per pharmacy, her vancomycin trough on [2183-8-12] before her next dose scheduled for 8 AM on [2183-8-12]. Transitional issues including follow-up of [Hospital1 18] culture data, ID consultation at [Hospital1 112], and continuing aforementioned antibiotics. # Desquamating lichenoid hypersensitivity reaction Patient recently presented to [Hospital1 18] ED on [7-11] with severe desquamating rash and transferred to [Hospital1 112] burn unit. Rash was determined to desquamating lichenoid hypersensitivity reaction which was treated by stopping ART, avoidance of cephalosporins and drugs of abuse such as cocaine. Dermatology was consulted on admission and recommended wrapping patient in saran wrap and using Vaseline for skin care. No mucosal involvement was noted on admission. She was given copious IVF, and [Initials (NamePattern4) ] [Last Name (NamePattern4) ] Hugger was utilized given insensible losses and impaired thermoregulation. Dermatology re-evaluation on [2183-8-11] revealed worsening mucosal involvement and new erythroderma. This raised concern for progression of her severe drug hypersensitivity eruption. This was felt to be secondary to ART, specifically abacavir and lamuvidine, and potentially ceftriaxone to her recent admission to [Hospital1 112]. She is not currently on any related medications. Of note, her last attempted ART was on [7-29] resulting in maculo-papular rash. Another consideration was Paraneoplastic pemphigus given extensive oral involvement and reported history of Castleman's disease. The patient's labs are concerning that she is not keeping up with insensible losses, among her other current physiologic needs, likely due to the loss of her barrier protection in her skin. It was recommended by dermatology that she be transferred to the burn unit given areas of skin breakdown, immunocompromised state, and need for aggressive nursing care and management of insensible losses although she does not have 10% BSA of full thickness epidermal necrosis Transitional issues include medication list review with discontinuation of unnecessary medications. Her only new medications are IV vancomycin and meropenem. She should also have daily CBC with differential (eosinophils [2183-8-8] 8% --> [2183-8-10] 16% --> [2183-8-11] 1%) in addition to daily LFTs. Biopsy was performed on [2183-8-11] at [Hospital1 18] by dermatology and should be followed up. It was advised that all areas of exposed skin be covered with mupirocin and xeroform. # C. difficile infection: Patient had positive C. Difficile stool toxin on [8-4] at rehab. She was switched from PO vancomycin to IV flagyl given lack of NGT initially but then swithced back to PO vancomycin 125 mg PO q 6 hr. ID should determine her final C. difficile course given aforementioned treatment of bacteremia with broad spectrum anti-microbials. # Acute metabolic encephalopathy: Patient was noted to be delirious recently at rehab in setting of hypoglycemia to 45 with self-discontinuation of her central access line. On admission, she was AAOx2 with fluctuating mental status. Her mental status continued to worsen - likely a combination of toxic-metabolic and septic encephalopathy given worsening laboratory abnormalities and infection. She was placed in wrist restraints. Head CT on [2183-8-11] did not show acute intracranial process. An LP was considered; however, given the areas of skin breakdown, it was favored that the risk would exceed the benefit at current time although could be considered if mental status does not improve. The patient was intubated in the afternoon on [2183-8-11] for failure to protect her airway from copious secretions. Her discharge ventilator settings are in physical exam section and last ABG in laboratory section. She was started on ARDSNet ventilation given appearance of CXR. A bronchoscopy was also performed showing no significant respiratory mucosal sloughing or debridement, mo mucosal lesions. The airways are patent with minimal blood-tinged, easily suctionable secretions in the right mainstem and the right upper lobe. There was no endobronchial masses # Adrenal insufficiency- Patient had iatrogenic Cushings disesae due to mucosal clobetasol when re-started on DRV/r/ABC/3TC and then experienced adrenal insufficiency secondary to withdrawal from clobetasol. She was initially given IV solumedrol given lack of enteral access. She was switched to PO prednisone 10 mg NG [Hospital1 ] for "stress dose" steroids given hypoglycemia on presentation and K/HCO3 abnormalities that could be suggestive of adrenal issues. She should have her steroids tapered after acute illness. # Acute on chronic kidney disease with Oliguric renal failure Her admission Cr was at baseline (~ 2) with rise to ~ 3. Her baseline is typically [1-24]. The patient was given copious IVF including up to 350 cc/hr for insensible losses. She developed oliguric renal failure in the afternoon on [2183-8-11]. She may require renal replacement therapy if she continues to be oliguric. # Hypoglycemia- Likely multifactorial in setting of poor PO intake and known history of acquired adrenal insufficiency. Her blood glucose improved with stress dose steroids and normalized with enteral feedings. # Eye infection- Patient has bilateral crusting of eyes with some discharge. Ophtamology evaluated the patient and was concerned about infection. She was started on multiple eye drops (see medication). Culture results were as below: GRAM STAIN (Final [2183-8-9]): Reported to and read back by I. DEMENEZES, R.N. ON [2183-8-9] AT 1010. NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Preliminary): STAPH AUREUS COAG +. HEAVY GROWTH. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. This isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . ESCHERICHIA COLI. MODERATE GROWTH. Piperacillin/tazobactam sensitivity testing available on request. PROTEUS MIRABILIS. SPARSE GROWTH. PRESUMPTIVE IDENTIFICATION. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| ESCHERICHIA COLI \| \| AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- =>64 R CEFTAZIDIME----------- =>64 R CEFTRIAXONE----------- =>64 R CIPROFLOXACIN--------- =>4 R CLINDAMYCIN----------- R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S <=1 S LEVOFLOXACIN---------- =>8 R MEROPENEM------------- <=0.25 S OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S =>16 R VANCOMYCIN------------ 1 S FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. She should have continued eye consultation at [Hospital1 112]. # HIV complicated by OI Her outpatient provider is [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] at [Hospital1 18]. Her ART continues to be on hold given aforementioned hypersensitivity reaction. Her famciclovir was changed to acyclovir for therapeutic exchange. # Diastolic heart failure/Hypertension Patient has history of diastolic heart failure and pulmonary hypertension. A TTE was performed (see results section). Her anti-ischemic/CHF regimen was held including isosrbide mononitrate, metoprolol, and hydralazine. There was also a question of drug-induced lupus with hydralazine at rehab, which should not be continued in the future. # Depression/anxiety Her bupropion andclonazepam were held. #ACCESS: Left femoral line ([2183-8-8]), will need to re-site to internal jugular site or obtain PICC/peripherals once less agitated/stabilized #Precautions: C. Diff/MRSA #CODE: Full code # Communication: The patient has two HCP A) [First Name4 (NamePattern1) 11894] [Last Name (NamePattern1) ] Relationship: mentor and friend Phone number: [Telephone/Fax (1) 97384] B) [First Name8 (NamePattern2) 2855] [Last Name (NamePattern1) 3175] Relationship: Son Phone number: [Telephone/Fax (1) 97385] # Pending studies - multiple blood cultures are pending - Pathology specimen was obtained on [2183-8-11], pathology pending # Transitional issues - as above - sutures in the right thigh from biopsy on [2183-8-11] can be removed in [10-5] days Medications on Admission: Home medications: unknown Discharge medication from rehab: - Arixtra 2.5 mg SC qD - vancomycin 1 gm IV qD - lidocaine patch topically left and right hip - vancomycin 250 mg PO q 6 hr - iron sucrose 100 mg IV daily, total of 1 gram - sodium chloride 2 gm PO q 8 hr - furosemide 40 mg PO qD - protonix 40 mg PO qD - magnesium oxide 400 mg PO BID - nitroglycerin prn - ambien prn - loratadine 10 mg PO qD - zinc sulfate 220 mg PO qD - famciclovir 500 mg PO qD - prednisone 5 mg PO qD - multivitamin PO qD - ergocalciferol 50,000 units PO BID - folic acid 1 mg PO QD - petroleum topically daily - isosorbide mononitrate 30 mg PO qD - mupirocin topically daily - metoprolol tartrate 12.5 mg PO BID - hydralazine 100 mg PO TID - ascorbic acid 500 mg PO BID - diphenhydramine/lidocaine/antacid 10 mL TID - bupropion 150 mg PO BID - clobetasol one topically [Hospital1 ] - trazodone 100 mg PO qHS - hydroxyzine 25 mg PO qHS - ophthalmic lubricant ophthalmically qHS - oxycodone prn - diphenhydramine prn - clonazepam prn - albuterol sulfate prn - acetaminophen prn Discharge Medications: 1. Acyclovir 400 mg PO Q12H 2. Aquaphor Ointment 1 Appl TP TID 3. Artificial Tears 1-2 DROP BOTH EYES Q2H dry eyes 4. Artificial Tears Preserv. Free 1-2 DROP BOTH EYES Q2H 5. DiphenhydrAMINE 25 mg IV Q6HR hold if too sedated 6. Famotidine 20 mg PO Q24H 7. Fentanyl Citrate 25-100 mcg/hr IV DRIP INFUSION Allow [Hospital1 1868]: Yes [Hospital1 ]: 50 mcg MR X2 Q1H PRN 8. Fexofenadine 120 mg PO BID 9. HYDROmorphone (Dilaudid) 0.5-2 mg IV Q2H:PRN Pain 10. Meropenem 500 mg IV Q12H d1 = [2183-8-11] chagned from aztreonam 11. Metoprolol Tartrate 12.5 mg PO BID hold for sbp<100 or hr<60 12. Midazolam 0.5-2 mg/hr IV DRIP TITRATE TO RASS -3 Moderate Sedation Movement/eye opening to voice (no eye contact) Allow [Month/Day/Year 1868]: Yes [Name (NI) ]: 1 mg MR X2 Q1H PRN Patient must have adequate airway support prior to administration of dose. 13. moxifloxacin NF 0.5 % OU QID Reason for Ordering: per eye consult wait 5 minutes between drops 14. moxifloxacin NF 0.5 % OU QID Reason for Ordering: per eye consult wait 5 minutes between drops 15. Polyethylene Glycol 17 g PO DAILY:PRN constipation 16. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES QID 17. PredniSONE 10 mg PO BID stress dose (not home dose) 18. Senna 1 TAB PO BID:PRN cosntipation 19. Vancomycin 1000 mg IV Q48H start: [2183-8-10] in PM 20. Vancomycin Oral Liquid 125 mg PO Q6H d1 = [2183-8-11] 21. Zinc Sulfate 220 mg PO DAILY Discharge Disposition: Extended Care Facility: [Hospital6 13753] - [Location (un) 86] Discharge Diagnosis: Desquamating Hypersensitivity skin reaction Respiratory failure Renal failure Gram negative rod bacteremia Coag negative staph bacteremia HIV Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic and not arousable. Activity Status: Bedbound. Discharge Instructions: Dear Ms. [Known lastname 97330], You were admitted to the [Hospital1 18] after you were found to have a blood stream infection when you were at rehab. While you were here you were seen by the dermatologist and infectious disease specialists and eye specailists. You were treated with IV antibiotics for your blood stream infection and had management of your skin problems. [Name (NI) ] became more confused and unable to protect your airway so you were intubated (breathing tube) on [8-11] and were found to have evidence of inflammation in your lungs. Your kidneys stopped making as much urine and it was felt that you would benefit from specialized care in a burn unit so are being transferred to [Hospital6 1708] burn unit. Trnasitional Issues: -management of respiratory function- patient is intubated and being ventilated based on a ARDS protocol given CXR findings -Biopsys were performed on [8-11] -results pending at [Hospital1 18] pathology lab -sutures will need to be removed -renal function needs to be monitored closely as decreased urine output despite attempts at aggressive fluid hydration -management of skin reaction- Biopsy was taken on [8-11] and is pending at [Hospital1 18] pathology at the time of transfer -Repeat TTE was transferred Followup Instructions: Department: [Hospital3 249] When: WEDNESDAY [2183-8-27] at 9:40 AM With: [Name6 (MD) ] [Name8 (MD) ], MD [Telephone/Fax (1) 2010] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: WEST [Hospital 2002] CLINIC When: THURSDAY [2183-10-16] at 11:00 AM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [Name8 (MD) ], MD [Telephone/Fax (1) 721] Building: De [Hospital1 ] Building ([Hospital Ward Name 121] Complex) [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage	[ "785.6", "255.0", "695.89", "780.52", "251.2", "584.9", "428.32", "300.00", "E931.7", "041.6", "428.0", "790.7", "070.54", "041.19", "305.60", "042", "348.31", "518.81", "280.9", "255.41", "287.5", "041.49", "585.9", "276.2", "311", "360.00", "403.90", "276.7", "698.2" ]	icd9cm	[ [ [] ] ]	[ "38.93", "96.04", "96.71", "33.23" ]	icd9pcs	[ [ [] ] ]	27413, 27486	13208, 21599	350, 449	27672, 27672	5611, 8888	29133, 29806	4384, 4512		25955, 27390		27507, 27651		24869, 24869			27812, 29110									4527, 5592					24887, 25932		8932, 13185		23204, 24843			21640, 23171													300, 312									477, 3327										27687, 27788							3349, 3865	3881, 4368
64,435	148,113	40280	Discharge summary	report	Admission Date: [2169-11-5] Discharge Date: [2169-11-10] Date of Birth: [2110-10-17] Sex: F Service: CARDIOTHORACIC Allergies: Latex / Lanolin Attending:[First Name3 (LF) 1505] Chief Complaint: Coronary Artery Disease Major Surgical or Invasive Procedure: [2169-11-6] Urgent coronary artery bypass grafting x3: Left internal mammary artery graft to left anterior descending, reverse saphenous vein graft to the marginal branch and right coronary artery. History of Present Illness: 59 year old female presented to outside hospital with Chest pain and ST segment elevation [11-4] started with pain on/off mid chest to epigastric area. She used tums and milk with some relief but then persisted and presented to OSH with ST elevations. Due to chest pain she was transferred to [Hospital1 ] for cardiac catheterization, which revealed significant three vessel coronary artery disease. She is now transferred for surgical evaluation Cardiac Catheterization: Date: [2169-11-5] Place: LGH report from progress note LM ok LCx large 90% serial lesion L>L collateral LAD TO mid RCA TO prox with bridging collateral EF 50% TR band right wrist Past Medical History: Hypertension Dyslipidemia Hypothyroidism Eczema Past Surgical History none Social History: Race: Caucasian Last Dental Exam: over a year ago Lives with: spouse Occupation: pre school teacher Tobacco: 45 pyh - currently smoking 1 pack a day ETOH: occassional Family History: Non contributory Physical Exam: Pulse: 72 Resp: 20 O2 sat: B/P Left: 114/59 unable to do right due to TR band Height: 63 inches Weight: 150 pounds General: no acute distress Skin: Dry [x] Eczema rash on buttock posterior legs HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur none Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] no palpable masses Extremities: Warm [x], well-perfused [x] Edema none Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: +2 Left: +2 DP Right: +2 Left: +2 PT [Name (NI) 167]: +2 Left: +2 Radial Right: +1 Left: +2 Carotid Bruit Right: no bruit Left: + bruit Pertinent Results: [2169-11-9] 04:45AM BLOOD WBC-7.6 RBC-3.05* Hgb-9.3* Hct-27.2* MCV-89 MCH-30.3 MCHC-34.0 RDW-13.6 Plt Ct-189 [2169-11-9] 04:45AM BLOOD Glucose-104* UreaN-13 Creat-0.7 Na-138 K-4.1 Cl-100 HCO3-31 AnGap-11 Echo [2169-11-6] Prebypass No atrial septal defect is seen by 2D or color Doppler. There is mild regional left ventricular systolic dysfunction with hypokinesia of the apical and mid portions of the inferior and inferoseptal walls. . Overall left ventricular systolic function is mildly depressed (LVEF= 45%). Right ventricular chamber size and free wall motion are normal. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. There was a period of myocardial ischemia post induction which was associated with worsening of the existing wall motion abnormalities. Resolved with nitroglycerine and metoprolol. Brief Hospital Course: The patient was admitted to the hospital and brought to the operating room on [2169-11-6] where the patient underwent an urgent coronary artery bypass grafting x3: Left internal mammary artery graft to left anterior descending, reverse saphenous vein graft to the marginal branch and right coronary artery. See operative note for full details. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable on no inotropic or vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. All narcotics were discontinued due to confusion. The patient was treated with Ibuprofen and Tylenol only for pain with no further delirium. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD #4 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged home with visiting nurse services in good condition with appropriate follow up instructions. Medications on Admission: Medications at home: Beta [Male First Name (un) ] cream [Hospital1 ] Amlodipine 5 mg daily Levothyroxine 100 mcg daily Crestor 20 mg daily Metoprolol 100 mg daily Vitamin D 1000 units [Hospital1 ] Calcium 600 mg 1-2 times a day Medications OSH: Coreg 3.125 mg [Hospital1 ] NTP 1" q8H ASA 325 mg daily Lisinorpil 2.5 mg daily Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:60 Capsule(s) Refills:0 2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 weeks. Disp:28 Tablet(s) Refills:0 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:1 4. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:1 5. cholecalciferol (vitamin D3) 400 unit Tablet Sig: 2.5 Tablets PO BID (2 times a day). Disp:150 Tablet(s) Refills:0 6. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 7. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 8. betamethasone valerate 0.1 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). Disp:1 tube Refills:1 9. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:1 10. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for itchiness. Disp:1 bottle Refills:0 11. potassium chloride 10 mEq Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day for 5 days. Disp:5 Capsule, Sustained Release(s) Refills:0 12. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. Disp:5 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: All Care VNA of Greater [Location (un) ] Discharge Diagnosis: Coronary Artery Disease s/p cabg Hypertension Dyslipidemia Hypothyroidism Eczema 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 Leg Right/Left - healing well, no erythema or drainage. Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon: Dr [Last Name (STitle) ] [11-30] @ 1:45pm Cardiologist: Dr [Last Name (STitle) 4922] on [12-8] at 1:00pm Please call to schedule appointments with your Primary Care Dr. [Last Name (STitle) 2903] in [3-27] weeks [Telephone/Fax (1) 65542] 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:[2169-11-10]	[ "401.9", "305.1", "292.81", "244.9", "433.30", "411.1", "692.9", "433.10", "272.4", "414.01", "458.29", "782.1", "E935.2" ]	icd9cm	[ [ [] ] ]	[ "36.15", "36.12", "39.61" ]	icd9pcs	[ [ [] ] ]	6758, 6833	3377, 4815	308, 513	6958, 7186	2306, 3354	8110, 8631	1513, 1531		5208, 6735		6854, 6937		4841, 4841			7210, 8087					4862, 5185				1546, 2287																									245, 270									541, 1213																	1235, 1312	1328, 1497
40,177	198,480	27108	Discharge summary	report	Admission Date: [2169-5-6] Discharge Date: [2169-5-12] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Last Name (NamePattern4) 290] Chief Complaint: cholangitis Major Surgical or Invasive Procedure: ERCP Percutaneous cholecystotomy Central line placement History of Present Illness: 86M cad s/p cabg, presents with cholangitis. He symptoms started several on [5-5] when he developed diffuse abd discomfort and fevers. His son drove him to [Name (NI) ] where he was found to have fever 103.1 and elevated transaminases with t bili 3.2. He was started on unasyn for cholangitis and transferred to [Hospital1 ] for ERCP. Of note, at [Hospital1 ], he was found to have positive troponin tni 3.3 and trop was normal at [Location (un) ]. ECG showed ST depressions. Cardiology consultant assessed this as demand related and recommended conservative measures. Hct was noted to be 24 from 27.6 at [Hospital1 ] and he was transfused 1 unit pRBCs. Stool guaiac neg. ERCP was attempted on [5-6] although cannulation was unsuccessful. He was transferred to [Hospital1 18] for further management. At [Hospital1 18], ERCP was attempted on [5-7] although cannulation was again unsuccessful. On [5-7], he had percutaneous biliary drain placed by IR. Zosyn was continued. Past Medical History: 1. Coronary artery disease s/p CABG [2149] 2. Hypertension 3. Hyperlipidemia 4. History of cerebrovascular accident with residual right sided weakness [2165] 5. Left carotid endarterectomy approximately [2155] 6. Glaucoma Social History: Lives with his wife in [Hospital3 ]. Walks with walker. Does not drive. Retired, but owned his own plastics company. Quit cigars in [2149]. Stopped alcohol use 15 years ago. Family History: brother had a stroke in his 70s. No other coronary artery disease, diabetes, or cancer in the family. Physical Exam: VS: Temp: 97.6 BP: 140/44 HR: 55 RR: 20 O2sat: 96 3L . Gen: elderly male, gaunt, in NAD HEENT: PERRL, EOMI. +icterus, MM slightly dry Neck: Supple, no LAD, no JVP elevation. Lungs: CTA bilaterally, no wheezes, rales, rhonchi. Normal respiratory effort. CV: RRR, early systolic murmur LUSB Abdomen: soft, mild TTP RUQ, percutaneous drain in place with brownish fluid in bag Extremities: warm, muscle wasting. no cyanosis, clubbing, edema. Neurological: alert and oriented X 3, R arm weakness, moving other extremities Skin: No rashes or ulcers. Psychiatric: Appropriate. Pertinent Results: labs- [2169-5-6] 11:45PM BLOOD WBC-5.5 RBC-3.03* Hgb-10.1* Hct-29.6* MCV-98 MCH-33.3* MCHC-34.1 RDW-14.5 Plt Ct-113* [2169-5-10] 07:15AM BLOOD WBC-6.9 RBC-3.40* Hgb-11.0* Hct-31.4* MCV-93 MCH-32.5* MCHC-35.1* RDW-14.9 Plt Ct-126* [2169-5-12] 02:57AM BLOOD WBC-15.9# RBC-2.57 Hgb-8.9# Hct-24.0 MCV-93 MCH-34.6* MCHC-37.1* RDW-15.2 Plt Ct-166 [2169-5-7] 12:52PM BLOOD Neuts-82.2* Lymphs-6.9* Monos-8.4 Eos-2.3 Baso-0.2 [2169-5-12] 02:57AM BLOOD Neuts-71* Bands-2 Lymphs-10* Monos-14* Eos-0 Baso-0 Atyps-1* Metas-2* Myelos-0 [2169-5-6] 11:45PM BLOOD PT-16.3* PTT-28.9 INR(PT)-1.5* [2169-5-12] 02:57AM BLOOD PT-22.5* PTT-98.9* INR(PT)-2.2* [2169-5-6] 11:45PM BLOOD Ret Man-1.8* [2169-5-11] 03:44PM BLOOD Ret Aut-1.4 [2169-5-6] 11:45PM BLOOD Glucose-115* UreaN-16 Creat-1.1 Na-139 K-4.0 Cl-110* HCO3-19* AnGap-14 [2169-5-12] 02:57AM BLOOD Glucose-112* UreaN-24* Creat-2.4* Na-134 K-5.8* Cl-107 HCO3-8* AnGap-25* [2169-5-6] 11:45PM BLOOD ALT-152* AST-114* CK(CPK)-764* AlkPhos-156* TotBili-4.6* DirBili-3.8* IndBili-0.8 [2169-5-12] 02:57AM BLOOD ALT-2396* AST-3728* LD(LDH)-6630* CK(CPK)-444* AlkPhos-103 TotBili-5.0* [2169-5-7] 12:52PM BLOOD Lipase-16 [2169-5-9] 07:10AM BLOOD Lipase-444* [2169-5-11] 11:00AM BLOOD Lipase-237* [2169-5-6] 11:45PM BLOOD CK-MB-6 cTropnT-0.22* [2169-5-7] 12:52PM BLOOD CK-MB-7 cTropnT-0.16* [2169-5-12] 02:57AM BLOOD CK-MB-11* MB Indx-2.5 cTropnT-0.25* [2169-5-6] 11:45PM BLOOD Albumin-3.3* Calcium-7.9* Phos-2.1* Mg-1.8 [2169-5-12] 02:57AM BLOOD Calcium-7.7* Phos-6.2# Mg-2.4 [2169-5-7] 12:52PM BLOOD Hapto-235 [2169-5-11] 03:44PM BLOOD Hapto-314* [2169-5-7] 12:52PM BLOOD HBsAb-BORDERLINE HBcAb-NEGATIVE HAV Ab-NEGATIVE [2169-5-7] 12:52PM BLOOD HCV Ab-NEGATIVE [2169-5-11] 09:06PM BLOOD Type-ART Rates-/30 FiO2-99 pO2-81* pCO2-16* pH-7.48* calTCO2-12* Base XS--7 AADO2-627 REQ O2-99 Intubat-NOT INTUBA [2169-5-12] 08:38AM BLOOD Type-ART Temp-36.2 Rates-14/21 Tidal V-500 PEEP-5 FiO2-100 pO2-404* pCO2-14* pH-7.31* calTCO2-7* Base XS--16 AADO2-314 REQ O2-57 Intubat-INTUBATED [2169-5-12] 08:38AM BLOOD Glucose-134* Lactate-9.7* Na-130* K-6.3* Cl-111 Reports- Echo The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. There is no ventricular septal defect. There is abnormal septal motion/position. 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 to moderate ([12-9]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) 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. Compared with the prior study (images reviewed) of [2166-3-17], the degree of AR and TR seen have increased CT abd/pelvis IMPRESSION: 1. Moderate to large hemoperitoneum. 2. Bilateral pleural effusion with dependent atelectasis. 3. PTC in place. Multiple gallstones. 4. Stone in common bile duct. CXR Lung volumes remain quite low and bibasilar atelectasis is severe. Small bilateral pleural effusions are stable. Upper lungs are clear, following resolution of mild edema seen on [12-9]. Heart size normal. No pneumothorax. Brief Hospital Course: 86M cad s/p CABG, who was admitted with cholangitis for ERCP from OSH where ERCP had not been successful. . # Hypotension - pt seen on morning rounds and vitals stable, no complaints. Informed of BP drop to 80s in the afternoon. pt re-evaluated throughout the day, mentating, alert and oriented X3, denying chest pain, abd pain, sob, any new sx. HR in 60's, still afebrile w nl sats on RA throughout the day. Labs reviewed and Lipase/bili downtrending. WBC was normal, hct was slightly lower, PTT elevated, Cardiac enzymes were stable. EKG without change. HR on tele 60's without event. Pt's normal bp meds of labetalol and imdur were discontinued after the AM dose. Cr mildly up to 1.2. Concern for possible over diuresis yesterday since the night before he had triggered for hypoxia [1-9] fluid overload and was given Lasix 10mg IV X 2 (during which time oxygen was weaned off from 4l to RA). CXR day before showed increased bibasilar effusion w possible LLL infiltrate but sputum had no growth. He had no fever and on was [Last Name (LF) ], [First Name3 (LF) ] was unlikely to be pna; more likely to be fluid since responded to Lasix. Given mild decrease in HCT, and persistent asymptomatic hypotension, labs repeated. HCT further dropped to 25. Discussed this w IR given recent Percutaneous biliary drain (4 days prior) and intermittent blood noted in drain tube. He had a non-contrast CT that was concerning for fluid noted around liver and intraperitonealy in pelvis concerning for bleeding. Paged Dr. [First Name8 (NamePattern2) 13414] [Name (STitle) ] in IR to inform, he reviewed CT scan. BP after 1.5 liter >100. Pt still mentating, not complaining of anything. Slightly hypothermic however at 94.4 and a tachypneic. Abx broadened to vanc and Flagyl. Continued w IV boluses to maintain pressures. Transferd to [Hospital Unit Name 153], given persistent hypotension w probable bleed and possible sepsis. . # Hypoxia - developed it on night of [5-9], AM of [5-10]. Most likely from fluid overload as was getting IVFs when NPO and has MR/AR which will predispose him to CHF. Pt improved given 10mg IV lasix X2 and was weaned off oxygen on [5-10]. Sats 93% on RA. At that time had a normal wbc, and was already on Zosyn. Since responded well to lasix, concern for MRSA pna low and vanc not added. Day before expiration abx broadened, see above. . # Cholangitis: Had two ERCP attempts that were unsuccessful. Pt underwent successful PTC placement by IR. Multiple gallstone and a CBD stone noted. Bile drainage continued during the rest of his course. Was continued on Zosyn for Cholangitis and then broadened to vanco and Flagyl on during last 24 hours. Bile cx showed a , fu bile cx showed pan sensitive e. coli. General surgery was consulted and followed pt. Had planned for future stone retrieval by IR. If successful, plan was to have lap chole. . #.Post-ERCP pancreatitis - Pt was kept NPO for 2 days as lipase was uptrending but started on clears and tolerated it well. Denied n/v/abd pain. . # NSTEMI: Had demand ischemia due to cholangitis and likely sepsis .Cardiac enzymes were initially negative at [Location (un) ] though turned positive at [Hospital1 ] in setting of lateral ST depressions on ECG. ECG changes are then resolved and then reoccurred during sepsis in last 24 hours. There was cardiology consult at [Hospital1 18] which assessed the event as demand related. Was given Lipitor, labetalol, and ASA. TTE showed nl EF, due to limited study a focal wall motion abnormality could not be excluded. . # Anemia Pt was transfused 1 u pRBCs at [Hospital1 ] for hct drop from 27.6 to 24. He was transfused another 1 unit pRBCs at [Hospital1 18] [Hospital Unit Name 153] for hct of 27.7 and bumped to 31.7. Pt's HCT then remained stable at ~30 on floor the last few days but before transfer fell to 20.8. Stool was brown w trace guaiac positivity. CT non-contrast of abd this eve showing fluid around liver and in pelvis concerning for bleed. IR informed. Type and Screen active. Was transfused 2 units with repeat HCT of 24. Pt was not stable for angiogram with embolism due to sepsis and did not appear to have current acute bleeding to be intervene on once in [Hospital Unit Name 153]. . [Hospital Unit Name 153] events: Initially concern that pt had been earlier hypotensive secondary to acute bleeding process in abd. Was given transfusion and IVF and did hct responded appropriately. However over the course of the night pt had a more septic shock appearance. He was hypothermic. He initially was alert and responsive, but his mental status steadily declined around 5AM, and he was more delirious with waxing and [Doctor Last Name 688]. He developed a respiratory alkalosis combined with a gap and non-gap metabolic acidosis. His lactate climbed from 2.1 to 9.7. Later had more of a acidosis overall. His LFTs rose to the [2159] likely from shock liver. And he had a WBC from 5 to 15 overnight. He was given aggressive IVF and despite this his labs showed rapidly progressive acute renal failure with ATN appearing urine lytes with little urine output. Also developed a coagulopathy. During morning rounds the patient went into PEA arrest. CPR was performed for a PEA arrest. Central line was placed and pressors were started, but unsuccessful. Pt also was intubated. Pt expired, and case was revived by medical examiner due to recent drain placement and ERCP procedures. Family declined autopsy. Medications on Admission: Medications on transfer: Unasyn 3 gm IV Q6H Nitrodur patch 0.4 mg TP DAILY Isosorbide mononitrate 30 mg PO DAILY Labetalol 200 mg PO BID Protonix 40 mg PO or IV Zocor 40 mg PO DAILY Timolol opthalmic solution 1 drop OU [Hospital1 ] Travoprost 0.004% opthalmic solution OU DAILY . Home medications: Labetalol 200 mg [Hospital1 ] Imdur 30 mg qd Lisinopril 30 mg daily Omeprazole Nitropatch 0.4 mg per day Hydrochlorothiazide 25 mg daily Cosopt OU [Hospital1 ] travaprose OU daily simvastatin 20' Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: none Discharge Condition: expired Discharge Instructions: none Followup Instructions: none [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292] Completed by:[2169-5-24]	[ "995.92", "518.0", "276.2", "414.00", "401.9", "276.7", "577.0", "285.1", "574.71", "511.9", "038.9", "272.4", "365.9", "276.51", "V45.81", "410.71", "576.1", "570", "584.9" ]	icd9cm	[ [ [] ] ]	[ "96.04", "51.98", "51.10", "96.71" ]	icd9pcs	[ [ [] ] ]	12292, 12301	6208, 11707	280, 337	12349, 12358	2567, 6185	12411, 12582	1854, 1957		12263, 12269		12322, 12328		11733, 11733			12382, 12388									1972, 2548					12035, 12240																				229, 242									365, 1382																11758, 12017	1404, 1639	1655, 1838
57,081	139,979	52334	Discharge summary	report	Admission Date: [2171-4-22] Discharge Date: [2171-4-24] Service: MEDICINE Allergies: Lipitor / Amoxicillin / Erythromycin Base / Sulfa (Sulfonamides) / Procainamide / Zocor Attending:[Last Name (NamePattern4) 290] Chief Complaint: Confusion / Hypoxia Major Surgical or Invasive Procedure: None History of Present Illness: The patient is an 87 yo male with history of CAD,A fib, dCHF (EF 55%), pHTN, PAD who presented to the ED from his nursing home with altered mental status and hypoxia. The patient was admitted to the ICU for hypotension and hypoxia in [12-26] in the setting of an aspiration pneumonia. For the last 7d, the patient by report had tremors. Additionally, he was having an element of increasing confusion, with visual hallucination and disorientation. He had been treated with levofloxacin for the last 4 days for a pneumonia seen on CXR and his lasix was increased from 40mg to 60mg daily. It is unclear the exact order of what component of these symptoms began after starting the levofloxacin. The patinet has been afrebrile. On the morning of presentation, he was having increased confusion, and was noted bo the hypoxic. He was sent to the ED for further evaluation. . On arrival to the ED, the patients temperatue was 98.3, 82, 109/36, and 96% on 4L. He had some degree of hypotension in the ED, with systolics in the high 80s. He was given a dose of CTX/Vanc and 2L of NS. His blood pressures improved to the 100s, and he was admitted to the MICU for further manegement. Past Medical History: severe C3-C4 and C6-C7 spinal stenosis Afib (not on coumadin secondary to falls) CAD - '[52] BMS to mid RCA, '[64] DES to mid RCA Diastolic CHF - [11-26] EF 55%, LA mod dilated, mild LVH, RV normal, aortic root mildly dilated, no AS, no AI, trivial MR, mod pHTN PAD - s/p stent to RLE SFA in [12-26] Prostate Cancer H/o bladder cancer in [2166](s/p local resection) hx of urethral stricture requiring permanent indwelling foley catheter h/o prostate CA (s/p external beam radiation and Lupron injections) Social History: Currently living at rehab, just discharged today. Was living in a two family house with family members. Denies current alcohol, IVDU, or smoking. He smoked cigarettes in the past, but quit 45 years ago. Family History: Mother: had heart problems Father: had heart problems brother: died from prostate cancer brother: died from MI Physical Exam: PHYSICAL EXAM GENERAL: Pleasant, well appearing elderly man in NAD HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. Mucous membranes dry. OP clear. Neck Supple, No LAD, No thyromegaly. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or [Last Name (un) 549]. JVP=flat LUNGS: CTAB, good air movement biaterally. No crackles, rhonchi or wheezes. ABDOMEN: mildly distended, NABS. Soft, NT, ND. No HSM EXTREMITIES: Large eschar on right posterior medial heel, with no surrounding erythema or fluctuance. No edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. [1-19]+ reflexes, equal BL. Normal coordination. Clones noted. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: [2171-4-22] 12:40PM BLOOD WBC-5.6 RBC-2.99* Hgb-8.3* Hct-26.8* MCV-90 MCH-27.6 MCHC-30.8* RDW-16.2* Plt Ct-213 [2171-4-24] 05:31AM BLOOD WBC-4.8 RBC-2.97* Hgb-9.0* Hct-28.3* MCV-95 MCH-30.3 MCHC-31.8 RDW-16.0* Plt Ct-228 [2171-4-22] 12:40PM BLOOD PT-13.7* PTT-25.3 INR(PT)-1.2* [2171-4-22] 12:40PM BLOOD Glucose-110* UreaN-44* Creat-2.2* Na-141 K-3.6 Cl-96 HCO3-34* AnGap-15 [2171-4-24] 05:31AM BLOOD Glucose-95 UreaN-23* Creat-1.4* Na-141 K-3.9 Cl-104 HCO3-28 AnGap-13 [2171-4-23] 03:55AM BLOOD ALT-6 AST-20 TotBili-0.1 [2171-4-24] 05:31AM BLOOD Calcium-8.3* Phos-2.4* Mg-2.2 [2171-4-23] 04:59PM BLOOD Type-ART pO2-81* pCO2-44 pH-7.47* calTCO2-33* Base XS-7 LENIs: No evidence of deep venous thrombosis in the lower extremities bilaterally on PRELIMINARY READ. CXR: CHEST, PA AND LATERAL: Again noted are extensive pleural calcifications. The heart is normal in size. Bilateral pericardial hazy opacities likely represent epicardial fat pads. Low lung volumes slightly limit evaluation. No focal consolidation is present. A paratracheal curvilinear density on the right is of uncertain etiology. There is no pneumothorax or pleural effusion. Degenerative changes are noted in the lower thoracic and upper lumbar spine. IMPRESSION: No definite evidence of acute cardiopulmonary process. Brief Hospital Course: #. Transient Hypotension: Resolved on arrival to the floor. The patient had one episode of hypotension in the ED with systolic pressures of 80. The patient received 2L NS with resolution of the hypotension. Given his mild acute renal failure, likely this is related to hypovolemia. Dry mucous membranes on exam consistent with volume depleation. No clinical evidence of pneumonia by symptoms, CXR, or [Last Name (LF) 108201], [First Name3 (LF) ] low suspicison of septic etiology. Systolic blood pressures remained above 100 throughout his hospitalizaiton. . #. Hypoxia: Unclear etiology. No clinical evidence of pneumonia. CXR without consolidation, no symptoms of cough or fevers, and no leukocytosis. Patient does have a history of dCHF, but no pulmonary edema on CXR, flat JVP, and dry MM. CXR does show pleural plaques, low O2 sats may be the product of chronic lung disease versus effects of scilent aspiration. Patient satting between 89% and 94% on RA at time of discharge. He should follow up with a pulmonologist and get an outpatient chest CT/PFTs. . # Aletered Mental Status: Unclear etiology, but resolved during hospitalization. No evidence of infection, with out pneumonia on CXR, no fevers/chills, negative UA. Patient with ARF, so may be secondary to uremia. Also takes oxycodone, so influence of narcotics also may be at play, in addition to newly started levofloxacin. No focal neurologic deficits, and no history of fall, so did not get a head CT. With holding of meds and addressing ARF, symptoms resolved. . # Positive urine culture: Pseudomonas on urine culture, which has been present in the past. No evidence of UTI based off UA, and this was believed to be colonization in the setting of a chronic indwelling foley. . #. Acute on chronic renal failure: Likely prerenal given volume depletion and hypotension. Improved to baseline with IVFs. . #. PAD: Recent stent placement to SFA on right to treat non-healing ulcer in [12-26]. Still with slowly healing ulcer, and recent follow up w/ vascular surgery. Persued wound care and continued aspirin and plavix. . #. CAD: No acute process, trop mildly elevated likely secondary to acute on chronic renal failure. Continued aspirin and plavix as above. The patient has a history of bradycardia, which is likely why he is not maintained on a beta blocker. No ACS on EKG. . #. Diastolic CHF: Preserved EF on recent echo in [11-26]. It appears the patient's ACE-I has been held since [Month (only) ] because of falls and low blood pressures. Will hold lasix in the setting of acute renal failure. Monitor for signs of volume overload. . # Atrial Fibrillation: Currently in sinus rhythm. Not on rate control secondary to bradycardia, not on coumadin secondary to falls. . #. History of prostate cancer/bladder cancer/uretheral stricture. Patient w/ indwelling foley. . #. Spinal Stenosis: Continued gabapentin with a dose reduction and held oxycodone. Patients pain well controlled at discharge. . #. Depression: Continude citalopram . . CODE STATUS: DNR/DNI . EMERGENCY CONTACT: [Name (NI) ] [Name (NI) ] HCP [Telephone/Fax (1) 108202], [Telephone/Fax (1) 108203], [First Name8 (NamePattern2) 4648] [Known lastname ] [Telephone/Fax (1) 108204] . Medications on Admission: 1. Clopidogrel 75 mg Tablet DAILY 2. Docusate Sodium 100 mg PO BID 3. Acetaminophen 325 mg Tablet PO Q6H as needed for pain. 4. Aspirin 81 mg Tablet DAILY 5. Cyanocobalamin 1000 mcg PO DAILY 6. Citalopram 20 mg Tablet PO DAILY 7. Pantoprazole 40 mg One PO Q24H 8. Ferrous Sulfate 325 mg PO DAILY 9. Gabapentin 300 mg PO HS; 200mg [Hospital1 ] 10. Multivitamin PO DAILY 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 13. Furosemide 40 mg Tablet DAILY 14. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for foot pain: hold for sedation or RR<12. 15. Calcium + Vit D Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours). 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 10. Collagenase Clostridium hist. 250 unit/g Ointment Sig: One (1) Appl Topical DAILY (Daily) as needed for right heel ulcer. Discharge Disposition: Extended Care Facility: [Hospital ] Healthcare & Rehabilitation Center - [Location (un) ] Discharge Diagnosis: Altered Mental Status Asbestosis lung disease Acute on chronic renal failure Discharge Condition: Stable, breathing comfortably on 1L of oxygen DNR/DNI Discharge Instructions: You were admitted to the hospital with altered mental status and hypoxia, and cared for in the ICU due to concern for low blood pressure on presentation. Your confusion was likely the consequence of medications (levofloxacin and oxycodone) in the setting of acute renal failure due to dehydration. There is no evidence of pneumonia, and your chest XR findings are more consistent with chronic pleural disease which will need outpatinet follow up including a pulmonogy appoitnment and chest CT. This may be causing some element of your hypoxia. Followup Instructions: You should follow up with your PCP upon [Name9 (PRE) ] from rehab. You should discuss with your PCP who he recommends for outpatinet pulmonolgy evaluation. You will need a chest CT to evaluate your abnormal chest XR findings. [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292]	[ "584.9", "V10.46", "428.0", "427.31", "788.30", "799.02", "440.23", "598.9", "501", "041.7", "458.0", "780.09", "E936.3", "707.07", "V10.51", "428.32", "724.00", "707.23", "599.0", "427.89", "276.51", "585.9", "414.01" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	9610, 9710	4755, 5839	322, 329	9831, 9888	3406, 4732	10483, 10854	2321, 2433		8742, 9587		9731, 9810		8054, 8719			9912, 10460									2448, 3387																									263, 284									357, 1535										5854, 8028							1557, 2083	2099, 2305
56,089	100,423	43469	Discharge summary	report	Admission Date: [2127-5-18] Discharge Date: [2127-5-27] Date of Birth: [2080-7-30] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1253] Chief Complaint: Seizure/ Found down Major Surgical or Invasive Procedure: Endotracheal intubation History of Present Illness: Patient is a 46y/o M with PMH of MVA with traumatic brain injury [11-16], and EtOH abuse admitted on [2127-5-18] after being found down for an unknown period of time. The patient has 2 witnessed GTC events and was brought to ED by EMS on a nasal trumpet. He found found to have a temp of 100.8, BP 202/123. Lactate 13 with EtOH 87. He was intubated for airway protection. Initally, there was some blood noted in his OP, but trauma eval was negative. In addition his temperature was 100.6, and he was cultured and received Ceftriaxone 1 g and Vanc 1 g IV. Neurology eval in the ED was notable for a left lateral gaze preference. recommended an LP which was negative for meningitis. In the MICU he was treated with EtOH withdrawal with ativan and valium, with large benzo requirements (>200mg on [5-21]). He underwent EGD for +NG lavage and was found to have portal hypertensive gastropathy with an area of ulceration was seen on the lesser curvature that was clipped. Neurology evaled the patient and he was started on keppra. EEG negative (on benzos). He is now stablized for transfer to the medical floor for continued management. Past Medical History: EtOH abuse Social History: homeless, goes often to Pine street Inn and [Doctor Last Name ] [Doctor Last Name 1924]. used to work as telemarketer, but currently not employed due to ETOH use. admits to extensive EtOH abuse (drinks daily x20 years, drinks several beers daily, 1 quart of gin, + vodka). smokes [1-10] ppd x10 years. +marijuana use a few days ago, +cocaine use (last time a few months ago), denies heroin or PCP. Family History: father and brother with etoh use Physical Exam: Admission Exam: GENERAL: intubated, sedated, opened eyes to voice and able to squeeze hands bilaterally, did not move toes to command HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA. Neck: c-collar in place CARDIAC: Regular rhythm, tachy. Normal S1, S2. No murmurs, rubs or [Last Name (un) 549]. LUNGS: Clear to auscultation bilaterally ABDOMEN: NABS. Soft, non-tender, non-distended, liver 2 cm below costal margin EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. SKIN: No rashes/lesions, ecchymoses, stigmata of chronic liver dz. NEURO: Opens eyes to command and squeezes hand; babinski downgoing, reflexes 2+ patellar and brachial Per neuro initial eval: "On the sedation, he is withdrawing from noxious stimuli with his 4 limbs. Opened his eyes and nodded to the examiner. He has a LEFT gaze preference and does not cross the midline toward the RIGHT. His pupils 2 to 1 mm (on sedation) but PERLA. No facial asymmetry. Closes his eyes purposely. His gag reflex is +. His corneal reflexes are positive. DTRs 2+ throughout with bl withdrawal to plantar" Transfer to Medicine Exam: VS: 99.8 106/84 102 18 97% on RA GENERAL: AA male sitting in bed, poor hygeine, eating dinner in sloppy fashion. HEENT: PERRLA, +anisocoria (L>R). scleral icterus, no sublingual jaundice. MMM, no oral lesions. no LAD. JVD flat without market response to hepatojugular reflex. CARDIAC: Regular rhythm, tachy. Normal S1, S2. No murmurs, rubs or [Last Name (un) 549]. LUNGS: Clear to auscultation bilaterally, decreased BS at bases. ABDOMEN: no caput medusa. no surgical scars. no tenderness of palpation. liver appears nodular to palpation. neg g/rt. no ascitic fluid wave. EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. +onochomycosis. SKIN: No rashes/lesions, ecchymoses, stigmata of chronic liver dz. NEURO: AOx2, speech appears slurred. Contemplative about quitting etoh. No asterixis. Pertinent Results: [2127-5-18] 06:05PM BLOOD WBC-11.8* RBC-3.75* Hgb-11.6* Hct-35.9* MCV-96 MCH-30.9 MCHC-32.2 RDW-13.9 Plt Ct-118* [2127-5-18] 06:05PM BLOOD Neuts-89.8* Lymphs-6.5* Monos-2.7 Eos-0.8 Baso-0.3 [2127-5-18] 06:05PM BLOOD PT-16.3* PTT-22.2 INR(PT)-1.5* [2127-5-18] 06:05PM BLOOD Glucose-202* UreaN-7 Creat-0.8 Na-140 K-3.7 Cl-88* HCO3-24 AnGap-32* [2127-5-18] 06:05PM BLOOD ALT-55* AST-356* CK(CPK)-296* AlkPhos-214* TotBili-2.8* [2127-5-18] 06:05PM BLOOD Lipase-122* [2127-5-18] 06:05PM BLOOD cTropnT-<0.01 [2127-5-19] 12:03AM BLOOD CK-MB-3 cTropnT-0.01 [2127-5-18] 06:05PM BLOOD Albumin-4.0 Calcium-8.4 Phos-5.6* Mg-1.3* [2127-5-18] 06:05PM BLOOD Osmolal-313* [2127-5-18] 06:05PM BLOOD ASA-NEG Ethanol-87* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . [5-18] EKG Probable sinus tachycardia. Prominent precordial lead QRS voltage raises the consideration of left ventricular hypertrophy, although is non-diagnostic. Non-specific ST-T wave abnormalities. Clinical correlation is suggested. No previous tracing available for comparison. . [5-18] CT head FINDINGS: There is no intracranial edema, mass effect, or vascular territorial infarction. An ovoid hyperdensity overlies the cribriform plates and measures 14 x 14mm (2:9), possibly representing a meningioma. Ventricles and sulci are normal in size and in configuration. Extracranial soft tissue structures are unremarkable. Mild mucosal soft tissue thickening is noted at the right maxillary sinus. Fluid in the posterior nasopharynx extends into the ethmoid air cells bilaterally. Otherwise, the paranasal sinuses and mastoid air cells are clear. There is no fracture. IMPRESSION: 1) Extra-axial ovoid hyperdensity overlying the cribriform plates, without mass effect, possibly representing a meningioma. Further characterization with MR [First Name (Titles) 151] [Last Name (Titles) ] is recommended. 2) No intracranial hemorrhage. . [5-18] CT C-spine w/o contrast: FINDINGS: There is no intracranial edema, mass effect, or vascular territorial infarction. An ovoid hyperdensity overlies the cribriform plates and measures 14 x 14mm (2:9), possibly representing a meningioma. Ventricles and sulci are normal in size and in configuration. Extracranial soft tissue structures are unremarkable. Mild mucosal soft tissue thickening is noted at the right maxillary sinus. Fluid in the posterior nasopharynx extends into the ethmoid air cells bilaterally. Otherwise, the paranasal sinuses and mastoid air cells are clear. There is no fracture. IMPRESSION: 1) Extra-axial ovoid hyperdensity overlying the cribriform plates, without mass effect, possibly representing a meningioma. Further characterization with MR [First Name (Titles) 151] [Last Name (Titles) ] is recommended. 2) No intracranial hemorrhage. . [5-19] Liver U/S FINDINGS: Examination is somewhat limited due to difficulty with patient positioning as well as overlying bowel gas. Allowing for this limitation, liver is diffusely echogenic without focal lesion. There is no intra- or extra-hepatic biliary dilatation. Common bile duct measures 6 mm in caliber. There are no gallstones. Pancreas is not well visualized. There is no ascites. Spleen is not enlarged measuring 8.2 cm in length. The main portal vein is patent and demonstrates antegrade flow. Velocity within the main portal vein measures 17.4 cm/sec. Flow within the right portal vein is noted and is antegrade. Flow within the left portal vein is reversed, compatible with portal hypertension. SMV and splenic vein are patent. IVC, right hepatic vein, left hepatic vein, and middle hepatic vein are all patent and unremarkable. IMPRESSION: 1. Diffusely echogenic liver, commonly seen with fatty infiltration. Other, more advanced forms of liver disease such as cirrhosis or fibrosis can have a similar appearance and cannot be completely excluded by ultrasound. 2. Flow reversal within the left portal vein, compatible with portal hypertension. Flow within the main portal vein is antegrade. There is no splenomegaly or ascites. [5-19] CXR FINDINGS: In comparison with the study of [5-18], the endotracheal tube remains about 4.5 cm above the carina. Nasogastric tube is coiled in the stomach with the tip projected close to the cardioesophageal junction. The lungs are essentially clear and there is no evidence of vascular congestion or pleural effusion. . [5-20] EEG IMPRESSION: This is a normal routine EEG in the waking and sleeping states. The generalized low voltage fast beta rhythms may be seen with medication side effects (e.g. benzodiazepines and barbiturates) or may be seen with anxiety. No focal slowing, epileptiform discharges or electrographic seizures were recorded. . EGD - [5-19] Normal mucosa in the esophagus. Erythema, congestion, petechiae and mosaic appearance in the whole stomach compatible with portal hypertensive gastropathy (endoclip). Normal mucosa in the duodenum. Otherwise normal EGD to third part of the duodenum Recommendations: Avoid all NSAIDS and [Doctor Last Name ]-2 inhibitors. Take tylenol for pain (max of 2 grams per day). D/C octreotide. Continue PPI IV BID. . MRI: FINDINGS: There is no evidence of hemorrhage, edema, midline shift, or infarction. The ventricles and sulci are prominent for age suggesting atrophy. There is right maxillary sinus mucosal thickening. No diffusion abnormalities are seen. Overlying the cribriform plate is a T1 bright 12 x 16-mm oval structure (series 3, image 10) which loses signal on fat suppression. The intracranial and vertebral and internal carotid arteries and their major branches appear normal without evidence of stenosis, occlusion, or aneurysm formation. IMPRESSION: 1. No infarct or acute intracranial hemorrhage. 2. Incidental note made of a lipoma adjacent to the cribriform plate. 3. Atrophy. Brief Hospital Course: ASSESSMENT AND PLAN: 46 year old man with history of traumatic brain injury and alcohol abuse now with new onset tonic clonic seizures, though to be due to alcohol withdrawal. #. Seizure: Felt most likely to be related to EtOH withdrawal. He also has a history of heavy alcohol use, and alcohol level on admission consistent with withdrawal. Given his head injury and focal slowing on EEG, felt to have a significant risk of seizure recurrence. Got meningitic doses of antibiotics in ED, had negative LP for meningitis. Neurology followed, recommended Keppra for seizure prophylaxis. Treated with valium CIWA scale. MRI showed incidental cribiform lipoma but no evidence of acute stroke or intracranial mass/structural lesions to explain seizures. PT consulted, recommended patient safe to be discharged to [Hospital1 ]. He was set up with neurology follow-up as outpatient. # EtOH Withdrawal - pt had large benzo requirements on admission (>200mg valium) now improving. Valium CIWA scale, treated with thiamine/folate/MVI. SW/Addictions were consulted, recommended discharge to [Hospital1 ] for alcohol rehab, to which patient agreed (is contemplative about quitting). # GIB - In ED, reportedly had >600cc bright red NG drainage. Underwent EGD with clipping of ulcers. Scope also suggestive of portal gastropathy. HCT stable on floor. Continued oral PPI on discharge. Kept active T&S, and adequate PIV access during admission. # EtOH Liver Disease - LFTs with AST/ALT ratio > 2 consistent with alcoholic hepatitis. Discriminant function 23 on admission. RUQ with portal HTN. Liver followed. Hepatitis serologies showed borderline hepatitis B. Mild fevers, likely due to alcoholic hepatitis. Infectious work-up negative (negative blood, urine cultures, CXR). # Tongue lesion - needs dental f/u on discharge given risk for head/neck cancer from alcohol and tobacco abuse. # Tobacco abuse - smoking cessation # Hypertension: Added amlodipine. # Cocaine/Marijuana use - SW consulted. Going to [Hospital1 ] for [Hospital ] rehab. Medications on Admission: Unknown Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 2. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital6 2222] - [Location (un) 538] Discharge Diagnosis: 1' Diagnosis Alcohol Related Seizures Delerium Tremens Alcohol Abuse Portal Gastropathy Discharge Condition: afebrile, hemodynamically stable, off valium Discharge Instructions: You were admitted with seizures. This was thought to be due to your alcohol use. You required intubation in the intensive care unit. You have agreed to go into an alcohol rehab program. Please take your medications as directed. Return to the hospital for chest pain, blood coming from your throat or your stools, seizures, abdominal pain, or any other symptoms not listed here concerning enough to warrant physician [Name Initial (PRE) 2742]. Followup Instructions: with your PCP [Name Initial (PRE) ] [Name10 (NameIs) ] MEDICAL FOUNDATION [Telephone/Fax (1) 11463]. with Dr. [First Name8 (NamePattern2) 553] [Last Name (NamePattern1) ] in epilepsy clinic [Telephone/Fax (1) 3294] in 1 month. Friday [2127-6-27] at 1:00 pm. Completed by:[2127-5-29]	[ "780.39", "794.8", "537.89", "780.60", "291.81", "791.6", "276.2", "529.0", "571.1", "285.1", "578.9", "518.81", "303.91", "276.8" ]	icd9cm	[ [ [] ] ]	[ "96.71", "96.04", "03.31", "45.13" ]	icd9pcs	[ [ [] ] ]	12497, 12570	9963, 12017	335, 360	12702, 12749	4063, 9940	13252, 13570	2010, 2044		12075, 12474		12591, 12681		12043, 12052			12773, 13229									2059, 4044																									276, 297									388, 1533																	1555, 1567	1583, 1994
62,034	176,704	36984	Discharge summary	report	Admission Date: [2183-9-3] Discharge Date: [2183-9-8] Service: SURGERY Allergies: Percocet / Sulfa (Sulfonamide Antibiotics) Attending:[Doctor First Name 5188] Chief Complaint: gallstone pancreatitis Major Surgical or Invasive Procedure: ERCP History of Present Illness: 89 y/o F with PMHx of Afib and HTN who presented with severe epigastric pain, nausea & vomiting to [Hospital 1562] Hospital on the evening of [9-2]. She was found to have a WBC of 21, Amylase 4590, lipase 3000, Tbili 1.3 and RUQ ultrasound revealing small gallstones and peripancreatic fluid. Per report, she was also found to have a UTI. She was given Zosyn, morphine and zofran prior to transfer to [Hospital1 18] ED for further management. . In the ED, initial vs were: T 97.4 P 94 BP 120/64 R 14 O2 sat 97% on 2L NC. Pt underwent RUQ which showed signs of early cholecystitis and mild intrahepatic biliary duct dilation. Both surgery and ERCP were consulted, she was given Zosyn, Morphine, Potassium and NS IVF prior to transfer east. . On arrival to the ICU, pt was sleepy and mildly uncomfortable, c/o generalized abd pain. She denied any current CP, SOB, nausea, fevers or chills. She did report decreased po intake and vomiting for 2 days. Past Medical History: Chronic Atrial Fibrillation Hypertension Osteoarthritis h/o SBO s/p LOA Social History: Social History: Pt lives at [Location 83418] [Hospital3 400], her son lives nearby and assists with some activities of daily living. Family History: N/c Physical Exam: Vitals: T: 97.6 BP: 135/56 P: 76 R: 18 Sats O2: 100% General: Alert, mildly disoriented HEENT: Sclera anicteric, dry MM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation anteriorly, no wheezes, rales, ronchi CV: RRR, normal s1/s2, soft gr II/VI SEM over LUSB Abdomen: soft, mild diffuse tenderness to palpation, bowel sounds present, no guarding Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . Pertinent Results: [2183-9-3] 02:20AM BLOOD WBC-21.6* RBC-3.58* Hgb-11.8* Hct-33.9* MCV-95 MCH-33.0* MCHC-34.9 RDW-12.6 Plt Ct-179 [2183-9-6] 09:10AM BLOOD WBC-11.7* RBC-3.53* Hgb-11.2* Hct-33.4* MCV-95 MCH-31.8 MCHC-33.6 RDW-12.8 Plt Ct-183 [2183-9-3] 02:20AM BLOOD Neuts-84* Bands-6* Lymphs-7* Monos-3 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2183-9-5] 04:38AM BLOOD Neuts-88.5* Lymphs-6.9* Monos-4.0 Eos-0.5 Baso-0.2 [2183-9-6] 09:10AM BLOOD Plt Ct-183 [2183-9-5] 04:38AM BLOOD PT-13.2 PTT-28.3 INR(PT)-1.1 [2183-9-3] 02:20AM BLOOD PT-14.4* PTT-25.5 INR(PT)-1.3* [2183-9-7] 06:13AM BLOOD Glucose-101 UreaN-19 Creat-0.7 Na-143 K-3.3 Cl-107 HCO3-26 AnGap-13 [2183-9-3] 02:20AM BLOOD Glucose-162* UreaN-25* Creat-1.0 Na-145 K-3.2* Cl-106 HCO3-26 AnGap-16 [2183-9-3] 02:20AM BLOOD ALT-103* AST-178* LD(LDH)-306* AlkPhos-87 TotBili-3.2* DirBili-2.7* IndBili-0.5 [2183-9-3] 11:34AM BLOOD ALT-92* AST-104* LD(LDH)-248 AlkPhos-76 Amylase-1437* TotBili-1.5 [2183-9-5] 04:38AM BLOOD Lipase-177* [2183-9-3] 02:20AM BLOOD Lipase-6375* [2183-9-4] 07:58PM BLOOD CK-MB-4 cTropnT-<0.01 [2183-9-5] 04:38AM BLOOD CK-MB-4 cTropnT-<0.01 [2183-9-7] 06:13AM BLOOD Calcium-8.5 Phos-3.0 Mg-1.7 [2183-9-3] 02:20AM BLOOD Albumin-3.9 Calcium-9.1 Phos-2.6* Mg-1.5* [2183-9-7] 10:38AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.013 [2183-9-7] 10:38AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-2* pH-6.0 Leuks-TR [2183-9-7] 10:38AM URINE RBC-2 WBC-6* Bacteri-FEW Yeast-NONE Epi-1 TransE-<1 . URINE CULTURE (Final [2183-9-4]): NO GROWTH . MRSA SCREEN (Final [2183-9-4]): POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS. IMAGING: ERCP [9-3]: Biliary dilation w/ CBD measuring 8mm; No definite stone seen, though the portion of the CBD posterior to the cystic duct was not well seen; d/t concern of cholangitis and current medical condition, sphincterotomy and duct sweep were not performed; a 10F 9cm Cotton [Doctor Last Name ] biliary stent was placed with excellent drainage post placement . ECHO [9-3]: mild symmetric LVH; overall LV systolic fxn is mildly depressed (LVEF= 40-50 %) secondary to hypokinesis of the inferior and posterior walls. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The ascending aorta is mildly dilated. There are focal calcifications in the aortic arch. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. . CONSULTS: [9-6] [Female First Name (un) 1634]: Patient with Confusion and Agitation: Recommendation to d/c Albuterol, Ipratropium, Quetiapine, to change famotidine for protronix and call again if needed [Pager number 83419] . [9-7] PT: anticipate pt will need rehab on d/c to maximize function; pt would benefit from OT at rehab to assess question of cognitive/safety deficits Brief Hospital Course: 89 y/o F with PMHx of Afib, HTN who presents with gallstone pancreatitis and early cholecystitis. . # Gallstone Pancreatitis: Admitted with lipase 6000s, WBC >20,000 with bandemia and lactate of 2.6 and RUQ US with evidence of early cholecystitis. Initially given aggressive IVF hydration and started on unasyn 3 gm Q6H. She was taken to ERCP where she was noted to have biliary dilitation with CBD measuring 8 mm without definitive stones. Due to concerns for cholangitis, sphincterotomy and duct sweep deferred. Biliary stent placed with good drainage. WBC trended down to 16,000 with improvement in pancreatic enzymes to lipase 177 and normalized LFTs at time of transfer. All cultures negative at time of transfer. . # Atrial fibrillation: With known history of atrial fibrillation. BB held in acute setting and reintroduced with improving LFTs, WBC. Transitioned from atenolol as outpatient to metoprolol 25 TID in house. Also continued on home digoxin. . # LBBB: Chest pain free. Prior ECG obtained and showed old LBBB. Pt did have an episode of transient chest pain on hospital day #2 that self-resolved. ECG without acute changes and cardic biomarkers negative. ECHO with mildly depressed LVEF at 40-50% with HK of inferior and posterior wall defects. . # Delirium: With waxing and [Doctor Last Name 688] mental status, with sun-downing. Felt that this is related to toxic metabolic encephalopathy/delirium in setting of of gallstone pancreatitis and cholecystitis. Given haldol prn with good effect. At time of transfer, written for QHS zyprexa and zyprexa as needed. . Medications on Admission: Digoxin 125 mcg daily Atenolol 25mg daily Isosorbide Mononitrate SR 60mg daily Lipitor 10mg daily Vasotec 5mg daily Discharge Medications: 1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 3. Enalapril Maleate 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for agitation. 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for agitation. 8. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Male First Name (un) 4542] Nursing Center - [Hospital1 1562] Discharge Diagnosis: Primary Pancreatitis Cholecystitis Secondary Chronic Atrial Fibrillation Hypertension Osteoarthritis Discharge Condition: Stable Discharge Instructions: You were admitted with inflammation of your pancreas and infection of your gallbladder. You were treated with antibiotics and had an ERCP to have a stent placed. Your pain improved and your lab tests indicating infection and inflammation also improved. The following medication changes were made during your hospital stay: 1. You are being given cipro/flagyl for your gallbladder infection 2. Your atenolol was switched to metoprolol for better control of your atrial fibrillation 3. Your lipitor was held in the acute setting 4. You are being started on zyprexa for your confusion Followup Instructions: Please follow up with your doctors as recommended by [Hospital 1562] hospital. [Name6 (MD) ] [Last Name (NamePattern4) ] MD, [MD Number(3) 5190] Completed by:[2183-9-8]	[ "575.0", "426.3", "427.31", "041.12", "349.82", "577.0", "401.9", "715.90", "599.0" ]	icd9cm	[ [ [] ] ]	[ "51.87" ]	icd9pcs	[ [ [] ] ]	7729, 7825	5211, 6814	271, 277	7970, 7979	2030, 5188	8614, 8834	1537, 1542		6981, 7706		7846, 7949		6840, 6958			8003, 8591									1557, 2011																									209, 233									305, 1267																	1289, 1363	1395, 1521
43,147	180,640	12752	Discharge summary	report	Admission Date: [2127-3-18] Discharge Date: [2127-3-27] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 9853] Chief Complaint: Respiratory failure Major Surgical or Invasive Procedure: extubation PICC line placement and removal History of Present Illness: [Age over 90 ] y/o F with recent admisison for PNA who presents from rehab with respiratory distress. Patient has a PMH of HTN, Alzheimer's, and chronic anemia who presents from her rehab facility after intubation for respiratory distress. Of note, the patient was recently admitted to [Hospital1 18] from [Date range (1) 39348] during which she was diagnosed with multifocal HAP for which she was treated with Vanc/Zosyn x 2 weeks. She completed Zosyn on [3-16]. Patient required intubation at that time due to hypoxia. Per the patient's daughter her mother had been very sleepy at the rehab facility after her recent discharge. However, approximately 3 days ago her energy level improved and she was more awake and responsive. The patient was able to recognize her and interact with her. In fact, the patient's daughter visited her mother this morning and noted her to be very responsive and was without complaints. The patient's daughter also reports that her mother was being treated for some "GI" infection which appears to have been possible c. diff. The patient was started on flagyl [3-13], to complete course on [3-27]. . At approximately 1350 today, the patient was found to be in respiratory distress with accessory muscle use and retracting. Room air sat was noted to be 74%. She was placed on NRB and her sats improved to 90-97%. ABG noted to be 7.17/82/177 on unknown amount of oxygen. Other VS were T 97.5 BP 170/70 HR 103-122, EKG showed sinus tach. She was given [1-5]" nitropaste and intubated at rehab. BP fell to 88/62 and nitropaste was wiped off and she was given IVF. . In [Hospital1 18] ED, initial vitals were T 97.6 BP 137/65 HR 93 O2 sat 100% on vent. She was given versed 2mg, vanco 1gm and zosyn 4.5gm IV x1. EKG showed no changes, Trop was 0.1. Repeat ABG 7.45/36/72. CXR showed worsening pleural effusions with pulm. edema. She was admitted to the [Hospital Unit Name 153] for further management. Past Medical History: 1. Hypertension, recently poorly controlled and fluctuating 2. Alzheimer's dementia 3. Pituitary macroadenoma, followed and unchanged per CT scans at [Hospital3 ] (2.5 cm) 4. Autonomic dysfunction, hyponatremia, secondary to ?SIADH ([2119])/free water intake 5. Low TSH 6. Thyroid Goiter 7. Syncopal episodes 8. Anemia of chronic disease 9. Recent multifocal PNA 10. R ACA infarct [2-10] with L-sided weakness and aphasia Social History: Since the R ACA stroke, pt has been living in a rehab. Fully dependent, as she is hemiplegic on left and alert and oriented to first name only. Per medical records: Tob: denies. EtOH: denies. Drugs: denies Family History: Noncontributory Physical Exam: T 97.5 BP 122/78 HR 80 RR 15 O2 100% on vent General: Russian speaking, not responsive to voice, intubated HEENT: ETT and NG in place, sclera anicteric, PERRL Neck: supple, JVP elevated above jaw, no bruits appreciated Lungs: rales present [3-5] way up lung fields b/l CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-distended, bowel sounds present, no organomegaly, no grimmacing to palpation. Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis Neuro: Not responding to voice, withdraws to painful stimuli. . Pertinent Results: [2127-3-18] 03:30PM BLOOD WBC-16.9* RBC-3.06* Hgb-9.0* Hct-28.1* MCV-92 MCH-29.4 MCHC-32.0 RDW-16.0* Plt Ct-510* [2127-3-22] 12:29AM BLOOD WBC-10.1 RBC-2.97* Hgb-8.5* Hct-26.3* MCV-89 MCH-28.6 MCHC-32.3 RDW-15.9* Plt Ct-488* [2127-3-18] 03:30PM BLOOD Neuts-91.8* Lymphs-4.9* Monos-2.7 Eos-0.5 Baso-0.2 [2127-3-19] 05:03AM BLOOD Neuts-84.1* Lymphs-8.5* Monos-6.4 Eos-0.7 Baso-0.2 [2127-3-18] 03:30PM BLOOD Glucose-160* UreaN-25* Creat-0.7 Na-127* K-5.3* Cl-96 HCO3-25 AnGap-11 [2127-3-22] 02:32PM BLOOD Glucose-103 UreaN-13 Creat-0.5 Na-131* K-5.2* Cl-99 HCO3-26 AnGap-11 [2127-3-18] 03:30PM BLOOD CK-MB-NotDone cTropnT-0.10* [2127-3-18] 09:56PM BLOOD CK-MB-7 cTropnT-0.02* proBNP-[Numeric Identifier 39349]* [2127-3-19] 05:03AM BLOOD CK-MB-5 cTropnT-0.03* [2127-3-18] 09:56PM BLOOD Cortsol-21.7* . . [2127-3-21] 12:14 pm SPUTUM Site: ENDOTRACHEAL Source: Endotracheal. GRAM STAIN (Final [2127-3-21]): [10-26] PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): BUDDING YEAST. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. RESPIRATORY CULTURE (Preliminary): ? OROPHARYNGEAL FLORA. YEAST. MODERATE GROWTH. . . CXR [2127-3-18] IMPRESSION: Bilateral pleural effusions with question of mild superimposed edema. No definite pneumonia identified. Please note the previous imaging to document the reported pneumonia is not available at this time. Also, incidentally noted is a left upper extremity approach PICC line with the distal tip of the catheter projecting over the superior vena cava. Brief Hospital Course: Ms. [Known lastname 39350] is a [Age over 90 ] year old Russian female with PMH of HTN, alzheimer's, recent CVA and PNA who was admitted from rehab with respiratory distress, requiring intubation and admitted to [Hospital Unit Name 153] for management. # Respiratory failure: On ABG at [Hospital 100] Rehab the pt had a mixed hypoxemic and hypercarbic picture. The patient was intubated at rehab. On admission the pt didn't have any evidence of pneumonia (she had recently completed a course of antibiotics for nosocomial pneumonia), and PE seemed unlikely as the pt had been on subcutaneous heparin at rehab and her oxygenation improved with intubation. The pt's chest xray did show mild pulmonary edema and effusions, so the pt was diuresed with IV lasix, which she tolerated well. On day 3 of admission the pt was successfully intubated, and soon was weaned to room air. On the day of extubation the pt was noted to have a leukocytosis and new infiltrate on chest xray, so a new course of antibiotics was initiated for a 7 day course for ventilator/hospital-acquired pneumonia (of Vancomycin and Cefepime) which she completed. The pt's sputum culture grew out gram + cocci in pairs and clusters. # Leukocytosis: See above, now improving. # Anemia: Baseline Hct low 30s, however was 24 on recent discharge, currently stable at 28. No evidence of bleeding. Attributed to chronic disease in past. # Hyponatremia: Resolved spontaneously during this admission. # History of CVA: During this admission ASA and statin were continued. ASA was stopped when she placed on the heparin gtt (see below). Statin was discontinued given her prognosis. # Cardiovascular: No documented h/o CAD, however has known PVD and also with q-waves on EKG which indicates a prior event. EKG is unchanged here. As seen in "results" section cardiac enzymes were cycled and trended down, elevation was likely demand in the setting of hypoxia. Beta blocker and ACEi were continued, ASA and statin were stopped as above. # afib with RVR: the patient had an episode of atrial fibrillation with RVR to the 140s. This resolved with IV metoprolol and there were no further episodes. Her metoprolol was increased. # HTN: On admission the pt's BP was elevated, further supporting evidence of pulmonary edema. Continued BB, ACE at home dose with holding parameters. FEN: Pt was restarted on tube feeds following extubation. Tube feeds are administered via NG tube. The NGT should ACCESS: L-PICC. During this admission the pt's left hand became edematous and ecchymotic. Left upper extremity ultrasound was ordered to evaluate for upper extremity thrombus. The ultrasound showed a non-occlusive thrombus in the left axillary vein. She was started on a heparin gtt after consulting with neurology who felt that she was far enough out from her stroke to make anticoagulation safe. She should be anticoagulated for a month (if goals of care do not change to hospice) but was not started on coumadin in case a PEG needs to be placed. If her peripheral IV access fails, she may be anticoagulated with Lovenox in the meantime. Given the risks of a central line, she should not return to the hospital specifically for line placement without discussing goals of care with the family. # Code Status: During this admission there was some discussion of the pt's code status, as even though the pt's HCP [Name (NI) 4248] (her daughter) stated that the pt was DNR, the pt's grandson was [Name2 (NI) ] that all treatments be pursued, including re-intubation if extubation was unsuccessful. After a family meeting it was decided that the pt would continue to be DNR but would be amenable to re-intubation (this was per the pt's wishes according to the HCP). EMERGENCY CONTACT: daughter [Name (NI) 4248] (HCP) [Telephone/Fax (1) 39351] (c) [Telephone/Fax (1) 39352] (h) **Goals of care Several discussions about goals of care were undertaken with the family (daughter, son-in-law, and grandson) by the medical team and palliative care consult team. The patient's prognosis including her aspiration risk, the fact that this would not be prevented by a PEG tube, and the low likelihood that her mental status would significantly improve. The family was unable to make a decision on whether or not to change her goals of care to comfort during the admission and would like to continue to monitor her at rehab for a few more days. Given the fact that the NGT needs to be removed within the next few days, the family is aware that they need to make a decision about her goals of care. The palliative care team at [Hospital 100] Rehab will support them in making this decision, and should they decide to pursue hospice, the arrangements can be made from there. Medications on Admission: 1. Aspirin 325 mg qd 2. Acetaminophen 325 mg Tablet [Hospital ]: 1-2 Tablets PO Q6H prn 3. Bisacodyl 10mg PR daily 4. Simvastatin 20mg qd 5. Lisinopril 5 mg qd 6. Metoprolol Tartrate 25 mg tid 7. Albuterol nebs prn 8. Azithromycin 500mg IV daily ([Date range (1) 39353]) 9. Famotidine 20mg daily 10. Iron 325mg [Hospital1 ] 11. Hep SQ 5000 units tid 12. Flagyl 500mg tid [Date range (1) ] 13. Nystatin powder Discharge Medications: 1. Acetaminophen 160 mg/5 mL Solution [Date range (1) ]: [10-21] mL PO Q6H (every 6 hours) as needed for fever, pain. 2. Bisacodyl 10 mg Suppository [Month/Year (2) ]: One (1) suppository Rectal once a day. 3. Lisinopril 5 mg Tablet [Month/Year (2) ]: One (1) Tablet PO DAILY (Daily). 4. Metoprolol Tartrate 25 mg Tablet [Month/Year (2) ]: 1.5 Tablets PO TID (3 times a day). 5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 6. Metronidazole 500 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO Q8H (every 8 hours) for 1 weeks. 7. Docusate Sodium 50 mg/5 mL Liquid [Last Name (STitle) ]: Ten (10) mL PO BID (2 times a day) as needed. 8. Insulin Lispro 100 unit/mL Solution [Last Name (STitle) ]: per sliding scale Subcutaneous ASDIR (AS DIRECTED). 9. Heparin (Porcine) in NS (PF) 1,000 unit/500 mL Parenteral Solution [Last Name (STitle) ]: per weight-based dosing guidelines Intravenous gtt. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Primary: acute systolic congestive heart failure, hospital-acquired pneumonia Secondary: hypertension, Alzheimer's dementia, s/p recent stroke, anemia, afib with RVR Discharge Condition: stable, breathing comfortably on room air, responsive to tactile stimuli, minimally responsive to voice, with spontaneous movements Discharge Instructions: The patient was evaluated for respiratory distress. This was thought to be from pulmonary edema and she improved with diuresis. After extubation, she developed a pneumonia and completed a course of broad spectrum antibiotics. She was also found to have a left upper extremity non-occlusive thrombus, likely related to a PICC line that was subsequentliy removed. Several discussions with family and palliative care addressed goals of care. Currently, the family is undecided about moving towards hospice/palliative care, so any concerning symptoms (such as fever, chills, shortness of breath) should be discussed with the family before sending her to the hospital for re-evaluation. Followup Instructions: She will be followed by the physicians at [Hospital 100**] Rehab as well as the palliative care team.	[ "285.21", "453.8", "294.10", "438.11", "263.9", "276.1", "331.0", "518.81", "428.21", "507.0", "997.31", "E879.8", "427.31", "428.0", "438.20", "227.3", "996.74" ]	icd9cm	[ [ [] ] ]	[ "96.07", "96.71", "38.93" ]	icd9pcs	[ [ [] ] ]	11637, 11703	5336, 10102	282, 327	11913, 12047	3634, 4830	12778, 12885	3037, 3054		10578, 11614		11724, 11892		10128, 10555			12071, 12755									3069, 3615												4871, 5313													223, 244									355, 2340																	2362, 2797	2813, 3021
52,751	144,442	1021	Discharge summary	report	Admission Date: [2107-8-23] Discharge Date: [2107-8-24] Date of Birth: [2050-6-4] Sex: M Service: UROLOGY Allergies: Iodine-Iodine Containing / Lopressor / Opioids-Morphine & Related / Ciprofloxacin / gabapentin Attending:[First Name3 (LF) 6736] Chief Complaint: Hypotension, hypoxia Major Surgical or Invasive Procedure: Cystoscopy History of Present Illness: 57 yo M non-ischemic cardiomyopathy [2096] with EF recovery to 50%, atrial flutter s/p ablation, cervical stenosis, and hematuriahere for cystoscopy. Pt desat to 60s after initial LMA placement, was reintubated with initiation of propofol/midazolam, and had another episode of desat to 60s for ~ 5mins, but was able to resume the procedure. During the procedure, pt was noted to appear "not well, and turning black". He became hypotensive to SBP 80s for about 20 mins, and dropped to SBP 50s for several minutes during the procedure. No definitive anaphylaxis and was premedicated with 100 mg hydrocortisone and benadryl prior to retrograde pyelogram. No contrast extravasation and has had previous CT with contrast without any issues. His hypotension responded to phenylnephrine, and was also given a total of 120 mcg epiniphrine for concerns of anaphylaxis. Minimal blood loss was reported. An A-line was put in. An introp TEE was performed, which showed EF 25-30% with inferior wall motion abnormalities. ABG showed respiratory acidosis 7.24/54/110/26, lactate 3.2. An EKG was unchanged from his baseline. Cardiology was consulted, and recommended transfer to the ICU for further management. On arrival to the MICU, patient's VS T 97.7, HR 81, BP 135/91 (to SBP > 200 within the hour of transfer). He was sedated and intubated for assist control ventilation. Labs were significant for WBC 14, lactate 3.2, . A CXR showed L pleural effusions as demonstrate by retrocardiac opacification, otherwise unchanged compared to a previous film in [2101]. Past Medical History: Past Medical History: 1. Idiopathic Nonischemic Cardiomyopathy [2096]: Presented with AFlutter and CHF, EF 10%, recovered to 50%. 2. Hypertension. 3. Atrial Flutter s/p ablation 4. Allergic rhinitis. 5. Hematuria. . Past Surgical History: 1. Left knee ACL repair. 2. Appendectomy. 3. Bilateral cataract repair 4. Cystoscopy Social History: Married to husband [Name (NI) ], works as social worker, quit tobacco, drinks 1 alcoholic drink/day, no drug use. Family History: Non-contributory Physical Exam: Admission Exam: Vitals: T: 98.6, BP: 134/82 mmHg supine, HR 88, RR 18 bpm, O2: 100% on 40% FiO2 CMV 500/15/10. Gen: Intubated, sedated HEENT: Small left subconjunctival hemorrhage. No icterus. MMM. OP clear. Intubated. NECK: Supple, No LAD. JVP low. Normal carotid upstroke without bruits. No thyromegaly. CV: PMI in 5th intercostal space, mid clavicular line. RRR. normal S1,S2. No murmurs, rubs, clicks, or [Last Name (un) 549]. LUNGS: CTAB. No wheezes, rales, or rhonchi. Mechanical breath sounds. ABD: NABS. Soft, NT, ND. No HSM. No abdominal bruits. EXT: WWP, NO CCE. Full distal pulses bilaterally. No femoral bruits. SKIN: No rashes/lesions, ecchymoses. NEURO: Sedated. PERRL. Withdraws to pain. Pertinent Results: Admission Labs: [2107-8-23] 01:19PM BLOOD WBC-14.0# RBC-6.73 Hgb-16.8 Hct-53.1* MCV-79* MCH-25.0* MCHC-31.7 RDW-17.8* Plt Ct-267 [2107-8-23] 01:19PM BLOOD Neuts-83.4* Lymphs-12.2* Monos-3.7 Eos-0.3 Baso-0.3 [2107-8-23] 01:19PM BLOOD Glucose-118* UreaN-13 Creat-1.1 Na-136 K-5.1 Cl-101 HCO3-23 AnGap-17 [2107-8-23] 01:19PM BLOOD ALT-38 AST-31 LD(LDH)-309* CK(CPK)-143 AlkPhos-40 TotBili-0.5 [2107-8-23] 01:19PM BLOOD CK-MB-2 cTropnT-<0.01 [2107-8-23] 01:19PM BLOOD Calcium-8.8 Phos-2.8 Mg-2.1 [2107-8-23] 11:39AM BLOOD Type-ART pO2-110* pCO2-54* pH-7.28* calTCO2-26 Base XS--1 [2107-8-23] 06:04PM BLOOD Type-[Last Name (un) ] Temp-37.1 pO2-45* pCO2-51* pH-7.37 calTCO2-31* Base XS-2 Intubat-NOT INTUBA [2107-8-23] 11:39AM BLOOD Glucose-118* Lactate-3.2* Na-136 K-4.0 Cl-99 [2107-8-23] 06:04PM BLOOD Lactate-1.3 [2107-8-23] 11:39AM BLOOD Hgb-16.9 calcHCT-51 [2107-8-23] 11:39AM BLOOD freeCa-1.18 [2107-8-23] 03:00PM URINE Color-Yellow Appear-Hazy Sp [Last Name (un) ]-1.017 [2107-8-23] 03:00PM URINE Blood-LG Nitrite-NEG Protein-30 Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-TR [2107-8-23] 03:00PM URINE RBC->182* WBC-7* Bacteri-FEW Yeast-NONE Epi-<1 [2107-8-23] 03:00PM URINE CastHy-8* [2107-8-23] 03:00PM URINE Mucous-RARE ECHO [8-23]: There is mild regional left ventricular systolic dysfunction with inferior wall akinesis. The remaining segments contract normally (LVEF = 40%). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: Mild regional left ventricular systolic dysfunction, c/w CAD. Mild mitral regurgitation. Technically-limited study. Compared with the report of the prior study (images unavailable for review) of [2100-4-20], definite regional wall motion abnormalities are now seen, anatomically-consistent with sequelae of CAD. CXR [8-23]: FINDINGS: AP single view of the chest has been obtained with patient in semi-upright position. The patient is moderately rotated to the right, apparently intubated and the tube seen to terminate in the trachea some 4 cm above the level of the carina. No pneumothorax can be seen. The patient is poorly ventilated at the time of the image exposure with very high positioned diaphragms and low volume. With the exception of a small plate atelectasis on the left base and some prominent mediastinal structures on the right side, no abnormalities are seen. The lateral pleural sinuses are free and no pneumothorax is identified in the apical area. The next preceding chest examination available in our records is dated [2101-8-14] and at that time normal chest findings were present. Brief Hospital Course: 57 year old male with non-ischemic cardiomyopathy [2096] (EF 50%), atrial flutter s/p ablation, cervical stenosis, and hematuria who presents with hypotension and hypoxia during elective cystoscopy. OR COURSE: Pt was initially scheduled for outpatient cystoscopy. LMA was placed, and despite easy ventillation and good EtCO2, pt desaturated. LMA was removed and mask ventillation failed to improved SpO2. Pt was then intubated with normalization of VS, and procedure progressed. During the procedure, pt became hypotensive, but did respond to several epinephrine boluses. TEE in OR showed depressed EF, so pt remained intubated and was transferred to the ICU for further management. ACTIVE ISSUES: # Hypotension: The cause of poor ventilation and hypotension was unclear. [Name2 (NI) ] may have had a reaction to the anesthetic drugs used and had also received hydrocortisone and benadryl. A anaphylactic reaction is unlikely. He was already intubated for hypoxia (see below), and his blood pressure responded to administration of phenylephrine and epinephrine. An emergent TEE showed inferior wall hypokinesis EF 25%. EKG showed left axis deviation and no new ischemic changes. He was given IV fluids and was transferred to the ICU. In the ICU labs were significant for elevated WBC 14, lactate 3.2, ABG 7.28/54/110, and negative cardiac enzymes. CXR showed a left retrocardiac opacity concerning for consolidation / atelectasis / infiltrate. There was concern for septic shock given hypotension, elevated WBC, and LLL infiltrate, however this was considered less likely as he remained afebrile, his lactate normalized, and his BP corrected quickly without antimicrobials or pressors. He was observed overnight, and his cardiac enzymes were negative x 3. A repeat TTE showed persistent inferior wall hypokinesis, however showed an improved EF to 40%. He was treated with PO predisone 40mg for 3 days given the concern for delayed anaphylactic reaction. His blood and urine cultures were negative at the time of discharge. # Hypoxia: he has a history of OSA, and his desaturation occurred durng LMA placement / intubation in the setting of his known OSA. CXR showed left lower lobe opacity concerning for effusion / consolidation / atelectasis, or aspiration pneumonitis. His hypoxia resolved with treatment of his hypotension, and he had minimal oxygen requirements after extubation. His OSA is currently untreated, as he does not respond well to BiPAP at night. There was low suspicion for PE given that the patient is not tachycardic and does not have any oxygen requirements. A repeat CXR showed resolution of the LLL retrocardiac infiltrate. He was treated with incentive spirometer. At the time of discharge, he did not have any oxygen requirements. # Leukocytosis: Most likely stress response to OR procedure and hypotension, vs aspiration pneumonitis. Patient has been afebrile, his lactate was downtrending, and his vitals were stable. Bl and urine cultures were sent. CXR showed a left retrocardiac opacity consistent with effusion / consolidation / atelectasis. He was monitored closely and his WBC at the time of discharge was 10.3. # S/P cystoscopy: he received an elective cystoscopy for hematuria. There was no evidence of active bleeding on cystoscopy, and his Hct was elevated at 53.1. INACTIVE ISSUES: FOLLOW-UP ISSUES: - Please follow-up on the patient's blood and urine cultures from [2107-8-23]. These were pending at the time of discharge. He also has tryptase level pending from [2107-8-23]. - He was discharged with carvedilol 3.125mg [Hospital1 ]. Please check his blood pressure, as he now takes carvedilol in addition to Losartan 50mg daily. - He should follow up with a cardiologist, and should receive a stress MIBI as outpatient. - Consider nighttime home O2 therapy for his OSA, as he does not tolerate BiPAP. He reports sleeping well in the hospital with 2L nasal cannula. Medications on Admission: 1. Fluticasone Propionate NASAL 2 SPRY NU Frequency is Unknown 2. Losartan Potassium 50 mg PO DAILY 3. Zolpidem Tartrate 10 mg PO HS 4. Tamsulosin 0.4 mg PO HS 5. melatonin NF unknown Oral qd 6. Nortriptyline 50 mg PO HS Discharge Medications: 1. Tamsulosin 0.4 mg PO HS 2. Zolpidem Tartrate 10 mg PO HS 3. Aspirin 81 mg PO DAILY RX Adult Low Dose Aspirin 81 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 4. Carvedilol 3.125 mg PO BID please hold for SBP < 100 or HR < 60 RX carvedilol 3.125 mg 1 tablet(s) by mouth Twice a day Disp #60 Tablet Refills:0 5. PredniSONE 40 mg PO DAILY Duration: 1 Days RX prednisone 20 mg 2 tablet(s) by mouth once per day Disp #2 Tablet Refills:0 6. Losartan Potassium 50 mg PO DAILY 7. Fluticasone Propionate NASAL 2 SPRY NU DAILY 8. melatonin NF* 0 units ORAL QD 9. Nortriptyline 50 mg PO HS Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Hypotension Secondary Diagnosis: CHF Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname 6737], It was a pleasure caring for you at the [Hospital1 827]. You were admitted for a cyscoscopy. During the procedure, your blood pressure was low and you were transferred to the Intensive Care Unit for testing and monitoring. We performed an ultrasound of your heart, which showed that your heart does not pump normally. You did NOT have a heart attack during this admission. We have arranged for you to follow up with one of the heart failure specialists here at [Hospital1 18]. You will need to have a special type of stress test to further evaluate your heart as an outpatient. We will communicate this to your new Cardiologist. You will also need to follow up with your Urologist. Thank you for allowing us to participate in your care. We made some changes to your medications, which the nurse will review with your at the time of discharge. Followup Instructions: Department: Primary Care Name: Dr. [First Name8 (NamePattern2) 915] [Last Name (NamePattern1) 6420] When: Monday [2107-8-29] at 11:50 AM Location: [Location (un) ] ASSOCIATES OF [Hospital1 ] HEALTH Address: [Street Address(2) ], 2ND FL, [Location (un) ],[Numeric Identifier 2900] Phone: [Telephone/Fax (1) 5723] Department: CARDIAC SERVICES When: TUESDAY [2107-8-30] at 1 PM With: [Name6 (MD) ] [Last Name (NamePattern4) 6738], MD [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: SURGICAL SPECIALTIES When: MONDAY [2107-9-5] at 4:30 PM With: [First Name8 (NamePattern2) 161] [Name6 (MD) 162] [Name8 (MD) 163], MD [Telephone/Fax (1) 921] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "E879.8", "518.51", "416.8", "425.4", "428.22", "599.70", "428.0", "600.00", "276.2", "327.23", "458.29", "E849.7", "403.90", "799.02", "585.9" ]	icd9cm	[ [ [] ] ]	[ "57.49", "87.74", "88.72", "96.71" ]	icd9pcs	[ [ [] ] ]	11006, 11012	6164, 6854	374, 386	11112, 11112	3252, 3252	12176, 13133	2490, 2508		10374, 10983		11033, 11033		10125, 10351			11263, 12153								2247, 2338	2523, 3233																									314, 336		6869, 9482							414, 1977			11085, 11091		9500, 10099	3268, 6141	11052, 11064			11127, 11239							2021, 2224	2354, 2474
4,929	167,945	46468	Discharge summary	report	Admission Date: [2133-2-18] Discharge Date: [2133-2-25] Date of Birth: [2060-9-26] Sex: F Service: ORTHOPAEDICS Allergies: Penicillins / Effexor / Topamax / Clindamycin Attending:[First Name3 (LF) 64] Chief Complaint: Failed left total hip replacement (multidirectional instability/dislocation)with nonunion of greater trochanter osteotomy. Major Surgical or Invasive Procedure: Revision left total hip replacement (femoral head and acetabular liner components) History of Present Illness: Ms. [Known lastname 97368] is a 72 year old female ~2 years status post left total hip replacement who has been experiencing multiderectional instability and dislocations. The decision was made to revise the left total hip. Dr. [Last Name (STitle) ] discussed the risks and benefits of the procedure, and Ms. [Known lastname 97368] elected to undergo the revision. Past Medical History: - Chronic rectal pain -> OMR note requesting no further admissions for rectal pain - Motor vehicle accident in [2126] (also had an additional motor vehicle accident that year that resulted in a tibia and fibula fracture). - Cataracts - Status post total hip replacement x 2 - Status post laminectomy [2123] - Chronic back pain - Lumbar spinal stenosis - Chronic pain syndrome Social History: Denies smoking at present; [Age over 90 ]y pack history. Family History: Father w/ ETOH, no known suicides. Both of patient's parents died of complications of heart disease, mother at 72 and father at 62. One brother had an MI at 48, but is otherwise generally healthy. Other brother is healthy. Physical Exam: At the time of discharge: AVSS NAD wound c/d/i without erythema [Last Name (un) 938]/FHL/TA/GS intact SILT distally Brief Hospital Course: The patient was admitted on [2133-2-18] and, later that day, was taken to the operating room by Dr. [Last Name (STitle) ] for a revision left total hip arthroplasty with change of the femoral head and acetabular liner without complication. Please see operative report for details. Postoperatively, the patient was hypotensive with SBP's in the 80-90s and was transferred to the ICU for closer management and treatment. She did not demonstrate any end-organ ischemia and her mental status was intact. She responded to fluid resuscitation and PRBCs and was transferred to the floor on POD#1. The patient was initially treated with a PCA followed by PO pain medications on POD#[12-5]. She complained of persistent pain both related to the hip as well as her prior lower back and sciatic pain; she was seen by the pain service who aided in her pain management. The patient received IV antibiotics for 24 hours postoperatively, as well as lovenox for DVT prophylaxis starting on the morning of POD#1. The drain was removed without incident on POD#1. The Foley catheter was removed with a failed trial of void. She will be discharged to rehab with a foley, and she is to continue Bactrim DS Qd until the foley is d/c'ed. The surgical dressing was removed on POD#2 and the surgical incision was found to be clean, dry, and intact without erythema or purulent drainage. While in the hospital, the patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was stable, and the patient's pain was adequately controlled on a PO regimen. The operative extremity was neurovascularly intact and the wound was benign. The patient was discharged to home with services or rehabilitation in a stable condition. The patient's weight-bearing status was weight bearing as tolerated with global precaution and to be in a knee immobilizer at all times. Medications on Admission: CITALOPRAM [CELEXA] - 40 mg Tablet - 1 Tablet(s) by mouth daily Increase as directed ESTRADIOL [ESTRACE] - 0.01 % Cream - apply to vagina twice a day GABAPENTIN [NEURONTIN] - 300 mg Capsule - 3 Capsule(s) by mouth three times a day HYDROCODONE-ACETAMINOPHEN [CO-GESIC] - 5 mg-500 mg Tablet - 1 Tablet(s) by mouth every 8 hours HYDROCORTISONE-PRAMOXINE - 2.5 %-1 % (4 gram) Cream - apply cream rectally twice a day IPRATROPIUM-ALBUTEROL [COMBIVENT] - 18 mcg-103 mcg (90 mcg)/Actuation Aerosol - 2 puffs four times a day as needed for cough and sortness of breath MUPIROCIN - 2 % Ointment - USE ON BURN TWICE DAILY PREGABALIN [LYRICA] - (Prescribed by Other Provider) - 25 mg Capsule - 1 Capsule(s) by mouth 3 times a day TIMOLOL MALEATE - (Prescribed by Other Provider) - Dosage uncertain TRAMADOL - 50 mg Tablet - [12-5] Tablet(s) by mouth twice a day as needed for recrtal pain Medications - OTC DOCUSATE SODIUM [COLACE] - 100 mg Capsule - 1 Capsule(s) by mouth twice a day POLYETHYLENE GLYCOL 3350 [MIRALAX] - (OTC) - 100 % Powder - 1 tablespoon by mouth daily as directed Discharge Medications: 1. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe Subcutaneous once a day for 3 weeks. 2. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO TID (3 times a day). 5. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Risperidone 0.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for aggitation. 7. Ketorolac Tromethamine 0.5 % Drops Sig: One (1) drop Ophthalmic q6 (). 8. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q8H (every 8 hours). 9. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 10. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 11. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal PRN (as needed). 12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Failed left total hip replacement (multidirectional instability/dislocation)with nonunion of greater trochanter osteotomy. Discharge Condition: Stable Discharge Instructions: experience severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers >101.5, shaking chills, redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your PCP regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not operate heavy machinery or drink alcohol when taking these medications. As your pain improves, please decrease the amount of pain medication. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (e.g., colace) as needed to prevent this side effect. 5. You may not drive a car until cleared to do so by your surgeon or your primary physician. 6. Please keep your wounds clean. You may get the wound wet or take a shower starting 5 days after surgery, but no baths or swimming for at least 4 weeks. No dressing is needed if wound continues to be non-draining. Any stitches or staples that need to be removed will be taken out by a visiting nurse at 2 weeks after your surgery. 7. Please call your surgeon's office to schedule or confirm your follow-up appointment at 4 weeks. 8. Please DO NOT take any NSAIDs (i.e. celebrex, ibuprofen, advil, motrin, etc). 9. ANTICOAGULATION: Please continue your lovenox for 3 weeks to prevent deep vein thrombosis (blood clots). After completing the lovenox, please take Aspirin 325mg twice daily for an additional three weeks. 10. WOUND CARE: Please keep your incision clean and dry. It is okay to shower after POD#5 but do not take a tub-bath or submerge your incision until 4 weeks after surgery. Please place a dry sterile dressing on the wound each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed by VNA in 2 weeks. If you are going to rehab, the rehab facility can remove the staples at 2 weeks. 11. VNA (once at home): Home PT/OT, dressing changes as instructed, wound checks, and staple removal at 2 weeks after surgery. 12. ACTIVITY: Weight bearing as tolerated on the operative leg with global precautions; wear knee immobilizer at all times. No strenuous exercise or heavy lifting until follow up appointment. Physical Therapy: Weight bearing as tolerated Global left hip precautions Knee immobilizer at all times Treatments Frequency: Lovenox injections. Wound checks and daily dry sterile dressing changes until wound dry. Staple removal at 2 weeks. Followup Instructions: Provider: [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1953], [MD Number(3) 1240]:[Telephone/Fax (1) 1228] Date/Time:[2133-3-13] 10:00	[ "276.52", "338.29", "458.29", "996.42", "285.1", "E878.1", "569.42", "366.9", "300.00", "V02.54", "514", "V15.82", "724.2" ]	icd9cm	[ [ [] ] ]	[ "00.71" ]	icd9pcs	[ [ [] ] ]	6090, 6156	1810, 3883	432, 517	6324, 6333		9039, 9242	1426, 1650		5017, 6067		6177, 6303		3909, 4994			6357, 7960									1665, 1787	8791, 8877	8899, 9016																							269, 394							7972, 8773		545, 925																	947, 1332	1348, 1410
66,711	188,878	38801	Discharge summary	report	Admission Date: [2138-2-17] Discharge Date: [2138-2-18] Date of Birth: [2120-4-13] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 598] Chief Complaint: Fall Major Surgical or Invasive Procedure: None History of Present Illness: 17 yo M who fell off a tree (~15 to 20 feet) high this morning initially seen at OSH then transferred here for further evaluation. + LOC, pt was unable to provide much history as he does not remember events immediately surrounding event. Per brother who was climbing the tree with him, they were climbing a tree at their aunt's house and the brother was coming down to get something to drink when he heard "thud, thud, thud" and saw the patient on the ground on his side. The patient was non-responsive/non-verbal with bluish but was moving all extremities in non-rhythmic manners and blinking. Per EMS he was found to have urinary incontinence and tongue lacerations. He has no prior hx of seizures. Social History: Noncontributory Family History: Noncontributory Physical Exam: On admission: Gen: Mildly uncomfortable appearing - some abrasion over R scalp but no bleeding. HEENT: Tongue abrasion - R frontal. Neck/Back: No some tenderness to palpation - both mid back and para spinally. Lungs: Clear Cardiac: RRR. No M/R/G Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: alert and oriented, cooperative, CN grossly intact, normal motor funtion, gross sensation intact, DTR 2+ symmetric, coordination intact Pertinent Results: [2138-2-17] 06:20PM BLOOD WBC-11.2* RBC-4.71 Hgb-14.1 Hct-40.6 MCV-86 MCH-30.0 MCHC-34.9 RDW-13.5 Plt Ct-345 [2138-2-17] 06:20PM BLOOD Plt Ct-345 [2138-2-17] 06:34PM BLOOD Glucose-101 Lactate-1.5 Na-142 K-4.2 Cl-103 calHCO3-27 [2138-2-17] 06:20PM BLOOD UreaN-10 Creat-0.9 [2138-2-17] 06:20PM BLOOD Lipase-38 [2138-2-18] 08:49AM BLOOD Phenyto-10.8 [2138-2-17] 06:34PM BLOOD Hgb-14.8 calcHCT-44 Imaging CT head: L frontal IPH CT C-spine: No fracture or malalignment CT abd: RLL pulm contusion R ankle XR: no evidence of acute fracture or dislocation CXR: Linear lucency projecting over the distal right acromion, fracture cannot be excluded. Recommend clinical correlation and consider dedicated imaging of this region. CT T-spine: no fracture Brief Hospital Course: Patient was admitted to trauma SICU for frequent neuro checks in the setting of closed head injury with IPH and seizure. No changes in neurologic examination were found and no further seizure activity. He was seen by neurosurgery. Patient was started on Dilantin load and will continue for one week. Patient continued to have diffuse back pain, without specific ttp and T/L spine plain films were ordered. There was concern over abnormality at T5 and therefore a CT t-spine was obtained that did not show evidence of fracture. Patient was able to ambulate without difficulty and had no new neurologic findings at the time of discharge. Medications on Admission: None Discharge Medications: 1. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) for 6 days. Disp:18 Capsule(s) Refills:0 2. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [2-18] hours as needed for pain: This medication will make you sleepy, do not drive while taking it. Disp:20 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Intraparanchymal hemorrhage Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were seen after a fall from a tree where you lost consiousness and may have had a seizure. You were found to have a small bleed in your brain. You were seen by the neurosurgery team and started on an antiseizure medication, which you should take for one week as prescribed. You should rest for the next 1-2 days, avoid heavy lifting and do not drive a car. Mild nausea and a mild headache are to be expected. You had several other imaging studies that looked at your chest and abdomen as well as you spine that did not show acute injury. You will likely be quite sore for the next few days from your fall. You should take motrin 400mg every 6 hours. Call your doctor or return to the Emergency Department right away if you develop prolonged nausea, vomiting, confusion, drowsiness, change in normal behavior, trouble walking, or speaking, numbness or weakness of an arm or leg, severe headache, convulsions or seizures, any thing else that concerns you. Followup Instructions: Follow up in trauma clinic with Dr. [Last Name (STitle) ], call [Telephone/Fax (1) 6429] for an appointment in [11-16] weeks. Follow up in Dr.[Name (NI) 9034] Clinic in 8 weeks with a follow up head CT scan. Call [Telephone/Fax (1) 1669] for an appoinment. [First Name8 (NamePattern2) ] [Name8 (MD) ] MD [MD Number(2) 601]	[ "305.20", "E849.8", "305.1", "851.86", "861.21", "788.30", "E884.9" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	3448, 3454	2397, 3040	318, 325	3526, 3526	1602, 2032	4667, 5056	1109, 1126		3095, 3425		3475, 3505		3066, 3072			3677, 4644									1141, 1141																									274, 280									353, 1060		2041, 2374						1155, 1583		3541, 3653								1076, 1093
44,451	121,529	12540	Discharge summary	report	Admission Date: [2125-3-8] Discharge Date: [2125-3-14] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4309] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: 86 year old woman with past medical history significant for type II diabetes, end stage renal disease (on HD via ), atrial fibrillation (on warfarin), and recent admissions for c diff colitis and pancreatitis, presenting with severe abdominal pain since 2am the night prior to admission. . Briefly, patient was in her otherwise usual health until she woke up at 2 am with nausea and vomiting. Patient describes her emesis as dark in color, without clots or bright blood. Patient also developed severe epigastric and abdominal pain, had small liquid bowel movement this morning, also passing gas. Denies any chest pain, shortness of breath, cough or runny nose. She believes this pain is very similar to last episode of pancreatitis. . In the ED, vital signs were initially: 98.8 95 192/67 18 99, Hct up to 46 from baseline for 20's to low 30's. Lipase 3800 (up from 67) Patient underwent CT of the abdomen and pelvis which revealed pancreatic inflammation and RUQ US revealed sludge. Patient was given 1.5L fluids and was transferred to ICU for further care. . REVIEW OF SYSTEMS: No fevers, chills, weight loss, diaphoresis, headache, visual changes, sore throat, chest pain, shortness of breath, nausea, vomiting, abdominal pain, constipation, diarrhea, melena, pruritis, easy bruising, dysuria, skin changes, pruritis. 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 [1-28] Social History: 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: BP 155/65, HR 66 General: Reciving HD, in no distress currently Abdomen: Soft, marked tenderness in epigastrium, no bruits Chest: Clear x 2 CV: No JVD, RRR Extremities: Nonpitting edema Lymph: No LAD in neck, axillae, supraclavear spaces Pertinent Results: ultrasound: INDICATION: Patient is an 86-year-old female with right upper quadrant pain. Evaluate for cholecystitis. EXAMINATION: Focused abdominal ultrasound of the liver and gallbladder. COMPARISONS: Comparison is made to prior examination from [2125-1-7] and CT examinations performed concurrently from [2125-1-8]. FINDINGS: Since prior examinations, no significant interval change. Persistently dilated gallbladder with sludge and possible layering stones. No other secondary signs of cholecystitis with a negative son[Name (NI) 493] [Name2 (NI) 515] sign. No pericholecystic fluid, gallbladder wall thickening, or edema. The liver demonstrates no focal or textural abnormalities. There is no intra- or extra-hepatic biliary dilatation with the common bile duct measuring up to 3 mm. The main portal vein is patent with appropriate hepatopetal flow. IMPRESSION: Unchanged appearance of persistently dilated gallbladder with sludge and possible gallstones. No other secondary signs of cholecystitis Brief Hospital Course: 86F with CAD, DM, ESRD on [Name2 (NI) 2286] (no UOP at baseline), A-fib on warfarin, h/o C. diff admitted for recurrence of acute pancreatitis. # PANCREATITIS: Patient admitted to the ICU with a recurrent episode of pancreatitis. RUQ U/S on admission demonstrated sludge and layering stones in the GB, but none visualized in the CBD. Per last workup, patient not hypertriglyceridemic, not on steroids, no clear medication culprit. Patient was made NPO, received IV pain control, and was placed on careful volume resuscitation given her ESRD. She responded well to treatment with rapid resolution of her abdominal pain and she was able to tolerate a regular diet. GI was consulted & felt that the patient may be intermittently passing small stones causing inflammation & transient changes in LFT's. Surgery was consulted and they recommended that the patient proceed with outpatient Surgery follow-up to evaluate for possible cholecystectomy. # END STAGE RENAL DISEASE: Patient received aggressive volume resuscitation in the ICU and underwent [Name2 (NI) 2286] while admitted in keeping with her M/W/F schedule. # ATRIAL FIBRILLATION: Patient currently in NSR, but noted during last admission to have runs of RVR. Her Coumadin was initially held out of concern for possible necrotizing pancreatitis and risk of hemorrhage, but her home Metoprolol 50mg PO TID was continued and she was discharged on her home Coumadin 4mg QHS. # HYPERTENSION: Patient continued her home Metoprolol Tartrate 50mg PO TID and Amlodipine 5mg PO daily. Her Isosorbide Mononitrate 60mg SR daily was initially held in the acute setting, but restarted as the patient tolerated a PO's. # Anemia: Patient with a chronic anemia [2-27] ESRD, with baseline Hct's in the 30's. Her # DIABETES: Patient maintained on an insulin sliding scale Medications on Admission: Amlodipine 5mg Atorvastatin 10mg Isosorbide mono 60mg SR daily Metoprolol Tartrate 50mg TID Warfarin 4mg daily Lidocaine patch Sevelamer 800mg TID Fluticasone 50mg [Hospital1 ] Hydrocortisone cream Insulin Lispro SSI NPH Insulin SSI (15 units daily) Oxycodone 2.5mg Q6H Pain Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Primary: Pancreatitis Secondary: Type II Diabetes End Stage Renal Disease, on HD via R arm fistula Hypertension Hyperlipidemia Coronary artery disease Atrial Fibrillation Anemia h/o Stroke and transient ischemic attack MGUS Osteoarthritis Peripheral Vascular Disease Discharge Condition: Alert and oriented x3 Pain free Normal vital signs ambulates with a walker Discharge Instructions: Dear Mrs. [Known lastname 25143], It was a pleasure taking care of you. You were admitted with abdominal pain and found to have severe pancreatitis. You were treated with fluids and pain medications. Your symptoms resolved. We think your symptoms may be related to gallstones. We recommend that you be evaluated in the surgical clinic for possible removal of your gallbladder. We did not make any changes to your medication regimen. We held your coumadin while you were in the hospital but restarted it prior to discharge. Please have your blood work done on Tuesday [2125-3-14] to monitor your coumadin. Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. Followup Instructions: You have the following appointment at your PCP's office: [Month (only) 956] Tuesday 23rd at 11:30AM. To reschedule, please call: [Telephone/Fax (1) 719] Please follow-up with a gastroenterologist, Dr. [First Name8 (NamePattern2) 553] [Last Name (NamePattern1) 1356], to evaluate your recurrent pancreatitis. Your appointment is on Tuesday [3-20] at 3:00PM. Her offices are located at [Last Name (NamePattern1) 12939], [Hospital Unit Name ] [Location (un) 858]. Please follow-up with a surgeon, Dr. [Last Name (STitle) 5182], to evaluate your need to have your gallbladder removed. You have an appointment on [3-20] at 2:30PM. His offices are located at the [Hospital1 18], [Hospital Ward Name 516], [Hospital Ward Name 23] Center, [Location (un) ].	[ "V58.61", "369.4", "V12.54", "250.50", "585.6", "414.01", "V12.51", "285.21", "403.91", "715.90", "362.01", "443.9", "574.20", "V45.11", "427.31", "577.0" ]	icd9cm	[ [ [] ] ]	[ "39.95" ]	icd9pcs	[ [ [] ] ]	6256, 6313	4098, 5926	276, 282	6625, 6702	3051, 4075	7460, 8270	2633, 2769				6334, 6604		5952, 6233			6726, 7437									2784, 3032																					1390, 1633				222, 238									310, 1371																	1655, 2252	2268, 2617
29,627	151,153	34336	Discharge summary	report	Admission Date: [2143-9-1] Discharge Date: [2143-9-16] Date of Birth: [2090-11-6] Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Neoprene Ankle Support / Reglan Attending:[First Name3 (LF) 6743] Chief Complaint: nausea, vomiting Major Surgical or Invasive Procedure: Examination under anesthesia, exploratory laparotomy, drainage of ascites, tumor debulking, intracolic omentectomy, small bowel resection with reanastomosis (stapled), bilateral salpingo-oophorectomy, supracervical hysterectomy, cystoscopy History of Present Illness: [Known firstname ] [Known lastname ] is a 52-year-old woman who presents with nausea and vomiting. She recently saw Dr. [Last Name (STitle) 2028] for initial visit after being referred to him by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] secondary to a recent discovery of an adnexal mass. She has been nauseous and intolerant of PO intake for the last 4 days. She feels that her abdominal distention is worse, and at times is making it difficult to breathe. Denies CP, fever, chills. . She is a gravida 1, para 0 woman who noted 2 weeks ago a little bit of spotting and abdominal bloating. An ultrasound was performed, which revealed a complex solid right adnexal mass concerning for an ovarian malignancy. A small amount of free fluid was noted. The uterus was notably normal in size measuring 6.4 x 2.7 x 3 cm and there was only a thin stripe. The right adnexal mass measured 10.3 x 7.4 x 11 cm and had a moderate amount of internal vasculature. There were central cystic changes and obviously it was solid as well. [Known firstname ] reports feeling quite bloated. Over the past couple of weeks, she notes that her pants do not fit, she is having difficulty taking a deep breath and actually ingesting food because she feels so bloated. She denies any chest pain, but does report feeling short of breath mostly from the pressure from her diaphragm. She denies any lightheadedness, visual or hearing changes. She does not have any family history suggestive of a predisposition to hereditary breast ovarian cancer syndrome. Past Medical History: PAST MEDICAL HISTORY: She does report a history of mitral valve prolapse. She does not use antibiotics for this. She does not have a history of hypertension, asthma, or thromboembolic disorder. She is not up-to-date with mammography. . PAST SURGICAL HISTORY: At the age of six, she had eye surgery. No other surgery. . OB/GYN HISTORY: She is a gravida 1, para 0. She reports that her last real menstrual cycle was a year ago. She does report a history of an abnormal Pap smear in the past, but biopsies have all been negative. She is up-to-date with her Pap smears, and her last was a year ago. She denies any history of pelvic infections. . Social History: She is a bookkeeper, denies tobacco, drug, or alcohol use. Her partner, [Name (NI) ], and her live in [State 32926]. They have no children. Family History: Grandfather had [Name2 (NI) 499] cancer. Physical Exam: GENERAL: lying in bed, appears tired, NAD. Heart: RRR +systolic murmur Lungs: CTA bilaterally posteriorly, decreased breath sounds in lower lung fields. Abd: +bowel sounds, soft, distended, nontender to palpation, no palpable mass. Ext: no lower extremity edema, no calf tenderness . From Dr.[Name (NI) 27357] clinic note [2143-8-28] PELVIC: Reveals normal external genitalia. The inner labia minora is normal. Digital exam reveals a normal vaginal canal and normal palpable cervix. I do not palpate any evidence of malignancy or irregularity. Rectal exam reveals good sphincter tone. There is some nodularity in the posterior cul-de-sac that I can appreciate only on bimanual exam. There is a palpable mass noted in the midline that extends superiorly. Pertinent Results: HEMATOLOGY ========== [2143-9-1] 07:02PM BLOOD WBC-13.8* RBC-3.30* Hgb-10.1* Hct-30.8* MCV-93 MCH-30.5 MCHC-32.8 RDW-12.4 Plt Ct-958# [2143-9-2] 08:55AM BLOOD WBC-12.2 RBC-3.04* Hgb-9.3* Hct-28.5* MCV-94 MCH-30.5 MCHC-32.6 RDW-12.5 Plt Ct-928* [2143-9-3] 07:10AM BLOOD WBC-12.8* RBC-2.96* Hgb-9.1* Hct-28.2* MCV-95 MCH-30.7 MCHC-32.3 RDW-12.8 Plt Ct-1067* [2143-9-3] 07:02PM BLOOD WBC-13.3* RBC-3.00* Hgb-9.3* Hct-26.8* MCV-89 MCH-31.1 MCHC-34.9 RDW-13.1 Plt Ct-599* [2143-9-3] 11:24PM BLOOD Hct-28.6* [2143-9-4] 05:35AM BLOOD WBC-16.8* RBC-3.71* Hgb-11.7# Hct-32.4 MCV-87 MCH-31.4 MCHC-36.0* RDW-14.8 Plt Ct-594* [2143-9-4] 01:58PM BLOOD Hct-30.7* [2143-9-5] 06:15AM BLOOD WBC-17.3* RBC-3.32* Hgb-10.2* Hct-30.2* MCV-91 MCH-30.8 MCHC-33.8 RDW-15.3 Plt Ct-668* [2143-9-6] 06:24AM BLOOD WBC-10.2 RBC-3.00* Hgb-9.3* Hct-27.7* MCV-92 MCH-31.1 MCHC-33.7 RDW-15.1 Plt Ct-650* [2143-9-6] 05:20PM BLOOD WBC-8.6 RBC-3.02* Hgb-9.5* Hct-27.6* MCV-91 MCH-31.4 MCHC-34.4 RDW-15.0 Plt Ct-625* [2143-9-7] 05:56AM BLOOD WBC-7.8 RBC-3.17* Hgb-9.5* Hct-29.6* MCV-93 MCH-30.1 MCHC-32.2 RDW-15.0 Plt Ct-669* [2143-9-8] 06:01AM BLOOD WBC-9.4 RBC-3.22* Hgb-9.7* Hct-30.2* MCV-94 MCH-30.2 MCHC-32.2 RDW-15.0 Plt Ct-695* [2143-9-9] 04:44AM BLOOD WBC-10.0 RBC-3.30* Hgb-10.0* Hct-31.0* MCV-94 MCH-30.3 MCHC-32.2 RDW-15.0 Plt Ct-684* [2143-9-10] 05:55AM BLOOD WBC-12.0* RBC-3.26* Hgb-10.0* Hct-30.8* MCV-95 MCH-30.8 MCHC-32.6 RDW-15.1 Plt Ct-719* [2143-9-11] 05:55AM BLOOD WBC-14.1* RBC-3.06* Hgb-9.4* Hct-29.1* MCV-95 MCH-30.8 MCHC-32.4 RDW-15.1 Plt Ct-726* [2143-9-12] 06:12AM BLOOD WBC-14.0* RBC-3.05* Hgb-9.3* Hct-29.1* MCV-95 MCH-30.5 MCHC-32.0 RDW-15.0 Plt Ct-765* [2143-9-14] 04:55AM BLOOD WBC-18.3* RBC-2.79* Hgb-8.8* Hct-26.5* MCV-95 MCH-31.6 MCHC-33.2 RDW-15.1 Plt Ct-819* [2143-9-15] 05:57AM BLOOD WBC-18.8* RBC-2.84* Hgb-8.9* Hct-27.6* MCV-97 MCH-31.5 MCHC-32.4 RDW-15.1 Plt Ct-900* [2143-9-3] 07:02PM BLOOD Neuts-91* Bands-2 Lymphs-2* Monos-3 Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-1* [2143-9-4] 05:35AM BLOOD Neuts-94.3* Lymphs-2.8* Monos-2.8 Eos-0 Baso-0 [2143-9-10] 05:55AM BLOOD Neuts-82* Bands-4 Lymphs-6* Monos-3 Eos-4 Baso-1 Atyps-0 Metas-0 Myelos-0 [2143-9-13] 05:57AM BLOOD Neuts-91.9* Lymphs-5.1* Monos-2.0 Eos-0.8 Baso-0.2 [2143-9-4] 05:35AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL [2143-9-10] 05:55AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL . CHEMISTRY ========= [2143-9-1] 07:02PM BLOOD Glucose-101 UreaN-10 Creat-0.6 Na-133 K-4.9 Cl-95* HCO3-29 AnGap-14 [2143-9-2] 08:55AM BLOOD Glucose-116* UreaN-11 Creat-0.7 Na-133 K-4.7 Cl-96 HCO3-31 AnGap-11 [2143-9-3] 07:10AM BLOOD Glucose-122* UreaN-12 Creat-0.6 Na-134 K-5.3* Cl-99 HCO3-29 AnGap-11 [2143-9-3] 07:02PM BLOOD Glucose-143* UreaN-9 Creat-0.3* Na-134 K-4.2 Cl-107 HCO3-24 AnGap-7* [2143-9-3] 11:24PM BLOOD Glucose-126* UreaN-8 Creat-0.3* Na-135 K-4.6 Cl-109* HCO3-24 AnGap-7* [2143-9-4] 05:35AM BLOOD Glucose-130* UreaN-8 Creat-0.4 Na-137 K-4.7 Cl-111* HCO3-24 AnGap-7* [2143-9-5] 06:15AM BLOOD Glucose-154* UreaN-10 Creat-0.4 Na-138 K-5.3* Cl-107 HCO3-27 AnGap-9 [2143-9-6] 06:24AM BLOOD Glucose-125* UreaN-12 Creat-0.3* Na-137 K-4.4 Cl-107 HCO3-28 AnGap-6* [2143-9-7] 05:56AM BLOOD Glucose-105 UreaN-15 Creat-0.3* Na-139 K-4.2 Cl-108 HCO3-27 AnGap-8 [2143-9-8] 06:01AM BLOOD Glucose-124* UreaN-14 Creat-0.3* Na-136 K-3.9 Cl-106 HCO3-27 AnGap-7* [2143-9-9] 04:44AM BLOOD Glucose-131* UreaN-14 Creat-0.2* Na-139 K-4.1 Cl-109* HCO3-27 AnGap-7* [2143-9-10] 05:55AM BLOOD Glucose-110* UreaN-15 Creat-0.3* Na-139 K-4.4 Cl-107 HCO3-25 AnGap-11 [2143-9-11] 05:55AM BLOOD Glucose-131* UreaN-19 Creat-0.3* Na-135 K-4.5 Cl-106 HCO3-23 AnGap-11 [2143-9-12] 06:12AM BLOOD Glucose-137* UreaN-18 Creat-0.3* Na-137 K-4.5 Cl-107 HCO3-24 AnGap-11 [2143-9-13] 05:57AM BLOOD Glucose-134* UreaN-19 Creat-0.4 Na-135 K-4.7 Cl-104 HCO3-22 AnGap-14 [2143-9-14] 04:55AM BLOOD Glucose-143* UreaN-15 Creat-0.4 Na-134 K-4.7 Cl-104 HCO3-24 AnGap-11 [2143-9-15] 05:57AM BLOOD Glucose-140* UreaN-23* Creat-0.4 Na-134 K-4.9 Cl-103 HCO3-24 AnGap-12 [2143-9-1] 07:02PM BLOOD Calcium-9.1 Phos-3.4 Mg-2.2 [2143-9-2] 08:55AM BLOOD Calcium-8.5 Phos-3.8 Mg-2.1 [2143-9-3] 07:10AM BLOOD Calcium-8.7 Phos-3.8 Mg-2.1 [2143-9-3] 07:02PM BLOOD Calcium-6.2* Phos-2.5* Mg-1.4* [2143-9-4] 05:35AM BLOOD Albumin-1.4* Calcium-6.0* Phos-2.6* Mg-2.3 [2143-9-5] 06:15AM BLOOD Calcium-7.4* Phos-2.3* Mg-2.2 [2143-9-6] 06:24AM BLOOD Calcium-7.0* Phos-2.1* Mg-2.2 [2143-9-7] 05:56AM BLOOD Calcium-7.3* Phos-3.4 Mg-2.2 [2143-9-8] 06:01AM BLOOD Albumin-1.5* Calcium-7.2* Phos-3.1 Mg-2.0 [2143-9-9] 04:44AM BLOOD Calcium-7.3* Phos-3.1 Mg-2.1 [2143-9-10] 05:55AM BLOOD Calcium-7.2* Phos-3.6 Mg-1.9 [2143-9-11] 05:55AM BLOOD Calcium-7.5* Phos-3.7 Mg-2.0 [2143-9-12] 06:12AM BLOOD TotProt-3.9* Albumin-2.0* Globuln-1.9* Calcium-7.6* Phos-3.6 Mg-1.9 [2143-9-13] 05:57AM BLOOD Calcium-7.5* Phos-3.4 Mg-1.9 [2143-9-14] 04:55AM BLOOD Calcium-7.8* Phos-3.4 Mg-1.9 [2143-9-15] 05:57AM BLOOD Calcium-8.0* Phos-3.8 Mg-2.1 [2143-9-11] 05:55AM BLOOD ALT-115* AST-137* TotBili-4.4* DirBili-3.3* IndBili-1.1 [2143-9-12] 06:12AM BLOOD ALT-117* AST-132* AlkPhos-176* Amylase-321* TotBili-4.8* [2143-9-13] 05:57AM BLOOD ALT-131* AST-148* Amylase-288* TotBili-6.0* [2143-9-14] 04:55AM BLOOD ALT-135* AST-124* AlkPhos-143* TotBili-5.3* [2143-9-15] 05:57AM BLOOD ALT-110* AST-80* AlkPhos-122* TotBili-3.8* [2143-9-4] 05:35AM BLOOD Triglyc-94 [2143-9-7] 05:56AM BLOOD Triglyc-194* [2143-9-3] 04:58PM BLOOD Type-ART pO2-197* pCO2-39 pH-7.41 calTCO2-26 Base XS-0 Intubat-INTUBATED [2143-9-3] 07:40PM BLOOD Type-ART Temp-36.8 Rates-14/0 Tidal V-500 PEEP-5 FiO2-100 pO2-412* pCO2-37 pH-7.40 calTCO2-24 Base XS-0 AADO2-273 REQ O2-52 -ASSIST/CON Intubat-INTUBATED [2143-9-3] 08:46PM BLOOD Type-ART Temp-36.8 Rates-14/ Tidal V-500 PEEP-5 FiO2-60 pO2-246* pCO2-41 pH-7.39 calTCO2-26 Base XS-0 -ASSIST/CON Intubat-INTUBATED [2143-9-3] 11:35PM BLOOD Type-ART Temp-36.8 Rates-14/ Tidal V-500 PEEP-5 FiO2-40 pO2-145* pCO2-44 pH-7.38 calTCO2-27 Base XS-0 -ASSIST/CON Intubat-INTUBATED [2143-9-4] 09:32AM BLOOD Type-ART Rates-14/ Tidal V-500 PEEP-5 FiO2-40 pO2-158* pCO2-38 pH-7.40 calTCO2-24 Base XS-0 -ASSIST/CON Intubat-INTUBATED [2143-9-4] 02:11PM BLOOD Type-ART Temp-37.2 pO2-99 pCO2-42 pH-7.39 calTCO2-26 Base XS-0 [2143-9-3] 04:58PM BLOOD freeCa-1.01* [2143-9-4] 09:32AM BLOOD freeCa-1.05* [2143-9-3] 04:58PM BLOOD Hgb-11.1* calcHCT-33 [2143-9-3] 04:58PM BLOOD Glucose-159* Lactate-2.1* Na-128* K-4.6 Cl-102 [2143-9-3] 08:46PM BLOOD Lactate-1.4 . SEROLOGY ======== [2143-9-12] 06:12AM BLOOD HCV Ab-NEGATIVE [2143-9-12] 06:12AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-POSITIVE IgM HAV-NEGATIVE . URINANALYSIS ============ [2143-9-3] 02:09AM URINE Color-AMBER Appear-Cloudy Sp [Last Name (un) ]-1.020 [2143-9-3] 02:09AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-5.5 Leuks-NEG [2143-9-3] 02:09AM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE Epi-0 [2143-9-3] 02:09AM URINE AmorphX-MANY [2143-9-3] 02:09AM URINE Hours-RANDOM UreaN-641 Creat-285 Na-LESS THAN K-52 [2143-9-3] 02:09AM URINE Osmolal-530 [2143-9-13] 03:10PM URINE Color-Yellow Appear-Hazy Sp [Last Name (un) ]-1.024 [2143-9-13] 03:10PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-TR Ketone-NEG Bilirub-LG Urobiln-4* pH-5.5 Leuks-NEG [2143-9-13] 03:10PM URINE RBC-1 WBC-6* Bacteri-FEW Yeast-NONE Epi-3 [2143-9-13] 03:10PM URINE CastUnk-2* . MICROBIOLOGY ============ [2143-9-13] urine and blood cultures pending at the time of this discharge summary . RADIOLOGY ========= CHEST PORT. LINE PLACEMENT Study Date of [2143-9-3] 7:51 PM Tip of the endotracheal tube is just above the sternal notch, approximately 6 cm from the carina, 2 cm above optimal placement. Aside from mild bibasilar atelectasis, lungs are clear. No pneumothorax is present. Pleural effusion, if any, is minimal on the right. Normal cardiomediastinal contour. Nasogastric tube ends in the lower esophagus and needs to be advanced At least 15 cm to move all the side ports into the stomach. Right jugular line ends in The upper SVC. . CHEST (PORTABLE AP) Study Date of [2143-9-5] 2:09 AM NG tube tip is in proximal stomach with the sidehole at the Gastroesophageal junction and should be advanced. New bibasilar opacities ____might be consistent with combination of atelectasis and aspiration, although infection cannot be excluded. Mild vascular engorgement. . UNILAT UP EXT VEINS US RIGHT Study Date of [2143-9-12] 8:45 AM IMPRESSION: No evidence of DVT involving the right upper extremity. . DUPLEX DOPP ABD/PEL Study Date of [2143-9-12] 8:45 AM 1. Echogenic liver consistent with fatty infiltration. Other forms of liver disease including fibrosis/cirrhosis cannot be excluded on this study. 2. Cholelithiasis without evidence of acute cholecystitis. 3. Ascites. 4. Unremarkable Doppler evaluation of the hepatic vessels. . CARDIOLOGY ========== TTE (Complete) Done [2143-9-3] at 7:47:28 AM FINAL Mild bileaflet mitral valve prolapse with mild mitral regurgitation. Preserved regional and global biventricular systolic function. Mild pulmonary hypertension. . ECG Study Date of [2143-9-3] 10:45:16 AM Baseline artifact. Sinus rhythm. Q waves in leads V1-V2 with mild ST segment elevation. Consider septal myocardial infarction, age undetermined. Other ST-T wave abnormalities. Compared to the previous tracing of [2143-8-30] no significant change in previously noted findings. Brief Hospital Course: Ms. [Known lastname ] was admitted for nausea, vomiting, and dehyration. On hospital day 3, she underwent examination under anesthesia, exploratory laparotomy, drainage of ascites, tumor debulking, intracolic omentectomy, small bowel resection with reanastomosis (stapled), bilateral salpingo-oophorectomy, supracervical hysterectomy, cystoscopy. Please see operative note for complete details. Post-operatively, she was transfered to the ICU briefly through post-operative day 1 when she was transfered to the floor. Her hospital course was characterized by the following issues: . ) Neuro: Upon transfer to the floor post-operative day 1, Ms. [Known lastname ] experienced hypoventilation (RR 5-6 during sleep) thought to be secondary to narcotics. She received naloxone x2, with resumption of normal respiratory rate. She was fully arousable during the period of hypoventilation. Her pain was subsequently managed with dilaudid and toradol with little relief of pain. The chronic pain service was consulted on post-operative day 3; she was subsequently placed on a morphine PCA with toradol as needed. After being made DNR/DNI (see below under Palliative Care), Ms. [Known lastname 16391] pain was also managed with a fentanyl patch. To help minimize pain from bowel edema and distention, Ms. [Known lastname ] was also placed on IV dexamethasone on post-operative day 13. . ) Cardiac: Given her history of mitral valve prolapse, an echocardiography was obtained and showed mild bileaflet mitral valve prolapse with mild mitral regurgitation; preserved regional and global biventricular systolic function mild pulmonary hypertension. . Ms. [Known lastname ] had hypotension intra-operatively, requiring 3 untis of PRBC and placement on a neosynephrine drip. She was transfused another 2 units of RPBC in the ICU, bolused 3 liters of IVF, and eventually weened off of the neo drip. She had no other episodes of hypotension nor any cardiac complaints during her hospital course. . ) Respiratory After extubation in the ICU on post-operative day 1, Ms. [Known lastname ] had no respiratory issues or complaints. . ) Renal Pre-operatively, Ms. [Known lastname ] had decreased urine output from pre-renal etiology (FeNA <0.1), likely secondary to third spacing from increased vascular permeability and decreased intravascular oncotic pressures. Her urine output remained marginal but adequate during her hospital course. Her creatinine was stable throughout her hospitalization. . ) Hematology/Oncology Ms. [Known lastname ] was anemic on admission. She was transfused a total of 5 units of PRBC as described above. Her hematocrit increased appropriately and remained stable for the remainder of her hospitalization. . RUE extremity edema > LUE was evaluated on post-operative day 9 with an unremarkable RUE doppler study. . Hematology oncology was consulted on post-operative day 8 for possible chemotherapy during hospitalization. Her pathology report was finalized on post-operative day 9 and after discussion of prognosis and potential response to chemotherapy with the medical oncologists and the palliative care service (see below), Ms. [Known lastname ] and her partner decided to decline chemotherapy. . ) Palliative Care Ms. [Known lastname ] and her partner desired to meet with the Palliative Care Service on post-operative day 10 after Ms. [Known lastname ] had an elevated temperature (see below), for which she declined work-up of other than blood and urine cultures. She was made DNR/DNI on post-operative day 10. . ) GI: Ms. [Known lastname ] was admitted and made NPO with IVF given her inability to tolerate PO. Her nausea pre-operatively was controlled with IV antiemetics. Given her small bowel resection, a NGT was placed intra-operatively. It was eventually discontinued on post-operative day 4. Ms. [Known lastname 16391] nausea was well-controlled on IV antiemetics until post-operative day 8 when she began having nausea and vomiting. Ms. [Known lastname ] also began appearing jaundiced at this time and LFTs revealed elevated AST, ALT, and bilirubin. RUQ ultrasound was unremarkable. Hepatitis serologies were positive only for Hepatitis A antibody. Possible etiologies included TPN induced transaminitis, pre-existing fatty liver disease (as seen on CT scan [2143-8-30]), or toradol induced hepatotoxicity. LFTs were stable for the remainder of her hospitalization. Plans were made for a repeat CT abdomen and pelvic to evaluate bowel patency; however, Ms. [Known lastname ] later declined that study. After being made DNR/DNI, gastric secretions were controlled with octreotide. She was also started on a scopolamine patch. She was given an intramuscular injection of octreotide prior to discharge from the hospital. . ) ID: afebrile Ms. [Known lastname ] received Ancef and Flagyl x 3 days post-operatively for infection prophylaxis. She remained afebrile until post-operative 10 when she had a T max 101.3. Erythema was noted on her incision. She declined work-up, except for urine and blood cultures. She was started on empiric antibiotics levofloxacin and flagyl; these were discontinued on discharge. She otherwise remained afebrile for the remainder of her hospital course. . ) FEN: Ms. [Known lastname ] was started on TPN on post-operative day 3. She was unable to tolerate more than liquids during her hospital course and, after her nausea and vomiting recurred, was NPO for the remainder of her hospital course. Her electrolytes were checked daily and repleted as needed. . Ms. [Known lastname ] was eventually discharged on post-operative day 13 with home hospice care. Medications on Admission: ativan prn for sleep Discharge Medications: 1. Ketorolac Tromethamine 30 mg/mL Solution Sig: Thirty (30) mg Injection Q6H (every 6 hours). Disp:qs mg* Refills:2 2. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). Disp:3 Patch 72 hr(s) Refills:2 3. Octreotide Acetate 100 mcg/mL Solution Sig: Three (3) ml Injection every eight (8) hours. Disp:qs Refills:2 4. medication Ativan 1mg transdermal every 8 hours as needed for nausea 5. medication Dexamethasone 10mg transdermal every 8 hours as needed for pain and nausea 6. medication Dexamethsone 20mg suppository every 12 hours as needed for pain and/or nausea 7. medication Compazine 25-50mg suppository every 12 hours as needed for nausea 8. Scopolamine Base 1.5 mg Patch 72 hr Sig: [1-24] Patch 72 hrs Transdermal ONCE (Once). Disp:qs Patch 72 hr(s) Refills:2 9. Ativan 2 mg/mL Solution Sig: 0.5-1 mg Injection every [4-28] hours as needed for nausea. Disp:qs Refills:2 10. Dexamethasone Sodium Phosphate 10 mg/mL Solution Sig: One (1) ml Injection twice a day. Disp:qs Refills:2 11. Morphine PCA PCA Settings: No basal rate, 0.7mg bolus with 6 minute lockout, maximum dose = 7 mg/hour Discharge Disposition: Home With Service Facility: VNA & Hospice of [Hospital3 ] Discharge Diagnosis: ovarian cancer Discharge Condition: stable Discharge Instructions: General instructions: * Take your medications as prescribed. . Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. Followup Instructions: Please call Dr. [Last Name (STitle) 2028] at [Telephone/Fax (1) 5777] if you have any questions [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [MD Number(2) 6753]	[ "998.59", "183.0", "458.29", "276.51", "285.1", "789.59", "276.7", "518.81", "424.0", "198.82", "197.6", "198.1", "E935.8", "794.8", "198.89", "198.6", "E878.6", "197.4" ]	icd9cm	[ [ [] ] ]	[ "57.32", "65.61", "99.04", "99.15", "54.4", "68.39", "45.62" ]	icd9pcs	[ [ [] ] ]	20711, 20775	13750, 19446	321, 562	20834, 20843	3878, 13727	21056, 21285	3023, 3070		19517, 20688		20796, 20813		19472, 19494			20867, 20930							20945, 21033	2451, 2840	3085, 3859																									265, 283									590, 2165																	2210, 2427	2856, 3007
25,751	103,930	9799	Discharge summary	report	Admission Date: [2163-4-20] Discharge Date: [2163-5-16] Date of Birth: [2092-1-17] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1283] Chief Complaint: Progressive dyspnea on exertion. Major Surgical or Invasive Procedure: Coronary artery bypass graft x 3 [2163-4-22]. Sternal rewiring [2163-5-2]. History of Present Illness: This is a 71 yo male patient with known history coronary artery disease who was previously turned down for a CABG in [2143] due to obesity and was lost to follow-up. He presented recently with complaints of worsening shortness of breath with exertion and was referred for cath showing 3VD. At that time he was transferred to the [Hospital1 18] for eval for CABG. Past Medical History: Coronary artery disease. Hypertension. Hyperlipidemia. CVA in [2148]. Social History: Lives in [Hospital1 10478] with his wife. Retired engineer. Not very active secondary to severe shortness of breath. Reports that he quit smoking 45 years ago afetr a 415 pack year history. Reports very rare ETOH consumption. Family History: Father deceased at age 50 with MI. Mother deceased at ago 72 with MI but [Last Name (un) 27185] MI in her 50s. Pertinent Results: [2163-5-16] 06:00AM BLOOD WBC-14.8* RBC-3.45* Hgb-10.1* Hct-30.7* MCV-89 MCH-29.3 MCHC-33.0 RDW-14.1 Plt Ct-232 [2163-5-16] 06:00AM BLOOD Plt Ct-232 [2163-5-7] 09:55AM BLOOD PT-16.9* PTT-28.2 INR(PT)-1.9 [2163-5-15] 04:45AM BLOOD Glucose-80 UreaN-12 Creat-1.1 Na-140 K-4.1 Cl-103 HCO3-29 AnGap-12 [2163-5-4] 06:30AM BLOOD ALT-30 AST-19 AlkPhos-74 Amylase-18 TotBili-0.5 [2163-5-8] 04:10AM BLOOD Calcium-7.9* Phos-3.0 Mg-2.0 Brief Hospital Course: Mr. [Known lastname 32993] was admitted from an OSH on [2163-4-20] pre-op for CABG. Because of his severe 3VD he was started on heparin and nitroglycerine drips for optimal control of his CAD. He underwent pre-op workup including pre-op head CT (with hx of CVA) and carotid ultrasound. On [2163-4-22] he proceeded to the OR and underwent a CABG x 3 with LIMA to the LAD, SVG to the OM, and SVG to the Ramus with patch angioplasty and repair of ramus posterior rupture (subacute). Please see OP note for full details. He was successfully weened and extubated on his operative evening. On POD one he remained in the ICU for ongoing hemodynamic monitoring and on POD two he was transferred to the in-patient telemetry floor for ongoing care. In the early morning hours on POD three, Mr. [Name14 (STitle) 32994] was found to be talking non-sensically and trying to get out of bed. A neuro consult, head CT and MRI were obtained for suspected acute CVA. He was found to have small right parietal, left cerebellar, and right cerebellar infarcts thought to be embolic with new post-operative atrial fibrillation. Over PODs four and five Mr. [Known lastname 32993] continued to wax and waine; he was continued on his heparin and coumadin per neuro recs. On POD six his mental status was noted to be significantly improved with neuro recs only for ongoing anticoagulation for stroke prevention. Also on POD six he was noted to have new sternal drainage. His WBC bumped up to 18 (from 13) for which he was pan-cultured. He had continued bursts of atrial fibrillation and was started on amiodarone. On POD seven his sternal drainage significantly increased; due to his elevated INR, he was unable to return immediately to the OR. On POD nine ([5-2]) his INR fell below 1.7 and he returned to the OR for sternal rewiring. On POD eleven he was found to be C. diff positive with multiple loose stools and on POD thirteen he was noted to have guaiac positive stools. An endoscopy showed bleeding ulcers in the duodenal bulb accounting for the patient's GIB and hemostasis was obtained. He was started on IV protonix with serial Hcts to monitor progress. He was transfused as necessary and was taken off of his anticoagulation. After two days in the ICU for close hemodynamic monitoring in light of GIB, he was again transferred to the inpatient floor on PODs 16 and 5. He continued to work with the physical therapy team throughout his stay but it was not felt that he was safe for home. He was screened for rehabilitation. On PODs 20 and 9, a new rash was noted on trunk and Mr. [Known lastname 32995] antibiotics were discontinued. The rash resolved and on PODs 24 and 13, it was decided that he was safe for transfer to a rehabilitation facility for ongoing management, treatment, and rehabilitation. Final recommendations from the neurology service are for coumadin as soon as cleared by GI with 325 mg aspirin daily until then; to follow-up with primary neurologist. GI recommends re-starting Coumadin 14 days post bleed: [2163-5-10]. Start coumadin at low dose and keep INR at low-end of theraupetic. Medications on Admission: Aspirin 325 daily. Multivitamin daily. Lipitor 20 daily. Nifidipine XL 30 daily. Mirapex 1.5 [Hospital1 ]. Reminyl 12 daily. Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. 2. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. 5. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Galantamine Hydrobromide 4 mg Tablet Sig: Three (3) Tablet PO bid (). 9. Pramipexole Dihydrochloride 1 mg Tablet Sig: 1.5 Tablets PO bid (). 10. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 11. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO once a day for 7 days: To be followed by 200 mg daily dosing. 12. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO once a day. Tablet(s) 13. Metoprolol Tartrate 25 mg Tablet Sig: [1-9] Tablet PO twice a day. 14. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital3 15644] Long Term Health - [Location (un) 47] Discharge Diagnosis: Coronary artery disease. Cerebral vascular accident. Sternal wound dehissence. Gastrointestinal bleed. Discharge Condition: Stable. Discharge Instructions: Wash incisions daily with soap and water. Rinse well. Do not apply any creams, lotions, powders, lotions, or ointments. No lifting greater than 10 pounds. Strict sternal precations. [Last Name (NamePattern4) 2138]p Instructions: Call to schedule appointment with Dr. [Last Name (Prefixes) ] in 4 weeks. Call to schedule appointment with Dr. [Last Name (STitle) 32996] in 2 weeks. Call to schedule appointment with cardilogist in 2 weeks. Call to schedule appointment with primary neurologist in [2-11] weeks. Please check Hct one week post-discharge from [Hospital1 18]. Low-dose Coumadin should be started [2163-5-20]. Completed by:[2163-5-16]	[ "008.45", "997.02", "401.9", "E934.2", "434.11", "998.31", "272.0", "427.31", "278.00", "693.0", "532.00", "E930.8", "414.01", "V12.59" ]	icd9cm	[ [ [] ] ]	[ "44.43", "99.04", "39.61", "88.72", "77.61", "99.07", "34.79", "36.15", "36.12" ]	icd9pcs	[ [ [] ] ]	6381, 6471	1811, 4950	354, 440	6618, 6627	1339, 1788		1204, 1320		5129, 6358		6492, 6597		4976, 5106			6651, 6836		6887, 7330																																282, 316									468, 841																	863, 938	954, 1188
29,073	111,552	48084	Discharge summary	report	Admission Date: [2112-3-30] Discharge Date: [2112-4-2] Service: MEDICINE Allergies: Ace Inhibitors / Gatifloxacin / Shellfish Derived / Hydrocodone/Acetaminophen Attending:[First Name3 (LF) 13386] Chief Complaint: Fall, Hypotension Major Surgical or Invasive Procedure: Surgiseal closure of head laceration History of Present Illness: 87yM with hx of COPD, dCHF, heart block s/p PPM, DM, and CKD who presented after a fall at nursing home. Patient was found down on bathroom floor with copious bleeding from head and staff called EMS. Patient denied LOC. Recently hospitalized at [Location 1268] VA when found fallen in the stairwell after an OP appointment at the VA. Discharged 4 days prior to current presentation with diagnosis of pneumonia. Of note, patient had another fall one day after discharge from VA. In ED, vitals 99.2, HR 64, BP 108/82, 16, 100% RA. Labs showed leukocytosis to 10.1, lactate to 2.4, Hct 28.5. SBP dropped to 80s which responded to 2L. Head CT, Abdomen/Pelvis CT, and FAST negative for bleeding. Forehead laceration from fall bled profusely and sealed with gel foam. On floor he received ceftriaxone and flagyl for presumed pneumonia. Was then found to be hypotensive to 80s despite numerous fluid boluses. Hct dropped to 23.8. Pt endorsed light-headedness, some difficulty breathing, +productive cough x2 weeks (no blood). RofS negative for abd pain, nausea, vomiting, diarrhea, chest pain, dysuria, weakness, numbness, tingling, headache. Past Medical History: -Bladder cancer --HGT1 w/ CIS, s/p BCG Therapy with subsequent BCG-osis - was found to have suspicious etiology in [8-2] and subsequently has had three atypical cytologies -Heart Block s/p PPM -Atrial Flutter -Seborrheic keratosis -Squamous Cell Carcinoma of Skin -CKD 4 -Senile Cataract -Hypertension - COPD - CHF (Diastolic) - AAA (s/p endovascular repair) - with bleeding in small intestine during capsule endoscopy - could not identify source. -Hyperlipidemia -DM type II -Prostate Benign Hypertrophy -Colonic Polyps Social History: Lives in [Hospital 599] nursing home x2 years. Two children in [State 4565], one locally in [State 350], one in [State 531]. Family History: Denies any family history of diseases including blood/bleeding diseases and cancer. Physical Exam: General Appearance: Well nourished, No acute distress Neuro: Alert, oriented, appropriate. Symmetric strength and sensation in all 4 extremities. Symmetric smile. Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic, Dry oral mucosa, large beefy tongue Lymphatic: JVP at level of ears with double pulsation. Cardiovascular: Normal S1 and S2. Grade III holosystolic murmur at LLSB which increases on inspiration. Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles : Course, Bilaterally at bases, L>R) Abdominal: Non-tender, Bowel sounds present, No(t) Tender: , Somewhat firm, bruising diffuse at inferior aspect. Extremities: Right lower extremity edema: Absent, Left lower extremity edema: Absent. Extremities warm and dry. Skin: Warm Neurologic: A&O x3Attentive, Follows simple commands, Responds to: Not assessed, Oriented (to): Place, Date, Time, Movement: symmetric in all 4 extremities. Pertinent Results: [2112-3-30] 08:16PM GLUCOSE-47* UREA N-73* CREAT-2.6* SODIUM-135 POTASSIUM-3.6 CHLORIDE-105 TOTAL CO2-22 ANION GAP-12 [2112-3-30] 08:50PM LACTATE-1.4 [2112-3-30] 08:16PM ALT(SGPT)-48* AST(SGOT)-24 LD(LDH)-195 ALK PHOS-122 TOT BILI-0.5 [2112-3-30] 08:16PM LIPASE-268* [2112-3-30] 08:16PM CK-MB-5 cTropnT-0.14* [2112-3-30] 08:16PM WBC-14.4* RBC-2.17* HGB-7.4* HCT-23.6* MCV-109* MCH-34.1* MCHC-31.5 RDW-17.2* [2112-3-30] 08:16PM PT-12.3 PTT-31.1 INR(PT)-1.0 . Discharge Labs: [2112-4-2] 06:30AM BLOOD WBC-9.4 RBC-3.01* Hgb-10.0* Hct-30.4* MCV-101* MCH-33.4* MCHC-33.0 RDW-19.7* Plt Ct-45* [2112-4-2] 06:30AM BLOOD Glucose-149* UreaN-68* Creat-2.3* Na-136 K-4.9 Cl-106 HCO3-19* AnGap-16 [2112-4-2] 06:30AM BLOOD Calcium-8.3* Phos-3.1 Mg-2.3 . Studies: [2112-4-1] CXR REASON FOR EXAM: Heart failure, received fluids. Comparison is made with prior study performed the same day in the morning. Cardiomediastinal contours are unchanged. Small bilateral pleural effusions associated with adjacent atelectasis, left greater than right, are minimally increased from prior. Pacer leads remain in place, as is the right PICC. There is no pulmonary edema. . [2112-4-1] R hand xray FINDINGS: There is a comminuted fracture of the fifth proximal phalanx. . [2112-3-31] Abd/pelvis CT IMPRESSION: 1. No evidence of retroperitoneal bleed. 2. Stable 5.5 cm infrarenal abdominal aortic aneurysm sac, status post endovascular repair. 3. Slightly increased small bilateral pleural effusions and slight increased free fluid in the pelvis. 4. Cholelithiasis. . [2112-3-31] Transthoracic Echo The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed (LVEF= 45-50 %) with mid to distal septal and distal inferior hypokinesis. There is no ventricular septal defect. The RV appears dilated with preserved systolic function.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. There is no mitral valve prolapse. Mild to moderate ([1-30]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Severe [4+] tricuspid regurgitation is seen. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2111-8-19], regional LV systolic dysfunction is now present and the severity of TR has increased. . [2112-3-29] CT Head IMPRESSION: 1. No acute intracranial abnormality. 2. Left frontal scalp laceration and subgaleal hematoma without underlying fracture. 3. Bilateral sinus disease with air-fluid levels may indicate acute sinusitis. Clinical correlation recommended. . [2112-3-29] CT spine IMPRESSION: 1. No acute fracture or malalignment. 2. Multilevel degenerative change with mild-to-moderate canal narrowing at C3-4 and C4-5 as above may predispose the patient to cord injury in the setting of trauma. If there is clinical concern for cord injury and there is no contraindication, MRI is recommended for further evaluation. 3. Unchanged mild compression deformity of C7. Brief Hospital Course: 87 M with MMP, presents s/p fall and hypovolemia admitted to the ICU for hypotension. . # Hypotension: Dropped to 80s in setting of elevated Cr, Lactate and compressable IVC. After 2L of NS in ED his blood pressure increased to the 110s. [Last Name (un) ] Stim was normal, so unlikely adrenal insufficiency. No fever or leukocytosis so unlikely sepsis/infection. TSH was normal so not hypothyroidism. Patient had ECHO with worsening EF (45-50%) and LV systolic dysfunction new since [7-/2111] so it was felt that his hypotension was likely due to hypovolemia and poor forward flow in the setting of CHF. Acute MI was ruled out with CE flat x3 (though troponin 0.14 0.12 in setting of ARF) He was not given any further fluid but transfused 3 units of PRBCs. His blood pressure meds were held and he remained normotensive in the ICU. Back on the floor his pressures were stable but he was kept off of all anti-hypertensives on discharge. . # Head laceration: Head lac not actively bleeding and surgiseal was applied in the ED. General surgery was consulted in the ICU and said that no further intervention is needed. The laceration will heal and the surgiseal slough off. . # R 5th digit fracture - he was elgvaulated by hand surgery and placed in a splint. Advised to keep RUE elevated. Has hand clinic followup on [2112-4-12]. To continue PT and OT in rehab. . # Macrocytic Anemia: HCT 28 on arrival and dropped to 23 after ICF resuscitation. After two units of PRBCs the patient's HCT improved to 28 and after a 3rd unit his HCT was >30. His retic was checked and was 5.8%. . # Heart Block s/p PPM, Atrial Fibrillation: Coumadin on med list, but INR 1. Coumadin was not restarted given head laceration and high risk of fall. His aspirin was also held per Geriatrics recommendations (given chronic thrombocytopenia and history of GI bleeding). He was in atrial fibrillation with a paced rate of 60. His heart rate did not increase in the setting of hypotension, remaining at 60bpm. The EP team interrogated his pacer, finding that he is almost entirely in Afib and paced at 60bpm. The pacer's responsiveness feature was activated and the basal rate was raised to 70bpm to hopefully reduce future hypotensive episodes. . # Acute on Chronic renal failure: Cr 3 from baseline 2.3-2.5. After 2L IVF and 2 units PRBCs his creatinine 2.1 so likely pre-renal azotemia. Creatinine was back at baseline 2.3. . # ? COPD: Unclear if patient has COPD or another underlying lung process. He was continued on his home nebs. . # CHF (Diastolic): Lasix was held in the setting of hypotension. . # DM type II: Patient placed on a diabetic diet and his home insulin regimen. However, serum glucose in the AM was 62 and he was taking poor POs so his NPH was cut in half and he was continued on SSI. He was returned to his usual insulin dose for discharge. . # ? Health care associated Pneumonia - the patient was started on antibiotics (vancomycin and cefepime) while in the ICU out of concern for pneumonia. Course began on [2112-3-30]. These were then taped to ceftriaxone on [2112-4-1], which was switched to cefpodoxime on discharge to complete a 10 day course ending [2112-4-8]. . # Code - DNR/I, confirmed Medications on Admission: Advair 25/50 1 puff [Hospital1 ] Spiriva 18mcg inhaler Forticort nasal spray Zocor 10mg PO Qhs Effexor 75mg PO QD Remeron 50mg PO QD Asa 81mg PO QD Isordil 10mg TID Lasix 100mg PO QD Colace 200mg PO QD Neurontin 200mg TID Senna 1 tablet PO BID Colace 200mg PO QD Lactulose 10g/50ml??????20ml PO QD Insulin NPH 15U Qam Regular Insulin Sliding Scale qAC &HS Calcitonin Ambien 5mg Qpm Discharge Medications: 1. 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 SOB. 2. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig: One (1) Spray Nasal DAILY (Daily): Alternating nostrils. 3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation [Hospital1 ] (2 times a day). 4. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours). 5. Lactulose 10 gram/15 mL Solution Sig: Thirty (30) mL PO once a day. 6. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 8. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 10. Venlafaxine 37.5 mg Capsule, Sust. Release 24 hr Sig: Two (2) Capsule, Sust. Release 24 hr PO DAILY (Daily). 11. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever. 13. Bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO once a day as needed for constipation. 14. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day) as needed for heartburn. 15. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 16. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 17. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: Fifteen (15) units Subcutaneous QAM. 19. Insulin Regular Human 100 unit/mL Solution Sig: As directed units Injection QACHS: Please take per sliding scale. 20. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 21. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO once a day for 6 days: course to end on [2112-4-8]. 22. Erythromycin 5 mg/g Ointment Sig: One (1) drop Ophthalmic QID (4 times a day). 23. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN (as needed) as needed for dry eyes. Discharge Disposition: Extended Care Facility: [Hospital1 599] of [Location (un) 55] Discharge Diagnosis: Primary diagnosis: Hypotension secondary to volume depletion, bleeding and possible sepsis Secondary diagnoses: Health-care associated pneumonia Discharge Condition: Mental Status: Subacute delirium Level of Consciousness: Alert, oriented to person and place Activity Status: Out of Bed with assistance to chair or wheelchair Discharge Instructions: You were admitted to the hospital after falling and cutting your head. The cut on your head was covered and your broke your finger, requiring a splint. You lost a lot of blood, requiring a total of 3 blood transfusions. Your blood pressure was low, and you received several liters of fluid. You are now ready to go back to rehab and work on getting strong. . Some changes were made to your medications: - Your blood pressure medications (are being held to prevent further hypotension or low blood pressure) - your coumadin (blood thinner) is also being held - you are being given a course of antibiotics to end on [2112-4-8] Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. Followup Instructions: You will be seen by the doctors at your rehab facility. . Follow-up in hand clinic on Tuesday, [2112-4-12]. Call the hand clinic at [Telephone/Fax (1) 3009] to make the appointment.	[ "428.32", "518.0", "427.31", "403.90", "250.00", "458.9", "276.52", "574.20", "816.01", "V10.51", "V45.01", "V58.61", "585.4", "486", "E888.9", "V10.83", "424.0", "873.42", "428.0", "584.9", "600.00", "496", "E849.7", "285.1" ]	icd9cm	[ [ [] ] ]	[ "38.93", "89.45" ]	icd9pcs	[ [ [] ] ]	12683, 12755	6783, 10014	303, 342	12945, 12945	3446, 3946	13876, 14070	2239, 2324		10450, 12660		12776, 12776		10040, 10427			13131, 13853	3963, 6760								2339, 3427			12889, 12924																						246, 265									370, 1515							12795, 12868			12960, 13107							1537, 2065	2081, 2223
46,154	163,315	54885	Discharge summary	report	Admission Date: [2196-7-29] Discharge Date: [2196-7-29] Service: MEDICINE Allergies: aspirin / Penicillins Attending:[First Name3 (LF) 1145] Chief Complaint: Monomorphic VT Major Surgical or Invasive Procedure: None History of Present Illness: [Known firstname 24039] is a [Age over 90 ] year old spanish speaking nursing home male with PMHx significant for CAD with prior MI s/p stent to LAD in early [2183], pacemaker [2186] for sick sinus, MR, COPD, PUD, asthma, gout, diverticultitis, a fib, CHF EF 35%, and a recent hospitalization at the OSH from [Date range (1) 112121] for PNA requiring intubation and mechanical ventilation who presents as a transfer from an OSH with Monomorphic VT. He initially presented to the OSH from his nursing home on [7-27] with SOB x48 hours and feeling weak, also complained of sharp pains in his stomach. In the ED he was hypotensive with SBP in the 70s and he was started on levophed and broad spectrum Abx. The patient remained a-febrile and ID recomended stoping Abx as his CXR was unchanged from his past hospitalization. He was weaned off levophed in the ED with stable BPs in the 110s. He had a V/Q scan that showed intermediate prob of PE, U/S negative for DVT. He was placed on heparin drip. He was sent to the floor. At 3pm on [7-28] he developed VT to 200-250s. He was mentating well at this time but he was DC cardioverted and given amiodarone. He converted to his baseline EKG and per report there were no EKG changes. 30 min later he again went into VT, and cardioverted again without conversion. 2grams Mg and 150mg Amio. 50mcg lidocaine and started on lidocaine drip. Converted back to a-fib. No change in his BP during these events. Transfered to the CCU where he became hypotensive to SBPs 60s. He was started on lidocaine, amio, dopa and devolped wide complex tachy with rates 150 sometime after 7pm. They increased his lidocaine to 2mg and he converted to a fib with rates in 60s, 50% pacer dependent. He was changed to neo drip, off dopamine, still on amio and lido at time of trasfer. Also of note per report, pacer working properly. He also had an episode of vomiting, followed by BP decreased requiring the above start of dopamine and then switched to neo. Per the family, vomitus was dark red, concerning for blood. At the OSH his labs were notable for troponin of 1.2 that trended to 0.6, a positive d-dimer. Vitals on transfer were not given. Per report the patients SBP was in the 90s. . On arrival to the floor, patient was minimally responsive. He was very cool to the touch and it was difficult to obtain an accurate BP, O2 sat or temperature. His urine output since 7pm was noted to be only 31 cc. Past Medical History: 1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, + Hypertension 2. CARDIAC HISTORY: -CABG: -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: pacemaker [2186] for sick sinus ([Hospital3 9642] Pacemaker) 3. OTHER PAST MEDICAL HISTORY: A-fib CAD with prior MI CHF with EF 35% COPD HTN PUD Asthma Diverticulosis Gout moderate MR Social History: Lives with his wife Family History: Non-contributory Physical Exam: VS: T=99.4 BP=83/50 HR=50 (v-paced) RR=35 O2 sat= unable to obtain GENERAL: Elderly man, laying in bed, tachpnic, uncomfortable. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple. CARDIAC: RR, brady cardic, distant heart sounds. normal S1, S2. Possible faint systolic murmer left sternal boarder, no r/g. No S3 or S4. LUNGS: Tachpnic, +use of accessory muscles, expitory ronchi bilaterally in all lung fields. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: Cool in all 4 extermities. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ DP dopplerable PT dopplerable Left: Carotid 2+ DP dopplerable PT dopplerable Pertinent Results: [2196-7-29] 02:39AM BLOOD WBC-10.8 RBC-3.16* Hgb-10.7* Hct-34.2* MCV-108* MCH-34.0* MCHC-31.4 RDW-14.3 Plt Ct-287 [2196-7-29] 02:39AM BLOOD Plt Ct-287 [2196-7-29] 02:39AM BLOOD PT-14.5* PTT-150* INR(PT)-1.4* [2196-7-29] 02:39AM BLOOD Glucose-231* UreaN-27* Creat-1.8* Na-137 K-3.2* Cl-112* HCO3-12* AnGap-16 [2196-7-29] 02:39AM BLOOD ALT-PND AST-PND LD(LDH)-PND CK(CPK)-38* AlkPhos-PND TotBili-PND [2196-7-29] 02:39AM BLOOD Albumin-PND Calcium-5.8* Phos-3.9 Mg-1.9 [2196-7-29] 06:35AM BLOOD Type-ART pO2-70* pCO2-60* pH-7.07* calTCO2-18* Base XS--13 [2196-7-29] 05:11AM BLOOD Type-ART pO2-309* pCO2-26* pH-7.31* calTCO2-14* Base XS--11 [2196-7-29] 06:35AM BLOOD Glucose-182* Lactate-5.8* Na-132* K-4.7 Cl-111* [2196-7-29] 05:11AM BLOOD Lactate-3.8* [2196-7-29] 06:35AM BLOOD freeCa-1.48* [2196-7-29] 06:35AM BLOOD O2 Sat-85 Brief Hospital Course: Mr [Known lastname 112122] is a [Age over 90 ] yo male with PMHx significant for CAD with prior MI s/p stent to LAD in early [2183], pacemaker [2186] for sick sinus, MR, COPD, PUD, asthma, gout, diverticultitis, a fib, CHF EF 35%, and a recent hospitalization at the OSH from [Date range (1) 112121] for PNA requiring intubation and mechanical ventilation who presents as a transfer from an OSH with hypotension and Monomorphic VT. He required increasing pressor support. He entered PEA arrest at 06:10 and was coded until 06:45. He had intermitant return of circulation and finally entered asystole that was non-responsive to medication. He was pronounced dead at 06:45. Medications on Admission: Preadmissions medications listed are incomplete and require futher investigation. Information was obtained from Family/Caregiver Outside hospital transfer note. 1. Clopidogrel 75 mg PO DAILY 2. Famotidine 20 mg PO BID 3. Simvastatin 40 mg PO DAILY 4. Carvedilol 6.25 mg PO BID 5. Ferrous Sulfate 325 mg PO DAILY 6. Allopurinol 300 mg PO DAILY AST Approval Required 7. Tiotropium Bromide 1 CAP IH DAILY 8. Acetaminophen 650 mg PO Q6H:PRN Pain AST Approval Required 9. Furosemide 20 mg PO DAILY 10. Quetiapine Fumarate 12.5 mg PO HS 11. Albuterol Inhaler [12-7] PUFF IH Q6H:PRN SOB 12. Symbicort NF (budesonide-formoterol) 160-4.5 mcg/actuation Inhalation [Hospital1 ] 13. Lisinopril 2.5 mg PO DAILY 14. Famvir NF (famciclovir) 500 mg Oral Q8hours Discharge Medications: Deceased Discharge Disposition: Expired Discharge Diagnosis: Deceased Discharge Condition: Deceased Discharge Instructions: Deceased Followup Instructions: Deceased	[ "427.31", "486", "V45.01", "533.90", "414.01", "789.00", "424.0", "428.0", "785.50", "427.1", "412", "584.9", "274.9", "562.10", "V45.82", "493.20", "427.5", "507.0" ]	icd9cm	[ [ [] ] ]	[ "96.04", "38.91", "99.60" ]	icd9pcs	[ [ [] ] ]	6457, 6466	4917, 5610	244, 250	6518, 6528	4021, 4894	6585, 6596	3148, 3166		6424, 6434		6487, 6497		5636, 6401			6552, 6562									3181, 4002				2843, 2971																					190, 206									278, 2733												3002, 3095					2755, 2823	3111, 3132
5,727	191,504	51917	Discharge summary	report	Admission Date: [2153-12-27] Discharge Date: [2154-1-2] Date of Birth: [2096-11-3] Sex: M Service: MEDICINE Allergies: Morphine Attending:[First Name3 (LF) 9240] Chief Complaint: shortness of breath, chest pain Major Surgical or Invasive Procedure: none History of Present Illness: 57 y/o M with h/o GIB, HTN, CAD, CHF, PAFib, DM2, CRI p/w 2 days intermittent CP, described as [5-23], sharp, not pressure, aggrevated by acitivity and relieved by rest, as well as worsening SOB, increased LE edema, and increased abdominal girth. ROS positive for orthopnea, cough with activity, and decreased functional status. Recent crack use two days ago. Denied black or bloody stools. Denied hematemesis. Hematocrit 17 in the ED with black guaiac + stool. . In the ED, given nitroglycerin SL 0.4 mg SL, aspirin 325mg, pantoprazole 40mg, hydromorphone, and 1 unit PRBCs. Per report, patient vehemently refused NGT and gastric lavage. . ICU Course: 4 units PRBC. Remained HDS. Dyspnea improved with Tx and lasix. S/P I&D of furnucle on face. . ROS: Positive for nightime coldness, hard stools. No night sweats, fevers, sick contacts, dysuria, or diarrhea. Past Medical History: Polysubstance abuse - crack cocaine, EtOH, tobacco. Hypertension Type II diabetes mellitus Dyslipidemia CAD s/p MI, MIBI in [11-18] showed inf/lat reversible defect CHF EF 20-30% severe global HK. Atrial Fibrillation CRI Anemia GI Bleed- Duodenal AVM's, Angioectasia in the proximal jejunum, Angioectasia in the stomach body, s/p thermal therapy, sigmoid diverticuli Hepatitis C Chronic pancreatitis Affective disorder s/p multiple psychiatric hospitalizations due to SI Depression GERD Gout s/p Arthroscopy with medial meniscectomy [5-/2149] Inflatable penile prosthesis [5-/2148] Social History: Usually lives in apt with his girlfriend. [Name (NI) ] used to be an electrician for [Company 31653], but has been on disability. Tob: 45 pack-yr EtOH: history of abuse with hospitalizations for delirium [Company 107492] and detoxification. Has not been drinking recently. Illicits: 15 yr h/o Crack cocaine use, last used two days ago. Family History: His father with alcoholism and an uncle who committed suicide by hanging, and a cousin with [Name2 (NI) 14165] cell anemia Physical Exam: T 97.6 BP 180/89 HR 112 RR 28 Sat 100% on 5LNC Wt 87 kg Mildly tachypneic, speaking in sentances elevated JVP rales midway up back low pitched systolic murmur at apex abdominal distention, mild right sided tenderness pitting edema of lower ext to thighs no blood in stool, black stool, trace guaiac positive Pertinent Results: [2153-12-27] 09:22PM GLUCOSE-96 UREA N-51* CREAT-3.3* SODIUM-140 POTASSIUM-4.4 CHLORIDE-110* TOTAL CO2-20* ANION GAP-14 [2153-12-27] 09:22PM CK(CPK)-116 [2153-12-27] 09:22PM CK-MB-5 cTropnT-0.10* [2153-12-27] 09:22PM CALCIUM-8.7 PHOSPHATE-3.8 MAGNESIUM-1.9 [2153-12-27] 09:22PM WBC-9.3 RBC-2.75* HGB-7.2# HCT-21.5 MCV-78* MCH-26.3* MCHC-33.7 RDW-17.8* [2153-12-27] 09:22PM PLT COUNT-297 [2153-12-27] 08:00AM GLUCOSE-279* UREA N-50* CREAT-3.3* SODIUM-137 POTASSIUM-4.3 CHLORIDE-108 TOTAL CO2-19* ANION GAP-14 [2153-12-27] 08:00AM estGFR-Using this [2153-12-27] 08:00AM ALT(SGPT)-11 AST(SGOT)-9 CK(CPK)-129 ALK PHOS-121* AMYLASE-246* TOT BILI-0.3 [2153-12-27] 08:00AM LIPASE-296* [2153-12-27] 08:00AM cTropnT-0.11* proBNP-7932* [2153-12-27] 08:00AM CK-MB-6 [2153-12-27] 08:00AM CALCIUM-8.6 PHOSPHATE-3.2 MAGNESIUM-1.9 [2153-12-27] 08:00AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2153-12-27] 08:00AM WBC-6.7 RBC-2.27# HGB-5.5# HCT-17.8# MCV-78 MCH-24.2# MCHC-30.9 RDW-18.4* [2153-12-27] 08:00AM NEUTS-82.1* LYMPHS-11.2* MONOS-4.5 EOS-1.5 BASOS-0.8 [2153-12-27] 08:00AM HYPOCHROM-3+ ANISOCYT-2+ POIKILOCY-1+ MICROCYT-2+ [2153-12-27] 08:00AM PLT COUNT-328 [2153-12-27] 08:00AM PT-14.2* PTT-27.6 INR(PT)-1.3* . abd XR: 1. Post-operative ileus. Cannot exclude early small bowel obstruction. . CXR: IMPRESSION: 1. Chronic congestive heart failure. No evidence of acute decompensation. 2. Moderate right effusion, persistent for a year, nature indeterminate. . CXR: PA and lateral chest compared to [11-27] and [12-27], [2153], moderate right and small left pleural effusion is smaller, but generalized interstitial abnormality has worsened slightly, probably edema. Moderate cardiomegaly is stable. No pneumothorax. Brief Hospital Course: # Acute blood loss anemia: Has a history of AVM's and [Last Name (LF) 107495], [First Name3 (LF) ] he has several reaasons to bleed. Could be slow bleed given lack of melena. Recieved a total of ~7 units PRBC in total but with brisk bleed. Hct then remained stable and patient asymptomatic. GI consulted and felt not necessary to scope unless pt. with frank blood or incessant bleeding. . # CHF: BNP > 7000. CXR with pleural effusion and ? edema, satting 100% on 2L. currently mildly vol overload - Afterload reduction with nitrate + hydralazine - Diurese with lasix, sent home on 40 mg daily lasix, will need to f/u Cr and weight with PCP. [Name10 (NameIs) ] cont. low salt diet and 1500cc fluid restriction. . # Chest Pain: No evidence of EKG changes. Troponin elevated but stable with negative CK/MB in setting of CKD. Now Asx - cont ASA, start statin - ruled out by CE's - avoid BB given h/o active cocaine use - increased nitrate for symptom relief . # Leukocytosis: RESOLVED - blood cx given skin infxn on antibx: pending - UA neg/[Last Name (un) ] cx - LFTs stable - repeat CXR: increased interstitial opacity c/w edema - diuresing - lactate normal, gap closing - on keflex for facial abscess . # Facial furuncle - s/p I & D in ICU and by plastics team - recommended wet to dry dressing change [Hospital1 ] with wick placement, having VNA to [Hospital1 ] with dressing changes - Keflex course for cellulitis . # Cocaine abuse: - likely contributing to GIB - SW c/s . # Chronic Renal Insufficiency: Creatinine is at baseline. No indication for acute dialysis at this time. - renally dose meds - follow lytes carefully . # Diabetes Mellitus 2: Last Hgb A1C 6.7 in [9-19]. Not checking sugars at home. Cont. standing and sliding scale insulin. . # Afib: On ASA. currently sinus. not good coumadin candidate. no bb given cocaine, no rate issues currently. Medications on Admission: ASA 81 mg QD Lasix 40 mg [Hospital1 ] Hydralazine 10 mg QID Terazosin 2 mg QHS Protonix 40 mg QD Discharge Medications: 1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). [Hospital1 ]:30 Tablet(s) Refills:2 2. Hydralazine 10 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). [Hospital1 ]:240 Tablet(s) Refills:2 3. Terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 4. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Ten (10) units Subcutaneous twice a day. 5. Humalog 100 unit/mL Solution Sig: sliding scale sliding scale Subcutaneous four times a day. 6. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours) for 3 days. [Hospital1 ]:6 Capsule(s) Refills:0 7. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a day). [Hospital1 ]:120 Tablet(s) Refills:2 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). [Hospital1 ]:60 Tablet, Delayed Release (E.C.)(s) Refills:2 9. Imdur 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. [Hospital1 ]:30 Tablet Sustained Release 24HR(s) Refills:2 10. HYDROmorphone 2 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for prior to dressing change. [Hospital1 ]:56 Tablet(s) Refills:0 11. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: GI Bleeding Acute Blood Loss Anemia NSTEMI Discharge Condition: stable Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1500cc Please continue to have your L cheek wound dressing and wick changed twice daily. A visiting nurse [First Name (Titles) ] [Last Name (Titles) ] you in learning how to do this. Please continue your medications as listed below. Please follow up with your PCP in the next week. Followup Instructions: 1. Please follow up with your PCP [Last Name (NamePattern4) ] 1 week for a check of your liver function studies and your blood counts. 2. Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 8157], M.D. Phone:[Telephone/Fax (1) 1971] Date/Time:[2154-1-30] 10:30	[ "285.1", "250.02", "428.20", "410.71", "585.9", "584.9", "569.85", "427.31", "305.61", "682.0", "428.0" ]	icd9cm	[ [ [] ] ]	[ "86.04" ]	icd9pcs	[ [ [] ] ]	7950, 8007	4574, 6466	301, 307	8094, 8103	2672, 4551	8560, 8861	2200, 2329		6617, 7927		8028, 8073		6492, 6594			8127, 8537									2344, 2653																									230, 263									335, 1201																	1223, 1818	1834, 2184
19,059	196,997	48134	Discharge summary	report	Admission Date: [2121-11-2] Discharge Date: [2121-11-5] Date of Birth: [2065-11-22] Sex: F Service: MEDICINE Allergies: Penicillins / Clindamycin / Celery / Bee Sting Kit Attending:[First Name3 (LF) 1973] Chief Complaint: lethargy Major Surgical or Invasive Procedure: none History of Present Illness: 55 F with significant OSA with hypoventilation syndrome likely complicated by pulmonary HTN and cor pulm who presents from home with increasing lethargy and respiratory failure. Pt admits to several days of non-complaince with diuretic therapy. During this time describes worsening LE edema and weight gain as well as increasing SOB. Has been complaint of BiPAP at home. Denies fever/chills, cough or chest pain. Past Medical History: 1)morbid obesity s/p hernia repair [6-1], 2)OSA on nocturnal BIPAP and 3-5L home O2, obesity hypoventilation syndrome, COPD, pul HTN (PAP 54) 3)SLE 4)R CHF 5)chronic anemia (bl 32), iron def anemia 6)asthma 7)restrictive lung dz 8)HTN 9)OA 10) Hay fever Social History: denies tobacco, occ EtOH, no other drugs. Family History: mother also uses BiPAP, and had breast ca Physical Exam: VS: 96.3, 105/48, 66 22-91% on BiPAP . PE: Gen: Obese woman in mild resp distress on BIPAP, sleepy but arousable Eyes: PERRL, EOMI, OP wnl, Sclerae anicteric Neck: thick and unable to appreciate JVD Chest: CTA b/l, symmetric, increased exp phase with diminished BS thru/o Cor: RR, nl S1 S2, no m/r/g ABD: Obese soft, NT, ND, +BS EXT: +1 DP pulses BL, 2+ pitting edema to knee Neuro: Sleepy but AO3, appropriate, follows commands and answers questions. Pertinent Results: [2121-11-2] 09:05PM WBC-10.5 RBC-4.78 HGB-12.5 HCT-43.4 MCV-91 MCH-26.1* MCHC-28.7* RDW-15.9* [2121-11-2] 09:05PM NEUTS-84.1* LYMPHS-10.8* MONOS-3.5 EOS-1.6 BASOS-0.2 [2121-11-2] 09:05PM cTropnT-<0.01 proBNP-3075* [2121-11-2] 09:05PM GLUCOSE-112* UREA N-25* CREAT-0.8 SODIUM-143 POTASSIUM-5.8* CHLORIDE-98 TOTAL CO2-39* ANION GAP-12 [2121-11-3] 05:10AM BLOOD Type-ART Temp-37.4 Rates-/15 Tidal V-420 PEEP-15 FiO2-45 pO2-95 pCO2-122* pH-7.24* calTCO2-55* Base XS-18 Intubat-NOT INTUBA Comment-PS=12 CXR AP portable ([11-2]): Mild pulmonary edema. More consolidative opacity in the left lower lobe could represent asymmetric edema, atelectasis, or an underlying pneumonia. Brief Hospital Course: Ms. [Known lastname ] was transferred to the MICU for hypercapneic respiratory failure upon admission. While in the ICU, she was diuresed and placed back on her home BiPAP regimen with a sleep medicine consult. Her mental status and respiratory status improved quickly back to her baseline requirement of 4-6L nc with sats in high 80s-low 90s. She was transferred out to the floor where she was put back on her home diuretic regimen and was continued on her chronic CHF, COPD, and pulmonary hypertension regimen. The sleep medicine service recommended that she have an autoset BIPAP machine with 4-6L home O2 at home with new settings of 18cm/15cm; they arranged for her to have this delivered home on the day of discharge. She was given the influenza vaccine and Pneumovax prior to discharge. Medications on Admission: 1. Sildenafil 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 2. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puffs Inhalation every six (6) hours as needed. 3. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puffs Inhalation every six (6) hours as needed. 4. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO twice a day: Take 2 pills in the morning and take 1 pill in the afternoon. Disp:120 Tablet(s) Refills:2 5. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 6. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO once a day. 8. Rhinocort Aqua 32 mcg/Actuation Spray, Non-Aerosol Sig: One (1) Nasal twice a day. 9. Lisinopril 2.5 mg Tablet Sig: 0.5 Tablet PO once a day. Disp:15 Tablet(s) Refills:2 10. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl Topical TID (3 times a day) as needed. Disp:1 tube Refills:0 11. Ammonium Lactate 12 % Lotion Sig: One (1) Appl Topical ASDIR (AS DIRECTED). Disp:1 tube Refills:2 Discharge Medications: 1. BIPAP BIPAP 18/15 with 4-6L O2 2. Sildenafil 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 3. Metoprolol Succinate 50 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 4. Lisinopril 2.5 mg Tablet Sig: 0.5 Tablet PO once a day. Disp:15 Tablet(s) Refills:2 5. Furosemide 80 mg Tablet Sig: One (1) Tablet PO qam. Disp:30 Tablet(s) Refills:2 6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO qpm. Disp:30 Tablet(s) Refills:2 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:30 Capsule(s) Refills:2 8. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation every six (6) hours as needed for wheezing. Disp:1 inhaler Refills:2 9. Fluticasone 110 mcg/Actuation Aerosol Sig: One (1) Puff Inhalation [Hospital1 ] (2 times a day). Disp:1 inhaler Refills:2 10. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). Disp:1 inhaler Refills:2 11. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day): apply to affected areas of face. Disp:1 tube Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) 6549] Discharge Diagnosis: Primary diagnosis: hypercarbic respiratory failure secondary to obstructive sleep apnea and hypoventilation syndrome Secondary diagnosis: pulmonary hypertension, cor pulmonale, asthma, hypertension, obesity Discharge Condition: stable Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Please take all medications as prescribed, particularly your Lasix. Please use your BiPAP breathing machine every night. Please attend all follow-up appointments. If you experience lethargy, shortness of breath, chest pain, high fevers, loss of consciousness, or other concerning symptoms, you need to seek medical attention. Followup Instructions: Provider: [First Name11 (Name Pattern1) 674] [Initial (NamePattern1) ] [Last Name (NamePattern1) ], M.D. Date/Time:[2122-1-13] 10:40	[ "428.0", "416.9", "276.3", "327.23", "518.81", "278.01", "428.23", "280.9", "493.20", "401.9", "710.0" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	5637, 5692	2388, 3192	321, 328	5944, 5953	1658, 2365	6429, 6581	1126, 1170		4383, 5614		5713, 5713		3218, 4360			5977, 6406									1185, 1639																									273, 283									356, 770			5852, 5923				5732, 5831										792, 1051	1067, 1110
31,290	133,855	32025	Discharge summary	report	Admission Date: [2199-12-23] Discharge Date: [2200-1-28] Date of Birth: [2143-8-4] Sex: M Service: CARDIOTHORACIC Allergies: Aldactone Attending:[First Name3 (LF) 1283] Chief Complaint: DOE Major Surgical or Invasive Procedure: [2199-12-24] redo sternotomy/PVR ( 29 mm aortic [Company 1543] Mosaic porcine valve)/TV repair (36 mmCE MC-3 annuloplasty ring)/MVR (33 mm [Company 1543] Mosaic porcine valve)/closure VSD/closure PFO [2200-1-2] PICC line [2200-1-8] trach/open J-tube History of Present Illness: 56 yo male with congenital heart disease who had a pulmonic valvulotomy in [2160] and a VSD repair in [2185]. He presented in with pulmonic stenosis and sx of CHF. Referred for surgery. Past Medical History: CHF congenital heart disease anxiety depression A fib RBBB RLE varicosities PSH: pulmonic valvulotomy [2160] VSD repair [2185] Right hernia repair appy Social History: disabled never used tobacco occasional ETOH Family History: father had MI at age 55 Physical Exam: Admission 68" 80.4 kg 97.5 108/64 HR 80 RR 20 95% RA sat pale neck supple, full ROM, no lymphadenopathy CTAB RRR 3/6 SEM soft, NT, ND extrems warm, well-perfused, no edema + fems/DP/PT/radials no carotid bruit appreciated Discharge VS T 98.2 HR 88 SR BP 139/55 RR 23 O2sat 100% on 50% [Last Name (un) ] collar Gen NAD Neuro A&Ox3, nonfocal exam Pulm scattered rhonchi. Trach site CDI CV RRR freq PVC's. Sternum stable, incision CDI Abdm soft, NT/+BS. Peg site CDI. Abdm wound w/vac-CDI. wound 1 in diam x 1 in depth Ext warm, no edema Pertinent Results: [2199-12-23] 10:13PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.022 [2199-12-23] 10:13PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [2199-12-23] 10:13PM URINE RBC-21-50* WBC-0-2 BACTERIA-RARE YEAST-NONE EPI-0 [2199-12-23] 07:30PM GLUCOSE-148* UREA N-30* CREAT-1.4* SODIUM-139 POTASSIUM-4.3 CHLORIDE-99 TOTAL CO2-32 ANION GAP-12 [2199-12-23] 07:30PM WBC-3.8* RBC-3.63* HGB-11.7* HCT-34.7* MCV-96 MCH-32.2* MCHC-33.6 RDW-13.7 [2199-12-23] 07:30PM PLT COUNT-120* [2199-12-23] 07:30PM PT-12.8 PTT-40.4* INR(PT)-1.1 [2200-1-13] 01:42AM BLOOD WBC-13.5* RBC-2.74* Hgb-8.6* Hct-26.4* MCV-96 MCH-31.5 MCHC-32.7 RDW-14.2 Plt Ct-450* [2200-1-13] 01:42AM BLOOD PT-15.9* PTT-57.5* INR(PT)-1.4* [2200-1-13] 01:42AM BLOOD Plt Ct-450* [2200-1-13] 01:42AM BLOOD Glucose-118* UreaN-25* Creat-0.7 Na-143 Cl-102 HCO3-39* [2200-1-13] 01:42AM BLOOD Calcium-8.3* Phos-1.6# Mg-2.1 COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2200-1-28] 04:34AM 11.2 2.44* 7.1* 23.2* 95 29.0 30.5* 15.9* 389 BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct INR(PT) [2200-1-28] 04:34AM 389 Source: Line-PICC [2200-1-28] 04:34AM 19.8* 31.5 1.8* Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [2200-1-28] 04:34AM 137* 34* 0.7 138 4.4 98 37* 7 [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname 1843], [Known firstname ] [Hospital1 18] [Numeric Identifier 75009]Portable TTE (Congenital, complete) Done [2200-1-2] at 3:00:05 PM FINAL Referring Physician [Name9 (PRE) ] Information [Last Name (Prefixes) 413], [First Name3 (LF) 412] Division of Cardiothoracic [Doctor First Name ] [First Name (Titles) ] [Last Name (Titles) ] [Hospital Unit Name 4081] [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2143-8-4] Age (years): 56 M Hgt (in): 66 BP (mm Hg): 126/76 Wgt (lb): 176 HR (bpm): 76 BSA (m2): 1.90 m2 Indication: s/p redo [Doctor Last Name ] MVR, TVR, PVR, PFO,VSD failure to wean of vent ICD-9 Codes: 745.4, 745.5, V43.3, 424.0, 424.2 Test Information Date/Time: [2200-1-2] at 15:00 Interpret MD: [First Name11 (Name Pattern1) 449] [Last Name (NamePattern4) ], MD Test Type: Portable TTE (Congenital, complete) Son[Name (NI) 930]: [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) 7749] Doppler: Full Doppler and color Doppler Test Location: West SICU/CTIC/VICU Contrast: None Tech Quality: Adequate Tape #: 2008W008-0:20 Machine: Vivid [6-10] Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 8.4 cm <= 4.0 cm Left Atrium - Four Chamber Length: 8.7 cm <= 5.2 cm Right Atrium - Four Chamber Length: 8.1 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: 1.4 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.3 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 5.9 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 3.8 cm Left Ventricle - Fractional Shortening: 0.36 >= 0.29 Left Ventricle - Ejection Fraction: 60% to 70% >= 55% Left Ventricle - Lateral Peak E': 0.07 m/s > 0.08 m/s Left Ventricle - Septal Peak E': 0.06 m/s > 0.08 m/s Left Ventricle - Ratio E/E': 26 < 15 Aorta - Sinus Level: 4.0 cm <= 3.6 cm Aortic Valve - Peak Velocity: 1.2 m/sec <= 2.0 m/sec Mitral Valve - Peak Velocity: 1.7 m/sec Mitral Valve - Mean Gradient: 8 mm Hg Mitral Valve - E Wave: 1.7 m/sec Mitral Valve - E Wave deceleration time: 423 ms 140-250 ms Tricuspid Valve - Peak Velocity: 1.0 m/sec Tricuspid Valve - Mean Gradient: 2 mm Hg TR Gradient (+ RA = PASP): 42 to 48 mm Hg <= 25 mm Hg Pulmonic Valve - Peak Velocity: 2.8 m/sec <= 1.5 m/sec Pulmonic Valve - Mean Gradient: 17 mm Hg Findings LEFT ATRIUM: Marked LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA. LEFT VENTRICLE: Mild symmetric LVH. Mildly dilated LV cavity. Overall normal LVEF (>55%). No resting LVOT gradient. Muscular VSD. RIGHT VENTRICLE: Normal RV wall thickness. Mildly dilated RV cavity. Normal RV systolic function. AORTA: Moderately dilated aortic sinus. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild to moderate ([12-4]+) AR. MITRAL VALVE: Bioprosthetic mitral valve prosthesis (MVR). MVR well seated, with normal leaflet/disc motion and transvalvular gradients. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Tricuspid valve annuloplasty ring. Normal tricuspid valve supporting structures. Mild [1+] TR. Moderate PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Abnormal PVR. Normal main PA. PERICARDIUM: No pericardial effusion. Conclusions The left atrium is markedly dilated. The right atrium is markedly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. Overall left ventricular systolic function is normal (LVEF60-70%). There is a possible muscular ventricular septal defect (VSD). The right ventricular cavity is mildly dilated with normal free wall contractility. The aortic root is moderately dilated at the sinus level. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild to moderate ([12-4]+) aortic regurgitation is seen. A bioprosthetic mitral valve prosthesis is present. The mitral prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. The tricuspid valve leaflets are mildly thickened. A tricuspid valve annuloplasty ring is present. There is moderate pulmonary artery systolic hypertension. The pulmonic prosthesis is abnormal. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [2199-12-16], the mitral, tricuspid, and pulmonic valves have been repaired/replaced. Electronically signed by [First Name11 (Name Pattern1) 449] [Last Name (NamePattern4) ], MD, Interpreting physician [Last Name (NamePattern4) ] [2200-1-2] 15:54 RADIOLOGY Preliminary Report CHEST (PORTABLE AP) [2200-1-13] 7:32 AM CHEST (PORTABLE AP) Reason: evaluation of effusion [Hospital 93] MEDICAL CONDITION: 56 year old man with s/p pvr mvr mvr REASON FOR THIS EXAMINATION: evaluation of effusion CHEST RADIOGRAPH INDICATION: Followup. COMPARISON: [2200-1-9]. FINDINGS: The tracheostomy tube and the central venous access line right are in unchanged position. Unchanged is the severity of the preexisting cardiomegaly with clear enlargement of the main pulmonary artery. The extent of the bilateral pleural effusions and of the perihilar opacities, both suggestive of fluid overload, are also unchanged. No newly appeared parenchymal changes. IMPRESSION: No relevant changes as compared to [2200-1-9]. DR. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 4130] DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 5785] PICC LINE PLACEMENT INDICATION: 56-year-old man who requires antibiotics. The procedure was explained to the patient. A timeout was performed. RADIOLOGIST: Drs. [Last Name (STitle) 1832] and [Name5 (PTitle) 4686] performed the procedure. Dr. [Last Name (STitle) 4686], the Attending Radiologist, was present and supervised the entire procedure. TECHNIQUE: Using sterile technique and local anesthesia, the right brachial vein was punctured under direct ultrasound guidance using a micropuncture set. Hard copies of ultrasound images were obtained before and immediately after establishing intravenous access. A peel-away sheath was then placed over a guidewire and a double lumen PICC line measuring 45 cm in length was then placed through the peel-away sheath with its tip positioned in the SVC under fluoroscopic guidance. Position of the catheter was confirmed by a fluoroscopic spot film of the chest. The peel-away sheath and guidewire were then removed. The catheter was secured to the skin, flushed, and a sterile dressing applied. The patient tolerated the procedure well. There were no immediate complications. IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided 5-French double lumen PICC line placement via the right brachial venous approach. Final internal length is 45 cm, with the tip positioned in SVC. The line is ready to use. Brief Hospital Course: Admitted [12-23] after surgery prior week was cancelled due to elev. INR. He was on lovenox prior to this admission. Underwent above procedure with Dr. [Last Name (STitle) 1290] on [12-24] and transferred to the CVICU in fair condition on epinephrine, phenylehrine, and propofol drips. Central line removed POD #3.Extubated on POD #4, but required re-intubation. Bronchoscopy done POD #4 to help evaluate inability to wean from vent. Tube feeds started and remained in a fib. Heparin continued for A fib/flutter. Extubated again on POD #8, but reintubated on POD #9. PICC placed by interventional radiology POD #9 also. Right thoracentesis done POD #10. Trach/open J-tube done by Dr. [First Name (STitle) ] on POD #14. Coumadin started and Heparin drip restarted after trach/J-tube. Coumadin started for anticoagulation. Trach mask during day;vent at night for rest. Off vent 18 hours on [1-12], but then back on for increasd WOB. Passey-Muir valve evaluation [1-13] and he tolerated wearing the valve for short periods of time. Some bleeding noted from abdominal wound on [1-14], the wound was opened and VAC dressing was placed, and his heparin drip was stopped. The bleeding resolved. He became confused and developed a fever on [1-16]. He was pan cultured, and started on ceftriaxone for gram neg dipplococci in sputum. Completed 10 day course for h. paraflu. He continued to tolerate trach collar during the day. Blood culture from [1-16] grew peptostreptococcus for which he will complete 2 weeks of vanocmycin. Video swallow performed again on [1-27] showed aspiration and recommendations were to remain strictly NPO with PEG feedings, as well as to possibly obtain a GI consult for upper esophageal sphincter dilation. Cleared for discharge to rehab on [1-28]. He has remained on trach mask for greater than 48 hours. He is day [6-16] of vancomycin. Medications on Admission: lasix 80 mg daily spironolactone 25 mg daily captopril 12.5 mg [Hospital1 ] lopressor 12.5 mg [Hospital1 ] coumadin ( held) prozac 20 mg daily klonopin 0.5 mg [Hospital1 ] iron magnesium MVI lovenox (LD [12-23] AM) Discharge Medications: 1. Atorvastatin 20 mg Tablet [Month/Year (2) ]: One (1) Tablet PO DAILY (Daily). 2. Ascorbic Acid 500 mg Tablet [Month/Year (2) ]: One (1) Tablet PO BID (2 times a day). 3. Fluoxetine 20 mg Capsule [Month/Year (2) ]: One (1) Capsule PO DAILY (Daily). 4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 5. Docusate Sodium 50 mg/5 mL Liquid [Last Name (STitle) ]: One (1) PO BID (2 times a day). 6. Spironolactone 25 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 7. Miconazole Nitrate 2 % Powder [Last Name (STitle) ]: One (1) Appl Topical QID (4 times a day) as needed. 8. Aspirin 81 mg Tablet, Chewable [Last Name (STitle) ]: One (1) Tablet, Chewable PO DAILY (Daily). 9. Camphor-Menthol 0.5-0.5 % Lotion [Last Name (STitle) ]: One (1) Appl Topical QID (4 times a day) as needed. 10. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization [Last Name (STitle) ]: One (1) Inhalation Q6H (every 6 hours). 11. Ipratropium Bromide 0.02 % Solution [Last Name (STitle) ]: One (1) Inhalation Q6H (every 6 hours). 12. Ferrous Sulfate 300 mg/5 mL Liquid [Last Name (STitle) ]: One (1) PO DAILY (Daily). 13. Clonazepam 0.5 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO QHS (once a day (at bedtime)). 14. Tramadol 50 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO Q6H (every 6 hours) as needed. 15. Metoprolol Tartrate 25 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO BID (2 times a day). 16. Nystatin 100,000 unit/mL Suspension [Last Name (STitle) ]: Ten (10) ML PO QID (4 times a day). 17. Zolpidem 5 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO HS (at bedtime). 18. Furosemide 40 mg Tablet [Last Name (STitle) ]: 1.5 Tablets PO BID (2 times a day). 19. Vancomycin in Dextrose 1 gram/200 mL Piggyback [Last Name (STitle) ]: One (1) Intravenous Q 12H (Every 12 Hours) for 7 days: [1-28] is Day [6-16]. 20. Insulin Glargine 100 unit/mL Solution [Month/Year (2) ]: Twenty (20) units Subcutaneous at bedtime. 21. Insulin Lispro 100 unit/mL Solution [Month/Year (2) ]: per sliding scale Subcutaneous four times a day. 22. Warfarin 2 mg Tablet [Month/Year (2) ]: Two (2) Tablet PO once for 1 doses: [1-28] dose. 23. Warfarin 1 mg Tablet [Month/Year (2) ]: as directed Tablet PO once a day: target INR 2-2.5. Discharge Disposition: Extended Care Facility: [Hospital6 1293] - [Location (un) 1294] Discharge Diagnosis: congenital heart disease redo sternotomy/MVR/PVR/TV repair/PFO closure/VSD closure [2199-12-24] respiratory failure s/p trach/ open J-tube [2200-1-8] A fib anemia anxiety depression CHF prior RBBB Discharge Condition: good Discharge Instructions: no lotions, creams or powders on any incision call for fever greater than 100.5, redness or drainage no lifting greater than 10 pounds for 6 weeks Bathe daily and pat incisions dry TARGET INR 2.0-2.5 for A fib Followup Instructions: see Dr. [Last Name (STitle) 24305] in [12-4] weeks see Dr. [Last Name (STitle) 1911] in [1-5] weeks See Dr. [Last Name (STitle) 1290] in 4 weeks [Telephone/Fax (1) 170] Completed by:[2200-1-28*]	[ "486", "285.9", "519.19", "300.00", "458.29", "998.11", "276.0", "599.0", "424.2", "518.5", "790.7", "427.31", "424.0", "428.0", "746.02", "112.3", "745.4" ]	icd9cm	[ [ [] ] ]	[ "39.61", "46.39", "89.60", "86.09", "38.93", "35.33", "35.72", "33.22", "96.6", "35.25", "35.23", "96.72", "34.91", "96.04", "31.1", "93.59", "99.04" ]	icd9pcs	[ [ [] ] ]	14830, 14904	10178, 12085	280, 553	15153, 15159	1652, 7964	15418, 15643	1039, 1064		12367, 14807	8001, 8038	14925, 15132		12111, 12344			15183, 15395									1079, 1633																									237, 242	8067, 10155								581, 776																	798, 961	977, 1023
70,004	165,715	34306	Discharge summary	report	Admission Date: [2181-11-18] Discharge Date: [2181-11-28] Date of Birth: [2127-12-6] Sex: M Service: NEUROSURGERY Allergies: Penicillins Attending:[First Name3 (LF) 1854] Chief Complaint: CSF Rhinorrhea Major Surgical or Invasive Procedure: [2181-11-21]: Right Crani for dural repair and lumbar drain placement History of Present Illness: 53M with a recent discharge from the neurosurgical service on [2181-11-16]. Underwent R temp craniotomy for metastatic adenocarcinoma on [2181-10-5] followed by XRT 10 sessions finishing mid [Month (only) ]. Presented to [Hospital1 18] [2181-11-7] with post nasal salty drainage and clear drainage from nose; admitted with lumbar drain placement for 1wk, was removed and had no nasal drainage. Discharged [2181-11-16] and called back on [11-18] am stating salty drainage from previous night back of throat and this morning several episodes "gushes of clear fluid" out his right nare. He also complains of left calf pain beginning yesterday that is exquisitly tender. Pt has only mild headache. Pt denies fever, chills, weakness, neuro changes. Past Medical History: Lung CA - s/p L Lower Lung Lobe resection [2180] [2181-10-5] - s/p Right craniotomy for resection of mass Social History: Social Hx: married, 50pk yr tobacco hx, occas EtOH Physical Exam: Upon Admission: PHYSICAL EXAM: O: T:98 BP:118/ 66 HR: 76 R16 O2Sats 95RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils:3->2 EOMs full Neck: Supple. Extrem: Warm and well-perfused. Left calf non erythematous, no swelling, very tender to light touch posterior cald below knee, +[Last Name (un) 5813] sign on left, neg on right Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3to2 mm bilaterally. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [Doctor First Name 81]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [6-12] throughout. No pronator drift Sensation: Intact to light touch bilaterally. Toes downgoing bilaterally Pertinent Results: [2181-11-18] 03:10PM WBC-10.3 RBC-4.42* HGB-13.6* HCT-40.4 MCV-91 MCH-30.7 MCHC-33.6 RDW-14.8 [2181-11-18] 03:10PM NEUTS-70 BANDS-1 LYMPHS-17* MONOS-7 EOS-2 BASOS-0 ATYPS-2* METAS-1* MYELOS-0 Brief Hospital Course: Mr. [Known lastname 78957] is a 53 yo Male readmitted to Nsurg on [2181-11-18] with CSF rhinorrhea. He had underwent a right craniotomy for mass resection on [2181-10-5]. The pathology was Metastatic adenocarcinoma. He was readmitted for CSF leak from [2181-11-7] to [2181-11-16] and had a lumbar drain from [2181-11-9] to [2181-11-16]. He had a recurrance of CSF rhinorrhea and was admitted on [2181-11-18]. Upon admission he also reported left calf tenderness with a positive [Doctor Last Name ] sign. Lower extremity doppler study was negative on [11-18]. Repeat studies showed LLE thrombosis involving superficial calf veins. He was kept on bedrest until being taken to surgery on [2181-11-21] for a right craniotomy for dural repair and lumbar drain placement with Dr. [Last Name (STitle) ]. He was extubated and transfered to the SICU after the procedure. The lumbar drain parameters were 15cc/CSF as goal. Post-op CT imaging showed mild pneumocephalus and post-surgical changes. He was trasnfered to the [Hospital Ward Name ] 11 floor. On [11-22] his HOB was at 25 degress max and he had no sign of CSF leak. On [11-23] he had a temp of 102. Fever work up was initiated which included CSF sample from lumbar drain. He became disoriented and agitated later that day. His CSF studies showed WBC 380. Peripheral WBC was 19. He was transfered to the SICU. ID was consulted and Vancomycin and Cefipime were ordered. They recommended that the LD be removed. The tip was sent for culture which had no growth. The patient improved clincally within 24 hours and had a normal neurological exam. He was transferred to surgical floor 48 hours later and remained afebrile. ID recommended 14 days of IV antibiotics and one week further treatment for C-Diff. He had no headache or rhinorrhea. PT recommended he be discharged home with with home PT on [11-28]. Medications on Admission: Simvastatin 40 mg Tablet PO DAILY Levetiracetam 500 mg 2 Tablets PO BID Docusate Sodium 100 mg Tablet PO BID Hydromorphone 2 mg Tablet PO Q4H PRN Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): Use while on pain medication hold for loose stools. Disp:40 Capsule(s) Refills:0 2. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:40 Tablet(s) Refills:0 5. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 3 days. Disp:12 Capsule(s) Refills:0 6. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day for 3 days. Disp:9 Tablet(s) Refills:0 7. Cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection Q8H (every 8 hours) for 11 days. Disp:33 Recon Soln(s) Refills:0 8. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush for 11 days. Disp:33 ML(s) Refills:0 9. PICC Line PICC Line care per home infusion protocols 10. Vancomycin 750 mg Recon Soln Sig: Two (2) Intravenous twice a day for 11 days. Disp:44 Refills:0 11. Outpatient Lab Work Please draw CBC, BUN, Creatinine, vanco trough Discharge Disposition: Home With Service Facility: [Location (un) ] Nursing Services Discharge Diagnosis: CSF Rhinorrhea s/p right craniotomy for dural repair Discharge Condition: Neurologically stable Discharge Instructions: General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and/or staples have been removed. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. Please have results faxed to [Telephone/Fax (1) 87]. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office on Monday [12-5] @ 1100 for removal of your staples or sutures. ??????Provider: [Name10 (NameIs) 706] MRI Phone:[Telephone/Fax (1) 327] Date/Time:[2181-12-10] 1:15 Provider: [First Name11 (Name Pattern1) 640] [Last Name (NamePattern4) 4861], MD Phone:[Telephone/Fax (1) 1844] Date/Time:[2181-12-10] 3:00 Completed by:[2181-11-28]	[ "997.09", "349.81", "E878.6", "008.45", "V15.82", "322.9", "453.6" ]	icd9cm	[ [ [] ] ]	[ "02.12", "03.09" ]	icd9pcs	[ [ [] ] ]	6199, 6267	2874, 4804	293, 368	6363, 6387	2646, 2851	7961, 8399			5001, 6176		6288, 6342		4830, 4978			6411, 7938									1423, 1751																									239, 255									396, 1171	2004, 2627							1408, 1408		1766, 1988							1193, 1309	1325, 1377
14,516	113,633	17123	Discharge summary	report	Admission Date: [2114-10-22] Discharge Date: [2114-11-16] Date of Birth: [2064-6-13] Sex: F Service: MEDICINE Allergies: Penicillins / Sulfur / Demerol / Amphotericin B / Allopurinol / Vicodin / Percocet Attending:[First Name3 (LF) 6169] Chief Complaint: Scheduled admission for chemotherapy Major Surgical or Invasive Procedure: s/p antegrade nephrostogram s/p PICC line placement History of Present Illness: Ms. [Known lastname ] is a 50 year old woman with history of AML, allogenic transplant in [2110-8-4], and recent admissions for right-sided hydronephrosis ([Month (only) 116]), donor lymphocyte infusion in (discharged [8-24]), and left-sided hydronephrosis (discharged [10-4]). She has been admitted for chemotherapy in preparation for donor lymphocyte infusion vs. second bone marrow transplant. . She reports feeling "lousy" for the past several weeks, with feelings of fatigue and lack of stamina. She has had increased bruising. Her steroids were increased last Friday to 40mg daily from 30mg daily. She reports a headache and fever to 100.5 last night which came down with Tylenol. Past Medical History: ONCOLOGY HX: - Acute myelogenous leukemia s/p allo transplant - [2110-8-4]: 5 of 6 matched family member allogenic BMT for AML. Father was her donor. She has remained in complete remission; no GVHD. Her performance status was 100%. - mid-[7-10] found to have peripheral blasts and host cells in marrow, suggestive of relapsed AML, planning for DLI . PMH: 1. AML- as above 2. Allergic rhinitis 3. Depression Social History: Married, lives with her husband and three children ages 13, 8, 6. Works as a controller. No tobacco or EtOH. Family History: Both parents living. Mother with HTN, MI, SLE; father with HTN. Father (donor) recently had MI. Siblings with hypertension. Physical Exam: Vitals: T 98.6 BP 107/67 P 98 RR 18 O2sat 98% Gen: Well-appearing, no acute distress HEENT: PERRL, EOMI, OP clear, MMM Neck: No LAD Card: RRR, normal S1/S2, no m/r/g Pulm: CTA bilaterally Back: No CVAT, mild tenderness around percutaneous nephrostomy insertion site, ecchymoses Abd: Soft, non-distended, RUQ and epigastric tenderness Ext: No clubbing or cyanosis, 1+ non-pitting edema bilaterally, 2+ pulses bilaterally Skin: Some ecchymoses, no rashes Neuro: A&Ox3, responds appropriately Pertinent Results: Urine cytology : NEGATIVE FOR MALIGNANT CELLS. . RUQ U/S [10-23]: Mildly distended gallbladder. Mildly distended common bile duct. Negative [Doctor Last Name 515] sign. HIDA can be performed for further evaluation if clinically warranted. . CT Abd/Pelvis [10-23]: 1. Ascites and edema of the small and large bowel. The appearances may be consistent with enteritis or a graft versus host disease. 2. No evidence of perforation. 3. Left nephrostomy tube. 4. Moderate dilation of right kidney. 5. Unchanged appearance of low attenuation lesions in pancreas and liver. . Abd X-Ray [10-23]: FINDINGS: Left nephrostomy tube is present. No dilated bowel loops are identified. Stool and air is present in the colon. The osseous structures are unremarkable. IMPRESSION: No obstruction. . [2114-11-5] BONE MARROW CORE BIOPSY: DIAGNOSIS: Markedly hypocellular bone marrow with extensive fibrosis and focal increased blasts, see note. Note: The aspirate material is aspicular. The core biopsy shows extensive areas of grade 3 reticulin fibrosis. An immunohistochemical stain for CD34 highlights a focal area with increased interstitial blasts within the extensively fibrotic background, which likely represents minimal residual disease. This was reviewed in consultation with Dr. [Last Name (STitle) ] [Last Name (NamePattern4) ] who concurs. Compared to the previous biopsy, the current biopsy shows a marked reduction in cellularity. MICROSCOPIC DESCRIPTION. Peripheral Blood Smears: Red blood cells show hypochromasia and anisopoikilocytosis with rare microcytes, red cell fragments and dacrocytes. The white blood cell count appears markedly decreased. Platelet count appears markedly decreased. Large/giant forms are not seen. A limited 25 cell differential shows 100% lymphocytes. Aspirate Smears: The aspirate material is inadequate for evaluation due to a lack of spicules, hemodilution, and clotted sample. Clot Section and Biopsy Slides: The biopsy material is fragmented, but adequate for evaluation. One bony piece is hypocellular with new bone formation and likely represents previous biopsy site. A second bony core fragment contains diffuse background fibrosis occupying more than half the length of this piece. In the remaining half, the cellularity is variable (overall 10%) and is comprised predominantly of plasma cells, lymphocytes, and hemosiderin-laden macrophages. A small lymphoid aggregate is seen. Maturing myeloid and erythroid precursors are extremely scant. A CD34 immunohistochemical stain is performed to better assess presence of blasts, given the architectural distortion by background fibrosis. The CD34 stain highlights scattered interstitial mononuclear cells within the fibrotic areas overall comprising ~10% of marrow cellularity (the remaining being lymphocytes and plasma cells). Special Stains: Iron stain is inadequate for evaluation due to lack of spicules. Reticulin stain shows extensive Grade 3 reticulin fibrosis. Trichrome stain does not show any collagen fibrosis. ADDENDUM: Additional immunohistochemical studies with antibodies against favor VIII-related antigen highlights endothelial cells. Definite staining amongst blasts is not seen, however, scant tissue remains on deeper sections used for immunohistochemical staining. . Renal U/S: IMPRESSION: No definite evidence of hydronephrosis. Left-sided nephrostomy tube is seen in place. Likely right-sided ureteral jet. No left ureteral jet identified. . [2114-11-15] Antegrade Nephrostogram:IMPRESSION: Persistent narrowing of the distal left ureter, probably from the extrinsic compression, unchanged from the study from one month ago Brief Hospital Course: #) AML. She was admitted for scheduled MEC with initial plans for either second DLI vs. second BMT. She tolerated MEC, but her course was complicated by severe mucositis. pain was controlled with Fentanyl PCA. She also developed diarrhea (C. diff and other stool cultures negative and symptomatically treated with immodium). Day 14 marrow revealed markedly hypocellular bone marrow with extensive fibrosis and focal increased blasts. On discharge, she is to follow-up with her outpatient oncologist for a repeat bone marrow bx and further discussion of additional chemotherapy/mini transplant. . #) Abdominal pain: Patient was admitted with complaints of mild abdominal discomfort. Then, on AM of [10-23], developed worsening abdominal pain, diffuse, worse in LLQ. KUB negative for free air and obstruction. She was given lorazepam 1g IV for anxiety and sent for CT abd/pelvis without contrast. After returning from CT, BP was found to be 70/40 with continued progression of her pain. She also had some associated nausea. She was mentating normally throughout. She was given a 1L NS bolus with transient improvement of her blood pressure to 95/50s. She was also given aztreonam 2g IV, vancomycin 1g IV, and metronidazole 500mg IV. She also received morphine 1mg IV for pain with little relief. Surgery was consulted and she was transferred to the ICU. Abd CT revealed ascites and edema of the small and large bowel. The appearances may be consistent with enteritis or a graft versus host disease with no evidence of perforation. Ultimately, this was felt not to be an acute surgical abdomen. Once her blood pressure stabilized and she was aggressively diuresed. Following diuresis, her abdominal pain also subsided. By the time of discharge, she was feeling well without abdominal discomfort. . #) Hypotension: In the setting of severe abdominal pain, she was found to have SBP in 80's, which responded well to fluid boluses. Initially, there was concern for sepsis, and she was started on stress dose steroids, which were ultimately tapered down. Afterwards, her BP remained stable. She was discharged on a tapered down dose of 5 mg prednisone QD. . #) Fevers: Beginning on [11-7], she developed fevers to 101. She was empirically covered with aztreonam, vancomycin and caspofungin. There was concern for a line infection from her left IJ, which waspulled. The tip was sent for culture, but no organisms grew. Blood cx subsequently grew out Lactobacillus X3. ID was consulted and suggested starting meropenam. Given she has a hx of hives to penicillins, she was premedicated and tolerated the meropenam without incident. She was discharged to complete a total of 14 day course of meropenam. Ertapenam as QD antibiotic was discussed, but as there was no literature to support its efficacy against lactobacillus, she was discharged with VNA services to help administer her IV meropenam. By dicharge, she had been afebrile for greater than 72 hours. . #) Hydronephrosis: Patient has a history of obstruction of her ureters. The etiology remains unclear as the ureters behave as if there is external compression, but there are no compressing masses seen on any imaging. She was s/p urgent placement of L nephrostomy tube, and had been responding well. On [11-10], she developed R flank pain (very mild and intermittent) as well as decreased urine output. There was concern for right ureteral obstruction as well, but Abd U/S revealed normal flow through R ureter. Urology was consulted regarding taking out her left nephrostomy tube prior to discharge. She had a antegrade nephrostogram, which revealed essentially unchanged partial obstruction of left ureter with only minimal and slow flow. the decision was made for her to follow-up with her urologist, Dr. [Last Name (STitle) 770], as an outpatient to further assess in 2 weeks. . #) F/E/N: IVF, bolus as needed, replete electrolytes as needed. She was started on TPN for nutrition given her abdominal pain and was gradually weaned off. By discharge, she was tolerating PO's. Medications on Admission: Ciprofloxacin 250mg [Hospital1 ] Ritalin 20mg QD Citalopram 20mg QD Loratadine 20mg QD Beclonase [Hospital1 ] Fluconazole 200mg QD Acyclovir 400mg [Hospital1 ] Protonix 40mg [Hospital1 ] Sudafed 30 mg QD Potassium 20mEq powder Fluconazole QD Prednisone 40mg (increased on Friday) Discharge Medications: 1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Loratadine 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 3. Pseudoephedrine HCl 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Methylphenidate 10 mg Tablet Sig: One (1) Tablet PO once a day. 5. Beclomethasone Diprop Monohyd 42 mcg (0.042 %) Aerosol, Spray Sig: One (1) Nasal [Hospital1 ] (2 times a day). Disp:qs qs Refills:2 6. 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:2 7. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Loperamide 2 mg Capsule Sig: One (1) Capsule PO Q4H (every 4 hours) as needed for diarrhea. Disp:30 Capsule(s) Refills:1 9. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:90 Tablet(s) Refills:2 10. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q8H (every 8 hours) for 7 days: Please premedicate with Tylenol. Disp:21 Recon Soln(s) Refills:0 11. Potassium Chloride 20 mEq Packet Sig: One (1) PO once a day. Disp:30 packets Refills:2 12. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 13. Line care Please flush and care for line as per IV network protocol Discharge Disposition: Home With Service Facility: VNS of [Location (un) 7188] and [Location (un) 16221] County Discharge Diagnosis: Primary: AML lactobacillus bacteremia ureteral stricture Discharge Condition: good Discharge Instructions: You have AML and received induction chemotherapy during this admission. During this hospital course, you have some narrowing of your left ureter requiring the nephrostomy tube to be in place. You will need to address this issue with your urologist, Dr. [Last Name (STitle) 770]. Also, you have a bacteria called Lactobacillus growing in your blood. To treat this bacteria, you will need to take an antibiotic called Meropenam IV every 8hours for one week. Please attend all follow-up appointments and take all medications as prescribed. Followup Instructions: Please follow-up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1557] at [Hospital1 18] [2114-11-19] at 12:30. . Also, please follow-up with your urologist, Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 770] to discuss when you can have your nephrostomy tube removed. Your appointment with him is on [2114-11-29] 2:50PM in [Hospital Ward Name 23] Building [Location (un) 436], [Hospital1 18] [Hospital Ward Name ].	[ "288.00", "528.00", "V58.11", "568.82", "593.3", "041.84", "458.9", "V42.81", "285.22", "780.6", "276.6", "790.7", "782.1", "569.41", "E947.9", "205.00" ]	icd9cm	[ [ [] ] ]	[ "38.93", "41.31", "99.05", "87.75", "99.15", "99.25", "99.04" ]	icd9pcs	[ [ [] ] ]	11925, 12024	6100, 10146	383, 437	12125, 12132	2408, 6077	12722, 13216	1754, 1879		10492, 11902		12045, 12104		10172, 10469			12156, 12699									1894, 2389																									306, 345									465, 1173																	1195, 1612	1628, 1738
53,536	196,098	10486	Discharge summary	report	Admission Date: [2197-8-14] Discharge Date: [2197-8-19] Date of Birth: [2124-3-23] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[First Name3 (LF) 1505] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [8-14] Aortic valve replacement ([Street Address(2) 11688]. [Hospital 923] Medical Epic valve), Bronchoscopy, Subtotal resection of right paratracheal mass History of Present Illness: This gentleman has a past medical history of Lymphoblastic lymphoma with radiation, high-dose chemotherapy and autologous stem cell rescue in 3/[2190]. He has remained in remission since that time. He also has a history of a heart murmur and underwent his initial echocardiogram back in [2187] where he was found to have aortic stenosis. He is followed with surveillance echocardiograms and his most recent study was on [2197-6-27] after he reported episodes of dyspnea. He was found to have severe concentric LVH, his overall left ventricular systolic dysfunction was normal and his EF was 55-60%. He had mild AR and severe AS. His peak aortic valve gradient was 104 mmHg, mean gradient was 59 mmHg and the aortic valve area was 0.57 cm2. He had mild MR, and mild pulmonary HTN with PASP 34 + 5 mmHg assuming his RV pressure was normal. In regards to symptoms his wife began noticing her husband having shortness of breath about one year ago. Initially they attributed it to his COPD and then some weight gain. She reports the dyspnea on exertion has progressively worsened over the last 6 months. Now is short of breath with one flight of stairs. In the interim since first evaluation with us on [7-6], he has had a bone marrow aspirate done by Dr. [Last Name (STitle) ], and PET scanning by Dr. [Last Name (STitle) ]. Past Medical History: Lymphoblastic lymphoma s/p autologous transplant without recurrence since [2190]/ XRT to left leg/chemo Adenitis Anemia Hyperlipidemia Hypothyroidism Lung cancer s/p right upper lobectomy Degenerative Joint Disease Chronic Obstructive Pulmonary Disease/emphysema Erectile dysfunction Arthritis of the knee, pending bilateral TKR in the future Abdominal hernia Slight cataract in the right eye Benign Prostatic Hypertrophy Past Surgical History s/p left salivary gland removal in [2195] s/p left knee surgery s/p left shoulder surgery s/p Tonsillectomy s/p left foot surgery x 2 for neuromas Social History: Occupation: disabled fireman Lives with wife [Name (NI) ]: Caucasian Tobacco: 35 PYH/ quit 20 years ago ETOH: Denies No recr. drugs Family History: Mother died of MI at 78 Physical Exam: Pulse:71 Resp: O2 sat: 99% RA B/P Right: 145/81 Left: 156/83 Height: 5' 10" Weight:215# General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] no JVD Chest: Lungs clear bilaterally [x] well-healed right post. thoracotomy and left anterior chest scars Heart: RRR [x] Irregular [] Murmur [3-31] throughout precordium to carotids Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] no HSM/ CVA tenderness, ventral hernia present Extremities: Warm [x], well-perfused [x] Edema; none Varicosities: None [x] left anterior tibial area with chronic skin changes from XRT to lymphoma site Neuro: Grossly intact, MAE [5-30]/ strengths, nonfocla exam Pulses: Femoral Right: ecchymotic 1+ Left: 2+ DP Right: 1+ Left: 1+ PT [Name (NI) 167]: 1+ Left: 1+ Radial Right: 2+ Left: 2+ Carotid Bruit murmur radiates to bil carotids Pertinent Results: [8-14] Echo: PRE-BYPASS: No atrial septal defect is seen by 2D or color Doppler. There is severe 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%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). Moderate (2+) aortic regurgitation is seen. Mild (1+) mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including phenylephrine. A well-seated bioprosthetic valve is seen in the aortic position with normal leaflet motion and gradients (mean gradient = 17 mmHg). Trace central aortic regurgitation is seen ( normal for this prosthesis) Biventrciular function is normal. Aorta is intact post decannulation. Other findings are unchanged Brief Hospital Course: Mr. [Known lastname ] was a same day admit after undergoing pre-operative work-up as an outpatient. On [8-14] he was brought directly to the operating room where he underwent a Aortic valve replacement, Bronchoscopy, and subtotal resection of right paratracheal mass. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. On post-operative day one he was transferred to the telemetry floor for further care. Chest tubes and epicardial pacing wires were removed per protocol. Mr. [Known lastname ] experienced intermittant self limitinbg atrial fibrillation and flutter - lopressor was increased and remained in NSR. Cleared stage V [Hospital 23261] rehab with physical therapy and was discharged to home on POD# 5 w/ VNA. Medications on Admission: Cyclobenzaprine 10 mg Tablet TID PRN, Finasteride [Proscar] 5 mg QD, Fluticasone-Salmeterol [Advair Diskus] 250 mcg-50 mcg/Dose Disk 1 (One) puff IH twice a day, Ibuprofen 800 mg Tablet 1 Tablet TID PRN, Levothyroxine 25 mcg QD, Simvastatin 20 mg QD, Tamsulosin [Flomax] 0.4 mg QD, Aspirin 81 mg QD 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. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: [1-27] Disk with Devices Inhalation [Hospital1 ] (2 times a day). 5. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 7 days. Disp:7 Tab Sust.Rel. Particle/Crystal(s) Refills:0 8. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 7 days. Disp:7 Tablet(s) Refills:0 10. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: Two (2) Capsule, Sust. Release 24 hr PO HS (at bedtime). 11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: VNA of Southeastern Mass. Discharge Diagnosis: Aortic Stenosis s/p Aortic Valve Replacement Right paratracheal mass s/p subtotal resection of right paratracheal mass Lymphoblastic lymphoma s/p autologous transplant without recurrence since [2190]/ XRT to left leg/chemo Adenitis Anemia Hyperlipidemia Hypothyroidism Lung cancer s/p right upper lobectomy Degenerative Joint Disease Chronic Obstructive Pulmonary Disease/emphysema Erectile dysfunction Arthritis of the knee, pending bilateral TKR in the future Abdominal hernia Slight cataract in the right eye Benign Prostatic Hypertrophy Past Surgical History s/p left salivary gland removal in [2195] s/p left knee surgery s/p left shoulder surgery s/p Tonsillectomy s/p left foot surgery x 2 for neuromas Discharge Condition: Good Discharge Instructions: 1)No driving for one month 2)No lifting more than 10 lbs for at least 10 weeks from the date of surgery 3)Please shower daily. Wash surgical incisions with soap and water only. 4)Do not apply lotions, creams or ointments to any surgical incision. 5)Please call cardiac surgeon immediately if you experience fever, excessive weight gain and/or signs of a wound infection(erythema, drainage, etc...). Office number is [Telephone/Fax (1) 170]. 6)Call with any additional questions or concerns Followup Instructions: Dr. [Last Name (STitle) ] in 4 weeks Dr. [Last Name (STitle) 7047] in [2-28] weeks Dr. [Last Name (STitle) ] in [1-27] weeks Dr. [Last Name (STitle) 25693] in [1-27] weeks [Telephone/Fax (1) 34600] Dr. [Last Name (STitle) ] in [1-27] weeks [Telephone/Fax (1) 4741] Completed by:[2197-8-19]	[ "716.96", "424.1", "V15.82", "244.9", "V10.71", "492.8", "600.00", "272.4", "196.1", "416.8", "427.32", "366.9", "V42.81", "V10.11" ]	icd9cm	[ [ [] ] ]	[ "34.3", "39.61", "33.22", "35.21" ]	icd9pcs	[ [ [] ] ]	7308, 7364	4835, 5754	298, 467	8125, 8131	3627, 4812	8673, 9013	2633, 2659		6103, 7285		7385, 8104		5780, 6080			8155, 8650									2674, 3608																									239, 260									495, 1841																	1863, 2464	2480, 2617
20,508	119,272	26470	Discharge summary	report	Admission Date: [2153-10-5] Discharge Date: [2153-10-16] Date of Birth: [2077-10-8] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1267] Chief Complaint: CP, SOB Major Surgical or Invasive Procedure: MVR [2153-10-10] ([Company 1543] Mosaic 29 mm pig valve) History of Present Illness: This is a 75 y/o F w/ COPD, CHF, nl EF, AF, severe MR who is tferred to the CCU team for further monitoring after an episode of acute pulonary edema and CP while on the floor. Patient was tferred from an OSH to the cardiothoracic surgery service today for evaluation for CABG-TVR-MVR. The patient was admitted on [2153-9-24] to OSH with increasing DOE and SOB as well as some chest "pressure." She was found to be in CHF on admission and was ruled out for an MI. She was reportedly diuresed with lasix and had an echo which showed LVH,, severe MR and severe TR, EF 60-65%. The patient went into atrial fibrillation on [2153-9-27], there is no clear prior history of this. She was started on heparin gtt which she remains on. She underwent a cardiac catheterization on [2153-10-1] which demonstrated prox LAD 50-60%, narrow RCA 60%, patent LMCA, severe MR, PA 65/25, LVEDP 15, EF 75%. She was accepted to the ct surgery service and on arrival this evening was c/o 8/10 chest pain as well as acute SOB. Her HR was reportedly in the 40s and she was reportedly cool and clammy, but when she was placed on tele she was in rapid afib w/RVR in the 140s. EKG without ischemic changes. A medicine resident was nearby and gave her lasix 20 mg IV and 2 SL NTG with improvement in her rate, SOB, and CP. The patient currently is sleeping but on arousal still c/o upper right sided [1-25] CP, feels like gas, no radiation, and says her breathing is much better. She denies any orthopnea, LH, palpitations, n/v. Past Medical History: 1. COPD, > 60 p-y smoking hx 2. CHF nl EF, severe MR, severe TR, pulmonary HTN 3. ?h/o rhumatic fever 4. h/o leukopenia 5. s/p ulcer surgery 6. s/p hip replacement and 3 revisions in [2151] 7. chronic pain 8. anxiety 9. osteoarthritis 10. TAH/BSO 11. HTN 12. A fib Social History: Lives with son. Smokes 1 ppd. Still volunteering at NH. No EtoH or drugs. Family History: NC Physical Exam: T 96/1 HR 109 irreg BP 122/48 RR 26 96% 4L NC GEN: asleep, flat, mild resp distress, completing full sentences, aaox3 HEENT: PERRL, o/p w/ dry mmm NECK: JVP 12-14 cm, supple CV: irreg irreg s1 s2, [1-21] sys murmur radiates to axilla LUNG: crackles at bases, course b/l, no wheezes ABD: soft, nt, bs+, no HSM EXt: tr edema, varicose veins, pulses 1+ dp Pertinent Results: EKG: afib rvr, nl to sl. rightward axis, no st depressions, twi 3, v5 . CXR: pulm edema, hyperinflated lungs/flattened diaphragms, fluid in fissure on right, sm. r pleural effuson, calc. aortic knob . Cath osh: prox lad 50-60%, lm patent, 60% narrow rca, severe MR Hemodynamics: RA [8-29], RV 65/12, PA 65/25, LVEDP 15 and 10-12after [Last Name (LF) 65404], [First Name3 (LF) ] 70-75% . Echo [9-24]: severe MR, severe TR, LVH, EF 60-64$, tiny posterior pericardial effusion [2153-10-5] 08:30PM URINE BLOOD-LG NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [2153-10-5] 08:34PM BLOOD WBC-5.8 RBC-3.98* Hgb-12.5 Hct-37.3 MCV-94 MCH-31.5 MCHC-33.5 RDW-14.6 Plt Ct-216 [2153-10-16] 06:20AM BLOOD WBC-5.5 RBC-3.57* Hgb-10.8* Hct-31.4* MCV-88 MCH-30.3 MCHC-34.4 RDW-14.9 Plt Ct-134* [2153-10-5] 08:34PM BLOOD Neuts-78.2* Lymphs-18.0 Monos-3.0 Eos-0.5 Baso-0.3 [2153-10-16] 09:40AM BLOOD PT-16.2* PTT-84.7* INR(PT)-1.8 [2153-10-5] 08:34PM BLOOD PT-13.5* PTT-59.2* INR(PT)-1.2 [2153-10-16] 06:20AM BLOOD Glucose-75 UreaN-18 Creat-0.7 Na-127* K-3.9 Cl-89* HCO3-30 AnGap-12 [2153-10-9] 06:30AM BLOOD Glucose-103 UreaN-44* Creat-1.0 Na-128* K-3.7 Cl-92* HCO3-24 AnGap-16 [2153-10-5] 08:34PM BLOOD ALT-37 AST-45* LD(LDH)-293* CK(CPK)-115 AlkPhos-72 Amylase-65 TotBili-0.9 [2153-10-5] 08:34PM BLOOD Lipase-23 [2153-10-6] 05:00PM BLOOD CK-MB-5 cTropnT-0.02* [2153-10-16] 06:20AM BLOOD Mg-1.9 [2153-10-5] 08:34PM BLOOD Triglyc-80 HDL-52 CHOL/HD-2.7 LDLcalc-74 [2153-10-6] 06:15AM BLOOD TSH-3.3 Brief Hospital Course: A/P: 75 y/o F w/ COPD, AF, CAD, severe MR, severe TR, a/w CHF to OSH, txferred to floor for surgery on [2153-10-10]. . #Cardiac: -Pump: Preserved EF with CHF. (EF estimated from echo and likely to be an overestimate based on reverse flow through MR/TR. - will hold on further Lasix as pt does not currently appear to be fluid overloaded. However, will be cautious as pt has flashed in past. Pt responded to IVF for decreased UOP. Current UOP over last 2 days approx 30xcc/hr. Renal function improving. -Monitor intake as previously pt had h/o flash edema. . -Rhythm: Pt still in asymptomatic afib. -Per notes, pt has been in AF since [9-27] at OSH. RVR on floor here. Lasix and SL nitro resolved. -[10-7] pt converted into sinus rhythm on tele monitoring. -[Date range (1) 65405]: reverted to afib - asymptomatic - increased metoprolol to 37.5 tid. However BP a little lower in mid 80s after morning rounds on [10-9]. - on heparin, will continue. Hold on warfarin for now . -Ischemia: no evidence. enzymes negative X3 here. - on BB, ACEI initially. given [Doctor First Name 48] acei held and changed to hydral in pt with severe MR [First Name (Titles) ] [Last Name (Titles) 65406] reduction. - cont ASA (has had ulcer surgery in past) . # Respiratory: Flashed on floor. - Flash was more related to rate than to overall fluid status. - Will monitor patient closely. - Cont metoprolol for BP control and rate control - Will hold on lasix for now. - repeat CXR on [10-7] - improved - no need to tap. . # COPD - hold albuterol nebs. Start ipratropium nebs and salmeterol and flovent inhalers. (pt well controlled). . # Renal: Pt with normal creat at OSH now with rising Creat to 1.9 - improved to 1.0. Urine lytes consistent with prerenal state on [2153-10-7]. Patient was cathed on [10-1], at risk for dye nephropathy - pt likely to have poor forward flow in setting of TR and MR. - repeat urine lytes consistent with prerenal stage given IVF . #Hx of ulcer - PPI. Pt is on ASA - will guaiac all stools. . #OA - chronic pain - takes vicodin . # FEN: Replete lytes as needed. Low Na/Heart healthy diet . #Osteoporosis - calcium and fosamax . #Ppx: Hep IV, ASA, tylenol, bowel reg, PPI . #Full Code Referred to Dr. [Last Name (STitle) ] for MVR/ possible CABG and underwent MVR with a 29 mm [Company 1543] Mosaic pig valve on [10-10]. Transferred to the CSRU in stable condition on epinephrine and propofol drips. Started amiodarone to help keep the patient in SR. Epinephrine DCed and nitroglycerin drip started on POD #1. Patient was extubated on POD #2 and chest tubes were also removed.Transferred to the floor that evening. She had some serous sternal drainage and was started on betadine dressings and vanco. Beta blockade was begun. CXR showed a left pleural effusion. She went back into Afib on POD #3. Coumadin was started and heparin IV began on POD #4 . She was alert and oriented and ambulating with her walker on the floor. She had some brief NSVT that evening, and Mg was repleted. Pacing wires were removed on POD #5 and vancomycin was stopped. It was agreed that the patient could go home with services as her son would be available to help her during the day. Target INR is 1.5- 2.0. Theophylline was restarted prior to discharge. Cleared for discharge on [10-16] with INR 1.8. Dr. [Last Name (STitle) 32665] [Telephone/Fax (1) 65407] will be following INR/coumadin dosing. Medications on Admission: Meds at home: vicodin, xanax, dig .125, enalapril 10, fosamx 70, lasix 20, atenolol 25, theophylline 200 [Hospital1 ] . Meds on tfer: hep gtt, bisoprolol 2.5 [Hospital1 ], xanax 1 hs, protonix, vasotec 25 [Hospital1 ], SL NTG, tylenol, vicodin, flovent, serevent, combivent Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): 20mg [Hospital1 ] x 10 days then QD. Disp:40 Tablet(s) Refills:2 2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours): 20 meq [Hospital1 ] x 10 days then QD. Disp:80 Capsule, Sustained Release(s) Refills:2 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 4. 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 5. Warfarin 1 mg Tablet Sig: as directed Tablet PO DAILY (Daily): 2mg on [10-16] and 30, then as directed by Dr [Last Name (STitle) 65408] target INR 1.5-2. Disp:60 Tablet(s) Refills:2 6. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:30 Tablet Sustained Release 24HR(s) Refills:2 7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain. Disp:40 Tablet(s) Refills:0 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 10. Theophylline 200 mg Capsule, Sust. Release 12HR Sig: One (1) Capsule, Sust. Release 12HR PO BID (2 times a day). Disp:60 Capsule, Sust. Release 12HR(s) Refills:2 Discharge Disposition: Home With Service Facility: VNA Care of [Location (un) 511] Discharge Diagnosis: s/p MVR (#29 [Company 1543] Mosaic) PMH:MR, AF, CAD, COPD, HTN, CHF, anxiety, THR, OA, TAH/BSO, ulcer surgery Discharge Condition: good Discharge Instructions: keep wounds clean and dry. OK to shower, no bathing or swimming. Take all medications as prescribed. Call for any fever, redness or drainage from wounds Followup Instructions: Dr [Last Name (STitle) ] in 4 weeks Dr [Last Name (STitle) 32665] in [12-21] weeks INR blood draw [10-18] and to be followed by Dr. [Last Name (STitle) 32665] Completed by:[2153-11-1]	[ "414.01", "427.31", "733.00", "428.0", "V43.64", "424.0", "401.9", "496", "300.00" ]	icd9cm	[ [ [] ] ]	[ "39.61", "35.23" ]	icd9pcs	[ [ [] ] ]	9720, 9786	4357, 7828	330, 397	9944, 9951	2737, 4334	10152, 10362	2341, 2345		8165, 9697		9807, 9923		7854, 8142			9975, 10129									2360, 2718																									283, 292									425, 1941																	1963, 2234	2250, 2325
22,933	160,210	8354	Discharge summary	report	Admission Date: [2110-10-9] Discharge Date: [2110-10-18] Date of Birth: [2055-3-2] Sex: F Service: MEDICINE Allergies: Cipro / Doxycycline / Paxil / Quinine / Compazine / Levaquin / Lithium Attending:[First Name3 (LF) 1493] Chief Complaint: Confusion Major Surgical or Invasive Procedure: Nasogastric tube Endotracheal intubation Left subclavian central venous catheter Left PICC History of Present Illness: The patient is a 55-year-old woman with hepatic sarcoidosis and regenerative hyperplasia s/p TIPS [12/2109] placed [3-15] variceal bleeding and portal hypertensive gastropathy s/p TIPS re-do with angioplasty and portal vein embolectomy, who was brought to the ED by her husband for evaluation after he noted worsening encephalopathy. The patient has a history of multiple previous admissions for encephalopathy, and her husband is very familiar with her episodes of encephalopathy. Her husband noted worsening asterixis and recognized this as a sign of impending encephalopathy, so he brought her in to the ED for further evaluation. While in the waiting room the pt became more combative and then unresponsive, consistent with her prior episodes of encephalopathy. Per the husband she had been religious with her lactulose. In the ED: VS - Temp 97.9F, HR 115, BP 122/80, R 18, O2-sat 98% 2L NC. She was unresponsive but able to protect her airway and so not intubated. She vomited x1 and received Zofran as well as 1.5 L NS. Labs were significant for K 5.5, BUN 46, Cr 2.2 (up from baseline of 0.8), and ammonia of 280. Stool was Guaiac negative. A urinalysis and CXR were done and are pending on transfer, and a FAST revealed hepatosplenomegaly but no intraperitoneal fluid. An NG tube was placed and she received Lactulose and Kayexelate. She is being admitted to the MICU for further care given her mental status. On arrival to the ICU the pt had another episode of emesis. NGT was placed to suction and 1.5L bilious material was drained. Past Medical History: # Hepatic sarcoidosis and regenerative hyperplasia - s/p TIPS [12-19] placed d/t GI bleeding from varices and portal gastropathy - TIPS re-do with angioplasty and portal vein embolectomy - severe portal hypertensive gastropathy - Grade II varices - grade 3 esophagitis # multiple SBOs, most recent [5-20] # Idiopathic cardiomyopathy: -ECHO demonstrating an EF of 15-20% (no report, ?OSH) and a p-mibi that confirmed an EF of 23% with no ischemic changes--> improving [6-17] to EF 40-45%, mild-to-moderate global left ventricular hypokinesis -Cardiac cath [2-16]: no angiographically apparent flow-limiting lesions, mild mitral regurgitation, and severe systolic ventricular dysfunction with a left ventricular ejection fraction of 20%. -Right heart cath: [2109-2-18]: Normal right sided filling pressures. Mild pulmonary artery hypertension. Preserved cardiac index. # COPD, followed by [First Name4 (NamePattern1) 4648] [Last Name (NamePattern1) ], PFTs WNL # Hx of SAH [2101] s/p coiling, 2 new aneurysms seen on angio [2108-6-21] # Colonic AVM and diverticulum # Evidence of CVA/TIA # Hypothyroidism # Anemia # s/p hysterectomy # s/p cholecystecomy # s/p appendectomy # Reflex Sympathetic Dystrophy s/p fall, on disability, now resolved # Raynauds Social History: Married, lives in [Hospital1 1474], has 2 sons and 5 grandchildren, 36 pack-year smoking hx quit 2.5 years ago, does not drink EtOH and denies former abuse, no h/o illicits or IVDU, does not work [3-15] disability for RSD. Family History: [Name (NI) 29555] MI [Name (NI) 29556] Physical Exam: VS - Temp 96.9F, BP 139/90, HR 119, R 16, O2-sat 100% 2L NC GENERAL - unresponsive to verbal / tactile stimuli, withdraws to pain HEENT - NC/AT, PERRL, sclerae anicteric, NGT in place on low intermittent suction NECK - supple, no thyromegaly or LAD LUNGS - faint crackles at right lung base, otherwise CTA, resp unlabored, no accessory muscle use HEART - regular, tachycardic, nl S1-S2, no MRG ABDOMEN - few BS, soft/NT, mildly distended and tympanitic to percussion across upper abdomen, no masses or HSM, no rebound/guarding EXTREMITIES - cool, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions, no jaundice or stigmata of chronic liver disease NEURO - good tone, reflexes 2+ and symmetric (biceps, patellar), 1-2 beats of asterixis / clonus Pertinent Results: [2110-10-9] 05:15PM WBC-9.1 RBC-4.62 HGB-14.4 HCT-41.3 MCV-90# MCH-31.3 MCHC-35.0 RDW-15.9* [2110-10-9] 05:15PM NEUTS-85.7* LYMPHS-7.8* MONOS-4.4 EOS-1.9 BASOS-0.2 [2110-10-9] 05:15PM PLT COUNT-112* [2110-10-9] 05:15PM PT-12.5 PTT-27.1 INR(PT)-1.1 [2110-10-9] 05:15PM GLUCOSE-132* UREA N-46* CREAT-2.2* SODIUM-143 POTASSIUM-5.5* CHLORIDE-107 TOTAL CO2-25 ANION GAP-17 [2110-10-9] 05:15PM ALT(SGPT)-28 AST(SGOT)-26 CK(CPK)-29 ALK PHOS-197* AMYLASE-116* TOT BILI-1.0 [2110-10-9] 05:15PM LIPASE-61* [2110-10-9] 05:15PM TOT PROT-7.4 ALBUMIN-4.9* GLOBULIN-2.5 CALCIUM-11.1* [2110-10-9] 05:15PM AMMONIA-280* [2110-10-9] 05:15PM TSH-0.94 [2110-10-9] 09:12PM URINE HOURS-RANDOM UREA N-661 CREAT-144 SODIUM-26 [2110-10-9] 11:39PM freeCa-1.21 [2110-10-9] 09:10PM URINE Color-Amber Appear-Hazy Sp [Last Name (un) ]-1.017 [2110-10-9] 09:10PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-NEG pH-5.0 Leuks-TR [2110-10-9] 09:10PM URINE RBC-[7-22]* WBC-0-2 Bacteri-MANY Yeast-NONE Epi-0 [2110-10-14] 12:22PM BLOOD Hct-22.6* [2110-10-14] 10:47PM BLOOD Hct-28.5* [2110-10-18] 05:45AM BLOOD WBC-3.9* RBC-2.82* Hgb-8.7* Hct-24.8* MCV-88 MCH-30.9 MCHC-35.1* RDW-15.7* Plt Ct-89* [2110-10-17] 06:30AM BLOOD PT-13.3 INR(PT)-1.1 [2110-10-18] 05:45AM BLOOD Glucose-93 UreaN-35* Creat-1.3* Na-141 K-3.3 Cl-107 HCO3-25 AnGap-12 [2110-10-16] 06:55AM BLOOD ALT-11 AST-21 LD(LDH)-211 AlkPhos-215* TotBili-0.9 BCx ([10-9] x2, [10-12]): negative UCx([10-9]): LACTOBACILLUS SPECIES. >100,000 ORGANISMS/ML.. BETA STREPTOCOCCUS GROUP B. 10,000-100,000 ORGANISMS/ML.. UCx ([10-12]): negative Sputum cx ([10-12]): MODERATE GROWTH OROPHARYNGEAL FLORA. Abd Dopper/RUQ U/S ([10-10]): IMPRESSION: Repeat occlusion of TIPS stent. No ascites. Heterogenous liver consistent with end stage disease related to sarcoid. Head CT ([10-10]): IMPRESSION: Unchanged head CT with no acute intracranial pathology. Chest/Abd/Pelvis CT ([10-10]): IMPRESSION: 1. No free air in the chest, abdomen or pelvis. 2. Mechanical small bowel obstruction proximal to the terminal ileus. The cecum and terminal ileus or tethered together in the right lower quadrant likely secondary to adhesions. 3. Ground-glass changes in the lungs bilaterally, possibly due to pulmonary edema. 4. Emphysematous changes in the lungs consistent with stated diagnosis of COPD. CXR ([10-12]): IMPRESSION: Atelectasis left lower lobe. CXR ([10-14]): FINDINGS: In comparison with the study earlier in this date, there is some prominence of interstitial markings with [Last Name (un) 16765] lines, consistent with elevated pulmonary venous pressure. Poor definition of the retrocardiac region raises the possibility of some atelectatic change at the base. Blunting of the costophrenic angles could be a manifestation of pleural fluid. CXR ([10-17]): FINDINGS: In comparison with the sequence of previous films from earlier in this month, there has been clearing of the left pleural effusion. Cardiac silhouette is within normal limits. Prominence of interstitial markings may reflect elevated pulmonary venous pressure, chronic lung disease, or both. No acute focal pneumonia. Brief Hospital Course: 1) Small bowel obstruction ?????? CT from [10-10] showed a transition point in the mid-distal ileum and no ascites. Surgery was consulted and an NG was placed with return of 1.5L of bilious fluid. SBO thought to be likely due to adhesions, possibly related to sarcoidosis. She was intubated for airway protection and a left subclavian CVC was placed for access. The NG tube had >1L output for first 1-2 days. Output then decreased and stools picked up so the NG tube was removed. She was extubated on [10-13] and had a PICC placed for TPN on [10-15]. Her diet was slowly advanced and the TPN was weaned. At discharge she was tolerating a regular diet and was moving her bowels. 2) Anemia ?????? Acute normocytic anemia. Initial hematocrit of 41 was likely due to dehydration as her baseline is in the mid 20s. Her hematocrit trended down to 22.9 with stool guaiac negative on multiple occasions. She also had negative hemolysis labs. She was transfused 1 U pRBCs on [10-14] and about 1 hour later developed acute pulmonary edema with SBP 200 and HR 130. She received lasix 40mg IV and her symptoms and vitals rapidly improved with a 1L output. The blood bank was notified due to the possiblity of TRALI. Her hematocrit rise was appropriate and remained in the mid 20s. 3) Hepatic sarcoidosis: Complicated by recurrent encephalopathy, patient status post TIPS and revision. Her platelets remained stable with negative HIT antibodies. Her encephalopathy improved rapidly following lactulose. Her TIPS was found to be occluded, but revision was not done due to concern that it would worsen her encephalopathy. She also initially received empiric flagyl to prevent bacterial translocation, but this was deemed unnecessary and discontinued. She was continued on her home ursodiol, PPI, and vitamins/minerals. She was initially on hydrocortisone while NPO, but switched to her outpatient prednisone before discharge. She was also restarted on her sucralfate, furosemide, and spironolactone at discharge. Her amitriptyline and zolpidem were held due to her encephalopathy and may be restarted as an outpatient if appropriate. 3) Pneumonia ?????? On [10-12], she spiked to 101.7 and there was concern for an infiltrate on CXR. Etiology aspiration versus VAP. She was started on vanc/zosyn, narrowed to zosyn, and was subsequently afebrile and without leukocytosis. She completed a 7 day course of antibiotics prior to discharge. 4) ARF ?????? Her BUN and Cr were elevated on admission to 46 and 2.2, respectively, up from baseline BUN [6-21] and baseline Cr 0.8-1.0. She was given IV LR for prerenal azotemia and her furosemide and spironolactone were held. She was also noted to have a GBS UTI and was orinigally given Pen G, but it was determined that the zosyn (see above) was adequate coverage. Her creatinine improved to 1.3 by the time of discharge and her diuretics were resumed. CTA did not show hydronephrosis. Medications on Admission: (per most recent discharge summary dated [2110-7-5]) - Prednisone 10mg PO daily - Gabapentin 600mg PO daily - Levothyroxine 88mcg PO daily - Amitryptyline 50mg PO QHS - Folic acid 1mg PO daily - Ursodiol 600mg PO QAM, 300mg PO QPM - Thiamine 100mg PO daily - Albuterol 90mcg 1-2puffs INH Q6hrs PRN - Lactulose 20g/30ml PO TID - Metronidazole 500mg PO BID (? in d/c summary, undefined course) - Ferrous sulfate 325mg (Iron 65mg) PO BID - Zolpidem 10mg PO QHS PRN - Spironolactone 50mg PO daily - Lasix 20mg PO daily - Omeprazole 20mg PO daily - Sucralfate 1gram PO QID - Vitamin B12 1000mcg/ml Inj once a month - Diltiazem 120mg PO BID (?) Discharge Medications: 1. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 3. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO QPM (once a day (in the evening)). 6. Ursodiol 300 mg Capsule Sig: Two (2) Capsule PO QAM (once a day (in the morning)). 7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: [2-12] Inhalation every six (6) hours as needed. 9. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 10. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 12. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO four times a day. 13. Vitamin B-12 1,000 mcg/mL Solution Sig: One (1) Injection once a month. 14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Primary: hepatic encephalopathy, acute renal failure, small bowel obstruction Secondary: hepatic sarcoidosis, hypothyroidism Discharge Condition: Stable Discharge Instructions: 1)You were admitted to [Hospital1 18] with confusion, worsened kidney function, and recurrence of the obstruction in your intestines. You were briefly intubated to protect your lungs from your vomiting. We are treated you with antibiotics for a suspected pneumonia. We slowly advanced your diet from nothing by mouth to a full diet, and gave you IV nutrition as well. Your confusion and kidney function gradually improved and you are tolerating a regular diet. 2)Please take all medications as written below. We made the following medication changes: - Holding your amitriptyline and zolpidem due to your recent confusion. Ask your primary care doctor whether to restart them. 3)Please attend all appointments as listed below. 4)If you experience and confusion, nausea, vomiting, abdominal pain, fevers, or any other concerning symptoms, please seek medical attention or come to the ER immediately. Followup Instructions: Provider: [Name10 (NameIs) ] [Last Name (NamePattern4) 2424], MD Phone:[Telephone/Fax (1) 2422] Date/Time:[2110-10-21] 3:15 Please call Dr. [Last Name (STitle) 29478], your primary care doctor, at ([Telephone/Fax (1) 29561] to [Telephone/Fax (1) ] a follow up appointment. Completed by:[2110-10-19]	[ "041.02", "V16.7", "E934.2", "135", "438.9", "287.4", "560.81", "572.8", "996.74", "V14.8", "276.7", "572.3", "530.19", "456.21", "585.9", "428.22", "425.8", "571.8", "244.9", "496", "573.0", "V17.49", "428.0", "584.9", "537.89", "572.2", "599.0", "276.51", "486", "V15.82", "285.9" ]	icd9cm	[ [ [] ] ]	[ "99.04", "96.07", "96.71", "99.15", "38.93", "96.04" ]	icd9pcs	[ [ [] ] ]	12630, 12636	7781, 10722	341, 434	12805, 12814	4441, 7758	13768, 14102	3590, 3638		11415, 12607		12657, 12784		10748, 11392			12838, 13374									3653, 4422																							13394, 13745		292, 303									462, 2016																	2038, 3326	3342, 3574
31,259	195,717	31742	Discharge summary	report	Admission Date: [2154-7-5] Discharge Date: [2154-7-8] Date of Birth: [2100-11-2] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1835] Chief Complaint: Blurred vision Major Surgical or Invasive Procedure: Right occipital Craniotomy with mass resection History of Present Illness: CC: Blurred vision HPI: Mr. [Known lastname 8907] [Last Name (Titles) 1834] an MRI of his head on [2154-6-26], which showed a new brain metastasis of 3.3 cm heterogeneous in the right occipital lobe mass effect/effacement/entrapment of the posterior [Doctor Last Name 534] and atrium in the right ventricle. Subsequently he [Doctor Last Name 1834] a right occipital craniotomy on [2154-7-5]. There have been no perioperative complications to report. Past Medical History: Lung mass Migrane Headaches Hypercholesterolemia Anxiety Brain mass Seizure activity GERD Social History: Married, lives with spouse non-tobacco >1year Family History: N/C Physical Exam: VSS: 98.3-150/90-60-18-97% Room air Alert and Oriented X3. Neurologically intact. Heart RRR Lungs Clear to Auscultation Abdomen rounded, soft, nontender; small umbilical hernia Extremities no ankle edema; 5/5 strength UE/LE; decreased sensation left heel, other wise intact Other CN II -XII grossly intac History & Physical performed by: [First Name8 (NamePattern2) 74545] [Last Name (NamePattern1) 74546] NP <esig> Pertinent Results: Anatomical pathology report pending at time of d/c Brief Hospital Course: To O.R. [2154-7-5] for right occipital craniotomy. No perioperative complications. Medications on Admission: Prilosec Valium Oxycodone MVI Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 4. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. Disp:30 Tablet(s) Refills:1 5. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO Q 12H (Every 12 Hours). Disp:60 Capsule, Delayed Release(E.C.)(s) Refills:2 7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO every twelve (12) hours. 12. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:80 Tablet(s) Refills:0 13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 14. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO q6h () for 4 doses. Disp:4 Tablet(s) Refills:0 15. Dexamethasone 2 mg Tablet Sig: 0.5 Tablet PO q6h () for 4 doses. Disp:2 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Right Occipital brain mass Discharge Condition: Stable Discharge Instructions: General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and/or staples have been removed. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Follow-Up Appointment Instructions ?????? Please return to the office in 10 days for removal of your staples and sutures. Followup Instructions: Dr. [Last Name (STitle) ] to be seen in four weeks. Please call for an appointment [Telephone/Fax (1) 1669]. Completed by:[2154-7-8]	[ "345.90", "V15.82", "198.3", "346.90", "162.3", "530.81", "300.00", "V15.3", "272.0", "V10.82" ]	icd9cm	[ [ [] ] ]	[ "01.59" ]	icd9pcs	[ [ [] ] ]	3292, 3298	1618, 1706	332, 380	3368, 3376	1543, 1595	5015, 5161	1078, 1083		1787, 3269		3319, 3347		1732, 1764			3400, 4992									1098, 1524																									278, 294									408, 886																	908, 999	1015, 1062
14,936	198,718	24883	Discharge summary	report	Admission Date: [2162-4-29] Discharge Date: [2162-5-10] Date of Birth: [2085-6-1] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 443] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: none History of Present Illness: 76yo M with h/o CAD, CABG, recent knee surgery, at rehab from knee surgery. Recently admitted [Date range (1) 62597] for dyspnea, noted to have ICD firing x2, also found to have UTI at that time, started on 2 wk course of zosyn as well as well as c.diff. Dyspnea felt to be [2-26] decnoditioning, infection. Returned on [4-23] for dyspnea. Had a CTA performed which was negative for PE, ? R heart failure. He was noted to have mild troponin leak. Planned for outpatient stress test after. He returns today after being noted to be somnolent and dyspneic. He notes dyspnea worsening over the last 2 days, now feels better that he is on nasal oxygen. He notes chronic dyspnea, although some worsening for last 2 days. Denies any associated chest pain, fever, chills. + associated non-productive cough. No rhinorrhea, sore throat. He denies increase in orthopnea. Prior dry weight 181, more recently 175, however no change in his dyspnea with the weight loss. Pt is unable to provide a very complete hx as he is somewhat somnolent and inattentive. . ED course: started on gentle IVF, received vanco and zosyn for ? CXR infiltrate, had L upper extremity u/s which showed extensive clot, started on heparin drip. ABG performed 7.45/27/121. Past Medical History: Cardiac Risk Factors: Diabetes, Dyslipidemia, Hypertension . Cardiac History: CABG, in [2142] anatomy as follows: SVG to LAD, OM and RCA - op report not available, seen on cath in '[61] CHF - sever, s/p BiV implant, EF 17% . Percutaneous coronary intervention, in [2161-9-24] anatomy as follows: Native three vessel coronary artery disease. Mildly elevated left sided filling pressure. SVG-LAD with 30% proximal and mid vessel stenoses. SVG-OM with minimal disease. Known occlusion of SVG-RCA. Reportedly has had prior PCI w/stenting but records unavailable . Pacemaker/ICD, in [2159] [Company 1543] ICD, Insync [First Name9 (NamePattern2) ] [Last Name (un) 19961] 7289 - last interrogation [2162-2-15] Has had multiple ICD firings, most recently in the ED, and another approximately one week ago . Other Past History: Recent C-diff @ rehab Diabetes mellitus since [2135] - on insulin History of prostate cancer. Depression. Osteoarthritis. Hypertension. Hypercholesteremia. Chronic renal insufficiency. Gout. Erectile dysfunction. Congestive heart failure. Peripheral neuropathy secondary to diabetes. Insomnia. prostate cancer , diagnosed [2156], [Doctor Last Name ] 6, no treatment thus far Social History: He is a retired lawyer. [Name (NI) ] is married and lives with his wife. They moved from [State 760] last year. He has 2 sons, one of which has diabetes, and 2 daughters. [Name (NI) ] tobacco. About one alcoholic drink per week. In the past, he smoked a pipe on occasion. Family History: Mother died age 88, DM and cancer. Father died age 74, secondary to prostate cancer. 1 brother deceased from cancer. 1 sister alive and well. Physical Exam: VS:Temp 96.8, BP 125/89, HR 72, RR 26, O2 sat 97% on 3L Gen: elderly male, mildly dyspneic, somnolent but arousable HEENT: anicteric, MM dry Neck: supple, no LAD, unable to see JV pulsations Resp: good air movement, no wheezes, mild crackles at bases CV: RRR, nl s1, s2, no m/r/g Abd: soft, NT, ND Extr: R forearm PICC in place, 1+ pedal edema b/l, 1+ pulses b/l. L arm 2+ edema, 1+ hand pulses Pertinent Results: Imaging: CHEST (PORTABLE AP) [2162-4-28] 9:35 PM IMPRESSION: Markedly limited study. Left lower lobe atelectasis likely although an early developing pneumonia cannot be entirely excluded. If clinically feasible, consider further evaluation with PA and lateral view. . CHEST (PORTABLE AP) [2162-4-29] 3:20 PM IMPRESSION: Left lower lobe infiltrate . CHEST (PA & LAT) [2162-4-29] 9:02 AM IMPRESSION: No evidence of overt edema. Retrocardiac opacity likely represents atelectasis; however, early infectious process cannot be entirely excluded. . CT HEAD W/O CONTRAST [2162-4-29] 2:04 AM IMPRESSION: No evidence of hemorrhage. . UNILAT UP EXT VEINS US LEFT [2162-4-29] 1:29 AM IMPRESSION: Extensive, acute-appearing occlusive thrombus within the left internal jugular, left subclavian, and left axillary veins. These findings were phoned immediately to Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. . ABDOMEN U.S. (COMPLETE STUDY) [2162-5-4] 9:07 AM IMPRESSION: 1. No intrinsic hepatic or biliary pathology is identified. Passive hepatic congestion is most likely cause for the elevated transaminase level. 2. Mild splenomegaly. . CT HEAD W/O CONTRAST [2162-5-5] 9:03 AM IMPRESSION: No acute intracranial pathology, including no sign of intracranial hemorrhage. . RENAL U.S. [2162-5-7] 10:38 AM IMPRESSION: 1.Increased echogenicity of the liver consistent with fatty liver. However, other forms of liver disease and more advanced liver disease including significant hepatic fibrosis/cirrhosis cannot be excluded. Passive hepatic congestion is a likely cause in this patient. 2) No hydronephrosis is detected. Non-obstructive stone of the mid pole of the left kidney measures 7 mm in greatest dimension. 3) Ascites and bilateral pleural effusion are present . C.CATH Study Date of [2162-5-7] COMMENTS: 1. Resting hemodynamics revealed severely elevated right and left heart pressures with a mean RA of 22mmHg and mean PCWP of 27mmHg. There was moderate pulmonary artery hypertension with a PASP of 57mmHg. The cardiac index was severely depressed at 1.2l/min/m2. FINAL DIAGNOSIS: 1. Severe biventricular diastolic dysfunction. 2. Markedly reduced cardiac index. . CHEST (PORTABLE AP) [2162-5-8] 9:38 AM IMPRESSION: Feeding tube placement as described . CHEST PORT. LINE PLACEMENT [2162-5-8] 7:56 AM SINGLE AP PORTABLE VIEW OF THE CHEST Swan- Ganz catheter tip is in the right pulmonary artery. The heart remains enlarged but stable. Left pacemaker leads terminate in standard position. Compared to prior study dated [2162-4-29] there has been interval increase in right small-to- moderate pleural effusion. There is mild interstitial pulmonary edema. There is no pneumothorax. . Micro: [2162-4-28] Blood Cx: negative Urine Cx: negative . [2162-5-5] Blood cx: negative . Labs: [2162-4-28] 07:30PM BLOOD WBC-5.9 RBC-5.12 Hgb-13.8* Hct-43.7 MCV-85 MCH-26.9* MCHC-31.5 RDW-21.2* Plt Ct-186 [2162-5-3] 04:20AM BLOOD WBC-5.3 RBC-4.36* Hgb-11.9* Hct-36.4* MCV-84 MCH-27.2 MCHC-32.6 RDW-22.0* Plt Ct-105* [2162-5-5] 10:28PM BLOOD WBC-4.7 RBC-4.32* Hgb-11.8* Hct-36.2* MCV-84 MCH-27.3 MCHC-32.5 RDW-22.1* Plt Ct-85* [2162-5-7] 07:55PM BLOOD WBC-6.8 RBC-4.14* Hgb-11.3* Hct-34.3* MCV-83 MCH-27.4 MCHC-33.0 RDW-21.5* Plt Ct-83* [2162-5-9] 06:17AM BLOOD WBC-11.2# RBC-4.39 Hgb-11.5* Hct-37.5* MCV-85 MCH-26.2* MCHC-30.7* RDW-21.7* Plt Ct-70* [2162-5-10] 05:38AM BLOOD WBC-9.1 RBC-4.45* Hgb-11.8* Hct-37.6* MCV-84 MCH-26.5* MCHC-31.4 RDW-21.7* Plt Ct-87* [2162-4-29] 12:25AM BLOOD PT-19.9* PTT-42.2* INR(PT)-1.9* [2162-5-1] 07:14AM BLOOD PT-20.6* PTT-63.6* INR(PT)-2.0* [2162-5-4] 06:03AM BLOOD PT-60.8* PTT-55.6* INR(PT)-7.5* [2162-5-5] 06:25AM BLOOD PT-76.9* PTT-57.5* INR(PT)-10.0* [2162-5-5] 02:04PM BLOOD PT-75.1* PTT-53.3* INR(PT)-9.7* [2162-5-6] 02:42AM BLOOD PT-40.8* PTT-53.0* INR(PT)-4.6* [2162-5-7] 07:55PM BLOOD PT-32.5* PTT-150* INR(PT)-3.5* [2162-5-8] 11:34AM BLOOD PT-29.5* PTT-56.3* INR(PT)-3.1* [2162-5-10] 05:38AM BLOOD PT-45.3* PTT-66.2* INR(PT)-5.2* [2162-4-28] 07:30PM BLOOD Glucose-187* UreaN-24* Creat-1.8* Na-128* K-5.9* Cl-98 HCO3-18* AnGap-18 [2162-5-1] 07:14AM BLOOD Glucose-109* UreaN-26* Creat-1.7* Na-135 K-4.1 Cl-102 HCO3-21* AnGap-16 [2162-5-3] 04:47PM BLOOD Glucose-226* UreaN-34* Creat-1.9* Na-131* K-3.9 Cl-97 HCO3-24 AnGap-14 [2162-5-5] 02:04PM BLOOD Glucose-237* UreaN-43* Creat-1.9* Na-132* K-3.7 Cl-95* HCO3-26 AnGap-15 [2162-5-7] 07:55PM BLOOD Glucose-174* UreaN-51* Creat-2.7* Na-135 K-4.5 Cl-95* HCO3-21* AnGap-24* [2162-5-9] 12:30AM BLOOD Glucose-84 UreaN-41* Creat-2.6* Na-131* K-4.5 Cl-100 HCO3-19* AnGap-17 [2162-5-10] 05:38AM BLOOD Glucose-171* UreaN-33* Creat-2.2* Na-129* K-5.2* Cl-99 HCO3-13* AnGap-22* [2162-4-28] 07:30PM BLOOD CK(CPK)-39 [2162-5-2] 04:14AM BLOOD ALT-96* AST-143* AlkPhos-74 TotBili-1.3 [2162-5-6] 02:42AM BLOOD ALT-193* AST-235* LD(LDH)-191 AlkPhos-70 TotBili-1.2 [2162-5-8] 05:57AM BLOOD ALT-196* AST-365* LD(LDH)-253* AlkPhos-87 TotBili-3.2* [2162-5-10] 05:38AM BLOOD ALT-257* AST-680* AlkPhos-86 TotBili-6.4* [2162-4-28] 07:30PM BLOOD CK-MB-NotDone cTropnT-0.09* [2162-4-29] 10:32AM BLOOD CK-MB-NotDone cTropnT-0.09* proBNP-[Numeric Identifier 62598]* [2162-5-3] 04:47PM BLOOD CK-MB-NotDone cTropnT-0.08* [2162-5-4] 06:03AM BLOOD CK-MB-3 cTropnT-0.09* [2162-4-29] 12:25AM BLOOD Albumin-2.6* [2162-5-2] 04:07PM BLOOD Mg-2.0 [2162-5-5] 02:04PM BLOOD Calcium-9.2 Phos-3.9 Mg-2.2 [2162-5-7] 11:50PM BLOOD Calcium-9.1 Phos-5.8* Mg-2.3 [2162-5-9] 06:17AM BLOOD Albumin-3.4 Calcium-9.8 Phos-4.1 Mg-2.4 [2162-5-10] 05:38AM BLOOD Calcium-9.9 Phos-3.4 Mg-2.4 [2162-5-4] 02:52PM BLOOD Hapto-24* [2162-5-5] 02:04PM BLOOD Hapto-20* [2162-5-6] 02:42AM BLOOD Hapto-<20* [2162-5-8] 05:57AM BLOOD calTIBC-164* VitB12-GREATER TH Folate-11.1 Hapto-<20* Ferritn-261 TRF-126* [2162-5-5] 05:10PM BLOOD Ammonia-23 [2162-5-5] 05:10PM BLOOD TSH-14* [2162-5-6] 02:42AM BLOOD TSH-14* [2162-5-7] 05:39AM BLOOD TSH-16* [2162-5-6] 02:42AM BLOOD T4-2.7* Free T4-0.85* [2162-5-7] 05:39AM BLOOD T4-2.8* T3-46* Free T4-0.92* [2162-5-8] 05:57AM BLOOD Cortsol-23.3* [2162-5-5] 05:10PM BLOOD IgM HBc-NEGATIVE [2162-5-4] 12:03PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE [2162-5-5] 05:10PM BLOOD PSA-10.8* [2162-5-4] 02:52PM BLOOD PEP-ABNORMAL B IgG-1124 IgA-194 IgM-1308* IFE-MONOCLONAL [2162-5-4] 12:03PM BLOOD HCV Ab-NEGATIVE Brief Hospital Course: A/P: 76 y/o man hx CAD s/p CABG, CHF (EF 20-25), recent prostatitis, c.diff admitted w/dyspnea with AMS changes which are simiilar to previous episodes during DHF exacerbations/hospitalizations . # CHF - Patient with florid CHF unresponsive to Lasix gtt, thus was transferred to the CCU. patient has a swan ganx catheter placed prior to arrival for optimal monitoring of intravascular volume status. patient required multiple pressors with improvement in cardiac status. Patient has all pressors removed, as per family's request, prior to passing. . # Altered mental status: has had AMS in setting of CHF exacerbations hospitalizations in the past. He has been on baby doses of alprazolam and lyrica as well which may have contributed. ? contribution of infection. He became more altered on the floor, which per family reports has not been that diffent than baseline oscillations at times. He was intermittently very sleepy and difficult to arouse. ABG was unchanged from admission and vital signs were stable. He was given his NPH in the AM but had been NPO and there was a thought that low blood sugar may have been contributing. He was given D50 with some improvement. Given the high level of nursing care given his mental status, he was tranferred to the ICU for further monitoring for one night, over which time he improved slightly, and was transferred back to the floor. Sedating meds were held and Neurology thought that this was likely multifactorial. The patient remained in the CCU without improvement prior to passing. . # elevated LFTs with elevated INR pre-coumadin: nl LFTs on [4-14]. has had long h/o INR elevation , but LFT abnormalitiew new. [Month (only) 116] be [2-26] congestion [2-26] CHF vs. new med. recently started on both flagyl and zosyn. 4-5% of people on zosyn have AST/ALT elevations. Hepatology consulted and it was thought that this transaminitis was due to congestive hepatology. hepatitis serologies were negative. . # [Last Name (un) 6055]-[Doctor Last Name ] breathing: Likely [2-26] to CHF. Noted apneic episodes while in ICU. Patient was transferred to CCU for treatment of CHF and remained on oxygen therapy prior to passing. . # Dyspnea - Due to heart failure on clinical exam, with increased LE edema and rapid improvement with diuresis. Patient was transferred to the CCU and required multiple pressors without improvement in CHF, thus no improvement in dyspnea. Patient ws requiring oxygen prior to passing. . # LUE DVT - no prior hx of central line on that side, though has pacer box in the area. Will need 6 months anticoagulation. Given elevated basline coags, must consider lupus anticoagulant as cause for hypercoagulable state. Upon arrival to CCU, patient was put on heparin gtt for DVT prophylaxis. . # prostate CA - planned for urology procedure as outpatient, if plan for 6 months of anticoagulation on heparin, will need to be delayed. . # prostatitis: per intern [Doctor Last Name ] at previous hospitalization, had large prostate that was tender at the time of + UA, so likely urine cx. represents prostatitis. Patient was continued on Meropenem while in the CCU. . # c.diff - + C. Diff at last hospitalization and has been on continuous antibiotics since that time, so will need flagyl until at least 2 weeks after meropenem course finished. will need to continue for at least 2 weeks after meropenem dose for prostatitis is finished . # urinary retention: has BPH and retention at recent hospitalization. urinary catheter placed for urinary retention and was recently started on flomax . # ARF: Patient with pre-renal ARF upon CRI, without good forward flow. patient put on pressors while in the CCU, and also had CVVH started for ultrafiltration. Patient did not diurese well while in the unit regardless of CVVH. . # DM II - home standing NPH insulin + HISS - Q4H FS for now, PRN D50 for FS<65 . . Patient passes away on [2162-5-10]. Medications on Admission: Aspirin 81 mg once daily Clopidogrel 75 mg once daily Atorvastatin 10 mg once daily Carvedilol 3.125 mg [Hospital1 ] Digoxin 125 mcg every THIRD day Piperacillin-Tazobactam 2.25 g q6H Metronidazole 500 mg TID Allopurinol 150 mg once daily Ferrous Sulfate 325 once daily Fluoxetine 20 mg once daily Pantoprazole 40 mg once daily Torsemide 80 mg once daily, 20mg qHS Tamsulosin 0.4 mg qHS Insulin 70/30: 28 Units QAM, 12 Units qPM Lyrica 25MG Q12HRS Heparin 5000 Units SC TID tramadol and Xanax as needed. Discharge Medications: None Discharge Disposition: Extended Care Discharge Diagnosis: None Discharge Condition: None Discharge Instructions: None Followup Instructions: None Completed by:[2162-5-12]	[ "785.51", "428.31", "357.2", "584.9", "272.4", "403.91", "286.9", "570", "599.7", "608.86", "572.2", "V45.81", "008.45", "274.9", "788.20", "V58.67", "453.8", "286.7", "573.0", "601.9", "600.01", "185", "250.60", "V53.32" ]	icd9cm	[ [ [] ] ]	[ "89.64", "38.95", "37.21", "39.95", "99.07", "00.17" ]	icd9pcs	[ [ [] ] ]	14892, 14907	10363, 10925	321, 328	14955, 14961	3759, 5887	15014, 15049	3185, 3328		14863, 14869		14928, 14934		14330, 14840		5904, 10340	14985, 14991									3343, 3740																									274, 283									356, 1604										10940, 14304							1626, 2867	2883, 3169
2,756	187,607	25886	Discharge summary	report	Admission Date: [2137-8-3] Discharge Date: [2137-8-10] Date of Birth: [2079-12-6] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [2137-8-6] Three vessel CABG(LIMA->LAD, SVG->OM, SVG->RCA) [2137-8-3] Cardiac catheterization History of Present Illness: This 57 year old male with family history of CAD presented to [Hospital1 ] with acute onset SSCP associated with SOB and N/V. He was lifting packages out of his car when the pain began. The pain was a [11-11] located over his sternum radiating to his left arm. He went inside and called 911 and was taken to [Hospital1 2519] ED. There he was found to have elevated troponin he was started on integrilin and nitro and transfered to [Hospital1 18] for cardiac catheterization. He had no F/C, no cough, no abdominal pain, no change in bowel or bladder. Past Medical History: GERD with ?ulcer, s/p L knee operation 7 years ago, s/p Back operation [2102]'s Social History: EtOh - 2 beers a day Smoking - 1.5 packs/day Wife and 6 children Postal clerk Family History: Father died from MI in 40s Physical Exam: Vitals signs Temp 96.6, BP 150/68, P 56, RR 16, 96% RA Gen: alert, oriented, cooperative male in NAD HEENT: PERRL, MMM, OP clear Neck: no JVD Lungs: clear to ausculation (anterior exam), no crackles or murmers CV: RRR, nl S1S2, no murmers Abd: soft, non-tender, non-distended, positive BS Groin: dressing with some slight dry blood, clean/dry/intact, + bruit at cath site Extremities: 2+ DP, PT pulses, no edema Neuro: grossly intact Pertinent Results: [2137-8-10] 05:40AM BLOOD Hct-32.9* [2137-8-9] 06:05AM BLOOD WBC-9.0 RBC-3.50* Hgb-11.1* Hct-30.4* MCV-87 MCH-31.7 MCHC-36.4* RDW-13.5 Plt Ct-187 [2137-8-10] 05:40AM BLOOD UreaN-7 Creat-0.5 K-4.6 [2137-8-9] 06:05AM BLOOD Glucose-92 UreaN-7 Creat-0.5 Na-133 K-3.8 Cl-101 HCO3-25 AnGap-11 [2137-8-10] 05:40AM BLOOD Mg-1.8 [2137-8-4] 05:26AM BLOOD Triglyc-69 HDL-63 CHOL/HD-2.1 LDLcalc-53 Brief Hospital Course: Mr. [Known lastname 64394] was admitted and underwent cardiac catheterization which was significant for three vessel coronary disease and normal left ventricular function. Angiography revealed a right dominant system with 60% left main lesion, mild disease of the left anterior descending, no significant disease of the circumflex and diffuse disease of the right coronary artery. Left ventriculogram estimated his ejection fraction at 60%. Based on the above results, he was referred for surgical coronary revascularization. He remained pain free on intravenous therapy. A new right groin bruit and hematoma were noted post catheterization for which an ultrasound was obtained - there was no evidence of pseudoaneurysm or fistula. His hematoma remained stable. Further evaluation included a transthoracic echocardiogram which found only trivial mitral regurgitation with mildly thickened mitral valve leaflets. There was no aortic regurgitation and a normal aortic root diameter. His LVEF was normal. The rest of his preoperative workup was unremarkable and he was cleared for surgery. On [8-6], Dr. [Last Name (STitle) ] performed three vessel coronary artery bypass grafting utilizing the LIMA to LAD, vein graft to OM and vein graft to distal RCA. Surgery was uneventful. After the operation, he was brought to the CSRU for further invasive monitoring. He intially experienced a mild postoperative coagulopathy which improved after multiple blood products. Within 24 hours, he awoke neurologically intact and was extubated without incident. He maintained stable hemodynamics and transferred to the SDU on postoperative day two. Beta blockade was resumed and advanced as tolerated. He remained in a normal sinus rhythm. Over several days, he made clinical improvement with diuresis. By discharge, he was tolerating room air with improvement in pleural effusions by chest x-ray. All chest tubes and wires were removed without complication. He worked daily with physical therapy and made steady progress. He was medically cleared for discharge to home on postoperative day four. Medications on Admission: None Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:50 Tablet(s) Refills:0 4. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily) for 7 days. Disp:7 Patch 24HR(s) Refills:0 6. Nicotine 7 mg/24 hr Patch 24HR Sig: One (1) Transdermal once a day for 14 days: Start after 14mg. dose completed. Disp:14 patches Refills:0 7. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). Disp:1 month supply Refills:2 8. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:90 Tablet(s) Refills:2 9. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:14 Tablet(s) Refills:0 10. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H (every 12 hours) for 7 days. Disp:14 Packet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Coronary artery disease Discharge Condition: Good Discharge Instructions: Follow medications on discharge instructions. You may not drive for 4 weeks. You may not lift more than 10 lbs. for 3 months. You should shower, let water flow over wounds, pat dry with a towel. Do not use creams, lotions, or powder on wounds. Call our office for sternal drainage, temp.>101.5 Followup Instructions: Make an appointment with Dr. [Last Name (STitle) ] in [2-3] weeks. Make an appointment with Dr. [Last Name (STitle) ] for 4 weeks. Completed by:[2137-8-28]	[ "414.01", "V45.82", "V17.3", "410.71", "305.1", "998.12", "V12.79" ]	icd9cm	[ [ [] ] ]	[ "99.04", "39.61", "88.56", "36.15", "88.53", "37.22", "36.12", "99.05" ]	icd9pcs	[ [ [] ] ]	5626, 5632	2187, 4282	331, 435	5700, 5706	1753, 2164	6049, 6223	1256, 1284		4337, 5603		5653, 5679		4308, 4314			5730, 6026									1299, 1734																									281, 293									463, 1036																	1058, 1144	1160, 1240
22,508	145,505	13049	Discharge summary	report	Admission Date: [2185-7-7] Discharge Date: [2185-7-19] Date of Birth: [2121-8-16] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 63 year old male with a past medical history significant for cirrhosis of unknown etiology for the past ten years. He presented to an outside hospital approximately three weeks prior to admission, complaining of change in the quality of his urine. His urine was noted to be dark brown in color. The patient did not have any the symptoms at the time but began to notice vague dyspepsia, weakness, los of appetite and fatigue. The patient was evaluated by his primary care physician and found to have elevated liver function tests. The patient was jaundiced and icteric. The patient underwent a magnetic resonance scan study on the [12-31] which showed a one to two cm mass, consistent with a possible Klatskin tumor. The patient was admitted on the [1-7] for percutaneous transhepatic cholangiogram and possible balloon dilatation of stricture, placement of external drain, placement of stent. The [Hospital 228] medical history is significant for variceal bleeding in [2174]. He was eventually diagnosed with chronic active hepatitis and cryptogenic cirrhosis of unknown etiology. PAST MEDICAL HISTORY: Hypothyroidism. Coronary artery disease. Status post myocardial infarction. Status post coronary artery bypass graft in 2/[2184]. Prior to procedure, the patient was afebrile; temperature was 97.3; blood pressure 123/75; heart rate of 52; respiratory rate of 18; saturating at 98% on room air. The patient was alert, oriented times three, jaundiced and icteric. Cardiovascular and respiratory examination was within normal limits. Abdominal examination was within normal limits. The patient had no peripheral edema. Preprocedure laboratory values were PT of 13.1; PTT of 25.1; INR of 1.1. White blood count of 4.7; hematocrit of 43.7; platelets of 314. Sodium of 136; potassium of 4.5; chloride of 101; C02 of 28; BUN 16; creatinine 1.1; glucose of 136. AST 141; ALT 233; alkaline phosphatase of 894. Total bilirubin of 18.2. Direct bilirubin of 13.5 Albumin of 3.6. HOSPITAL COURSE: The patient underwent PTC by interventional radiology. Please refer the procedure report on line in the medical records for further details. Post procedure, the patient was admitted to the medical service for further observation. The surgical team was consulted for possible surgical intervention. During his overnight stay for observation, the patient experienced hypertension, going from blood pressure of 100/72 post procedurally to pressure of 85 over palpable. Hematocrit drifted down preprocedurally from 43.7 to 26.7. The patient was complaining of right upper quadrant pain, weakness and nausea, which was confirmed on physical examination showing right upper quadrant tenderness to light palpation. The patient received Crystalloid resuscitation of two units of PRBC's and was transferred to the Intensive Care Unit for further management. A CAT scan study after the patient was stabilized showed a large, subhepatic hematoma, measuring three cms in thickness. Intrahepatic biliary ductal dilatation to the level of the common hepatic duct was also seen. During his resuscitation, the patient received a total of four units of PRBC's, three units of FFP and one unit of platelets. The patient remained normotensive with stable hematocrit and was transferred to the Intensive Care Unit on hospital day number eight. The patient was also receiving Levaquin p.o. prophylactically, status post manipulation of the biliary system. Once on the floor and stable, the patient received PTC of the left side to finish decompression of his biliary system, considering his elevation of the total bilirubin level. The patient underwent left sided PTC by interventional radiology without any complications. A repeat CAT scan of the abdomen revealed a stable, subcapsular, hepatic hematoma which had not changed in size. There was no evidence of active extravasation. Transthoracic echocardiogram noted a possible pericardial effusion and this was evaluated with CT of the chest which showed no pericardial effusion but worsening of the right pleural effusion which extends across the posterior mediastinum. There was also a small effusion on the left. The patient underwent a thoracentesis of the right chest, draining 1.5 liters of old clotted blood. The patient underwent the procedure without any complications. Considering his differential diagnosis of primary sclerosing cholangitis versus Klatskin tumor, the patient underwent ultrasound guided needle biopsy of the liver. The procedure was completed without any complications. The pathology and the cytology came back negative for malignant cells. The patient was discharged on hospital day number 13, stable, without any complaints. DISCHARGE DIAGNOSES: Rule out primary sclerosing cholangitis. Rule out Klatskin tumor. Status post PTC drainage with subcapsular hematoma. Hypothyroidism. Coronary artery disease. Status post myocardial infarction. DISCHARGE MEDICATIONS: Levothyroxine 112 mcg p.o. q. day. Zocor 10 mg p.o. q. day. Multi-vitamins one tablet p.o. q. day. Colace 100 mg p.o. twice a day. Actigall 300 mg p.o. three times a day. Protonic 40 mg p.o. q. day. Benadryl 25 mg p.o. q h.s. Percocet 5/225 mg one to two tablets p.o. every four to six hours. Nadolol 40 mg p.o. q. day. The patient is to follow-up with Dr. [First Name (STitle) ] within seven to fourteen days. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 1331] Dictated By:[Last Name (NamePattern1) 10201] MEDQUIST36 D: [2185-7-19] 11:24 T: [2185-7-21] 05:01 JOB#: [Job Number 39926]	[ "412", "571.49", "511.9", "156.1", "789.5", "571.5", "E878.8", "998.12", "576.1" ]	icd9cm	[ [ [] ] ]	[ "51.98", "51.12", "50.11", "34.91", "38.93" ]	icd9pcs	[ [ [] ] ]								4930, 5125	5148, 5842					2205, 4909																																													159, 1280																	1303, 2187
69,354	168,692	51818	Discharge summary	report	Admission Date: [2181-9-12] Discharge Date: [2181-9-22] Date of Birth: [2130-6-17] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2758] Chief Complaint: Fatigue, Fever, SOB Major Surgical or Invasive Procedure: Central line placement History of Present Illness: Mr. [Known lastname 80287] is a 51 M with a medical history notable for multiple sclerosis requiring self bladder catheterization and recurrent urinary tract infections who presented with fatigue, fever and SOB starting at 2pm on the day of admission. He reported that he was in his usual state of health until 2pm when he ate meatballs. He then started to feel poorly and laid down to rest; when he woke he continued to feel very weak and called an ambulance. Of note, patient reports that he injured his urethra while catheterizing himself 2 days prior to admission; denies any purulent drainage, but did note hematuria. In the ED, initial VS were: 103.4F 124/68 134 20 95% on RA. Patient was found to have lactate of 6.8, WBC 4.9 with 10% bands and a positive UA with 11-20 WBC's. Prelim CXR WNL; KUB pending. He was given 5L NS and started on vanc/zosyn; HR went down to 120s-130s. Has RIJ and 2 large bore PIVs. CVP 5-6, UOP increased. Received acetaminophen 1000mg. He was admitted to the ICU and treated with aggressive IV hydration, vancomycin, Zosyn, and pressors for blood pressure support. He had blood cultures positive for gram negative rods and urine culture positive for ESBL E Coli, and his antibiotics were changed to meropenem (first dose 10/7). He was never intubated. His blood pressure improved and he was transferred to the floor. Past Medical History: 1. MS- clinically definite since [2167]- secondary progressive type 2. Status post ADCF C5-C7 ([2171-9-25]) 3. History of depression [2164] to [2166] and currently. 4. History of alcoholism in the past (last drank 10 years ago) 6. Recurrent UTIs with multi-drug resistance urinary pathogens 7. Hyperlipidemia 8. Greater trochanteric ulcers Social History: Single, lives alone, has 2 home health aides. Works Smokes: [12-9] ppd, 20 pk/yr history. Smokes marijuana once every 2 months. Family History: No family history of MS. Physical Exam: Physical exam on arrival to the floor: VS: afebrile, BP 138/77, HR 86, RR 95% RA GEN: NAD HEENT: EOMI, PERRL, moist mucous membranes, no OP lesions, no JVD, neck supple, right IJ in place, no cervical or supraclavicular LAD CV: RRR, NL S1S2 no MRG PULM: CTAB anteriorly and in axillae ABD: hypoactive BS+, soft, NTND, baclofen pump subcutaneously in LLQ, no HSM LIMBS: no LE edema, 2+ DP/PT pulses SKIN: very warm, macular, blanching rash on neck. Two ulcers on left trochanter. NEURO: Face symmetric, somewhat stiff face. Increased tone in lower extremities, able to move all extremities, some spasticitiy. Psych: flat affect. Pertinent Results: ADMISSION LABORATORIES: - [2181-9-12] 05:20PM GLUCOSE-92 UREA N-19 CREAT-1.2 SODIUM-140 POTASSIUM-5.1 CHLORIDE-101 TOTAL CO2-18* ANION GAP-26* LACTATE-6.8* CALCIUM-10.2 PHOSPHATE-4.8* MAGNESIUM-1.9 - [2181-9-12] 05:20PM WBC-4.9 (NEUTS-81* BANDS-10* LYMPHS-8* MONOS-0 EOS-0 BASOS-0 ) RBC-4.88 HGB-14.4 HCT-45.4 MCV-93 MCH-29.6 MCHC-31.9 RDW-13.4 PLT COUNT-236 - [2181-9-12] 05:20PM PT-13.3 PTT-25.6 INR(PT)-1.1 - [2181-9-12] 05:25PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.009 BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG RBC-[5-17]* WBC-[5-17]* BACTERIA-MANY YEAST-RARE EPI-0-2 TRANS EPI-0-2 DISCHARGE LABORATORIES: - [2181-9-17] 05:14AM WBC-13.3 HCT-32.7 PLT COUNT-200 - [2181-9-20] 07:00AM GLUCOSE-80 UREA N-16 CREAT-0.6 SODIUM-139 POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-28 MICROBIOLOGY: [2181-9-12] 5:20 pm BLOOD CULTURE FINAL REPORT [2181-9-18] Blood Culture, Routine (Final [2181-9-18]): ESCHERICHIA COLI. FINAL SENSITIVITIES. WARNING! This isolate is an extended-spectrum beta-lactamase (ESBL) producer and should be considered resistant to all penicillins, cephalosporins, and aztreonam. Consider Infectious Disease consultation for serious infections caused by ESBL-producing species. SENSITIVE TO Piperacillin/Tazobactam sensitivity testing confirmed by [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 8 S CEFAZOLIN------------- =>64 R CEFEPIME-------------- R CEFTAZIDIME----------- R CEFTRIAXONE----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R Aerobic Bottle Gram Stain (Final [2181-9-13]): REPORTED BY PHONE TO DR. [First Name8 (NamePattern2) 1112] [Last Name (NamePattern1) 18569] @ 1035A, [2181-9-13]. GRAM NEGATIVE ROD(S). [2181-9-12] 5:25 pm URINE Site: CATHETER URINE CULTURE (Preliminary): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- =>64 R CEFTRIAXONE----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R [2181-9-15] 6:01 am BLOOD CULTURE Source: Line-RIJ. Blood Culture, No Growth to date at discharge. RADIOLOGY STUDIES: - [2181-9-16] Plain films: No radiographic evidence for osteomyelitis. If continued clinical concern for a bone infection, further evaluation with MRI is recommended. Brief Hospital Course: Mr. [Known lastname 80287] was admitted with urosepsis related to his intermittent self-catheterizations. He was initially treated in the ICU with Vancomycin, Zosyn, and vasoactive pressors for hypotension; he was never intubated. His blood and urine cultures returned ESBL E coli and he was strated on meropenem on [2181-9-13]. He continued to improve and was transitioned to the floor. He will complete a 2 week course of meropenem on [2181-9-26]. He will then need to restart his methenamine hippurate for suppressive therapy. Other active issues in the intensive care unit included acute renal failure that improved with supportive therapy and multiple decubitus ulcers. Management of the decubitus ulcers and other chronic medical problems outlined below. 1. left greater trochanter ulcers - on exam, these ulcers appear to be superficial and hip films were without evidence of osteomyelitis. MRI was not pursued given the above exam finding - wound care: wound cleanser and Mepilex dressing every 3 days 2. Multiple sclerosis: - continued on his baclofen pump and continued with physical therapy 3. Urinary retention - Mr. [Known lastname 80287] has a specific type of catheter he uses for self-catheterization. We were unable to obtain these and given his recent injury he was unwilling to utilize a different sized catheter. As soon as his regular catheters can be obtained, he should have his Foley catheter removed to prevent further infections. 4. Hyperlipidemia: continued ezetimibe 5. Depression: continued fluoxetine Patient confirmed he is full code during this hospitalization Medications on Admission: HOME MEDICATIONS: -Aspirin 325 mg po qd -Fluoxetine 40 mg po qd -Ezetimibe 10 mg po qd -Lidocaine HCl 2 % Gel Sig: One (1) Appl -Mucus membrane as needed for Self-cath -Oxybutynin Chloride 10 mg [Hospital1 ] po -Methenamine Hippurate 1 gram Tablet Sig: One (1) Tablet PO BID To be restarted on [7-30] after course of antibiotics complete. -Vitamin C 1,000 mg po bid . Medications on transfer: Discharge Medications: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 3. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. lidocaine HCl 2 % Gel Sig: One (1) Appl Mucous membrane PRN (as needed) as needed for self-catheterization. 5. oxybutynin chloride 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. methenamine hippurate 1 gram Tablet Sig: One (1) Tablet PO twice a day: to be restarted on [2181-9-27] after meropenem is complete. 7. Vitamin C 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 8. meropenem 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q6H (every 6 hours): last dose on [2181-9-26] for a total 14 day course. 9. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. 10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 11. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: SIRS/septic shock Bacteremia Acute renal failure Multiple sclerosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: at baseline, unable to use lower extremities for ambulation from multiple sclerosis. Discharge Instructions: Dear Mr. [Known lastname 80287], You were admitted with a urinary tract infection and a blood stream infection. These happen sometimes with your straight catheterizations. You improved with IV antibiotics. You will need a total of 14 days of meropenem to treat this severe infection and your last dose will be [2181-9-26]. We made no other changes to your medications though you will need to restart your methenamine on [2181-9-27] after the meropenem is complete. It is also very important that you have your Foley catheter removed as soon as possible to prevent further infections. You can either order new straight catheters or have someone bring you some from home. Followup Instructions: Please follow-up with Dr. [Last Name (STitle) ] in [12-9] weeks after discharge from your rehab hospital.	[ "V58.66", "038.42", "785.52", "788.29", "276.2", "707.03", "272.4", "707.21", "707.22", "584.9", "599.0", "311", "995.92", "707.04", "340" ]	icd9cm	[ [ [] ] ]	[ "38.97" ]	icd9pcs	[ [ [] ] ]	9526, 9596	6380, 7345	335, 360	9708, 9708	2984, 5418	10627, 10744	2293, 2319		8454, 9503		9617, 9687		8028, 8028			9918, 10604									2334, 2965					8046, 8404																				276, 297						5453, 6357	7357, 8002		388, 1748										9723, 9894						8431, 8431	1770, 2127	2143, 2277
31,389	142,212	34037	Discharge summary	report	Admission Date: [2174-7-9] [Month/Day/Year ] Date: [2174-7-18] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1481] Chief Complaint: s/p Motor vehicle crash; left sided chest pain Major Surgical or Invasive Procedure: [2174-7-9] Left chest thoracostomy [2174-7-9] Epidural catheter placement [2174-7-13] Removal of epidural catheter [2174-7-16] Removal of left chest tube History of Present Illness: 84 yo male restrained driver s/p motor vehicle crash; was T-boned by another vehicle on driver side. He was taken to an area hospital where found to have mulitple rib fractures and was then transferred to [Hospital1 18] for further care. Past Medical History: Colon CA Hernia PSH: Lap. colectomy, hernia repair, retinal surgery Family History: Noncontributory Physical Exam: Upon admission: General: AAO x 3 Head/Eyes: pupils 2mm minimally reactive ENT/Neck: collared, no crepitus Chest/Respiratory: Bilateral breath sounds. Chest tube on L. Tender to palpation. Cardiovascular: RRR, nl S1S2 GI/Abdominal: Soft, nontender, nondistended. GU: Normal rectal tone, normal prostate. Musculoskeletal Extremities: Displaced clavicle. Ecchymoses R knee, L shoulder. Neuro: GCS15. Moving all extremities. Pertinent Results: [2174-7-9] 06:07AM GLUCOSE-164* UREA N-16 CREAT-0.7 SODIUM-142 POTASSIUM-3.9 CHLORIDE-107 TOTAL CO2-26 ANION GAP-13 [2174-7-9] 06:07AM CALCIUM-8.0* PHOSPHATE-2.7 MAGNESIUM-1.9 [2174-7-9] 06:07AM WBC-11.3* RBC-3.43* HGB-10.9* HCT-31.7* MCV-93 MCH-31.7 MCHC-34.3 RDW-13.1 [2174-7-9] 06:07AM PLT COUNT-133* [2174-7-9] 06:07AM PT-14.2* PTT-29.1 INR(PT)-1.2* [2174-7-9] 01:11AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2174-7-9] CT HEAD WITHOUT CONTRAST: No comparison studies are available. No acute intracranial hemorrhage, mass effect, shift of normally midline structures, or major vascular territorial infarct is apparent. There are mild periventricular white matter hypodensities and basal ganglia lacunes indicative of chronic microvascular angiopathy. There are marked atherosclerotic calcifications of the cavernous portions of the internal carotid arteries bilaterally. There is fluid in several ethmoid air cells on the right. However, no temporal bone fracture is identified. There is some mucosal retention cyst in the right maxillary sinus. Mild mucosal thickening is seen in several ethmoid air cells. Surrounding soft tissue structures are unremarkable. IMPRESSION: 1. No acute intracranial hemorrhage. No evidence of fracture. 2. Fluid in mastoid air cells on the right without evidence of temporal bone fracture. [2174-7-9] CT C-SPINE WITHOUT CONTRAST: C-spine is visualized from skull base through T1. There is no prevertebral soft tissue swelling. No acute C-spine fracture is seen. There are marked degenerative changes at multiple levels. There are nondisplaced or minimally displaced fractures of the first through third ribs on the left and a nondisplaced fracture of the left transverse process of T1. There is subcutaneous emphysema tracking along the left neck and back and into the superior mediastinum in this patient status post chest tube placement. There is biapical scarring and a right apical bronchiectasis. There is a small left-sided hemothorax. IMPRESSION: 1. Fractures of the left spinous process of T1 as well as of all visualized ribs on the left. This is better assessed on the accompanying torso CT. 2. Small left-sided hemothorax with associated rib fracture sites. 3. Subcutaneous emphysema tracking from the left chest wall into the upper mediastinum and left neck and back. 4. No evidence of acute fracture or dislocation of the cervical spine. 5. Degenerative changes. [2174-7-9] CT CHEST WITHOUT CONTRAST: There are non-displaced fractures of all posterior left ribs (rib 1 to 11, rib 12 not present), causing a flail chest. Ribs 2, 3, 5, 6, and 7 are fractured in two separate places. There is a small associated hemothorax along the rib fractures posteriorly. There is also left lower lobe atelectasis. A left-sided chest tube is in place terminating anteriorly at the anterior mediastinum. There is minimal residual anterior pneumothorax. There is [Hospital1 ]-apical scarring and bronchiectasis, chronic. There is subcutaneous emphysema tracking along the left chest wall and into the left neck region and upper mediastinum. The airways appear patent. There is no pericardial effusion. The outline of the vessels appears unremarkable within the limitations of this non-contrast study. CT ABDOMEN WITHOUT CONTRAST: There is a small amount of contrast in the renal pelves and ureters from study performed at the outside hospital. Also there is vicarious excretion of contrast into the gallbladder. Within the limitations of this non-contrast study, outline of the liver, spleen, fatty replaced pancreas, adrenal glands, and bowel loops are unremarkable. The left kidney contains a hypoattenuating focus incompletely characterized, but statistically most likely representing a cyst. There is no free fluid or free abdominal air. Sutures are seen from a prior bowel resection. There is extensive descending colonic diverticulosis. CT PELVIS WITHOUT CONTRAST: There is extensive sigmoid diverticulosis. The bladder contains a Foley catheter and excreting contrast and appears intact. The prostate contains central calcifications. Multiple surgical clips are seen in the right inguinal region presumably from prior hernia repair. IMPRESSION: 1. Fractures involving all left posterior ribs. Ribs #2, 3, 5, 6, and 7 have two separate fractures, resulting in a flail chest. 2. Small hemothorax adjacent to the rib fractures posteriorly on the left. 3. Left lower lobe atelectasis. 4. Minimal residual pneumothorax anteriorly on the left, status post chest tube placement. 5. Subcutaneous emphysema tracking along the left chest wall into the left neck and upper mediastinum. 6. Limited evaluation of parenchymal organs and vasculature given the absence of intravenous contrast. Within these limitations, there is no evidence of traumatic injury to abdomen or pelvis. 7. Incidental findings of biapical scarring and bronchiectasis, colonic diverticulosis, right inguinal hernia repair, and hypoattenuating left renal lesion. Cardiology Report ECG Study Date of [2174-7-9] 1:14:34 AM Sinus rhythm. Prolonged Q-T interval. Non-specific ST-T wave changes. No previous tracing available for comparison. Intervals Axes Rate PR QRS QT/QTc P QRS T 69 156 84 456/471 45 -18 113 [7-10] 8:04 CHEST (PORTABLE AP) IMPRESSION: 1. Multiple left-sided rib fractures with hemopneumothorax on the left. 2. Subcutaneous emphysema in the left chest wall and left side of the neck. This has decreased since the prior study. Small left pleural effusion. [7-10] 19:43 CHEST (PORTABLE AP) Chest tube remains in place with medial location, terminating at level of origin of left main bronchus, corresponding to the sixth left posterior rib level. Moderate left hydropneumothorax is present with small apical pneumothorax component and a moderate amount fluid tracking to the apex. Allowing for positional differences, the amount of pleural fluid is not substantially changed, but note is made of slight improvement in left retrocardiac opacity, as well as a new hazy area of opacity at the right base, which may be due to right pleural effusion or focal lung parenchymal abnormality such as aspiration or atelectasis. [7-11] 10:13 CHEST (PORTABLE AP) AP chest radiograph compared to [2174-7-10] shows unchanged left apical pneumothorax with moderate amount of fluid tracking to the apex. Chest tube remains in place. The remainder of the exam shows no short term change [7-11] 19:29 CHEST (PORTABLE AP) FINDINGS: Single AP chest radiograph compared to prior exam from seven hours prior demonstrates no short-term interval change. Left apical pneumothorax and moderate amount of fluid tracking to the apex persists. Left chest tube remains in place. The remainder of the exam shows no short term change. [7-12] CHEST (PORTABLE AP) Single AP chest radiograph compared to [2174-7-11] shows slightly increased left pleural effusion. Left apical pneumothorax is unchanged. Chest tube remains in place. The remainder of the exam including left retrocardiac atelectasis is stable. [7-13] CHEST (PA & LAT) IMPRESSION: Unchanged moderate left pneumothorax and small to moderate pleural effusion. Repositioned chest tube. [7-13] KNEE (AP, LAT & OBLIQUE) RIGHT IMPRESSION: No fracture. [7-17] CHEST (PA & LAT) FINDINGS: As compared with the previous radiograph, there is no relevant change. The extent of the left-sided apical pneumothorax is constant, also constant are the small pleural air-fluid levels in projection over the left lung base. Unchanged retrocardiac atelectasis. Unchanged dimension of the cardiac silhouette. Brief Hospital Course: He was admitted to the Trauma Service and underwent CT imaging to rule out intracranial and abdominal processes. No head or abdominal injuries were identified. He was noted to have multiple left rib fractures; a left hemopneumothorax for which a chest tube had already been placed and a clavicle fracture. He was transferred to the Trauma ICU once stabilized in the Emergency department. The Acute Pain Service was consulted for placement of an epidural for managing pain associated with his rib fractures; this remained in place for several days and was then removed. He was then placed on an oral pain regimen; a bowel routine was also initiated at that time. He was noted to become slightly confused with the oral narcotics and this was stopped; he is currently on Tylenol around the clock and prn Ultram. On [7-13] he was noted to complain of right knee pain, upon examination the knee was bruised and swollen. An xray was obtained and showed an effusion but did not reveal any fracture. Serial chest radiographs were followed which continued to show persistent left pleural effusion; his chest tube did continue to put out serosanguinous fluid. He was placed on water seal, follow chest film was obtained and the chest tube was removed on [7-16]. He has required supplemental oxygen and was also started on scheduled nebulizer treatments and was instructed on incentive spirometry and coughing and deep breathing. He is currently being treated for conjuctivitis left eye. Physical therapy was consulted and have recommended acute rehab after hospital stay. Medications on Admission: ASA, Vit B12, Folate [Month/Day (1) ] Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML Injection TID (3 times a day). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) NEB Inhalation Q6H (every 6 hours). 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 5. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 8. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed for pain. 9. Ciprofloxacin 0.3 % Drops Sig: 1-2 Drops Ophthalmic QID (4 times a day) for 3 days. 10. Vitamin B-12 1,000 mcg Tablet Sig: One (1) Tablet PO once a day. 11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. [Month/Day (1) ] Disposition: Extended Care Facility: [Hospital3 1107] [Hospital ] Hospital - [Location (un) 38] [Location (un) ] Diagnosis: s/p Motor vehicle crash Multiple left sided posterior rib fractures ([3-22]) Small left hemopneumothorax Manubrium fracture Left clavicle fracture (nonoperative) Conjuctivitis Urinary retention [Month/Year (2) ] Condition: Hemodynamically stable, toelrating regular diet, pain adequately controlled [Month/Year (2) ] Instructions: DO NOT bear any weight on your left arm because of the fractured clavicle (collar bone). Continue to wear the sling for comfort. Followup Instructions: Follow up in 2 weeks with Dr. [Last Name (STitle) ], Trauma Surgery. Call [Telephone/Fax (1) 600] for an appointment. Follow up with your primary care doctor [First Name (Titles) ] [Last Name (Titles) ] from rehab. Completed by:[2174-7-20]	[ "807.09", "805.2", "810.00", "788.29", "372.39", "511.8", "924.11", "280.0", "807.2", "E812.0" ]	icd9cm	[ [ [] ] ]	[ "34.04", "03.90", "97.87", "99.04", "97.41" ]	icd9pcs	[ [ [] ] ]		9073, 10650	319, 491		1344, 9050	12383, 12646	871, 888						10676, 11849												903, 905																								11881, 12360	233, 281									519, 762								919, 1325									784, 855
14,750	128,454	45658	Discharge summary	report	Admission Date: [2138-6-5] Discharge Date: [2138-6-11] Service: MED HISTORY OF PRESENT ILLNESS: The patient is an 88 year old, Spanish speaking female patient with a history of hypertension who presented to her primary care physician with [Name Initial (PRE) ] several week history of shortness of breath. The patient was recently evaluated in clinic two weeks ago and given antibiotics for a UTI. She returned to her primary care physician on the day of admission after a fall. She was prescribed antibiotics for right knee cellulitis. At that time the patient also complained of a two week history of progressive dyspnea on exertion, experiencing shortness of breath after 10 to 20 paces. The patient's son states that is significantly unchanged from her baseline. The patient denies any history of chest pain, palpitations, orthopnea, PND, but does report lower extremity edema that has become progressively worse over the last two weeks. In addition to these symptoms, the patient reports an occasional dry cough and clear rhinorrhea. The patient was sent to the emergency department for echocardiogram which revealed a moderate sized pericardial effusion with tamponade physiology and was sent immediately to the cardiac catheterization lab for pericardiocentesis. PAST MEDICAL HISTORY: Hypertension. Anemia. Urinary tract infection diagnosed two weeks prior to admission. Memory loss. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Zestril 5 mg p.o. b.i.d. 2. Zithromax. SOCIAL HISTORY: The patient currently lives alone and does her own ADLs. Her son lives nearby and the patient is seen by home physical therapy occasionally. She denies a history of tobacco use and only drank occasionally throughout her life. PHYSICAL EXAMINATION: Temperature 99.3, heart rate 101, blood pressure 187/70, respiratory rate 32, 100 percent on 4 liters. In general, somewhat ill appearing, elderly woman in mild respiratory distress, moaning and speaking incoherently. HEENT pupils equal, round, reactive to light. Extraocular movements intact. Dry mucous membranes. Oropharynx was clear. Neck jugular venous pressure was at the angle of the jaw. There was no thyromegaly or lymphadenopathy. Lungs had decreased breath sounds in bilateral bases with crackles up approximately half way in bilateral lung fields. Cardiac regular rate and rhythm, normal S1, S2, no murmurs, rubs or gallops appreciated. Abdomen normoactive bowel sounds, soft, nondistended, nontender. Extremities 1 plus DP and PT pulses bilaterally with 1 to 2 plus edema in bilateral lower extremities. Femoral pulses were 2 plus bilaterally. Carotid pulses were 1 plus bilaterally with no bruits. Psych the patient was extremely anxious and had very poor memory, minimally cooperative with the exam. LABORATORY DATA: White blood cells 12.6, hematocrit 32.8, platelets 178. INR 1.1. Sodium 137, potassium 4.4, BUN 27, creatinine 1.1, glucose 117. EKG sinus rhythm at 100 beats per minute, there were low limb lead voltages with no electrical alternans and no ischemic changes. Echocardiogram ejection fraction 60 percent, 1 to 2 plus AI, moderate effusion with tamponade physiology. HOSPITAL COURSE: Pericardial effusion. As noted previously, the patient presented with a two week history of progressive dyspnea on exertion and lower extremity edema, found on echocardiogram to have moderate pleural effusion with tamponade physiology. The patient was taken emergently to the cardiac catheterization lab where she underwent pericardiocentesis of 450 cc of bloody effusion. An echocardiogram performed after the procedure showed no residual effusion and hemodynamics revealed improved RA pressure of 10 and pericardial pressure of 4 following pericardiocentesis. The patient was transferred to the CCU for monitoring, given mild respiratory distress. Workup for the etiology of the pericardial effusion was performed and was negative. The patient had [Doctor First Name ] and rheumatoid factor that were negative. TSH was normal. She had a PPD that was negative. She had SPEP and UPEP to rule out amyloid, the results of which are pending at the time of dictation. The patient had iron studies which did not suggest hemochromatosis, but rather revealed anemia of chronic disease. Cytology performed on the pericardial fluid was negative. The likely etiology of the patient's pericardial effusion is considered infectious versus malignant. It is anticipated that the patient will evaluated with age appropriate cancer screening as an outpatient. The patient was evaluated with serial echocardiograms throughout the remainder of her hospitalization that showed no reaccumulation of fluid and no evidence of tamponade physiology. The patient remained hemodynamically stable and asymptomatic throughout the remainder of her hospitalization. CHF. As noted previously, the patient was evaluated with multiple echocardiograms throughout her hospitalization which revealed an ejection fraction of 60 percent. The patient is considered to have diastolic dysfunction and was started on a beta blocker and continued on an ACE inhibitor throughout this admission. The patient was diuresed gently throughout her hospitalization and had improvement in her lower extremity edema and oxygen saturation. Serial chest x-rays showed very little change in the patient's bilateral pleural effusions. The patient was evaluated by the interventional pulmonary team who performed thoracentesis. Evaluation of the pleural fluid revealed a transudate and the etiology was considered likely secondary to diastolic dysfunction. The plan is to continue gentle diuresis, though if the bilateral pleural effusions persist, the interventional pulmonary team recommended considering bilateral pigtail chest tubes. The patient's beta blocker dose was titrated up as tolerated by her blood pressure. Rhythm. The patient was noted throughout this admission to have periodic episodes of atrial fibrillation, atrial bigeminy and multifocal atrial tachycardia. As noted previously, the patient was started on a beta blocker, the dose of which was titrated up. Given persistent paroxysmal atrial fibrillation, the patient was started on amiodarone. The patient had improved rate and rhythm control prior to discharge, but will need an event monitor on discharge to follow her QT interval and rate. Renal. The patient was admitted with creatinine of 1.1 which increased to 1.5 with Lasix treatment. As her diuresis with Lasix was decreased, the patient's creatinine improved. Cellulitis. The patient was admitted with a recent history of cellulitis of her right knee after a fall. Given an initial concern for concomitant pneumonia, the patient was started on levofloxacin which she continued for seven days. The patient's erythema, edema and warmth improved dramatically with antibiotic therapy. FEN. The patient was continued on a cardiac diet throughout this hospitalization. She was evaluated by the speech and swallow consult service prior to discharge. The patient demonstrated an adequate ability to swallow without evidence of aspiration. Per the patient's request and given her dementia, the speech and swallow consult service recommended a pureed solid diet. Psych. The patient was extremely anxious throughout her hospitalization with episodes of agitation and yelling. She was evaluated by the psychiatry consult service who felt that her clinical presentation was most consistent with moderate dementia likely Alzheimer type with superimposed mild delirium. As noted previously, the patient's TSH was normal and RPR was checked to complete the medical workup. The patient was treated with Seroquel 25 mg p.o. q.h.s. CONDITION ON DISCHARGE: Good. Oxygenating well on 2 liters. DISCHARGE STATUS: The patient is discharged to an extended care facility. DISCHARGE DIAGNOSES: Pericardial effusion. Diastolic dysfunction. Paroxysmal atrial fibrillation. Dementia likely Alzheimer type. Cellulitis. DISCHARGE MEDICATIONS: 1. Metoprolol 75 mg p.o. t.i.d. 2. Zestril 5 mg p.o. b.i.d. 3. Amiodarone 200 mg p.o. t.i.d. for one week, then 400 mg p.o. q.day times one month. 4. Aspirin 325 mg p.o. q.day. 5. Alendronate 35 mg p.o. q.Sunday. 6. Tylenol one to two tablets p.o. q.four to six hours p.r.n. 7. Colace 100 mg p.o. b.i.d. p.r.n. constipation. 8. Senna one tablet p.o. b.i.d. p.r.n. constipation. 9. Ipratropium one neb q.six hours p.r.n. shortness of breath or wheezing. 10. Seroquel 25 mg p.o. q.h.s. p.r.n. agitation or insomnia. FOLLOWUP: The patient will be followed by the physicians at the extended care facility. The patient will be seen by nurse practitioner, [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], who works with Dr. [Last Name (STitle) 665], on [2138-7-10], at 11:00 a.m. She has a followup appointment with Dr. [Last Name (STitle) 665] on [2138-9-2], at 10:20 a.m. The patient has a followup appointment with cardiologist, Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], on [2138-7-14], at 2:00 o'clock p.m. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) ], MD [MD Number(2) 12421] Dictated By:[Last Name (NamePattern1) 12325] MEDQUIST36 D: [2138-6-10] 12:44:13 T: [2138-6-10] 13:51:51 Job#: [Job Number 97338]	[ "428.31", "682.6", "285.29", "401.9", "511.9", "423.9", "427.31", "424.1", "428.0" ]	icd9cm	[ [ [] ] ]	[ "34.91", "37.0" ]	icd9pcs	[ [ [] ] ]								7925, 8051	8074, 9439					3228, 7764																										1794, 3210																			117, 1304																	1327, 1525	1542, 1771	7789, 7903
30,101	105,529	49518	Discharge summary	report	Admission Date: [2122-9-3] Discharge Date: [2122-9-18] Service: MEDICINE Allergies: Trazodone Attending:[Doctor First Name 3290] Chief Complaint: Back pain Major Surgical or Invasive Procedure: Placement of tunneled hemodialysis line Placement of PICC line History of Present Illness: Ms. [Known lastname ] is a 87 yo F PMHx sig for HTN, HL, AAA, s/p b/l renal artery stents and R CEA presented to the ED last night ([9-3]) with back pain x 1-2 months w/ acute worsening x 1-2 days. [1-18] days ago, she had acute worsening of pain with difficulty with bowel/bladder control and episodes of incontinence. In the ED, she denied fevers. Cr was found to be 7 from mid-1s in 9/[2121]. CT AP showed increase in size of known AAA without evidence of rupture. She was admitted to vascular surgery. renal was consulted for ARF and anuria. The evening of admission, she spiked a temp to 102. Blood Cx were done, and CXR was without any obvious PNA. This morning, she became hypotensive to 80/34 and got 2L fluids with improvement in BP to the 90s. She became hypoxic to 84%, and is now on 3L O2. She was started in vanc/Zosyn and a medicine consult was called given concern for early sepsis. . Her AAA was first noted in [2118], 3.9x3.9. On CT last night, it was measured 5.3cm but not felt to be emergent by the vascular team. There was no evidence for dissection blocking renal arteries, Of note, B/L renal artery stents placed in [2121] by Dr. [Last Name (STitle) 14533] which appearred patent on US. Renal was consulted who felt that there was no indication for HD at this time and recommnedded a number of studies for further workup with supportive management and trending Cr for now. . On the floor, when evaluated by the MICU, the patient was mentating and asymptomatic, but did endorse feeling overwhelmed with all the information and not thinking well. She had recently defervesced, with VS T99.3, Tm 102.3, HR 61-76, BP 91/32 in trendelenburg (baseline 120/80s), RR17-20, 94% on 3L nasal cannula. Past Medical History: * Chronic kidney disease, stage III/IV * Coronary artery disease and NSTEMI in [2116] (s/p DES/LCx, BMS/RCA [5-/2118], refused CABG) * Atrial fibrillation, not on coumadin but was on amiodarone * Congestive heart failure (EF 70% [2121-8-8]) * Aortic stenosis ([Location (un) 109] 1.2-1.8, mild in [7-/2121]) * Anemia * Hyperlipidemia * Hypertension * Infrarenal AAA last measured 4.4 cm [5-/2121] * Rheumatic heart disease as child * Left breast cancer (stage 1 infiltrating ductal carcinoma) s/p hormonal therapy with arimidex [2118], T1b, N0, M0; ER positive, PR negative and HER-2/neu negative * Bilateral renal artery stent [2119-4-27] * Right carotid endarterectomy [2116] Social History: (per OMR) - Lives with her husband whom she cares for (he has COPD, on home oxygen) - Tobacco: Quit smoking >20 years ago - Alcohol: Denies - Illicits: Denies The patient is married and lives with her 80-year-old husband who is a home O2 dependent. She cares for him. They have two children, a son 55 who lives here in the area and a single granddaughter. She has one daughter who is 54 and lives in [State 4565]. She smoked cigarettes from age 20-50 : approx [1-18] ppd. ETOH rare. significant for the absence of current tobacco use - does have a previous 15 pack year smoking history. There is no history of alcohol abuse. Family History: Renal disease in her brother Negative for cancer except for one nephew with melanoma at age 60. Mother-CVA at 77. Father died in an accident young age. She has one brother 82 who has had a history of an abdominal aortic aneurysm and one sister 80 with heart disease. Physical Exam: On arrival to the MICU Vitals: T: 96.2 BP: 95/39 P:51 R:15 18 O2:96% on 3L General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: sinus bradycardia, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place with no urine visible Ext: warm, well perfused, no clubbing, cyanosis or edema Discharge exam: PHYSICAL EXAM: VS - Temp 97.9F, BP 180/52, HR 57, R 18, O2-sat 94% on RA GENERAL - well-appearing elderly woman in NAD, comfortable, appropriate. HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no carotid bruits. JVD to 1.5cm above clavicle with bed reclined to 30 degrees. LUNGS ?????? Mild expiratory crackles at lung bases bilaterally, no rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR. Blowing systolic crescendo/decrescendo murmur heard at LLSB. No rubs or gallops, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses. Liver palpable to 4cm below costal margin; no splenomegaly. No rebound/guarding. No CVA or flank tenderness. EXTREMITIES - WWP, no c/c, 1+ pitting edema of lower extremities bilaterally with [Male First Name (un) ] support stockings on; 2+ radial pulses; 1+ DP and posterior tibialis pulses SKIN ?????? Scattered 0.5-2cm ovoid purple ecchymoses across stomach, arms and legs. LYMPH - no cervical, axillary, or supraclavicular LAD NEURO - awake, A&Ox3. CNs II-XII intact with exception of right-sided facial droop consistent with baseline per MICU, with forehead sparing. Moves all extremities, sensation grossly intact throughout. Pertinent Results: Admission labs: [2122-9-3] 10:30AM BLOOD WBC-8.2# RBC-2.92* Hgb-9.9* Hct-27.4* MCV-94 MCH-33.9* MCHC-36.1* RDW-13.1 Plt Ct-82* [2122-9-3] 10:30AM BLOOD Neuts-90.8* Bands-0 Lymphs-4.6* Monos-4.4 Eos-0.1 Baso-0.1 [2122-9-4] 07:50AM BLOOD PT-13.2 PTT-24.9 INR(PT)-1.1 [2122-9-3] 10:30AM BLOOD Glucose-103* UreaN-86* Creat-7.0# Na-132 K-3.5 Cl-93* HCO3-19* AnGap-24* [2122-9-3] 09:00PM BLOOD Calcium-6.7* Phos-6.2# Mg-2.2 [2122-9-3] 11:04AM BLOOD Lactate-1.5 [2122-9-4] 07:50AM BLOOD WBC-6.0 RBC-2.93 Hgb-10.1* Hct-27.8* MCV-95 MCH-34.5* MCHC-36.3* RDW-13.2 Plt Ct-79* [2122-9-5] 05:53AM BLOOD WBC-7.5 RBC-2.86* Hgb-9.9* Hct-27.8* MCV-97 MCH-34.7* MCHC-35.8* RDW-13.4 Plt Ct-87* [2122-9-6] 02:40AM BLOOD WBC-8.3 RBC-3.23* Hgb-10.9* Hct-31.7* MCV-98 MCH-33.9* MCHC-34.5 RDW-13.6 Plt Ct-112* [2122-9-7] 02:45AM BLOOD WBC-5.9 RBC-2.88* Hgb-9.8* Hct-27.8* MCV-97 MCH-34.0* MCHC-35.2* RDW-13.3 Plt Ct-114* [2122-9-8] 02:27AM BLOOD WBC-5.4 RBC-2.81* Hgb-9.2* Hct-26.5* MCV-95 MCH-32.7* MCHC-34.6 RDW-13.2 Plt Ct-107* [2122-9-10] 05:04AM BLOOD WBC-4.9 RBC-2.69* Hgb-9.0* Hct-26.5* MCV-98 MCH-33.5* MCHC-34.0 RDW-13.3 Plt Ct-94* [2122-9-11] 05:31AM BLOOD WBC-5.5 RBC-2.61* Hgb-8.7* Hct-25.5* MCV-98 MCH-33.4* MCHC-34.2 RDW-13.2 Plt Ct-100* [2122-9-12] 06:11AM BLOOD WBC-6.0 RBC-2.43* Hgb-8.1* Hct-23.8* MCV-98 MCH-33.6* MCHC-34.2 RDW-13.1 Plt Ct-98* [2122-9-13] 06:45AM BLOOD WBC-7.2 RBC-2.54* Hgb-8.7* Hct-25.0* MCV-98 MCH-34.2* MCHC-34.8 RDW-13.5 Plt Ct-81* [2122-9-14] 06:29AM BLOOD WBC-8.1 RBC-2.51* Hgb-8.7* Hct-24.9* MCV-99* MCH-34.9* MCHC-35.2* RDW-14.0 Plt Ct-106* [2122-9-4] 07:50AM BLOOD Neuts-89.2* Lymphs-5.8* Monos-4.4 Eos-0.3 Baso-0.3 [2122-9-12] 06:11AM BLOOD Neuts-86.6* Lymphs-9.4* Monos-1.8* Eos-2.0 Baso-0.2 [2122-9-13] 06:45AM BLOOD Neuts-85.4* Lymphs-10.6* Monos-1.7* Eos-2.0 Baso-0.3 [2122-9-5] 05:53AM BLOOD Plt Ct-87* [2122-9-6] 02:40AM BLOOD PT-13.0 PTT-35.0 INR(PT)-1.1 [2122-9-6] 02:40AM BLOOD Plt Ct-112* [2122-9-7] 02:45AM BLOOD PT-13.0 PTT-34.9 INR(PT)-1.1 [2122-9-7] 02:45AM BLOOD Plt Ct-114* [2122-9-8] 02:27AM BLOOD PT-13.6* PTT-34.3 INR(PT)-1.2* [2122-9-8] 02:27AM BLOOD Plt Ct-107* [2122-9-9] 06:07AM BLOOD Plt Ct-103* [2122-9-10] 05:04AM BLOOD Plt Ct-94* [2122-9-11] 05:31AM BLOOD Plt Ct-100* [2122-9-12] 06:11AM BLOOD Plt Ct-98* [2122-9-13] 06:45AM BLOOD Plt Ct-81* [2122-9-14] 06:29AM BLOOD Plt Ct-106* [2122-9-5] 05:53AM BLOOD Glucose-89 UreaN-111* Creat-8.3* Na-135 K-4.3 Cl-101 HCO3-13* AnGap-25* [2122-9-5] 08:00PM BLOOD Glucose-111* UreaN-114* Creat-8.8* Na-131* K-5.5* Cl-97 HCO3-13* AnGap-27* [2122-9-6] 02:40AM BLOOD Glucose-107* UreaN-118* Creat-9.0* Na-134 K-5.4* Cl-100 HCO3-15* AnGap-24* [2122-9-6] 06:00AM BLOOD UreaN-123* Creat-9.4* Na-136 K-4.3 Cl-99 [2122-9-6] 03:28PM BLOOD Glucose-121* UreaN-130* Creat-9.4* Na-135 K-4.1 Cl-98 HCO3-14* AnGap-27* [2122-9-7] 02:45AM BLOOD Glucose-102* UreaN-139* Creat-9.8* Na-133 K-4.1 Cl-96 HCO3-13* AnGap-28* [2122-9-8] 02:27AM BLOOD Glucose-108* UreaN-88* Creat-6.9# Na-136 K-3.7 Cl-99 HCO3-22 AnGap-19 [2122-9-10] 05:04AM BLOOD Glucose-102 UreaN-92* Creat-7.3* Na-135 K-3.7 Cl-99 HCO3-21* AnGap-19 [2122-9-11] 05:31AM BLOOD Glucose-100 UreaN-54* Creat-5.0# Na-137 K-3.7 Cl-100 HCO3-27 AnGap-14 [2122-9-12] 06:11AM BLOOD Glucose-96 UreaN-29 Creat-3.5# Na-138 K-3.7 Cl-102 HCO3-33 AnGap-7* [2122-9-13] 06:45AM BLOOD Glucose-100 UreaN-44* Creat-4.7# Na-136 K-4.0 Cl-99 HCO3-31 AnGap-10 [2122-9-14] 06:29AM BLOOD Glucose-119 UreaN-56* Creat-5.5* Na-136 K-3.9 Cl-98 HCO3-30 AnGap-12 [2122-9-6] 02:40AM BLOOD ALT-172* AST-372* AlkPhos-112* TotBili-0.3 [2122-9-8] 02:27AM BLOOD ALT-97* AST-71* AlkPhos-94 TotBili-0.3 [2122-9-9] 06:07AM BLOOD ALT-72* AST-54* AlkPhos-108* TotBili-0.2 [2122-9-10] 05:04AM BLOOD ALT-65* AST-52* AlkPhos-108* TotBili-0.2 [2122-9-11] 05:31AM BLOOD ALT-60* AST-59* LD(LDH)-183 AlkPhos-97 TotBili-0.2 [2122-9-6] 02:40AM BLOOD Calcium-8.8 Phos-8.9* Mg-2.5 [2122-9-6] 03:28PM BLOOD Calcium-8.3* Phos-8.8* Mg-2.4 [2122-9-7] 02:45AM BLOOD Calcium-8.1* Phos-9.0* Mg-2.5 [2122-9-8] 02:27AM BLOOD Calcium-8.2* Phos-5.6# Mg-2.1 Iron-110 [2122-9-9] 06:07AM BLOOD Calcium-7.7 Phos-5.0* Mg-2.1 [2122-9-10] 05:04AM BLOOD Calcium-7.9* Phos-5.1* Mg-2.1 [2122-9-11] 05:31AM BLOOD Albumin-2.5* Calcium-7.9* Phos-3.7 Mg-2.1 [2122-9-14] 06:29AM BLOOD Calcium-9.0 Phos-3.5 Mg-2.2 [2122-9-8] 02:27AM BLOOD calTIBC-137* Ferritn-430* TRF-105* [2122-9-7] 04:53PM BLOOD TSH-2.4 [2122-9-9] 06:07AM BLOOD Cortsol-28.4* [2122-9-4] 07:50AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [2122-9-6] 06:00AM BLOOD Vanco-15.3 [2122-9-6] 02:46AM BLOOD Type-[Last Name (un) ] Temp-36.8 pH-7.20* Comment-GREEN TOP [2122-9-7] 02:49AM BLOOD Type-[Last Name (un) ] Temp-35.7 pH-7.25* Comment-GREEN TOP [2122-9-7] 02:49AM BLOOD freeCa-1.07* [2122-9-14] 06:29AM BLOOD WBC-8.1 RBC-2.51* Hgb-8.7* Hct-24.9* MCV-99* MCH-34.9* MCHC-35.2* RDW-14.0 Plt Ct-106* [2122-9-15] 07:30AM BLOOD WBC-6.4 RBC-2.35* Hgb-7.9* Hct-23.6* MCV-100* MCH-33.7* MCHC-33.6 RDW-13.8 Plt Ct-114* [2122-9-13] 06:45AM BLOOD Neuts-85.4* Lymphs-10.6* Monos-1.7* Eos-2.0 Baso-0.3 [2122-9-15] 07:30AM BLOOD Neuts-82.6* Lymphs-12.1* Monos-2.6 Eos-2.2 Baso-0.4 [2122-9-14] 06:29AM BLOOD Plt Ct-106* [2122-9-15] 07:30AM BLOOD Plt Ct-114* [2122-9-4] 07:50AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL [2122-9-14] 06:29AM BLOOD Glucose-119* UreaN-56* Creat-5.5* Na-136 K-3.9 Cl-98 HCO3-30 AnGap-12 [2122-9-15] 07:30AM BLOOD Glucose-90 UreaN-33* Creat-3.7# Na-137 K-3.9 Cl-100 HCO3-29 AnGap-12 [2122-9-14] 06:29AM BLOOD proBNP-[Numeric Identifier ] [2122-9-14] 06:29AM BLOOD Calcium-9.0 Phos-3.5 Mg-2.2 [2122-9-15] 07:30AM BLOOD Calcium-8.2* Phos-1.9# Mg-2.0 [2122-9-16] 06:32AM BLOOD WBC-7.3 RBC-2.51 Hgb-8.5* Hct-25.2* MCV-101* MCH-33.9* MCHC-33.7 RDW-14.0 Plt Ct-129* [2122-9-16] 06:32AM BLOOD Plt Ct-129* [2122-9-16] 06:32AM BLOOD Glucose-98 UreaN-43* Creat-4.2* Na-139 K-3.9 Cl-100 HCO3-30 AnGap-13 [2122-9-16] 06:32AM BLOOD Calcium-8.6 Phos-2.6* Mg-2.0 . CXR [2122-9-3]: No acute cardiopulmonary process. . CT AP [2122-9-3]: 1. Infrarenal abdominal aortic aneurysm has increased in size in comparison to prior study from [2118] now measuring up to 5.3 cm without evidence of rupture. A curvilinear hyperdense focus in the periphery of the aortic aneurysm sac may represent calcification within the thrombotic portion of the aneurysm which is favored, or alternatively, could represent focal hemorrhage into the thrombus. Assessment for dissection is limited on this study. Further evaluation with MRI is recommended. 2. Extensive atherosclerotic disease with bilateral renal stents, the patency of which cannot be assessed on this exam. 3. Likely hemorrhagic cyst in the left kidney. . Rneal US with Doppler [2122-9-3]: 1. Well-vascularized symmetric-appearing kidneys bilaterally, with moderately elevated RIs. Both renal arteries are patent. 2. 1.4-cm complex cyst within the upper pole of the right kidney for which a followup ultrasound in one year is recommended. 3. 9-mm simple cyst of the upper pole of the left kidney. . Echo [2033-9-4] The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is unusually small. Overall left ventricular systolic function is normal (LVEF 65%). However, mechanical dyssynchrony is present. 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 moderately thickened. There is severe aortic valve stenosis (valve area 0.9 cm2). Mild to moderate ([1-18]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([1-18]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [2121-8-8], the aortic valve effective orifice area is further reduced. . Abdominal US with Doppler [2122-9-5] 1. Cholelithiasis without specific evidence of cholecystitis. 2. Patent hepatic vasculature as described above FINAL REPORT [2122-9-6] URINE CULTURE (Final [2122-9-6]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Piperacillin/tazobactam sensitivity testing available on request. 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 CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 32 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S [2122-9-4] 7:31 pm URINE Source: Catheter. FINAL REPORT [2122-9-6] URINE CULTURE (Final [2122-9-6]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Piperacillin/tazobactam sensitivity testing available on request. 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 CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 32 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Time Taken Not Noted Log-In Date/Time: [2122-9-4] 9:10 pm URINE CHM S# [Serial Number 103590]M ADDED [9-4]. FINAL REPORT [2122-9-5] Legionella Urinary Antigen (Final [2122-9-5]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). Performed by Immunochromogenic assay. A negative result does not rule out infection due to other L. pneumophila serogroups or other Legionella species. Furthermore, in infected patients the excretion of antigen in urine may vary. [2122-9-5] 3:59 am STOOL CONSISTENCY: LOOSE Source: Stool. FINAL REPORT [2122-9-6] CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [2122-9-6]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). [2122-9-9]- Blood Cultures-negative. [2122-9-15] Vein Mapping Study for placement of AVF. [2122-9-11] Negative blood culture [2122-9-18] 07:47AM BLOOD WBC-6.4 RBC-2.87* Hgb-9.7* Hct-28.2* MCV-98 MCH-33.8* MCHC-34.4 RDW-15.0 Plt Ct-91* [2122-9-18] 07:47AM BLOOD Plt Smr-LOW Plt Ct-91* Brief Hospital Course: 87yo F with known CKD s/p B/L renal artery stents who was admitted with back pain, concerning for growth of her AAA. She was initially admitted to vascular surgery, but transfered to the MICU for hypotension, new O2 requirement, and urosepsis. #UTI complicated by sepsis/bactermia: 1 of 2 blood cultures grew pan-sensitive E. coli. Urine culture also grew pan-sensitive E. Coli. She was initally on ceftriaxone and levofloxacin for community aquired organisms, but this was narrowed to ceftriaxone based on Cx data. C. diff negative, RUQ u/s negative for acute cholecystitis. After transfer to the general medicine floor, she was transitioned to ceftazidime on [9-13] to allow for simultaneous hemodialysis administration. Ceftazidime was switched to PO cefpodoxime starting on [2122-9-16]. Continue cefpodoxime for 14 days after first negative blood cultures. First negative blood cultures were drawn on [9-9]. [9-11] blood cultures were also negative. # Acute on chronic renal failure: FeNa 11% on admission. Initial urinalysis showed many white cells and some muddy brown casts. Her acidosis (likely secondary to uremia) was worsening, so HD was initiated [2122-9-7]. Worsening renal failure (high of Cr was 9.8) was thought to be due to acute ischemic damage from sepsis. UPEP revealed significant polyclonal bands but no monoclonal predominance and no Bence-[Doctor Last Name ] proteins. She remained with low urine output (~100smL/24 hrs) through her stay on the general medicine floor. She responded well to hemodialysis with appropriate reductions in BUN/Cr and normalization of electrolytes. # Hypoxia: Felt to be due to volume overload in setting of worsening renal failure. She was maintained on 2L O2 nasal cannula with O2 sats in the 98-100% range. She was tried on room air on [9-14] and desaturated to 86%; her O2 sat recovered immediately after replacement of nasal cannula. On [9-16], at HD were able to successfully remove 1.5L. Pt has been on RA since [9-16]. She had another 1.5L removed on [9-17] and 1L on [2122-9-18]. # Atrial Fibrillation: During a session of HD, she went into a-fib, and became hypotensive. She dropped her pressures into systolics of 70s, and she was fluid responsive to 250cc boluses. She was amiodarone loaded and she converted into sinus rhythm. She was continued on amiodarone 400mg PO BID from [Date range (1) 103591]. She is to switch to amiodarone 200mg PO daily afterward. # Severe aortic stenosis: She showed clinical signs of congestive heart failure consistent with aortic stenosis during hospitalization, including bilateral 1+ pitting edema of lower extremities, pulmonary edema, 3/6 systolic crescendo-decrescendo murmur at LLSB, and widened pulse pressure. Her echocardiogram from [2122-9-5] showed severe aortic stenosis with a cross-sectional area of 0.9cm. She was evaluated by the cardiothoracic surgery team for possible aortic valve replacement but was thought to be a poor candidate for either surgical or catheter-based valve replacement given her age and dialysis. # Hypocalcemia: Likely related to progressive renal failure. Corrected calcium of 7.4. Follow ionized calcium and repleted PRN. PTH 497, vit D 44ng/ml. Patient is on Calcitriol. # Transaminitis: No EtOH Hx. Hypotension unlikely profound enough for shock liver. Followed labs and they trended down. RUQ US as noted above with no acute cholecystitis. Statin held in the setting of LFT abnormalities. # CAD: Held ASA in the setting of thrombocytopenia. # HLD: Held anti-hypertensives given transient hypotension and renal failure. # Breast CA: Hold letrozole in setting of low CrCl # Code: Full (confirmed with patient) Pending Issues Blood culture [9-11] pending We held patient's letrozole 2.5 mg daily as has low CrCl We held her BP meds: Olmesartan-HCTZ 20mg-12.5mg daily, Amlodipine 10mg daily - Nitroglycerin 0.4mg SL PRN because of low BP here. her ASA was switched from 325mg to 81mg because of thrombocytopenia We held Rosuvastatin 20mg daily because of transaminitis We held her Ergocalciferol 50,000 units every other week and are giving her Calcitriol 0.25 mcg PO EVERY OTHER DAY These medications may be restarted/titrated in conjunction with her PCP and [Name9 (PRE) 62587] physicians. - Medications on Admission: * Amlodipine 10mg daily * Ergocalciferol 50,000 units every other week * Letrozole 2.5mg daily * Olmesartan-HCTZ 20mg-12.5mg daily Rosuvastatin 20mg daily Aspirin 325mg daily * Ferrous sulfate 325mg daily * Nitroglycerin 0.4mg SL PRN Discharge Medications: 1. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 2. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY OTHER DAY (Every Other Day). 3. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. 4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 5. sodium chloride 0.65 % Aerosol, Spray Sig: [1-18] Sprays Nasal QID (4 times a day) as needed for nasal dryness. 6. cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO QMONWEDFRI (): Last day is [2122-9-23]. Please give after each dialysis session, Monday,Wednesday Friday. 7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: 0.5 Tablet Extended Release 24 hr PO once a day. Discharge Disposition: Extended Care Facility: [Hospital 3137] Care Center - [Location (un) 1468] Discharge Diagnosis: Urosepsis Acute Kidney Injury End Stage Renal Disease Severe Aortic Stenosis 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: It was a pleasure to care for you during your hospitalization at [Hospital1 69]. You were admitted to the hospital for back pain. During your admission, we performed laboratory tests and determined that you had renal failure and a urinary tract infection, which then infected your blood stream. You were treated in the intensive care unit (ICU), and given IV fluids and antibiotics. You were given hemodialysis to replace the kidneys' function in cleaning your blood. You were also given physical therapy to rebuild your strength after your stay in the ICU. . You also had signs of heart failure related to your aortic valve stenosis, including leg swelling, changes in your blood pressure, and fluid in your lungs. Our cardiothoracic surgeons evaluated you and currently believe that surgical replacement of your aortic valve while on dialysis poses more risks than benefits. You may wish to ask your primary care provider about this issue at a future date. . Please make sure to attend your hemodialysis appointments three times a week as scheduled. Upon arrival to rehab facility, please see the facility's physician. [Name10 (NameIs) ] discharge from rehab facility, please call your PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) 7726],[First Name3 (LF) 177] A. at [Telephone/Fax (1) 7728] to schedule a follow up appointment concerning your hospitalization. . You were evaluated by the nephrologists and the attending internal medicine physician, [Last Name (NamePattern4) ]. [Last Name (STitle) ] [Name (STitle) ], who feel that it is safe for you to be transferred to the rehabilitation hospital now. . We made several changes to your medications. You should STOP taking the following medication until your primary care doctor says otherwise: -amlodipine -letrozole -nitroglycerin -olmesartan-hydrochlorothiazide (Benicar) -rosuvastatin -Ergocalciferol . You should START taking: -Cefpodoxime 200mg on MWF (with dialysis)- (last day is [2122-9-23]) -Metoprolol succinate 12.5mg ONCE daily -Amiodarone- 200mg once daily -Tylenol as needed for pain -Calcitriol -B complex-vitamin C-folic acid Followup Instructions: Department: TRANSPLANT CENTER When: THURSDAY [2122-10-15] at 1:20 PM With: [First Name11 (Name Pattern1) 674] [Last Name (NamePattern4) 675], MD [Telephone/Fax (1) 673] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: RADIOLOGY When: FRIDAY [2122-12-11] at 10:10 AM With: RADIOLOGY [Telephone/Fax (1) 327] Building: [Hospital6 29] [Location (un) 861] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Completed by:[2122-9-18]	[ "799.02", "428.33", "V45.82", "585.5", "287.5", "590.80", "272.4", "395.0", "427.31", "275.41", "441.4", "276.2", "570", "584.5", "038.42", "244.9", "403.91", "782.3", "351.0", "276.1", "428.0", "573.3", "V46.2", "785.52", "995.92", "414.01", "V10.3", "V15.82" ]	icd9cm	[ [ [] ] ]	[ "38.95", "39.95" ]	icd9pcs	[ [ [] ] ]	22599, 22684	17075, 21384	227, 291	22804, 22804	5553, 5553	25157, 25764	3468, 3737		21672, 22576		22705, 22783		21410, 21649			22987, 25134									4297, 5534								4282, 4282																	178, 189									319, 2062						5569, 17052				22819, 22963							2084, 2800	2816, 3452
4,347	159,031	19017	Discharge summary	report	Admission Date: [2165-7-8] Discharge Date: [2165-7-18] Date of Birth: [2104-6-18] Sex: M Service: CCU HISTORY OF PRESENT ILLNESS: The patient is a 61-year-old male with hypertension, anxiety, and gastroesophageal reflux disease, and no significant prior cardiac history, who presented to us today for acute onset of chest pain and shortness of breath. The patient was at work today, the day of admission, he noted a brief and sudden onset of chest pain, shortness of breath. He went to his primary care doctor's office, and was found to have ST elevations in V1 through V4. He presented to an outside hospital and received aspirin, Lopressor, was placed on a nitrodrip and a Heparin drip. His pain improved, but he still had ST elevations. The patient presented to our Catheterization Laboratory with the lowest systolic blood pressure in the 70s-90s. In the Catheterization Laboratory, the patient was found to have a normal left main artery. His left anterior descending artery was found to be totally occluded proximally just beyond the left marginal branch. His left circumflex artery was found to have two serial discrete 70-80% lesions. His right coronary artery was found to be 85% occluded at the origin and to have faint collaterals. His left anterior descending lesion was stented proximally with 0% residual occlusion. TIMI-III flow was noted in the LAD. MEDICATIONS AT HOME: 1. Prevacid 30 mg once a day. 2. Paxil 20 mg once a day. 3. Ativan 1 mg once a day. PHYSICAL EXAM ON ADMISSION TO CCU: Demonstrated a normotensive blood pressure of 104/68, heart rate of 95. He was sating 97% on 4 liters. He was afebrile. In general, the patient was lying in bed in no acute distress. His membranes were moist. His neck was supple. He had no jugular venous distention. On his chest examination, he had rales anteriorly. Patient, on cardiac exam, he had a regular rhythm. His abdomen demonstrated no abnormalities. His extremities were warm. He had good pulses, and he was alert and oriented times three. LABORATORY VALUES ON ADMISSION: Significant for a white count of 13.7. CK of 1862 and a troponin greater than 50. ELECTROCARDIOGRAM: Showed a normal sinus rhythm at 93 beats per minute, a normal axis and intervals. He had [Street Address(2) 1766] elevation in leads V2 to V3. On CCU day one, the patient arrived with an intra-aortic balloon pump inside of him. The patient was started on aspirin, Plavix, Integrilin. HOSPITAL COURSE: On hospital day two, the patient was running a low grade temperature overnight. Was given 1 gram of Vancomycin and was started on levofloxacin and Flagyl for presumed aspiration pneumonia. A chest x-ray obtained showed a left lower lobe opacity. The aortic balloon pump was still in place. He obtained an echocardiogram which showed an ejection fraction of 30% and left ventricular hypokinesis globally. On CCU day three, the patient had an episode of chest pain. A sublingual nitroglycerin was given. Subsequently, his blood pressures dropped a bit to systolics 70s. He was given a fluid bolus of 500 cc and his pressure increased to 100 systolic. His ACE inhibitor was increased to 25 mg 3x a day. On CCU day four, the patient's aortic balloon pump was removed. He was started on Coreg 3.125 and his captopril was held at 25 tid secondary to systolic blood pressures in the 90s. On CCU day five, the patient had an episode of lightheadedness. His captopril dose was held at 25 mg tid. He was given a 500 cc bolus of normal saline, and he responded appropriately. He also was complaining of one episode of [3-18] chest pain. An electrocardiogram was performed that showed no changes. Cardiac enzymes were sent. The pain resolved with Morphine. The decision was made to recath the patient secondary to persistent chest pain [3-18] and persistent electrocardiogram changes that were unresolved since admission. Postcatheterization procedure, the patient was transferred out to the floor. In the evening, he had an episode of chest pain with his blood pressures running in the 100 systolic. Morphine and Ativan were given. The patient was not chest pain free. The sheath was pulled from the patient. He had a vagal episode, and decreased his blood pressure. A 1 liter fluid bolus was given, and he became normotensive. He subsequently was still experiencing the chest pain. More Morphine was given. His blood pressure remained in the 60s systolic with heart rate in the 60s. 750 cc of fluid were given, and decision was made to transfer the patient to the CCU for closer monitoring. His pressures normalized in the CCU with systolic blood pressures ranging from 95-110. Of note, during these episodes of chest pain on the floor and into the CCU, the patient did not have any electrocardiogram changes, and enzymes were sent, but there were no subsequent changes in his cardiac enzymes as well. On hospital day nine, the patient remained stable in the CCU. A low dose beta blocker was started, and Coumadin was started as well. The Coumadin dose was 5 mg once a day. By this time, the patient was off levofloxacin and Flagyl for the presumed aspiration pneumonia on the previous hospital day two. By hospital day 10, the patient remained stable, normotensive, and afebrile, and was discharged to home. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: Full code. DISCHARGE DIAGNOSIS: Acute myocardial infarction. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg once a day. 2. Plavix 75 mg once a day. 3. Atorvastatin 10 mg once a day. 4. Protonix 40 mg once a day. 5. Paxil 30 mg once a day. 6. Lisinopril 5 mg once a day. 7. Carvedilol 12.5 mg twice a day. 8. Lovenox 80 mg subcutaneously every 12 hours for five days. FOLLOW-UP PLANS: The patient is to followup with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 51937] in his office for an INR check at 2 pm on [2165-7-22]. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1008], M.D. [MD Number(1) 1009] Dictated By:[Last Name (NamePattern1) 3809] MEDQUIST36 D: [2165-8-2] 15:43 T: [2165-8-13] 17:06 JOB#: [Job Number 51938]	[ "458.2", "414.01", "599.0", "410.11", "507.0", "401.9", "530.81" ]	icd9cm	[ [ [] ] ]	[ "36.07", "37.61", "36.05", "37.23", "36.01", "99.20", "88.56", "88.53", "36.06" ]	icd9pcs	[ [ [] ] ]									5490, 5768		5437, 5467			2510, 5350							1428, 2081																							5786, 6229															160, 1407								2096, 2492											5375, 5415
48,304	162,550	34446	Discharge summary	report	Admission Date: [2128-3-31] Discharge Date: [2128-4-6] Date of Birth: [2072-9-1] Sex: F Service: MEDICINE Allergies: Lisinopril / Losartan Attending:[First Name3 (LF) 4327] Chief Complaint: right sided facial and right arm tingling Major Surgical or Invasive Procedure: intubation [3-31] extubation [4-3] History of Present Illness: 55F with Hx of nonischemic dilated cardiomyopathy (EF 25%) with BiV ICD (replaced generator on [2128-2-26]), progressive mitral regurgitation, HTN, HL, obesity, presenting with acute onset of tingling on the right side of her face and right arm. Associated with some lightheadedness. Denies HA, blurry vision, numbness, or weakness. No CP or palpitations. . She stated that she has had similar symptoms of right-sided tingling in the recent past, but was not seen by a physician at that time. One day prior to admission she was on the toilet having a BM when she passed out and was found by a family member with her head leaning on the wall. She did not fall from the toilet seat. She had no CP or palpitations prior to her fall, but it is unknown if there was head trauma. In addition, she has felt as though she was going to pass out multiple times in last few days. During these episodes she would feel "startled .. as if electricity went through her face .. as if she went far .. far away" but did not actually pass out or lose consciousness. She is worried that these symptoms are due to a problem with her pacer as the generator was recently changed. . Per a Cardiology/EP visit on [3-8], the patient reported passing on on [2-28] in front of a friend and woke up after the device had shocked her. On [3-4], she had another episode of VT/VF at a rate of 250 beats per minute at 1:30 in the morning. The ICD delivered ATP therapy which failed followed by a 34 joule shock which terminated the arrhythmia. There were three nonsustained VT episodes that were concurrent with the previous two VT/VF episodes. The device has been atrially sensing/ventricularly sensing 1.5%, atrially sensing/ventricularly pacing 93.3%, and atrially pacing/ventricularly pacing 5.2% of other time. . In the ED, initial vitals were 98.5 78 128/77 18 94%. She was observed to be confused at times. Neurology consult was requested with the conclusion that her transient disorientation was not neurologic in etiology but rather cardiac. EP interrogated pacemaker and found 12 episodes of VT/VF. On [2128-3-31] given Acetaminophen 1000mg, Valsartan 80mg, Omeprazole 20mg, Torsemide 80 mg, Spironolactone 25mg, Carvedilol 25mg. She remained in the ED overnight, and was transferred to the floor mid-day [3-31]. During her time in the ED she complained of episodes of right-sided tingling. . On arrival to the floor, patient denies chest pain or palpitations. She complains of mild tingling around her right eye. . REVIEW OF SYSTEMS On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. Severe nonischemic dilated cardiomyopathy with LVEF of 20%, unknown etiology, diagnosed originally in [State 531]. We started following the patient in [2123]. 2. Progressive mitral regurgitation 3. Hypertension 4. Hyperlipidemia 5. Obesity 6. BiV ICD originally implanted in [State 531] in [2123], recent generator change [2128-2-26] 7. GERD 8. Past positive PPD 9. Thyroid nodule Social History: The patient is originally from [Country 2045], immigrated [2112], now US citizen. She speaks French Creole. She lives with her brother, [Name (NI) ], in a one family home. No tobacco, ETOH or illicit drug use. Family History: Parents had diabetes, hypertension, and heart disease. Mother: CAD, HTN Father: DM Brother: DM Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS: 97.3 113/67 67 26 96% RA GENERAL: NAD. Alert and oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM, OP clear. No sinus tenderness, no scleral injection. NECK: Supple with JVP of [7-4] cm. CARDIAC: RRR, normal S1, S2. No MRG. LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no rales, wheezes or rhonchi. ABDOMEN: Soft, non-tender, non-distended. No HSM. EXTREMITIES: No cyanosis, clubbing, or edema. DP and PD 2+ bilaterally NEURO: CN II-XII tested and intact, strength 5/5 throughout, sensation grossly normal. Gait not tested. . DISCHARGE PHYSICAL EXAMINATION: VS: 98.0 127/89 73 18 98% RA GENERAL: NAD. Alert and oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM, OP clear. NECK: Supple with JVP of [7-4] cm. CARDIAC: RRR, normal S1, S2. No MRG. LUNGS: CTAB, no rales, wheezes or rhonchi. ABDOMEN: Soft, non-tender, non-distended. EXTREMITIES: No cyanosis, clubbing, or edema. Pertinent Results: Admisssion Labs: [2128-3-30] 09:40PM BLOOD WBC-8.3 RBC-3.84* Hgb-11.9* Hct-36.8 MCV-96 MCH-31.1 MCHC-32.4 RDW-13.7 Plt Ct-186 [2128-3-30] 09:40PM BLOOD Neuts-58.8 Lymphs-33.9 Monos-4.0 Eos-2.3 Baso-1.0 [2128-3-30] 09:40PM BLOOD PT-13.5* PTT-31.9 INR(PT)-1.3* [2128-3-30] 09:40PM BLOOD Glucose-157* UreaN-14 Creat-1.3* Na-145 K-3.6 Cl-102 HCO3-30 AnGap-17 [2128-3-30] 09:40PM BLOOD Calcium-9.2 Phos-3.6 Mg-2.2 ABGs: [2128-3-31] 09:55PM BLOOD Type-ART pO2-211* pCO2-56* pH-7.38 calTCO2-34* Base XS-6 [Hospital3 ]: [2128-3-30] 09:40PM BLOOD TSH-2.6 [2128-4-1] 04:07AM BLOOD TSH-1.9 [2128-4-5] 07:20AM BLOOD ALT-17 AST-21 AlkPhos-80 TotBili-0.5 [2128-4-4] 06:54AM BLOOD [Doctor First Name ]-NEGATIVE [2128-4-1] 04:07AM BLOOD Digoxin-1.5 [2128-4-4] 06:54AM BLOOD ANGIOTENSIN 1 - CONVERTING [Last Name (un) ]-PND Discharge Labs: [2128-4-6] 06:50AM BLOOD WBC-7.3 RBC-3.83* Hgb-12.4 Hct-38.3 MCV-100* MCH-32.4* MCHC-32.4 RDW-14.2 Plt Ct-171 [2128-4-6] 06:50AM BLOOD Glucose-113* UreaN-26* Creat-1.5* Na-144 K-3.7 Cl-105 HCO3-29 AnGap-14 [2128-4-6] 06:50AM BLOOD Calcium-9.2 Phos-4.8* Mg-2.2 Microbiology: MRSA swab pending Imaging: CT head [2128-3-30] There is no acute intracranial hemorrhage, edema, mass effect or large acute territorial infarction. There are moderate, confluent hypodensities in the centra semiovale and periventricular white matter, consistent with sequelae of chronic small vessel disease. There is no fracture or suspicious bony lesion. There is no large scalp subgaleal hematoma. The paranasal sinuses and mastoid air cells are clear. IMPRESSION: No acute intracranial abnormality. CXR [2128-3-30] FINDINGS: There is severe cardiomegaly and moderate vascular congestion, but no pulmonary edema. ICD/Pacemaker leads end in the right atrium and right ventricle and coronary sinus, unchanged from [2128-2-24]. CXR [2128-3-31] FINDINGS: As compared to the previous radiograph, there is an increased in general lung density, likely to reflect pulmonary edema after cardiac failure. Presence of a small pleural effusion cannot be excluded. There is evidence of retrocardiac atelectasis. The patient has been intubated, the endotracheal tube projects 3 cm above the carina with its tip. There is no evidence of pneumothorax or other complication. CXR [2128-4-1] FINDINGS: As compared to the previous radiograph, there is no relevant change. Tip of the endotracheal tube projects 3 cm above the carina. The transparency of the lung parenchyma has increased, likely reflecting improved ventilation. Unchanged retrocardiac atelectasis. The course of the nasogastric tube is constant. Unchanged left pectoral pacemaker. CXR [4-2]: FINDINGS: In comparison with the study of [4-1], the monitoring and support devices are essentially unchanged. There is continued enlargement of the cardiac silhouette with pacer devices in place. Retrocardiac opacification with obliteration of the hemidiaphragms consistent with volume loss in the left lower lobe and pleural effusion. At the right base, there is some patchy area of increased opacification. It is unclear whether this could represent some asymmetric pulmonary edema or a developing consolidation, especially since the upper part of the right heart border is not sharply seen. EKGs [2128-3-30] Predominantly ventricular pacing with a pacing artifact falling at the end of what appears to be a P wave, but also several non-paced QRS complexes of at least two morphologies, one of which suggests a fusion beat. Both the ventricular paced and non-paced QRS complexes have a left bundle-branch block, left axis deviation configuration. Prolonged Q-T interval. ST segment flattening in leads I and aVL, with appropriate secondary repolarization abnormalities in the other leads on ventricularly paced beats. Compared to the previous tracing of [2128-2-24], the overall rate is slightly faster. The P wave morphology is broader. Natively conducted and likely fusion ventricular complexes are new. Configuration of the paced beats is unchanged. [2128-3-31] Ventricular pacing throughout falling on the end of what appears to be a P wave with thus very short interval between the P wave and the QRS complex. Left atrial abnormality. Prolonged Q-T interval. Compared to tracing #1 there are no longer any natively conducted non-paced QRS complexes. Morphology of the paced QRS complexes is unchanged. Previously noted ST segment flattening in leads I and aVL persist with no change in the appropriate secondary repolarization abnormalities in the other leads. [2128-4-2] Sinus rhythm with atrial sensing and ventricular pacing. Compared to the previous tracing of [2128-4-1] there is no significant change. Brief Hospital Course: 55F with Hx of nonischemic dilated cardiomyopathy (EF 25%) with BiV ICD (replaced generator on [2128-2-26]), progressive mitral regurgitation, HTN, HL, obesity, presenting with acute onset of tingling on the right side of her face and right arm, found to have had multiple firings of her ICD for VF/VT. . # VT/VT: The patient's paceer interrogation showed multiple episodes of VF and VT and associated firing that most likely explain her symptoms of syncope, near-syncope, and right sided tingling. Electrolytes normal with repletion. The afternoon of admission the patient experienced two further episodes of VT/VF that instigated firing of her device, bringing the total to 14 over 2 days. She confirmed that this was the source of her presenting complaint. Given the frequency of these events, she was determined to be in VT storm. . She was transferred to the ICU for sedation and intubation to reduce the catecholamine drive for these arrhythmias and reduce the number of shocks instigated. The patient was initiated on loading doses of amiodarone to suppress her ventricular arrythmia. She was intubated and sedated for approximately 24 hours without VT/VF. The patient subsequently self-extubated, tolerated this well, and was diuresed to improve her volume overload. She was doing well and was transferred back to the floor. The etiology of these arrhythmias was uncertain, although sarcoidosis is one possibility that could be investigated once she stabilizes. TSH was normal, digoxin level within therapeutic range. [Doctor First Name ] negative, ACE pending at time of discharge. . Prior to discharge her QTc was noted to be prolonging to 490s, therefore amiodarone dose was decreased to 200 mg daily and mexiletine was initiated. Digoxin and mexiletine doses were 50% of typical due to interaction with amiodarone. . # CORONARIES: Last cath in [2124] showed clean coronaries. Continued statin; switched from lovastatin to atorvastatin on admission due to formulary availability, switched back on discharge. . # PUMP: The patient is known to have severe nonischemic dilated cardiomyopathy with EF 25% with progressive MR [First Name (Titles) ] [Last Name (Titles) ], chronic systolic heart failure. In [2128-1-28] she was admitted to this facilty with an acute heart failure exacerbation and her diuretics were increased. Per Dr[Name (NI) 3536] recent note, she may be referred to [Hospital1 3278] for consideration of heart transplantation. Euvolemic on admission. Digoxin, spironolactone, torsemide, and [Last Name (un) ] continued. . # HTN: well-controlled on [Last Name (un) ], beta blocker, diuretics. These were held in the ICU while the patient was hypotensive on sedation, and were subsequently re-started with good control. . # HLD: [2127-5-28] total 172, LDL 111, HDL 34, TG 133. Continued statin. . # Chronic kidney disease: baseline Cr 1.3-1.5, remained at baseline . # Dysuria: [4-4] overnight the patient developed dysuria, UA showed signs of infection. Received 1 dose Cipro, switched to cefpodoxime due to concern of QT prolongation. Cefpodoxime continued on discharge for planned 6 day course. . # Right heel pain: [4-5] the patient noted right heel pain, worse with weight-bearing. There is some slight swelling, no skin erythema or point tenderness. Worse with ankle flexion, tendon manipulation. Provided ibuprofen 600mg x1 with good effect. Improved the following morning, although may continue to require treatment with Tylenol. . # Elevation of PT, INR: Persistent elevation of PT (15-16) and INR (1.3-1.4) since [2123], PTT normal. No sign of liver disease. [Month (only) 116] represent acquired factor inhibitor or low-level factor deficiency. Could consider mixing study, not acute workup so defer to outpatient providers. . # GERD: continued omeprazole . # IGT: HbA1c 6.3 in [2128-2-26], no treatment necessary . # Thyroid nodule: TSH 2.1 in [2127-5-28], remained normal . CODE: FULL EMERGENCY CONTACT: [Name (NI) ] (brother, [Telephone/Fax (1) 79179]) . Transitional Issues: - follow left heel pain - potential workup of elevated PTT - consider sarcoid workup for underlying etiology of arrhythmia, ACE level pending - please follow EKG for QTc prolongation given concurrent therapy with digoxin, amiodarone, and mexiletine. Please avoid other QT prolonging medications. - please follow electrolytes after discharge to avoid hypokalemia; may require KCl supplementation Medications on Admission: Carvedilol 25 mg twice a day digoxin 0.125 mg daily lovastatin 20 mg daily omeprazole 20 mg daily spironolactone 25 mg daily torsemide 80 mg daily Diovan 80 mg in the morning and 40 mg in the evening Discharge Medications: 1. digoxin 125 mcg Tablet Sig: [12-29] Tablet PO DAILY (Daily). 2. lovastatin 20 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. torsemide 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 6. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day. 7. valsartan 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 9. mexiletine 150 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). Disp:60 Capsule(s) Refills:0 10. cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 2 days. Disp:8 Tablet(s) Refills:0 11. phenol 1.4 % Aerosol, Spray Sig: One (1) Spray Mucous membrane Q4H (every 4 hours) as needed for sore throat. Disp:1 bottle Refills:0 12. Outpatient Lab Work Please draw a basic metabolic panel (chemistry) on Thursday, [4-8], send results to PCP to check [Name Initial (PRE) ] and Cr. Please replete K as necessary to keep > 4. 13. EKG Please do an EKG on Thursday, [4-8] to check QT interval. Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: ventricular tachycardia and ventricular fibrillation defibrillator firing Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure taking care of you at [Hospital1 827]. You came to the hospital because your implantable defibrillator fired twelve times. Once you came to the hospital, it fired twice more. This was caused by an irregular heart beat. You were sedated and intubated to help reduce the frequency of this irregularity. You were extubated successfully, and did not have further irregular beats. Your device was checked and was working properly. We are not sure what caused this irregular heart beat. We made the following changes to your medications: - START cefpodoxime for urinary tract infection (4 more days, last dose 4/14) - START amiodarone and mexiletine to control your heart rhythm - REDUCE your digoxin and valsartan doses, as these drugs can interact with amiodarone Please follow-up with your physicians as listed below Weigh yourself every morning, call your doctor if your weight goes up more than 3 lbs. Followup Instructions: Please go to [Hospital1 ] to get blood work done on Thursday. You will need a basic metabolic panel to check your potassium and creatinine as well as an EKG to check QT interval. Name: Dr [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 79180] (works with Dr [Last Name (STitle) ] Location: [Hospital 3578] COMMUNITY HEALTH CENTER Address: [Hospital1 3579], [Location (un) ],[Numeric Identifier 3580] Phone: [Telephone/Fax (1) 3581] Appt: [4-13] at 1:30pm Department: CARDIAC SERVICES When: MONDAY [2128-4-26] at 11:00 AM With: ECHOCARDIOGRAM [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: CARDIAC SERVICES When: MONDAY [2128-4-26] at 1 PM With: DEVICE CLINIC [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: CARDIAC SERVICES When: MONDAY [2128-4-26] at 1:30 PM With: DR. [First Name8 (NamePattern2) ] [Doctor Last Name ] [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: CARDIAC SERVICES When: FRIDAY [2128-4-30] at 2:20 PM With: [Name6 (MD) ] [Name8 (MD) ], MD [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "427.1", "428.22", "278.00", "794.31", "729.5", "403.90", "272.4", "530.81", "782.0", "286.9", "427.41", "416.8", "424.0", "V53.39", "425.4", "599.0", "428.0", "585.9" ]	icd9cm	[ [ [] ] ]	[ "96.71" ]	icd9pcs	[ [ [] ] ]	16221, 16278	10127, 14231	322, 366	16395, 16395	5316, 6186	17502, 19112	4164, 4260		14899, 16198		16299, 16374		14675, 14876			16545, 17078	6202, 10104								4275, 4285															4933, 5297			14252, 14649		17107, 17479					241, 284									394, 3467										16410, 16521							3489, 3905	3921, 4148
25,517	135,019	21144	Discharge summary	report	Admission Date: [2137-6-10] Discharge Date: [2137-6-18] Date of Birth: [2067-5-29] Sex: F Service: MED ADMISSION DIAGNOSIS: Metastatic melanoma. DISCHARGE DIAGNOSIS: Metastatic melanoma. HISTORY OF PRESENT ILLNESS: Ms. [Known lastname 56075] is a 70-year-old [Country ] Rican Spanish-speaking woman with history of hypertension, diabetes mellitus and malignant melanoma, who presented to the [Hospital Ward Name 23] Outpatient Surgery Center for recurrence of a neck mass which was concerning for a melanoma recurrence. She was taken to the Operating Room on [2137-6-10], and underwent a resection of a right preauricular subcutaneous soft tissue mass and right parapharyngeal space dissection, resection of parapharyngeal space mass which included resection of a portion of the right internal jugular vein. [Year (4 digits) ] she was found to have mental status changes which turned out to be a result of anesthesia. PAST MEDICAL HISTORY: Includes malignant melanoma, status post parotidectomy in [2135], hypertension, non-insulin- dependent diabetes mellitus. No evidence of coronary artery disease (normal MIBI [10-5]), psychotic depression status post ECT and glaucoma. OUTPATIENT MEDICATIONS: Include Celexa, glipizide, Metformin, meclizine, atenolol, Hyzaar and Neurontin. ALLERGIES: No known drug allergies. HOSPITAL COURSE BY SYSTEM: Ms. [Known lastname ] [Last Name (Titles) 26476] was found to have mental status changes which required a neurology workup. She was kept in the Intensive Care Unit for several days and transferred to the floor on postoperative day five, [2137-6-15]. 1. As mentioned Ms. [Known lastname 56075] had mental status changes in which she was minimally responsive in the Post Anesthesia Care Unit. A head CT was performed at that time which was negative. EKG was performed which was negative. Over the course of the next one or two days her mental status improved and she was at her baseline mental status. She has a history of psychotic depression, requiring ECT in the past. She did return to her baseline mental status where her postoperative delirium did improve. However, of note, on [2137-6-13], Ms. [Known lastname 1794] was found on the floor after a fall. A neuro examination was without any significant changes. 1. Cardiovascular: EKG in the Post Anesthesia Care Unit was normal. She has history of hypertension which was somewhat controlled to her baseline. She was restarted on her home blood pressure medications. She was hemodynamically stable throughout her hospital stay. 1. Respiratory: She was extubated on postoperative day two. Chest x-rays in the Intensive Care Unit have been stable. 1. Gastrointestinal: On postoperative day zero an NG tube was placed for a large gastric polyp found on chest x-ray. She has a question of liver disease due to some abnormal PET scan as reported by the daughter. A set of liver function tests were drawn. They were normal. Bedside swallow evaluation [2137-6-13], was performed by Speech and Swallow. This was normal. She was started on a regular diet. She is currently tolerating a regular diet. 1. Renal: The Foley catheter was removed on postoperative day four by the Surgical Intensive Care Unit team. She is currently voiding. Her creatinine is normal. 1. Hematology: Her hematocrit is stable and her white count is within normal limits. She is ambulating several times per day. 1. Oncology: She was seen by her oncologist while in house. She will follow up with him for radiation therapy if indicated. DISPOSITION: Ms. [Known lastname 56075] was seen by Physical Therapy and Occupational Therapy who recommended rehabilitation. She is ready for discharge to rehab when stable. DISCHARGE MEDICATIONS: Per discharge order. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], [MD Number(1) 30193] Dictated By:[Last Name (NamePattern1) 56076] MEDQUIST36 D: [2137-6-17] 10:26:04 T: [2137-6-17] 10:42:07 Job#: [Job Number 56077]	[ "285.9", "518.5", "V10.82", "211.1", "250.00", "401.9", "293.9", "198.89" ]	icd9cm	[ [ [] ] ]	[ "38.62", "29.39", "18.21" ]	icd9pcs	[ [ [] ] ]									3931, 4222		202, 224								1419, 3907																				1271, 1391		158, 180																		253, 979																	1002, 1246
13,753	155,089	5086	Discharge summary	report	Admission Date: [2165-8-21] Discharge Date: [2165-9-12] Date of Birth: [2088-11-12] Sex: M Service: MEDICINE Allergies: Ace Inhibitors Attending:[First Name3 (LF) 3507] Chief Complaint: Jaundice and unintentional weight loss Major Surgical or Invasive Procedure: ERCP History of Present Illness: 76 M with no known liver disease, now here with unintentional wt loss x 4 weeks and elevated bili/jaundice. Patient reports a decreased appetite and some intermittent nausea over this 4 week period, but denies dysphagia, vomiting, diarrhea, fevers/chills or night sweats. He complains of frequent urination at night, which he reports to be dark in color, but otherwise, no hematuria/dysuria. No occult blood. Past Medical History: stable CAD - ETT MIBI [8-31] demonstrating a severe fixed defect in the inferior and lateral wall from apex to base with global HK and an LVEF of 18%. s/p CABG [2150] ED h/o pancreatitis Afib CHF - ischemic - EF 18%, class II - III, refused anticoagulation and ICD/BiV pacer hypertension dyslipidemia h/o obesity Social History: He lives with his wife. [Name (NI) ] reports that family helps both of them with ADLs since wife has also been ill with strokes. No current or former smoking or alcohol. Family History: NC Physical Exam: VITAL SIGNS: Wt181 ([4-4]) -> 178 ([5-4]) -> 163 ([2165-8-8]) -> 123 ([2165-8-20]) GENERAL: Awake, alert, cachectic, NAD HEENT: NC/AT, PERRLA, EOMI, scleral icterus, OP non-erythematous NECK: Supple. No lymphadenopathy HEART: RRR, S1, S2 nl, II/VI systolic murmur at RUSB CHEST: CTAB ABDOMEN: Soft, NT, ND, +BS, no rebounding, but guarding, denies pain EXTREMITIES: No c/c/e Pertinent Results: [2165-8-21] 12:13PM PT-15.1* PTT-34.9 INR(PT)-1.4* [2165-8-21] 12:13PM PLT COUNT-110* [2165-8-21] 12:13PM ANISOCYT-2+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-1+ [2165-8-21] 12:13PM NEUTS-51.6 LYMPHS-41.9 MONOS-3.8 EOS-1.8 BASOS-0.9 [2165-8-21] 12:13PM WBC-3.2* RBC-4.87 HGB-15.7 HCT-45.5 MCV-94 MCH-32.3* MCHC-34.5 RDW-19.2* [2165-8-21] 12:13PM ALBUMIN-3.3* [2165-8-21] 12:13PM LIPASE-194* [2165-8-21] 12:13PM ALT(SGPT)-64* AST(SGOT)-104* ALK PHOS-271* AMYLASE-168* TOT BILI-20.6* [2165-8-21] 12:13PM GLUCOSE-74 UREA N-19 CREAT-1.2 SODIUM-134 POTASSIUM-4.8 CHLORIDE-100 TOTAL CO2-23 ANION GAP-16 [2165-8-21] 02:20PM proBNP-8637* [2165-8-21] 02:20PM LD(LDH)-681* [2165-8-30] 03:33PM BLOOD WBC-5.6 RBC-3.41* Hgb-11.0* Hct-31.8* MCV-94 MCH-32.2* MCHC-34.5 RDW-19.4* Plt Ct-219 [2165-8-30] 03:33PM BLOOD Glucose-89 UreaN-25* Creat-0.8 Na-134 K-4.3 Cl-107 HCO3-19* AnGap-12 [2165-8-30] 03:33PM BLOOD ALT-26 AST-38 LD(LDH)-226 CK(CPK)-43 AlkPhos-138* TotBili-18.4* [2165-8-30] 04:34AM BLOOD Lipase-79* [2165-8-27] 04:45AM BLOOD calTIBC-190* Hapto-40 Ferritn-489* TRF-146* . CT abd [8-20]: IMPRESSION: 1. Diffuse fatty infiltration of the liver without focal hepatic mass. 2. Small-to-moderate amount of ascites. 3. Two, tiny non-obstructing renal calculi within both kidneys. 4. Cholelithiasis without cholecystitis. 5. Cardiomegaly with distension of the hepatic veins suggestive of cardiomyopathy. 6. No intra-abdominal tumor identified. . Liver US [8-21]: IMPRESSION: 1. Stable appearance of the liver and gallbladder compared to the previous day's CT. 2. No biliary ductal dilatation. 3. Marked distention of the IVC and hepatic veins consistent with right heart failure. 4. Stable appearance of the nondistended gallbladder with thickened wall, cholelithiasis, and adenomyomatosis. 5. Ascites. . Echo: 1. The left atrium is mildly dilated. 2. The left ventricular cavity is dilated. There is severe global left ventricular hypokinesis. Overall left ventricular systolic function is severely depressed. 3. The right ventricular cavity is dilated. There is severe global right ventricular free wall hypokinesis. 4. The aortic valve leaflets (3) are mildly thickened. Trace aortic regurgitation is seen. 5. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. . Liver US [8-23]: 1. Hepatic veins and IVC are patent without evidence of thrombosis. Marked distention of these vessels is considered most likely due to right heart failure. 2. Expected pneumobilia in the setting of recent ERCP. . ERCP [8-22]: 1. Localized erythema of the mucosa was noted in the antrum and stomach body. These findings are compatible with gastritis. 2. Two superficial erosions with overlying exudates and surrounding erythema were noted in the duodenal bulb. Cold forceps biopsies were performed for histology at the dudoenal bulb. 3. Cannulation of the biliary duct was initally unsuccessful with a sphincterotome using a free-hand technique. Subsequently a small sphincterotomy was performed in the 12 o'clock position using a needle-knife to help guide bile duct cannulation. Thereafter, deep cannulation of the CBD was successfully achieved using a sphincterotome. 4. Cholangiogram showed a single irregular stone in the distal CBD. No proximal dilation was noted. 5. To help faciliate stone extraction, the sphincterotomy was gently extended in the 12 o'clock position using a sphincterotome over an existing guidewire. 6. A 12mm balloon was then used to sweep the CBD with sucessful extrusion of sludge and bile. Although post sweep cholangiogram did not show evidence of residual stones, it is possible that some framgents may have been left behind. 7. To assist sluge and stone fragment drainage, a 7cm by 10Fr Cotton [Doctor Last Name ] biliary stent was placed successfully in the CBD. Clear bile was noted to flow from the site. Brief Hospital Course: The patient is a 76 year old male w/CAD s/p CABG (EF 18%) who presented with 50 lb wt loss x 4 weeks and jaundice. Prior to admission the patient had mild dull, intermittent, lower quadrant abdominal pain, anorexia, fatigue, and intermittent nausea with emesis (brown) for the prior 4 weeks. Neither nausea or abdominal pain was related to food, and no ETOH or NSAID use recently. No fevers, chills, night sweats, melena, hematochezia, dysphagia. When the patient presented to [Hospital1 18] and was found to have elevated LFT's with bilirubin of 21. He underwent ERCP s/p small stone extraction, sphincterotomy, and stent placement on [8-22]. . Subsequently on the floor the patient became hypotensive with SBP's in the 80-90's (baseline 110's on valsartan, BB, imdur) which responded poorly to gentle fluid boluses and holding of his antihypertensives. He also was noted to have a rising BUN and dropping HCT (45.4 on [8-21].8 on [8-23].2 on [8-28], and 30 s/p 1 unit RPBC's on [8-29]) with guaic positive stools and dark stools. He also had an increased WBC from 3.2 on admission to 6.6. Additionally, the patient had a mild amount of ascites on ultrasound but radiology did not feel that there was an adequate amount to tap. In concern for SBP, he was started on flagyl and ceftriaxone, although it is unclear if he recieved these meds d/t lack of IV access. He was ordered 2 units PRBC's prior to transfer, one of which he recieved prior to arriving in [Hospital Unit Name 153]. . He was admitted to the ICU for management of hypotension and ?GI bleed. Repeat EGD did not show any evidence of active bleeding. Housestaff and attendings had many conversations both with the patient and with his health care proxy, and decided given the patients underlying co-morbidities and preferences, that he be made DNR/DNI/CMO. The son/patient requested no blood draws, no more fluids, no more antibiotics, no more invasive monitoring. He was transfered back out to the floor and was noted to be intermittently delerious. He recieved Zyprexa qhs and TID prn with good effect. He was subsequently transferred to rehab for comfort care. Medications on Admission: Lasix 40 mg QAM K supplement Aldactone 50 QD ASA 325 Lipitor 20 - stopped [1-31] transaminitis Bactrim DS x 7 days up to [8-19] BiDil 20-37.5 mg PO TID Calcitriol 0.25 3x/week Diovan 80 mg QD Toprol XL 100 QD Discharge Medications: 1. Acetaminophen 160 mg/5 mL Solution Sig: Six [Age over 90 1230]y (650) mg PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:qs mg Refills:0 2. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid Dissolve PO TID (3 times a day) as needed for agitation/confusion. Disp:qs Tablet, Rapid Dissolve(s) Refills:0 3. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO QHS (once a day (at bedtime)). Disp:qs Tablet, Rapid Dissolve(s) Refills:2 4. Morphine 2 mg/mL Syringe Sig: 1-2 mg Injection Q4H (every 4 hours) as needed. Disp:qs mg Refills:0 5. Scopolamine Base 1.5 mg Patch 72HR Sig: One (1) patch Transdermal every seventy-two (72) hours as needed for increased secretions. Disp:qs patches Refills:0 Discharge Disposition: Extended Care Facility: [Location (un) ] health care Discharge Diagnosis: Primary Diagnoses: Unexplained Weight loss, underlying malignancy possible Hyperbilirubinemia Choledocolithiasis s/p ERCP Delerium GI bleed Secondary Diagnoses: CAD s/p CABG [2150] CHF (EF 18%) ED h/o pancreatitis Afib Hypertension Dyslipidemia h/o obesity Discharge Condition: Comfort Care Only Discharge Instructions: Please make sure that the patient is as comfortable as possible. He is written for Zyprexa for agitation and can receive Morphine, Tylenol, and Ibuprofen as needed for pain. He should not have any vitals or lab draws. Followup Instructions: Provider: [Name10 (NameIs) ],[Name11 (NameIs) ] [Name Initial (NameIs) ]. [Telephone/Fax (1) 250] Call to schedule appointment	[ "284.8", "272.4", "998.11", "401.9", "199.1", "585.9", "427.31", "E878.8", "276.2", "782.4", "V45.81", "428.0", "574.50" ]	icd9cm	[ [ [] ] ]	[ "51.87", "99.04", "51.88", "51.85", "45.13", "45.14" ]	icd9pcs	[ [ [] ] ]	8941, 9000	5723, 7883	315, 322	9306, 9326	1744, 5700	9594, 9742	1313, 1317		8151, 8918		9021, 9162		7909, 8128			9350, 9571									1332, 1725			9183, 9285																						237, 277									350, 761																	783, 1106	1122, 1297
46,380	146,556	49605	Discharge summary	report	Admission Date: [2130-2-7] Discharge Date: [2130-2-8] Date of Birth: [2060-7-16] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 443] Chief Complaint: s/p Carotid stent Major Surgical or Invasive Procedure: Primary: Carotid angiogram Carotid Stenting (left) History of Present Illness: The patient is a 69yo male with a history of coronary artery disease s/p LAD and RCA stent placement, hypertension, and hyperlipidemia initially presented with dizziness in [Month (only) 1096] [2128] in the setting of a bowel movement. He was seen initially at [Hospital3 3765] where his symptoms were likely related to vasovagal response. Follow-up carotid ultrasound demonstrated 70-99% stenosis of the left ICA and 50-69% stenosis of the right ICA. Per report, echo, ECG, and stress test were all relatively unremarkable. He is admitted to the CCU s/p left carotid artery stenting. He underwent a carotid artery angiography and left carotid stenting on the day of admission. His angiography demonstrated left carotid with 95% origin stenosis in the ICA that was crossed was predilated and stented, then post dilated with 5.0 balloon with 0% residual. During the post dilation period, te patient was hypotensive and bradycardic despite treatment with atropine and was transiently on dopamine and neosynephrine, but was stabilized and off these medications prior to arrival in the CCU. The patient denies any recent dizziness, focal weakness, or numbness. He does report occasional ??????floaters?????? in both eyes. He denies any amaurosis fugax. He denies any chest pain or dyspnea. He does report being on an antibiotic last week for an URI. He denies any edema. He does report some calf discomfort when he walks. He denies any PND or orthopnea. Past Medical History: 1. Tachycardia since age 31 2. CAD s/p PCI to LAD in [2117], most recently cypher [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] 2 to the RCA in [2126] 3. Hypertension 4. CRI 5. GERD-now resolved, pt feels was r/t folic acid 6. Hyperlipidemia 7. Tonsillectomy Social History: Social history is significant for the absence of current tobacco use. stopped smoking in [2091]. Owns an italian deli in [Location (un) 745]. Lives with his significant other, [Name (NI) ] who will bring patient to the procedure. Has 3 grown children. Family History: There is no history of alcohol abuse. There is no family history of premature coronary artery disease or sudden death. Physical Exam: VS - 98.6, 62, 110/85, 99% RA Gen: NAD A&Ox3 HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: thick neck, unable to assess JVP. no bruit auscultated 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: CTAB, 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. Groin: rt groin oozing. small hematoma. no bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: [2130-2-7] 07:22PM BLOOD WBC-12.8# RBC-3.93 Hgb-11.9* Hct-34.9* MCV-89 MCH-30.3 MCHC-34.1 RDW-13.3 Plt Ct-274 [2130-2-8] 02:55AM BLOOD WBC-8.8 RBC-3.51* Hgb-10.8* Hct-30.8* MCV-88 MCH-30.9 MCHC-35.1* RDW-13.5 Plt Ct-210 [2130-2-7] 07:22PM BLOOD Glucose-107* UreaN-19 Creat-1.0 Na-141 K-3.8 Cl-106 HCO3-27 AnGap-12 [2130-2-7] 07:50AM BLOOD CK(CPK)-101 [2130-2-7] 07:22PM BLOOD CK(CPK)-55 [2130-2-8] 02:55AM BLOOD CK(CPK)-43 [2130-2-8] 11:40AM BLOOD CK(CPK)-51 [2130-2-7] 07:50AM BLOOD CK-MB-3 [2130-2-7] 07:22PM BLOOD CK-MB-3 [2130-2-8] 02:55AM BLOOD CK-MB-3 [2130-2-8] 11:40AM BLOOD CK-MB-NotDone Catheterization [2-7]: 1. Access was via the RFA with a 6F shuttle sheath. Limited hemodynamics with initial central pressure of 133/80 with HR 61. 2. Imaging of the right carotid showed moderate non-flow limiting disease. Imaging of the left carotid revealed an proximal left internal 95% stenosis with slow flow. 3. Given very tight stenosis we elected to proceed to intervention. Heparin was given. We advanced a Angled glide catheter to external carotid on left and exchanged for a SupraCore wire. We used this to advance the 6F Shuttle to the left common carotid. We crossed the lesion with a Choice PT XS wire and exchanged for a 6mm Spider filter. After predilation with a 2.5mm NC balloon we stented with a Precise 8mm self expanding tapered carotid stent of 40mm length. We posted with a Quantum Maverick 5x20 to 8atm. With post dilation patient had bradycardia treated with atropine and transient dopamine. The filter was removed without incident and with no visible clot. Final angiography with no residual and no complications. 4. Post intervention imaging of the cerebral circulation via the left common carotid revealed the left carotid to fill the MCA and fetal origin PCA. The ACA was filled from right side presumably. 5. Groin closure with Perclose and patient transferred to CCU for observation. Brief Hospital Course: Patient was admitted to the CCU for monitoring status post carotid stent placement for carotid stenosis. In the CCU, he was initially hypotensive requiring a dopamine drip. He also was given atropine once for bradycardia, nausea, and hypotension. By the following morning, he was weaned off dropamine and hemodynamically stable. He was asymptomatic and had no neurologic deficits. At discharge, the patient was advised to resume his imdur, but to hold his atenolol until outpatient follow up. Medications on Admission: Atenolol 100mg daily Zocor 20mg daily Imdur 30mg daily Plavix 75mg daily Asa 325mg daily Antioxidant daily Fish oil daily Discharge Medications: 1. Zocor 20 mg Tablet Sig: One (1) Tablet PO once a day. 2. Imdur 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 3. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day. 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. 5. Fish Oil 1,000 mg Capsule Sig: One (1) Capsule PO once a day. 6. Antioxidant Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary: Carotid stenosis Secondary: CAD Discharge Condition: stable Discharge Instructions: You were admitted to the hospital for a stent in your left carotid artery. You had this procedure and were monitored in the cardiac intensive care unit overnight to monitor your blood pressure. The following changes were made to your medications: 1. Imdur was held during your hospitalization, but can be restarted the after you leave the hospital, [2130-2-9]. 2. Please hold atenolol until your follow up appointment Dr. [Last Name (STitle) ] next week. Please call your doctor or come the emergency room if you have lightheadedness, chest pain, change in vision or any other concerning symptoms. Followup Instructions: Neurology: Provider: [First Name8 (NamePattern2) ] [First Name11 (Name Pattern1) 640] [Last Name (NamePattern4) 3445], MD Phone:[Telephone/Fax (1) 44] Date/Time:[2130-3-7] 7:30 Cardiology: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] Phone:[Telephone/Fax (1) 5768] Date/time: Wednesday [2-15] at 11:30 Completed by:[2130-2-8]	[ "401.9", "272.4", "585.9", "458.9", "414.01", "403.90", "433.10", "427.89", "V45.82" ]	icd9cm	[ [ [] ] ]	[ "88.41", "00.61", "00.40", "00.63", "00.45" ]	icd9pcs	[ [ [] ] ]	6451, 6457	5351, 5845	330, 383	6543, 6552	3351, 5328	7208, 7593	2475, 2595		6017, 6428		6478, 6522		5871, 5994			6576, 7185									2610, 3332																									273, 292									411, 1876																	1898, 2178	2194, 2459
16,112	142,504	50608	Discharge summary	report	Admission Date: [2172-4-23] Discharge Date: [2172-5-12] Date of Birth: [2093-12-30] Sex: M Service: MEDICINE Allergies: Ace Inhibitors / Heparin Agents / Fragmin Attending:[First Name3 (LF) 297] Chief Complaint: Hematuria Major Surgical or Invasive Procedure: Thoracentesis Endotracheal Intubation Hemodialysis Line placement Central venous line placement Tracheotomy History of Present Illness: HPI-78 yo male with MMP as below incluiding ESRD s/p failed tx on HD, ischemic CM with EF 20%, PVD, DMII who presented to OSH with hematuria now being transferred for further management of his chronic pleural effusion. Patient presented to OSH from NH on [4-22] with hematuria. He was found to have an equivocal UA and was discharged back to the nursing home for 14 day course of Bactrim. He represented later that day so he was admitted. Foley was placed and hematuria cleared with irrigation with hct remaining stable with coumadin held. Cystoscopy was performed this am which revealed and enlarged hyperemic prostate with hemorrhagic bladder mucosa but no tumor. CXR on admission also revealed known chronic left sided effusion which was aspirated and found to be an exudate(serum) with glucose 282(321) LDH 110(152) and protein 3.4(6.3). Bactrim was discontinued due to negative urine culture. Due to no available dialysis at [Location (un) 620] and possible definitive treatment for his chronic pleural effusion by Dr. [Last Name (STitle) 952], he was transferred to [Hospital1 18]. Past Medical History: Past Medical History: 1. Insulin dependent diabetes with neuropathy and neprhopathy 2. 3 vessel CAD s/p cath [4-23] and [12-26]: PTCA LAD and LCX, course complicated by ischemic CM with EF 20% 3. s/p Right Femoral-popliteal bypass 4. CHF: [1-23] ischemic cardiomyopathy w/ EF <20% 5. ESRD on HD (Tues, Thurs, Sat at gabmbro at [Location (un) ]) [1-23] diabetic nephropathy 6. Anemia of chronic disease, baseline HCT 30 7. h/o VF arrest [4-/2170] 8. Hypertension 9. stroke: Left posterior deep white matter CVA [7-24], right sided weakness, resolved aphasia 10. Seizures in the setting of sepsis: [4-23] on dilantin 11. Urinary retention 12. Left pleural effusion 13. s/p OS catract, s/p OD catract [2166] 14. s/p thoroscopic, parietal decrotication for hemothorax [4-23] 15. s/p tracheostomy [4-23] 16. s/p EGD with percutaneous gastrostomy [4-23] 17. s/p cholecystectomy [7-24] 18. s/p appendectomy 19. Bell's Palsy 20. h/o MRSA bacteremia 21. h/o lower extremity dvt, [9-/2170], [12/2170] on coumadin 22. h/o heel ulcer colonized with MRSA 23. h/o left foot osteo with VRE 24. Left BKA 25. DVT x2 NOTE: PT. HAS NEVER HAD A KIDNEY TRANSPLANT. PT. HAS ALSO NEVER HAD HIT! Social History: Patient is married. He has been between hospital, [Hospital1 ] and [Hospital1 11851] since [4-23]. He is a retired court officer and state representative. Denies any history of tobacco, alcohol, or illicit drug use. At baseline, he is able to feed himself (thickened liquid diet), he does not dress himself and he wears a diaper at baseline. Family History: Mother: died at 92, diabetes and breast cancer Sisters ages 70 and 80 - one has CAD and had MI, other with MR, thyroid problems Brother died at 52 of cancer of unknown type Physical Exam: On admission T 96.6 HR 81 BP 121/68 RR 18 O2 sat97% 2L NC Gen-mod resp distress HEENT-PERRL, MMM, no elevated JVP, OP clear, no ant or post cerv LAD Hrt-tachy RR nS1S2 no MRG Lungs-bronchial BS at left 1/2 up, no crackles or wheeze otherwise Abdomen-soft, ND, no organomeg, NABS, NT, feeding tube in place without erythema Extrem-1 + rad pulses bilat, left BKA, multiple poorly healing ulcers on RLE with 2+ pitting LE edemai bilat Neuro-left sided 7th nerve palsy with inability to close eye on rt as well., [2-23] strenght in UE and LE on rt and [3-25] on left, bilat distal sense to soft touch intact, oriented to person and place but thought it was [Month (only) ] but knew [2171], bilat UE intention tremor and occasional lip smacking Pertinent Results: [2172-4-24] CXR: IMPRESSION: 1. Large left pleural effusion with lingular and left lower lobe collapse. 2. Mild-to-moderate asymmetric pulmonary edema. 3. No pneumothorax. . [2172-4-26] RUQ U/S: IMPRESSION: No evidence of cholecystitis. Anechoic foci in the left lobe of liver, likely hepatic cysts. . [2172-4-28]: The overall volume of the moderate left hydropneumothorax is unchanged since [4-25] following surgical procedure, but the fluid component has increased. Lower lobe atelectasis has worsened. Widespread interstitial abnormality in the right lung is unchanged. Mild-to-moderate enlargement of the cardiac silhouette is stable. Azygos distention indicates elevated central venous pressure. No right pneumothorax. Tip of the right supraclavicular dual channel catheter projects over the superior cavoatrial junction. . [2172-4-28] Renal U/S: IMPRESSION: 1. No evidence of obstruction. 2. Slightly thickened bladder wall. . [2172-4-29] CXR: IMPRESSION: 1. Unchanged moderate left hydropneumothorax and left lower lobe atelectasis. 2. ET tube tip at the level of clavicles. . [2172-4-30] CT head: IMPRESSION: 1. No evidence of hemorrhage or mass effect. 2. Periventricular white matter hypodensities consistent with chronic microvascular ischemia. . [2172-5-2] MRI: IMPRESSION: No significant change since the previous study. Moderate ventriculomegaly indicating predominant central atrophy is again seen. Mild- to-moderate changes of small vessel disease noted. No acute infarct. . [2172-5-6] CXR:IMPRESSION: Persistent moderate left hydropneumothorax. . [2172-5-8] CXR: IMPRESSION: Almost complete resolution of pneumothorax. Tracheostomy tube satisfactory. Brief Hospital Course: ## Resp failure: Pt. initially came into hosptial w/ chronic pleural effusions that were followed by IP (see below). On floor pt. w/ multiple episodes of tachypnea and difficulty breathing w/ increased work of breathing. on [4-24] pt. w/ increased work of breathing, but this improved after thoracentesis. On [4-29], pt. noted to be unresponsive w/ ? of seizure activity, fever and hypotension. At that time, concern for respiratory process and ABG was performed 7.11/104/94. Pt. started to desat into the 80s. At that time, anesthesia was called and pt. was intubated for hypercarbic resp. failure and transferred to MICU. Pt. on vent and began to oxygenate/ventilate well over the next few days. Pt. w/ numerous gases that would suggest he could be extubated, but pt. always tired out on PS and had poor NIFs. Likely pt. very weak. Pt. had a h/o trach in the past and decision was made to have a trach placed. This occurred on [5-8]. The vent settings that the patient left on remained: CPAP+PS 12/5, FIO2 of 0.4. Patient taking in tidal volumes of: 250-350. Latest VBG: 7.36 pCO2 59 pO2 37 HCO3 35 BaseXS 5 Patient is to be weaned at rehab as tolerated. . ## Pleural effusions: Pt has known hemothorax s/p parietal pleura decortication causing poor venous and lymphatic drainage. This has been stable for an extending period of time and it is not clear from documentation that he has become more symptomatic. Labs of effusion suggest exudate but with his multiple surgeries c/b his uremia there is no clear cause but it does not appear to be empyema. On [4-25], IP performed a paracentesis of L side w/ improved breathing - found that lung ws trapped and no evidence of hydroptx. This tap did NOT show empyema and effusion may be due to uremic effusion. Pt. w/ no subjective complaints of dyspnea so decision was made by IP not to performa pleuridex as pt. w/ a lot of comorbidities and pt. not having dyspnea. . ## MS changes/seizures: Pt. w/ chronic altered mental status secondary to vascular dementia, but had been oriented on the floor. Pt. also w/ seizure disorder history on dilantin. Most MS changes noted during dialysis or infections. On [4-29], on floor, pt. was noted to be unresponsive and had twitching of his face. Pt. was subtherapeutic on dilantin and was loaded without much improvement in MS. [First Name (Titles) ] [Last Name (Titles) 4221]. Infectious/metabolic w/u ensued. EEG showed seizure activity, but this stopped the next day. Pt. was reloaded on dilantin and pt. came out of status w/ improvement in MS. Pt. w/ no acute changes on CT/MRI. Neuro followed and dilantin levels were followed. . ## GNR sepsis: Pt. came w/ fever of unknown source -urine originally? Suspect urinary source given recent cysto, and growth of enterococcus and proteus (in blood [2172-4-24]) but unclear of source. Pt. had blood ctx on [4-24] that showed enterococcus/preotesus bacteremia. Pt. was started on vanco/zosyn and fevers resolved over the next few days. Pt. switched to vanco/ceftriaxone. On [2172-4-29], pt. was found unresponsive on floor w/ hypotension and fever to 102 - [1-23] GNR sepsis. TTE w/ no evidence of endocarditis. Line unlikely given proteus/enterococcus. Pt. w/ a few episodes of hypotension in MICU which responded to fluids and MAPs usually above 55 during those times. This seemed to occur more frequently on dialysis days. Due to fluid loss vs. sepsis? Eventually, pt. became normotensive. Surveillance cx have remained negative. UCx growing yeast. Pt. remained afebrile since [5-3] and pt. completed antibiotic course. On [2172-5-12] pt. had HD line removed from right subclavian and it was changed to left IJ line. . ## ESRD: THERE WAS AN INCORRECT H/O RENAL TRANSPLANT. PT. HAS NOT HAD A TRANSPLANT. Pt. has ESRD [1-23] diabetic nephropathy. Pt. has been receiving HD for approximately 1 year for renal failure. Renal was following pt. throughout hospital stay and pt. was receiving HD. At time of admission renal has recommended treating through bacteremia with dialysis line in place. . ## Hypernatremia - Pt. w/ increased sodium in MICU. Pt. received free water boluses w/ improvement of hypernatremia. . ## CAD s/p PCI: Pt. w/ no CP or SOB during hospital stay. No active ischemia. Beta blocker re-started after pt. remained normotensive for a few days. Pt. on statin and aspirin . ## DMII: Pt. on insulin drip when he appeared to be septic and was transferred to the MICU. Pt. eventually switched to a sliding scale and sugars were controlled until [5-10] when his sugars increased. Pt. re-started on home insulin and IV insuline given. Pt. maintained on ISS. . ## h/o DVT: Pt's coumadin and anticoagulation was held in setting of hematuria and then in anticipation of procedure. Pt. originally not on heparin, b/c it was thought that pt. had HIT. It was determined that pt. did not have HIT and he was placed on heparin subQ during this time. On [5-9], coumadin restarted and INR monitored w/ goal of [1-24] . ## Hematuria: Pt. originally sent for hematuria. However, cystoscopy showed hyperemic prostate, no bladder tumor and hematuria resolved at [Hospital1 ]. No evidence of UTI on multiple cultures. Pt. w/ stable crit. . [Name (NI) 1623] Pt. found to be aspirating on the floor, so tube feeds were started. Pt. maintained on TF in MICU. . Px- PPI, heparin SQ, bowel regimen, pain control. . NOTE: 1. patient has NEVER had a transplant (per renal attending) and he has been on HD only x 1 yr. 2. PATIENT NEVER HAD ACTIVE HIT: PER RENAL ATTENDING ([Doctor Last Name ]) IT WAS SUSPECTED, HIT WAS NEVER POSITIVE Medications on Admission: Outpt Meds- ASPIRIN 81MG--One tablet once a day ATORVASTATIN CALCIUM 80MG--One tablet once a day CALCITRIOL 0.25MCG--One tablet by mouth once a day HUMALOG 100 U/ML--Use as directed by dr. [Last Name (STitle) ] of [Last Name (un) 387] INSULIN GLARGINE,HUM.REC.ANLOG 100 U/ML--45 units sc at bedtime INSULIN NPH HUMAN RECOM 100 U/ML--10 units sc every morning ISOSORBIDE MONONITRATE 30MG--One tablet by mouth once a day LASIX 20MG--One tablet by mouth once a day METOPROLOL SUCCINATE 25MG--One tablet by mouth once a day MODAFINIL 100MG--One tablet by mouth once a day PHENYTOIN SODIUM EXTENDED 100MG--3 capsules daily PRILOSEC OTC 20MG--One tablet once a day QUETIAPINE FUMARATE 25MG--One tablet once a day SPIRONOLACTONE 25MG--[12-23] tablet by mouth once a day TAMSULOSIN HCL 0.4MG--One tablet once a day WARFARIN SODIUM 2.5MG--Use as directed by [Hospital3 ] . Meds on transfer- 200ml tube feed flush glucerna shakes zocor 40mg qd Vit C Prilosec 20mg qd Vit D and calcium Phenytoin ext 100mg [Hospital1 ] Metoprolol 25mg [Hospital1 ] Guaifenesin with codeine MOM [Name (NI) 55883] inhalers q4hours Bisacodyl 10mg qhs Tylenol 1g q6h prn Vicodin 1tab q6h prn MVI [Name (NI) ] 81mg qd Avapro 75mg qd folate trazadone 12.5mg qhs zyprexa 2.5mg qhs lantus 25mg qhs RISS bactrim DS [Hospital1 ] started [4-22] to complete 14 day course Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 4. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed: apply to groin. 8. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty (30) mg via NG tube PO DAILY (Daily). 9. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation Q6H (every 6 hours) as needed. 10. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation QID (4 times a day). 11. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day): Heparin 5000 unit injection. 13. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 14. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day): Hold for systolic blood pressure < 100, HR <55. 15. Insulin sliding scale Sig: One (1) sliding scale four times a day: Please see attached sheet. 16. Phenytoin 100 mg/4 mL Suspension Sig: Five (5) mL PO Q12H (every 12 hours): Please give 125 mg PO/NG PO q 12 hours. 17. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 18. Lorazepam 2 mg/mL Syringe Sig: 0.5 mg IV Injection q 4-6 hrs PRN as needed for agitation. Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Respiratory Failure Congestive Heart Failure Pleural Effusions Seizures Hematuria Sepsis Renal Failure Discharge Condition: Fair Discharge Instructions: . Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1.5 L You should take all the medicatsion as prescribed. You should call your physiciain for shortness of breath, chest pain, nausea, vomiting, fevers, chills or any other changes in your medical condition that concern you. You will receive dialysis at your rehab facility on Tuesday, Thursday, and Saturday Followup Instructions: 1. You should follow up with your primary care physician in the next week 2. You will need to follow up with [Name8 (MD) ] in 1 month. You can call [Telephone/Fax (1) 2528] Completed by:[2172-5-12]	[ "403.91", "583.81", "428.0", "599.7", "290.40", "357.2", "511.8", "276.0", "414.8", "437.0", "585.6", "780.39", "995.92", "707.05", "250.40", "V58.67", "038.3", "518.81", "250.60" ]	icd9cm	[ [ [] ] ]	[ "96.04", "34.91", "96.6", "39.95", "96.72", "00.14", "38.95", "31.1", "86.05" ]	icd9pcs	[ [ [] ] ]	14762, 14841	5905, 11597	312, 421	14988, 14995	4169, 5296	15474, 15687	3201, 3377		13022, 14739		14862, 14967		11623, 12999			15019, 15451									3392, 4150																									263, 274									449, 1554		5305, 5882															1598, 2813	2829, 3185
66,690	125,078	38582	Discharge summary	report	Admission Date: [2106-4-27] Discharge Date: [2106-5-1] Date of Birth: [2043-8-23] Sex: M Service: MEDICINE Allergies: No Drug Allergy Information on File Attending:[First Name3 (LF) 2279] Chief Complaint: Found down Major Surgical or Invasive Procedure: none History of Present Illness: 55 yo man found unresponsive by EMS (Pro Ambulance). Per discussion with ambulance company and [Hospital1 8] police, the patient's elderly father called the [Name (NI) 8] police after not having heard from the patient for several days. The [Hospital1 8] police called EMS. Per OSH ED notes, the pt was found in an unclean apartment lying on left side with dried emesis in mouth and hair. Pt's FSBG was HI per glucometer. Pt was noted to have left sided flaccidity with skin breakdown and necrotic ulcer to sacrum. Pt was unable to communicate, but was moving right hand. At [Name (NI) 8] Hosp, pt received Insulin 10u IVx1, folic acid 1mg IV, thiamine 100mg IV, MVI, lidocaine 100mg IV x1, propofol 40mg IV x1, vecuronium 6mg IV x1, propofol gtt, banana bag, labetalol 10mg IV x1 and was intubated and transferred. CT head showed an intraparenchymal bleed. On transfer was hypertensive to 150's. His transfer vital signs were: T95.7, 73, 175/113, 18, 100% intubated. On exam in the ED, pupils were sluggish, rectal was guaiac positive, and pt was noted to have dark stools with "oozing." The patient was continued on a propofol gtt, CTA was done to look for aneurysm and pt was started on dilantin. A type and screen were sent and the pt was crossmatched for 2 units. Vanco and Zosyn were started for hypothermia, leukocytosis. UA, CXR were negative. Pt was given 1u of platelets and 8u insulin. Vitals on transfer were: P75, 123/85, 500/18/100%/5 Review of systems: Unable to obtain. Past Medical History: ? head injury per father Social History: Live alone, never married, father and brother involved. Family History: Father is 90 and in very poor health with severe diabetes, obesity, and macular degeneration to the point of almost total blindness Physical Exam: Vitals: T: 96.8 BP: 130/62 P: 85 RR: 10 O2Sat: 96% RA Gen: gaspint breaths HEENT: blown left pupil, right minimally responsive NECK: Supple, No LAD, No JVD CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops LUNGS: CTA, BS BL, No W/R/C ABD: Soft, NT, ND. NL BS. No HSM EXT: ungoing toes on babinski SKIN: Several 8cm eschars/ulcers on back, coccyx, heels NEURO: ungoing toes on babinski. does not withdraw to pain. Pertinent Results: [2106-4-26] 11:28PM BLOOD WBC-15.3* RBC-5.18 Hgb-14.2 Hct-44.4 MCV-86 MCH-27.4 MCHC-31.9 RDW-13.1 Plt Ct-325 [2106-4-30] 11:57AM BLOOD WBC-24.5* RBC-3.16* Hgb-9.4* Hct-26.3* MCV-83 MCH-29.7 MCHC-35.7* RDW-15.0 Plt Ct-194 [2106-4-26] 11:28PM BLOOD PT-13.4 PTT-22.4 INR(PT)-1.1 [2106-4-26] 11:28PM BLOOD Plt Ct-325 [2106-4-30] 11:57AM BLOOD PT-14.5* PTT-29.4 INR(PT)-1.3* [2106-4-30] 11:57AM BLOOD Plt Ct-194 [2106-4-26] 11:28PM BLOOD Fibrino-631* [2106-4-26] 11:28PM BLOOD UreaN-211* Creat-3.7* [2106-4-27] 05:06AM BLOOD Glucose-367* UreaN-208* Creat-3.7* Na-160* K-4.4 Cl-123* HCO3-22 AnGap-19 [2106-4-30] 02:25AM BLOOD Glucose-119* UreaN-95* Creat-2.6* Na-147* K-3.9 Cl-122* HCO3-16* AnGap-13 [2106-4-30] 11:57AM BLOOD Glucose-119* UreaN-97* Creat-2.5* Na-150* K-3.7 Cl-123* HCO3-17* AnGap-14 [2106-4-26] 11:28PM BLOOD CK(CPK)-850* [2106-4-27] 09:05AM BLOOD ALT-70* AST-57* LD(LDH)-283* CK(CPK)-1238* AlkPhos-58 TotBili-1.5 [2106-4-28] 04:14AM BLOOD CK(CPK)-956* [2106-4-28] 03:59PM BLOOD CK(CPK)-808* [2106-4-27] 05:06AM BLOOD Calcium-8.5 Phos-6.3* Mg-3.7* [2106-4-27] 09:05AM BLOOD Albumin-3.2* Calcium-9.1 Phos-5.5* Mg-3.3* [2106-4-30] 02:25AM BLOOD Calcium-6.8* Phos-4.1 Mg-2.3 [2106-4-30] 11:57AM BLOOD Calcium-7.1* Phos-3.9 Mg-2.6 [2106-4-27] 09:05AM BLOOD Osmolal-413* [2106-4-28] 10:05AM BLOOD TSH-0.45 [2106-4-27] 09:05AM BLOOD Vanco-22.0* [2106-4-28] 04:14AM BLOOD Vanco-9.9* [2106-4-29] 03:34AM BLOOD Vanco-17.2 [2106-4-30] 02:25AM BLOOD Vanco-7.2* [2106-4-26] 11:28PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2106-4-26] 11:28PM BLOOD EDTA Ho-HOLD [2106-4-27] 12:35AM BLOOD Type-ART Rates-/14 FiO2-100 pO2-510* pCO2-49* pH-7.31* calTCO2-26 Base XS--2 AADO2-161 REQ O2-36 -ASSIST/CON Intubat-INTUBATED [2106-4-27] 06:19AM BLOOD Type-ART Temp-36.4 pO2-158* pCO2-32* pH-7.45 calTCO2-23 Base XS-0 [2106-4-27] 06:50PM BLOOD Type-ART Temp-36.6 Rates-/32 Tidal V-500 PEEP-5 FiO2-40 pO2-174* pCO2-34* pH-7.42 calTCO2-23 Base XS--1 -ASSIST/CON Intubat-INTUBATED [2106-4-28] 04:32AM BLOOD Type-ART Temp-37.9 PEEP-5 FiO2-40 pO2-207* pCO2-31* pH-7.46* calTCO2-23 Base XS-0 -ASSIST/CON Intubat-INTUBATED [2106-4-29] 05:58AM BLOOD Type-ART Temp-38.2 FiO2-40 pO2-208* pCO2-35 pH-7.52* calTCO2-30 Base XS-6 Intubat-INTUBATED [2106-4-29] 10:17AM BLOOD Type-ART Temp-37.9 Rates-16/26 Tidal V-580 PEEP-5 FiO2-40 pO2-208* pCO2-27* pH-7.53* calTCO2-23 Base XS-1 -ASSIST/CON Intubat-INTUBATED [2106-4-29] 12:41PM BLOOD Type-ART Temp-37.6 Rates-18/4 Tidal V-600 PEEP-4 FiO2-40 pO2-190* pCO2-26* pH-7.49* calTCO2-20* Base XS--1 -ASSIST/CON Intubat-INTUBATED [2106-4-29] 04:37PM BLOOD Type-ART Tidal V-550 PEEP-5 FiO2-100 pO2-416* pCO2-27* pH-7.47* calTCO2-20* Base XS--1 AADO2-282 REQ O2-53 -ASSIST/CON Intubat-INTUBATED [2106-4-30] 12:42PM BLOOD Type-ART Temp-37.3 Rates-16/10 Tidal V-690 PEEP-5 FiO2-40 pO2-199* pCO2-18* pH-7.53* calTCO2-16* Base XS--4 -ASSIST/CON Intubat-INTUBATED Vent-SPONTANEOU [2106-4-26] 11:36PM BLOOD Glucose-349* Lactate-2.6* Na-164* K-3.7 Cl-119* calHCO3-23 [2106-4-27] 05:13AM BLOOD Lactate-2.0 [2106-4-27] 06:50PM BLOOD Lactate-1.8 [2106-4-28] 04:32AM BLOOD Lactate-1.2 [2106-4-29] 06:37AM BLOOD Lactate-1.4 [2106-4-29] 12:41PM BLOOD Lactate-1.4 [2106-4-29] 04:37PM BLOOD Lactate-1.1 [2106-4-29] 05:58AM BLOOD freeCa-1.03* [2106-4-29] 12:41PM BLOOD freeCa-1.01* [2106-4-29] 04:37PM BLOOD freeCa-0.98* [2106-4-26] 11:28PM URINE Hours-RANDOM [2106-4-27] 02:38PM URINE Hours-RANDOM UreaN-1050 Creat-90 Na-11 K-61 [2106-4-28] 10:05AM URINE Hours-RANDOM UreaN-1289 Creat-67 Na-LESS THAN [2106-4-26] 11:28PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG [2106-4-27] 02:38PM URINE Osmolal-577 [2106-4-28] 10:05AM URINE Osmolal-608 [2106-4-26] 11:28PM URINE Blood-LG Nitrite-NEG Protein-25 Glucose-250 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [2106-4-27] 02:38PM URINE Blood-LG Nitrite-NEG Protein-25 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [2106-4-28] 10:05AM URINE Blood-LG Nitrite-NEG Protein-25 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG CTA Head on Admission: 1. Hemorrhage centered within the right thalamus, with secondary intraventricular extension, most consistent with a hypertensive hemorrhagic stroke. Differential considerations also include an underlying mass lesion or vascular malformation, although these possibilities are considered less likely. 2. Unremarkable CTA of the head, without evidence of an aneurysm, hemodynamically significant stenosis, or dissection. 3. The orogastric tube is noted to curl within the patient's mouth. CT HEAD W/O CONTRAST Study Date of [2106-4-29] 8:20 AM 1. Unchanged right thalamic and intraventricular hemorrhage with a 5-mm shift of midline structures to the left. 2. A hypodense lesion in the right cerebellar hemisphere, conspicuous on the current exam likely represents a focal lesion such as an infarct. MRI and MRA Head are recommended for further workup, if not contra-indicated. GI Bleed Study: IMPRESSION: Moderate lower GI bleed likely arising from the sigmoid colon. MICROBIOLOGY: [2106-4-28] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-PRELIMINARY {STAPH AUREUS COAG +} INPATIENT [2106-4-28] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2106-4-28] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2106-4-27] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2106-4-27] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT Brief Hospital Course: 55 yo M with unknown past medical history presents after being found down with intraparenchymal hemorrhage, respiratory failure, acute renal failure, hypothermia, GI bleeding, hypernatremia, anion-gap acidosis. Per discussion with family made comfort measures only on Friday [4-30] and passed away on [5-1] # Comfort: patient kept comfortable on a morphine gtt after family meeting. He was electively extubated with the family by his side. # Intraparenchymal hemorrhage: Was found down at home and came to ED where he was found to have the ICH. He was intubated for airway protection and had serial CT scans of his head which showed relative stability. [Name2 (NI) ] did not improve neurologically throughout his stay desipte holding all sedation. He had a gag and R corneal, but no other signs of purposeful or reflexive movement. Neuro and neurosurg were following along. He was not an operative candidate. As above, he was made CMO and extubated and passed away. # GI bleed: Pt w/ large amount of melena/brb output per flexi seal and passed large clot [4-29], transfused total of 4 units, tagged RBC scan showed sigmoid bleeding, IR felt unable to intervene on clot. Was hypotensive during this time and started on pressors for a short while. His hemodynamics improved with transfusions. After one day his stool returned to brown, although still guiac positive. He did not have futher workup as his goals of care were changed to CMO. # Respiratory failure: Pt was intubated at OSH for airway protection/respiratory failure. ABG in ED showed 7.31/49/510. CXR remains clear. Had respiratory acidosis from hyperventilation thought to be due to his neurological injury. Terminally extubated after made CMO. # Hypernatremia: came in with Na of 165, corrected with IV and PO free water. Neurologically, he did not improve once his sodium was corrected. # Sacral ulcers: Large (8cm in diameter) eschars on L back and coccyx and heel suggest that patient was down for several days, GNRs in blood culture. Was treated with vanco/zosyn for broad spectrum coverage. Wound care followed and plastic surgery debrided the wounds. Continued skin care until he passed away. # Bacteremia: GNR on outside hospital labs. Was on broad spectrum abx until his goals of care were changed. # NSTEMI/Troponin leak: At OSH pt had trop I of 0.06. EKG does not show evidence of ST changes. CKs here attributed to rhabdo. No cardiac workup was persued. # Hypothermia: Intermittently hypothermic. Possible reasons for pt's hypothermia include: central hypothermia, exposure, infection, hypothyroidism, adrenal insufficiency. Warmed with a BAIR hugger. # Patient passed away on the floor with a morphine gtt for respiratory comfort. His father and brother were presents for his goals of care meetings and comfortable with the plan. Medications on Admission: none known Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: intracranial hemorrhage lower GI bleed bacteremia Discharge Condition: expired Discharge Instructions: n/a expired Followup Instructions: n/a expired [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 2285] Completed by:[2106-5-6]	[ "780.01", "276.0", "707.02", "790.7", "707.03", "331.4", "707.22", "V66.7", "707.07", "790.01", "991.6", "348.30", "578.1", "584.9", "041.85", "E888.9", "728.88", "431", "518.81", "790.29", "458.8", "276.2", "288.60", "707.05" ]	icd9cm	[ [ [] ] ]	[ "88.47", "96.71", "38.93", "86.22" ]	icd9pcs	[ [ [] ] ]	11218, 11227	8277, 11125	306, 312	11320, 11329	2572, 6876	11389, 11552	1983, 2117		11186, 11195		11248, 11299		11151, 11163			11353, 11366									2132, 2553																					1827, 1846				256, 268									340, 1808								6890, 8254									1868, 1894	1910, 1967
3,044	187,434	24071	Discharge summary	report	Admission Date: [2148-3-18] Discharge Date: [2148-3-22] Date of Birth: [2095-7-7] Sex: M Service: NEUROLOGY Allergies: Penicillins / Cephalosporins / Ssri &Antipsych,Atyp,Dop&Serotonin Antag / Vioxx Attending:[First Name3 (LF) 13787] Chief Complaint: transfer from OSH for EEG, seizure? Major Surgical or Invasive Procedure: extubation MRI EEG History of Present Illness: CC:[Name9 (PRE) 61219] HPI: 52 yo RH man who has a history of back pain and pain medication overuse who was found with altered mental status by the patient's wife on [Name (NI) 1017] [2148-3-17]. He was exhausted from running errands the day before presentation and decided not to go kayaking. Wife went kayaking, came back at 2pm on [Month/Day/Year 1017] (day of presentation to OSH), was asleep on couch but arousable. At 5pm she found him curled up with head between knees, sitting but fallen/slumped forward. Kept repeating "It's the clock" when asked what was wrong. Did not admit to taking any meds/opiates to the wife. Drooling, both arms shaking, sweating, wife walked him to BR, very unsteady on his feet, emesis. Wife noticed [Name2 (NI) 61220] missing about 20, 1mg each. Noticed 3 methadone missing from pill box, 40 mg each. Wife called 911, and [Name2 (NI) 9168] came to house and according to wife "gave him a shot" (?narcan, ?flumazenyl). Brought to ED at [Hospital1 1562], very agitated. For "repeated seizure +/- myoclonus" he was intubated. Had seizure activity in the ambulance, and ED doc noted "GTC sz" activity. 20 mg ativan given with some relief but still with some leg jerking. Intubated for airway protection. Given fosphenytoin, phenobarbital. Then, per notes, was agitated on propofol drip thus versed was added (flailing limbs, security was called). Still flailed so morphine was added. When awakened, moved all extremities but did not follow commands. EEG not available at OSH, thus transferred here for further care and to r/o nonconvulsive status epilepticus. Was started on levo/clinda for "aspiration pna." Had CT head shows small area of encephalomalacia near left insular cortex extending multiple cuts, from basal ganglia to temporal lobe (?) NO h/o seizures per wife. [Name (NI) ] [Name2 (NI) 61221] illnesses or complaints known to wife. After patient was extubated, patient was asked what happened to him. He has very little memory of the events of that day. He states he ate lunch, felt ill, vomited, then the next thing he remembers is [Hospital 1562] hospital, having a foley placed. He has no h/o febrile seizures or any seizures in the past, no h/o stroke, no [Hospital 61221] illnesses. Past Medical History: 1. s/p 2 sugeries on his back secondary to trauma, lifting an oil tank 2. Pain syndrome and opiates addition secondary to back surgeries, has been to detox programs, etc. Currently on Methadone 3. Left knee replacement surgery [2146] 4. High cholesterol 5. s/p CCY Social History: Married in [2140], + MJ qHS, no tob, no IVDA, out of work on disability due to back pain (former enviromental consultant), no kids. Family History: no seizures known to wife, mom died of COPD. Physical Exam: Vitals: T 99.4, 83 NSR, 102/60, RR 17, 100% on vent GEN: intubated, sedated HEENT: NC/AT, anicteric sclera, mmm NECK: supple, no carotid bruits CHEST: CTA bilat CV: RRR without mur ABD: softly distended, +BS, no HSM EXTREM: trace edema x 4, DP pulses 2+ bilaterally, aline right arm, knee scar over left knee NEURO: MENTAL STATUS: nonverbal, unresponsive to voice and painful stimuli (intubated, sedated) CRANIAL NERVES: Pupil exam: 4->2mm bilaterally EOM exam: no dolls Corneal reflex: + bilaterally Facial symmetry: winces upper face symmetrically, ETT obstructs exam of lower face Gag reflex: no gag to ETT wiggle MOTOR: no motor response to pain, no spontaneous movement, normal symmetric tone x 4 SENSORY: winces face to pain x 4 REFLEXES: 1+ bilat [Hospital1 ]/tri/BR, 1 on right pat, absent left patellar (surgery), 1 ach bilat, down going toes bilaterally Upon awakening and extubation, patient was slow to answer questions and mildly inattentive (but this improved next day). Mental status was otherwise normal. Cranial nerves normal. Motor exam normal (slightly limited by pain but if asked for full strength for one second, he is full strength). Reflexes: 1+ bilateral [Hospital1 ]/br, 2+ tri bilat, 2+ right pat, 0 left pat (surgical), 1+ ach bilat, toes down bilat. Slow but accurate f-t-n bilat, nl [Doctor First Name ]. Gait - antalgic. Pertinent Results: [2148-3-18] 09:58PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.020 [2148-3-18] 09:58PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-6.5 LEUK-NEG [2148-3-18] 09:58PM URINE RBC-3* WBC-0 BACTERIA-NONE YEAST-NONE EPI-<1 [2148-3-18] 09:42PM URINE HOURS-RANDOM [2148-3-18] 09:42PM URINE bnzodzpn-POS barbitrt-POS opiates-NEG cocaine-NEG amphetmn-NEG mthdone-POS [2148-3-18] 09:38PM TYPE-ART TEMP-37.4 RATES-16/0 TIDAL VOL-670 O2-100 PO2-166* PCO2-40 PH-7.43 TOTAL CO2-27 BASE XS-2 AADO2-525 REQ O2-85 INTUBATED-INTUBATED VENT-CONTROLLED [2148-3-18] 09:18PM GLUCOSE-83 UREA N-8 CREAT-0.7 SODIUM-144 POTASSIUM-3.7 CHLORIDE-107 TOTAL CO2-27 ANION GAP-14 [2148-3-18] 09:18PM ALT(SGPT)-16 AST(SGOT)-27 ALK PHOS-58 TOT BILI-0.6 [2148-3-18] 09:18PM CALCIUM-8.4 PHOSPHATE-3.1 MAGNESIUM-1.8 [2148-3-18] 09:18PM PHENOBARB-9.7* PHENYTOIN-6.6* [2148-3-18] 09:18PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-POS barbitrt-NEG tricyclic-NEG [2148-3-18] 09:18PM WBC-9.5 RBC-3.85* HGB-11.9* HCT-35.3* MCV-92 MCH-30.9 MCHC-33.7 RDW-13.0 [2148-3-18] 09:18PM NEUTS-79.2* LYMPHS-17.1* MONOS-3.1 EOS-0.4 BASOS-0.2 [2148-3-18] 09:18PM PLT COUNT-192 [2148-3-18] 09:18PM PT-13.0 PTT-26.8 INR(PT)-1.1 CXR: The tip of the endotracheal tube lies 5 cm from the carinal angle. The heart is not enlarged, atelectasis is present in both the right and left lower lobes. No definite pneumonia is present. The nasogastric tube is present with the tip in the stomach. MRI/A brain with gad and stroke protocol: 1) MRI is somewhat limited, but reveals no areas of edema or infarction. There is no evidence of an enhancing intracranial mass. 2) MRA of the circle of [Location (un) 431] demonstrates flow in the major branches of the circulation. EEG: ABNORMALITY #1: There were frequent brief bursts of mixed frequency theta and delta slowing with a bifrontal emphasis. ABNORMALITY #2: There were additional bursts of slowing in the delta range seen primarily over the left frontal temporal region. BACKGROUND: Background rhythm included a well-formed 10 Hz alpha frequency in posterior areas bilaterally during wakefulness. HYPERVENTILATION: Produced no activation of the record. INTERMITTENT PHOTIC STIMULATION: Produced no activation of the record. SLEEP: The patient appeared to remain awake or minimally drowsy throughout the recording. No stage II sleep was obtained. CARDIAC MONITOR: Showed a generally regular rhythm. IMPRESSION: Abnormal EEG in the waking and drowsy states due to the occasional bursts of bifrontal or generalized slowing and due to the minimal slowing in the left anterior quadrant. These findings suggest focal subcortical abnormalities in the left hemisphere or in deeper midline structures (or both). Nevertheless, there were no areas of persistent focal slowing. This find may result from vascular disease or other causes. There were no epileptiform features. OBJECT: QUESTION SEIZURE. Brief Hospital Course: This patient was transferred from [Hospital 1562] hospital to [Hospital1 18] for "r/o nonconvulsive status epilepticus." He had an episode that is not quite clear - he was minimally responsive, vomiting, and had some sort of activity in the ambulance ride to [Hospital1 1562] that was interpretted as a seizure (may have been myoclonus). Documentation sent from OSH was extremely sparse and admitting physician was not an actual eye witness to the activity. Regardless, he was started on multiple medications including phenobarbital, dilantin, versed gtt, morphine gtt, propofol gtt, etc. And when sedation was lightened at OSH he was awake but not following commands, thus rose the concern for nonconvulsive status. He was transferred to the [Hospital1 18] on [3-18]. PB and versed were stopped. Dilantin was continued. MRI/A of brain with gad and stroke protocol was obtained as an adequate exam was not able to be obtained off sedation and CT at OSH showed a small area of encephalomalacia. Although limited by motion artifact, MRI was normal. He was extubated the following day. After extubation he was extremely aggitated (possibly due to baclofen withdrawl). Pain service was consulted and recommended ativan for bzdp withdrawl and restarting multiple home meds (including baclofen, neurontin, indomethicin). In addition, a clonidine patch was started. This was done and his mental status and mood improved dramatically. He was called out to the floor. Neurologic exam was essentially normal (see exam). Once on the floor, EEG was obtained. EEG showed bifrontal slowing. Dilantin was 2.4 on [2148-3-21]. Dilantin was discontinued. Prior to discharge, his PCP (Dr. [Last Name (STitle) 174] [Telephone/Fax (1) 23329]) was contact[Name (NI) ] and his complicated outpatient medication regimine was verified. We called his psychiatrist, Dr. [Last Name (STitle) 61222] (?spelling), [Telephone/Fax (3) 61223], who confirmed his meds. He requested rehab for both back pain and detoxification. He was accepted to [Hospital3 ]. It's not entirely clear what happened on the day of presentation. Patient denied taking any substances, but his wife remarks that 20mg of her ativan was missing as well as 3 methadone pills (40mg each). Medications on Admission: 1. Temazepam 60mg qHS 2. Gabapentin 600mg one QID 3. Ambien 15mg qHS 4. Methadone 40mg q6hrs - Dr. [Last Name (STitle) 174] (PCP) prescribes 5. Carisoprodol 350mg q 8hrs 6. lipitor 10mg qD 7. baclofen 40mg q 12 hrs 8. diclofenac sod 75mg q12hrs - for arthritis 9. phenazopyridine 200 mg q8hr - for bladder 10. Indomethacin 25mg one q 8hrs 11. ranitidine 150mg 12. etodolac 400mg one to two qd with food Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for fever, pain. 2. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO QID (4 times a day). 3. Methadone HCl 40 mg Tablet, Soluble Sig: One (1) Tablet, Soluble PO Q6H (every 6 hours). 4. Indomethacin 25 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 5. Zolpidem Tartrate 5 mg Tablet Sig: Two (2) Tablet PO ONCE (once). 6. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) dose Injection TID (3 times a day). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 8. Clonidine HCl 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QTUES (every Tuesday). 9. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 10. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. Temazepam 15 mg Capsule Sig: Three (3) Capsule PO HS (at bedtime) as needed. 12. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day). Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Medication complications (altered mental status) Chronic pain syndrome Discharge Condition: stable - ambulating, eating, normal Discharge Instructions: Please take all medications. Attend all followup appointments. If your symptoms recur, or you experience difficulty breathing, change in mental status, or increased drug use, please contact your physician or return to the ED. Followup Instructions: Please followup with your PCP and psychiatrist. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 13790] MD, [MD Number(3) 13791] Completed by:[2148-3-22]	[ "E849.0", "967.8", "780.79", "E852.8", "724.2", "780.39", "304.61", "272.0" ]	icd9cm	[ [ [] ] ]	[ "38.91", "89.14", "96.71" ]	icd9pcs	[ [ [] ] ]	11617, 11687	7717, 10016	377, 397	11802, 11839	4659, 7694	12113, 12323	3194, 3241		10485, 11594		11708, 11781		10042, 10462			11863, 12090									3256, 3575																									302, 339									425, 2725	3682, 4640									3590, 3664							2747, 3024	3040, 3178
4,004	184,838	16079	Discharge summary	report	Admission Date: [2171-7-29] Discharge Date: [2171-9-13] Date of Birth: [2121-1-27] Sex: F Service: TRANSPLANT SURGERY HISTORY OF PRESENT ILLNESS: The patient is a 50 year-old female with a history of positive kidney disease and polycystic liver disease who presented on [7-28] preoperative for a combined orthotopic liver and cadaveric renal transplant. The patient had a recent cardiac workup, which was negative and endoscopy for gastrojejunal polyps, which was also negative for malignancy. The patient denied fevers or chills, coughs, nausea, vomiting, chest pain or shortness of breath, bowel and bladder dysfunction. The patient had a history of multiple abdominal surgeries and massive ventral hernias with very little abdominal wall left. The patient was last seen in the [Hospital 1326] Clinic in [2171-4-6]. The patient also had family members that suffered from polycystic kidney disease with family members with cadaveric kidney transplants. She also had family members that suffered from polycystic liver disease as well consistent with abdominal dominant inheritance. PAST MEDICAL HISTORY: Polycystic liver and kidney disease. Multiple ventral hernia repairs in [2161]. Anemia. Hypertension. Total abdominal hysterectomy. Bilateral salpingo-oophorectomy. Status post cholecystectomy in [2153]. Status post appendectomy in [2155]. Status post exploratory laparotomy LOA in [2163]. MEDICATIONS: 1. Aldactone. 2. Lasix. 3. Norvasc. 4. Mycelex. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient does not drink or smoke. PHYSICAL EXAMINATION ON ADMISSION: Afebrile, blood pressure 114/62, 81, 20, 98% on room air. The patient weighed 105 kilograms. The patient was awake and alert on physical examination and abdominal examination showed obese massive ventral hernias with an ulcer on the left side, surgical scars well healed, soft and nontender. The rest of the patient's physical examination on admission was unremarkable. LABORATORY: The patient has a TSH on admission of 3.5, hepatitis B and A negative. HIV negative. Echocardiogram showed normal left ventricular ejection fraction, normal PAP. Stress test was normal. Gastrojejunal biopsy was negative for malignancy. Chest x-ray was clear. White blood cell count 7.8, hematocrit 33, platelets 233, fibrinogen of 438, urinalysis negative. Chemistry showed a sodium of 137, potassium 4.5, chloride 103, bicarb 20, BUN 74, creatinine 2.4, glucose 120. Serologies included EBV, IGG positive by EIA. RPR was nonreactive. CMV positive, VZV positive, rubella IGG positive [2171-6-19], toxo IGG negative. PROCEDURES DURING HOSPITAL COURSE: 1. Orthotopic liver transplantation and cadaveric renal transplantation combined procedure [7-29]. 2. Perforated small bowel oversewn [8-4]. 3. Hemoperitoneum with exploratory laparotomy [8-15]. 4. Perforated colonic anastomosis status post transverse colectomy, [Doctor Last Name 3379] pouch and end colostomy on [8-24]. HOSPITAL COURSE: Cadaveric kidney transplantation, orthotopic liver transplantation combined procedure was performed on [2171-7-29]. The patient had a kidney transplant that was intraperitoneal with ureterurostomy with stent and a right native nephrectomy. The patient had an orthotopic liver transplantation at the same time with prolonged hospital course as well as Intensive Care Unit stay. Initial operations complicated by dense adhesions for multiple previous operations, which took approximately three hours to enter the abdomen. During the course of the adhesiolysis a colotomy was made in the transverse colon requiring sleeve resection. The patient also had serosal tear of small bowel, which was repaired. The patient was transferred to the Intensive Care Unit for postoperative care. On [8-4] the patient developed pneumoperitoneum and was taken back to the Operating Room where a small bowel perforation was found and repaired. Even preoperatively the patient had large amount of ascitic fluid requiring 8 liters of paracentesis preoperatively. Postoperatively, the patient had very large acidic output over 3 liters a day. Postoperatively, the patient care was complicated by bouts of atrial fibrillation and echocardiogram by cardiology by cardiology revealed pericardial effusion and tamponade physiology without systemic hemodynamic systems. Repeat echocardiogram revealed increased tamponade with worsening tamponade physiology. For this, on the evening the [7-15] pericardiocentesis was performed. The patient was returned to the Intensive Care Unit when hematocrit began to fall and rapid atrial fibrillation ensued. The patient was taken emergently to the Operating Room where she was found to have a pericardial drain in the pericardium and a large hemoperitoneum. The patient's abdomen was washed out for hemoperitoneum and the pericardial window was performed with follow up echocardiogram that showed complete resolution of the pericardial effusion. On the 19th the patient again developed worsening pneumoperitoneum and was taken back to the Operating Room for exploratory laparotomy. The patient was found to have completely walled off abscess at the site of the previous colonic resection. The patient had a transverse colectomy, Hartmann's pouch and ascending colostomy. The patient was washed out and drains were placed. The remainder of the [Hospital 228] hospital course was noted as being normal with normal hepatic function, creatinine that remained at 2.5 and 3 liters of acidic output a day. Acidic creatinine was 2.7. Because of high index suspicion nuclear renal scan was obtained and demonstrated urinary leak. Cystoscopy was performed demonstrating migration of the stent into the ureter and two areas of leak. A bridging stent was placed across. The remainder of the hospital course showed noted improvement. The patient was advanced to and tolerated a regular diet with normal colostomy function. Creatinine decreased to 1.0 and JP output decreased to 30 cc and was removed. The patient is currently working with physical therapy and is out of bed to chair. The patient is to be discharged to rehabilitation on [2171-9-13] to have immunosuppressive medications adjusted according to blood levels by transplant team only and blood work every Monday and Thursday in the a.m. prior to Neoral and Prograf ingestion. CBC with differential, chem 7, calcium, magnesium, phosphate, albumin, AST, ALT, alkaline phosphatase, T bili, direct bili and either Prograf or Cyclosporin level depending upon which drug the patient is taking at the time. Laboratory results need to be faxed to [Telephone/Fax (1) 697] on the same day they are drawn. The patient is to have clinic visit every Wednesday at [Last Name (NamePattern1) 439] [Location (un) ] for the first three months. Follow up is scheduled and dates and times will be provided to the patient. Contact person for patient is [First Name8 (NamePattern2) 1022] [Last Name (NamePattern1) ], R.N. liver transplant coordinator at [Telephone/Fax (1) 10575], direct line or main number is [Telephone/Fax (1) 673]. Please notify transplant coordinator at least two days prior to discharge from rehabilitation to order a shipment of transplant medications. DISCHARGE MEDICATIONS: 1. Bactrim 400-80 mg tablets one po q.d. 2. Valcyte 450 mg tablet one po q.o.d. 3. MMF 500 mg tablet two tablets po b.i.d. 4. Lasix 40 mg tablet one tablet po q.d. 5. Prednisone 5 mg tablet 2.5 tablets po q.d. 6. Fluconazole 200 mg tablet one po q.d. 7. Protonix 40 mg tablet one po q.d. 8. Amiodarone 300 mg tablet one po q.d. 9. Nystatin suspension. 10. Cyclosporin 125 mg b.i.d. po. DISCHARGE STATUS: To rehabilitation. DISCHARGE CONDITION: Good. DISCHARGE DIAGNOSES: 1. Status post orthotopic liver transplantation, cadaveric kidney transplantation combined procedure. 2. Small bowel perforation oversewn. 3. Exploratory laparotomy. 4. Colonic anastomosis status post transverse colectomy, Hartmann's and end colostomy. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707], M.D.,Ph.D. 02-366 Dictated By:[Name8 (MD) 6297] MEDQUIST36 D: [2171-9-13] 08:58 T: [2171-9-13] 09:12 JOB#: [Job Number 45995] cc:[Hospital3 30866]	[ "789.5", "997.4", "996.81", "998.11", "584.5", "753.12", "569.83", "996.65", "751.62" ]	icd9cm	[ [ [] ] ]	[ "55.69", "50.11", "54.12", "46.73", "46.13", "45.74", "54.59", "99.15", "50.59", "55.23", "37.12" ]	icd9pcs	[ [ [] ] ]				7862, 7869				7890, 8428	7404, 7840					3082, 7381																																													180, 1135								1665, 2700									1158, 1574	1591, 1650
54,610	100,003	19215	Discharge summary	report	Admission Date: [2150-4-17] Discharge Date: [2150-4-21] Date of Birth: [2090-5-19] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 12174] Chief Complaint: coffee ground emesis Major Surgical or Invasive Procedure: EGD Right IJ CVL History of Present Illness: Mr. [Known lastname 52368] is a 59M w HepC cirrhosis c/b grade I/II esophageal varices and portal gastropathy (last EGD [3-/2150]), who p/w coffee-ground emesis and melena x2 days. . Pt was in his USOH until about 2-3 days PTA, when he began experiencing intermittent nausea. He had 2-3 episodes of coffee-ground emesis and 1 episode of tarry black stool in the morning of admission. He reports some lightheadedness which is not new, but denies frank hematemesis, BRBPR, abdominal pain, fever, chills, significant increases in his abdominal girth. He denies drinking or medication non-compliance. He also reports taking naproxen for back pain 2-3 times a day in the recent past. . In the ED, his vitals were 97.4, 93/41, 69, 18, 100% on RA. He was given 4L NS IV, protonix 40mg IV, started on an octreotide drip. He had guaiac positive brown stool on rectal exam. He was seen by the liver fellow in the ED who felt this was unlikely a variceal bleed and recommended work up for infection. An NG tube was attempted, however, patient was unable to tolerate it in the ED. Abdominal ultrasound was done which showed a patent portal vein, scant ascites but not enough to tap. BP dropped to 80/34, pt transferred to MICU for hemodynamic monitoring. . In the MICU, pt was given 3 pRBC, Hct bumped from 21.3 to 28. Started on norepinephrine gtt for a few hours, but BP stabilized. On transfer to the floor, remains hemodynamically stable. Feels good, denies tarry or bloody BMs, emesis. Past Medical History: HCV Cirrhosis (tx with interferon x2 with no response) Portal Gastropathy Grade II Esophageal varices HTN Social History: He lives alone. He is drinking alcohol, usually one session per week. He has four to five drinks per session. He was told to completely abstain from alcohol, effective as of today. He smokes about 20 cigarettes per day. Family History: NC Physical Exam: ON ADMISSION: VS: T95.9 HR 71 BP 83/36 RR 11 96% 2L NC Gen: somnolent, oriented x 3, unable to assess for asterixis given somnolence HEENT: PERRLA, EOMI Neck: supple, JVP at angle of jaw (fluid bolus running wide open) CV: RRR s1 s2 no appreciable murmur Lungs: CTAB Abd: distended, non tender, no rebound or guarding, bowel sounds positive Ext: 1+ pitting edema bilaterally Skin: warm, diaphoretic, no rash or lesions noted Pertinent Results: LABS ON ADMISSION: [2150-4-17] 01:30PM BLOOD WBC-17.9# RBC-2.78 Hgb-8.5* Hct-26.0* MCV-94 MCH-30.6 MCHC-32.7 RDW-20.6* Plt Ct-186 [2150-4-17] 01:30PM BLOOD Neuts-61.2 Lymphs-28.8 Monos-6.9 Eos-2.2 Baso-0.9 [2150-4-17] 02:13PM BLOOD PT-17.7* PTT-34.5 INR(PT)-1.6* [2150-4-17] 01:30PM BLOOD Glucose-92 UreaN-51* Creat-1.3* Na-131* K-5.7* Cl-104 HCO3-21* AnGap-12 [2150-4-17] 01:30PM BLOOD ALT-126* AST-260* LD(LDH)-426* AlkPhos-157* TotBili-3.3* [2150-4-17] 06:41PM BLOOD Calcium-7.5* Phos-3.8 Mg-1.9 . LABS ON DISCHARGE: [2150-4-21] 05:00AM BLOOD WBC-10.7 RBC-2.94* Hgb-9.6* Hct-27.0* MCV-92 MCH-32.6* MCHC-35.6* RDW-21.2* Plt Ct-110* [2150-4-21] 05:00AM BLOOD PT-17.4* PTT-35.6* INR(PT)-1.6* [2150-4-21] 05:00AM BLOOD Glucose-84 UreaN-15 Creat-1.0 Na-132* K-4.4 Cl-99 HCO3-25 AnGap-12 [2150-4-21] 05:00AM BLOOD ALT-113* AST-210* AlkPhos-111 TotBili-3.6* [2150-4-21] 05:00AM BLOOD Calcium-8.1* Phos-3.8 Mg-1.7 . OTHER LABS: [2150-4-18] 06:25AM BLOOD CK-MB-9 cTropnT-<0.01 [2150-4-17] 06:41PM BLOOD CK-MB-11* MB Indx-4.9 cTropnT-<0.01 [2150-4-17] 01:30PM BLOOD Lipase-85* . URINE: [2150-4-17] 11:01PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.016 [2150-4-17] 11:01PM URINE Blood-LG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG [2150-4-17] 11:01PM URINE RBC-63* WBC-7* Bacteri-NONE Yeast-NONE Epi-<1 . MICROBIOLOGY: Blood, urine cultures - negative H.pylori serum antibody - negative . CARDIOLOGY: . TTE ([4-18]): Conclusions The left atrium is dilated. Left ventricular wall thicknesses and cavity size are normal. Left ventricular systolic function is hyperdynamic (EF>75%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Hyperdynamic LV systolic function. Mild mitral regurgitation. Moderate pulmonary artery systolic hypertension. . EKG ([4-17]): Sinus rhythm Prolonged QT interval is nonspecific but clinical correlation is suggested No previous tracing available for comparison Intervals Axes Rate PR QRS QT/QTc P QRS T 70 160 96 462/479 70 55 52 . GI: EGD ([4-20]): 1. Varices at the lower third of the esophagus and middle third of the esophagus. 2. Erythema and erosion in the antrum and pylorus compatible with non-steroidal induced gastritis. 3. Bleeding from a pyloric ulcer in the pylorus compatible with non-steroidal induced ulcer (injection, thermal therapy). 4. Normal mucosa in the duodenum. 5. Otherwise normal EGD to third part of the duodenum . RADIOLOGY: . CXR ([4-17]): The prominent bulge to the right heart border could be due to pericardial effusion, _____ cyst, and enlarged right atrium. There is no mediastinal vascular engorgement to suggest cardiac tamponade. Pulmonary vasculature is normal. The lungs are clear and there is no pleural effusion. Overall heart size is normal. Right jugular line ends at the junction of the brachiocephalic veins. No pneumothorax or pleural effusion. . ABD U/S ([4-17]): IMPRESSION: 1. No son[Name (NI) 493] evidence for portal venous thrombosis. Portal vein flow is hepatopetal and wall-to-wall. 2. No significant ascites. A sliver of perihepatic ascites. 3. Persistent coarsened echotexture of the liver consistent with known history of cirrhosis. 4. Splenomegaly Brief Hospital Course: Mr [Known lastname 52368] is a 59M w HCV cirrhosis w grade II esophageal varices admitted w coffee-ground emesis and melena concerning for UGIB, s/p MICU stay for hypotension. . # UGIB: Pt did not have any more bleeds while in hospital. EGD revealed erythema and erosion in the antrum and pylorus compatible with non-steroidal induced gastritis. Pt did remember taking increased doses of naproxen for backache. Started on pantoprazole 40mg PO BID for one week with repeat endoscopy scheduled in one week ([4-30]). Recommended to take tylenol (max daily dose of 2gm) for pain instead of NSAIDs. Blood pressure meds were held at first, given MICU admission for hypotension, but were restarted on discharge. . # HCV Cirrhosis: appears to be progressing to liver failure, with elevated INR at 1.6, decreased albumin at 2.6, tbili slightly elevated at 3.6, and chronic LE edema. Pt was continued on prophylactic medications. . # FULL CODE Medications on Admission: FUROSEMIDE 20mg daily LISINOPRIL 10 mg daily SPIRONOLACTONE 100 mg daily Discharge Medications: 1. Phenol 1.4 % Aerosol, Spray Sig: One (1) Spray Mucous membrane PRN (as needed). 2. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [6-15] hours as needed: no more than 6 tablets of regular strength tylenol per day. 8. Terbinafine 1 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) for 1 weeks. Disp:qs Refills:0 9. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day for 1 weeks: then take 1 tablet daily. Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 11. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for itching. Disp:qs Refills:0 12. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Peptic ulcer GI bleed Discharge Condition: asymptomatic Discharge Instructions: You were admitted for bleeding from an ulcer in your stomach. This ulcer is at least partially caused by naproxen. You should stop taking naproxen and take only tylenol for pain. You should not take any NSAIDS for pain including ibuprofen, naproxen, aleve, motrin, aspirin, toradol, or advil. It is okay to take tylenol but do not take more than 4 extra strength tylenol a day (2gram daily maximum). . The following medication changes were made: Do not take naproxen Take pantoprazole 40 mg twice daily for one week. Then take 40 mg daily. . You are scheduled to get a repeat endoscopy next week. Prior to the procedure do not have anything to drink or eat after midnight. . Please return to the ER if you have any chest pain, lightheadeness, fever, chills, bloody or black stools or any other concerning symptoms. Followup Instructions: Provider: [Name10 (NameIs) ] [Apartment Address(1) ] (ST-3) GI ROOMS Date/Time:[2150-4-30] 1:30 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 7290], MD Phone:[Telephone/Fax (1) 463] Date/Time:[2150-4-30] 1:30 Provider: [Name10 (NameIs) ] [Last Name (NamePattern4) 2424], MD Phone:[Telephone/Fax (1) 2422] Date/Time:[2150-5-7] 11:00 Completed by:[2150-4-24]	[ "571.5", "285.1", "531.00", "535.50", "782.3", "456.21", "070.54", "537.89", "401.9" ]	icd9cm	[ [ [] ] ]	[ "38.93", "96.07", "44.43", "99.04" ]	icd9pcs	[ [ [] ] ]	8600, 8606	6357, 7300	337, 356	8671, 8685	2721, 2726	9552, 9981	2256, 2260		7423, 8577		8627, 8650		7326, 7400			8709, 9529									2275, 2275																									277, 299					3267, 3678				384, 1872								2740, 3248									1894, 2001	2017, 2240		3690, 6334
20,528	170,398	48954	Discharge summary	report	Admission Date: [2140-9-23] Discharge Date: [2140-10-9] Date of Birth: [2079-8-23] Sex: F Service: MEDICINE Allergies: Ciprofloxacin / Cortisporin / Bactrim / Keflex / Latex / Levofloxacin Attending:[First Name3 (LF) 2145] Chief Complaint: Fevers Major Surgical or Invasive Procedure: Incision and drainage of pannus hematoma PICC line placement History of Present Illness: Pt is a 61yo morbidly obese F with h.o recurrent UTIs, DMII, hemolytic anemia, h/o PE ([2130]) who presented to the ER on [9-23] with Temp. 102 x 1 day. She denied localizing sxs or CP/SOB. She noted erythema on her lower abdominal pannus x several days. Of note, patient recently ([7-22]) noted to have large lower abdominal hematoma (40 x17cm) in setting of supratherapeutic INR that was being managed conservatively during admission with dressing changes and stopping anticoagulation(warfarin d/c'd in [7-22] but restarted [8-22] by PCP). . On [9-24], an abdominal u/s of the area and abdominal CT showed a large 40x3 cm fluid collection 2 cm underneath the skin surface, with intraluminal gas and a thickened wall suggestive of cellulitis. Surgical removal was scheduled for [9-25]. An aspirate of the wound Gm stain revealed 2+PMN, 2+GNR, 1+GPC. The patient was broadly coverred with vanc, aztreonam, and clinda per ID's recommendation. Past Medical History: h/o pulmonary embolism s/p right ankle fracture and sedentary (about 7 years ago and continued on coumadin) DMII x 7-8 years recent pannus hematoma but no surgical intervention coumadin held and then resumed 2 weeks prior to admission hypothyroidism chronic pain s/p parathyroidectomy PAF - Dr. [Last Name (STitle) 73] is her cardiologist hemolytic anemia s/p Keflex recurrent UTIs on nitrofurantoin GERD COPD pickwickian syndrome on home 4 liters O2 at night and CPAP Depression Fatty liver Hypercholesterolemia Social History: The patient lives alone. No EtOH, tobacco, drugs. Family History: Non-contributory Physical Exam: VS: Tm 100.1, Tc 99.2 BP=112/58, HR=100, RR=20, 97% on RA Gen: Morbidly obese female in NAD, AAOX3 HEENT: PERLLA, dry MM, no LAD Heart: RRR, II/VI SEM at LUSB, nl S1 S2 Lungs: occasional mild expiratory wheezes, otherwise CTA Abdomen: Large pannus with LLQ catheter and ostomy draining large amount of thick brown fluid into bag. Back: No rashes Ext: No C/C/E Neuro: AAOx3, moving all extremities equally Pertinent Results: [2140-9-23] 06:01PM BLOOD WBC-17.2# RBC-3.95 Hgb-13.0 Hct-38.4 MCV-97 MCH-32.9* MCHC-33.8 RDW-15.5 Plt Ct-303 [2140-10-7] 05:16AM BLOOD WBC-10.6 RBC-3.12* Hgb-9.9* Hct-30.4* MCV-97 MCH-31.7 MCHC-32.5 RDW-16.2* Plt Ct-343 [2140-9-23] 06:01PM BLOOD Neuts-90.8* Bands-0 Lymphs-6.4* Monos-2.3 Eos-0.2 Baso-0.2 [2140-10-7] 05:16AM BLOOD PT-16.0* PTT-67.7* INR(PT)-1.8 [2140-9-24] 09:10AM BLOOD PT-13.7* PTT-26.7 INR(PT)-1.3 [2140-9-23] 06:01PM BLOOD Glucose-157* UreaN-18 Creat-1.3* Na-138 K-4.2 Cl-103 HCO3-22 AnGap-17 [2140-10-7] 05:16AM BLOOD Glucose-142* UreaN-9 Creat-1.0 Na-137 K-4.3 Cl-101 HCO3-26 AnGap-14 [2140-9-24] 09:10AM BLOOD ALT-8 AST-12 LD(LDH)-232 AlkPhos-110 Amylase-31 TotBili-1.2 [2140-10-7] 05:16AM BLOOD Calcium-7.5* Phos-4.0 Mg-1.5* [2140-10-5] 05:00AM BLOOD calTIBC-229* Hapto-256* Ferritn-482* TRF-176* [2140-9-25] 12:10PM BLOOD Cortsol-13.5 [2140-9-26] 01:02AM BLOOD Cortsol-20.2* [2140-9-26] 01:33AM BLOOD Cortsol-25.1* [2140-10-4] 07:35PM BLOOD Vanco-19.6* [2140-10-6] 11:35AM URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG . Blood cultures: [9-23]: negative x2 [9-25]: NGTD x2 [9-30]: NGTD [10-1]: NGTD [10-2]: NGTD Urine: [9-23], culture negative [10-1] urine culture no growth [9-25] Wound swab: pansensitive Enterbacter cloace, pansensitive entercoccus, and S. viridans . [10-5] Portable CXR: Examination is somewhat limited due to underpenetrated technique and large body habitus of the patient as well as slight rotation. Cardiac and mediastinal contours are stable. The lungs demonstrate no focal areas of consolidation . V/Q scan: Low likehood of interval pulmonary embolus . [10-6] Sputum culture: coag positive staph Brief Hospital Course: Pt is a 61 yo morbidly obese female with multiple medical problems including OSA, diabetes, recurrent UTI, h/o PR, PAF, HTN and pannus hematoma presenting with fever with abdominal U/S on [9-24] revealing evidence of pannus hematoma. Abdominal CT showed a large 40x3 cm fluid collection 2 cm underneath the skin surface, with intraluminal gas and a thickened wall suggestive of cellulitis. Surgical removal was scheduled for [9-25]. An aspirate of the wound Gm stain revealed 2+PMN, 2+GNR, 1+GPC. The patient was broadly covered with Vancomycin, aztreonam, and Clindamycin per ID's recommendation. She was planned to got to the OR on [9-25] but went into Afib became hypotensive but was asymptomatic. She was transferred to the [Hospital Unit Name 153], bolused with 5 L IVF and had I&D of her pannus wound at the bedside with 1.5 L drainage of purulent and bloody fluid. While in the ICU she received a total of 10 L NS, started on corticosteroids for concern of adrenal insufficiency and remained asymptomatic, converting back to NSR soon after her arrival back to the ICU. [Last Name (un) ] Stimulation was equivocal test and steroids were d/c'd after 36hrs due to stable BP and low suspicion for adrenal insufficiency. She was transferred to the floor for further monitoring with plans for surgery. . 1. Infected pannus hematoma: Coumadin and aspirin continued to be held. Patient was hemodynamically stable and taken to the OR for incision and drainage. The procedure was uncomplicated and she was transferred back to the floor. Wet to dry dressing changes TID were performed with significant decrease in drainage. Her hematocrit slowly trended down and she was transfused 2 units pRBCs. Her hematocrit remained stable in the low 30's for the rest of admission. She will follow up with Dr. [Last Name (STitle) ] for monitoring of her wound and to discuss possible plastic surgery referral for pannectomy. An infectious disease consult was obtained as above. Cultures grew pan sensitive Enterobacter cloacae, s. viridans and enterococcus. She was continued on vancomycin and aztreonam and switched from clindamycin to Flagyl. Her vancomycin troughs were kept between 15-20. A full 14 day course of antibiotics will be administered from the time of incision and drainage. A PICC line was placed for antibiotic administration. She will have weekly labs including vancomycin trough checked and results will be faxed to Dr. [First Name (STitle) 2505] in the [Hospital ] clinic. She will follow up with him in [Hospital ] clinic with CT abdomen and pelvis prior to her appointment. Wet to dry dressing TID will be continued. Given that her HCT remained stable and that she has documented atrial fibrillation (noted several times to go in/out during this hospitalization), she was restarted on anticoagulation. This decision was made after discussion with the surgery service, who agreed it was safe to anticoagulate now that her hematoma had been drained and her wound was to heal by secondary intention. Any sign of re-bleeding would be immediately noticeable. She should have her INR checked every third day given recent restarting of Coumadin will goal INR from 2-2.5. . 2. Respiratory: On admission to the ICU there was concern for possible PE given that the patient was hypotensive in atrial fibrillation given her history and multiple risk factors. CTA of the chest was obtained that was difficult to interpret, but had questionable new filling defect. Given her risk for bleeding at that time, poor study quality, negative lower extremity Dopplers, lack of symptoms and the fact that she was maintaining good O2 sats she was not anticoagulated. Her O2 sats remained stable. However, POD 4 after I&D she had increased O2 requirement and increasing cough productive of sputum. CXR was a poor study but did not reveal any consolidation. Given her history, she was started on heparin drip and a V/Q scan was obtained which showed low likelihood of PE. He O2 sats improved and remained stable. She continued to ave productive of sputum. Sputum cultures revealed COAG positive staph aureus with sensitivities pending. Given that she is on vancomycin, no changes were made to her antibiotic regimen and chest x-ray was not repeated as her lung exam was unchanged but it is likely that she developed an early pneumonia. At discharge her O2 sat was 97% on RA. . 3. Paroxysmal atrial fibrillation: Patient went into a. fib with hypotension prior to her originally scheduled I&D on admission but rapidly converted and was rate controlled with diltiazem. There were 2 further episodes of atrial fibrillation one of which was associated with palpitations at which time she was given a one time dose of diltiazem. She converted back to sinus rhythm and remained in NSR thereafter. As mentioned above, given that her HCT was stable she was restarted on Coumadin. Her INR was 2.7 on the day of discharge after 3 days of 5 mg Coumadin with heparin drip overlap. Her dose was decreased to 3 mg po QHS on the day of discharge as her goal INR should be 2-2.5 given her bleeding risk. Her INR should be checked every third day for now until her INR is within the therapeutic range. . 4. Hypertension: Patient was hypotensive in the ICU in the setting of atrial fibrillation. Her SBPs on the floor ranged from low 90s to low 100's throughout her admission. Her lisinopril was held during her entire hospitalization. Her diltiazem was continued for rate control. Her diltiazem will be continued as an outpatient primarily for rate control. . 5. Anemia: Original drop in HCT was due to acute blood loss into hematoma. Her new baseline HCT was 30-35. Her HCT slowly trended down during admission, hemolysis labs were negative and after 2 units pRBCs her HCT was in the low 30's and stable. Slow trending down was likely due to some slow blood loss from draining wound. She sees a hematologist as an outpatient as she has a history of hemolytic. 6. Hypothyroidism: TSH [7-24] was normal. She was continued on her current levothyroxine. A repeat TSH was obtained which was 7, but could not be interpreted in the setting of acute illness. Her TSH will be monitored as an outpatient after resolution of her acute illness. . 7. Chronic renal insufficiency. Cr at baseline of 1.4-1.6. After hydration her creatinine improved. AT discharge her creatinine was 1.1 . 8. Diabetes: She was continued on Glyburide with RISS for tight glycemic control in the setting of infection. Her fingersticks remained well controlled. She will continue on Glyburide as an outpatient and RISS while she is being treated for her infection. She will follow up with her primary doctor. 9. Pickwickian syndrome: She was on CPAP with 4 L of O2 at home. During her hospitalization she was changed to BiPAP 7/8 with 4 L of O2 with O2 sats 99-100% on this regimen. She will continue on these settings. . 10. Chronic pain: Continue outpatient regimen. . 11. FEN: Diabetic, cardiac diet was maintained throughout admission. She required magnesium repletion so was started on daily PO repletion. Medications on Admission: Advair 1 qd [Doctor First Name ] 1 qd allopurinol 100 mg PO QD ASA 81 qd -recently held Calcium 500 [Hospital1 ] Cardizem CD 360 mg PO QD Protonix, Coumadin 5 qd except Friday 2.5 on hold since [7-22] Iron Folic acid, Lactulose prn Glyburide 2.5 qd, Levothyroxine 125 mcg qd, Lipitor 20 mg PO QD Lisinopril 10 mg PO QD Oxybutynin 5 five times a day, Morphine CR 15 mg PO BID Nitrofurantoin 100 mg PO QHS Trazodone 150 qd, Lorazepam 500 mcg tid, Oxycodone 5 tid, Allopurinol 100 qd, Lactulose, Ursodiol 250 [Hospital1 ] Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 3. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Folic Acid 1 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. Levothyroxine Sodium 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. Ursodiol 250 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 13. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for no BM x 1 day. 15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for no BM x 2 days. 16. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 17. Trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). 18. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 19. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 20. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 21. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1) units Subcutaneous ASDIR (AS DIRECTED). 22. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 23. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4 times a day): Hols for SBP <100 HR <60. 24. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 25. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO HS (at bedtime) as needed. 26. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 27. Sodium Chloride 0.65 % Aerosol, Spray Sig: [12-20] Sprays Nasal QID (4 times a day) as needed. 28. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 29. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 30. Beclomethasone Diprop Monohyd 0.042 % Aerosol, Spray Sig: One (1) Spray Nasal [Hospital1 ] (2 times a day) for 1 weeks. 31. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 32. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q4H (every 4 hours). 33. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. 34. Warfarin 3 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 35. Dolasetron 12.5 mg/0.625 mL Solution Sig: 12.5 mg Intravenous Q8H (every 8 hours) as needed. 36. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. 37. Outpatient [Hospital1 ] Work Please check CBC with differential, BUN, CRE, ALT, AST, alk phos, T bili, and vancomycon trough weekly starting [2140-10-10]. fax results to [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 2505] at [Telephone/Fax (1) 1419] 38. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 6 days. 39. Vancomycin 1,000 mg Recon Soln Sig: 1000 (1000) mg Intravenous every twelve (12) hours for 6 days. 40. Aztreonam 1 g Recon Soln Sig: Two (2) grams Injection Q8H (every 8 hours) for 6 days. 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 3. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Folic Acid 1 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. Levothyroxine Sodium 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. Ursodiol 250 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 13. Magnesium Oxide 400 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for no BM x 1 day. 15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for no BM x 2 days. 16. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 17. Trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). 18. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 19. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 20. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 21. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1) units Subcutaneous ASDIR (AS DIRECTED). 22. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 23. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4 times a day): Hols for SBP <100 HR <60. 24. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 25. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO HS (at bedtime) as needed. 26. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 27. Sodium Chloride 0.65 % Aerosol, Spray Sig: [12-20] Sprays Nasal QID (4 times a day) as needed. 28. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 29. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 30. Beclomethasone Diprop Monohyd 0.042 % Aerosol, Spray Sig: One (1) Spray Nasal [Hospital1 ] (2 times a day) for 1 weeks. 31. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 32. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q4H (every 4 hours). 33. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. 34. Warfarin 3 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 35. Dolasetron 12.5 mg/0.625 mL Solution Sig: 12.5 mg Intravenous Q8H (every 8 hours) as needed. 36. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. 37. Outpatient [Hospital1 ] Work Please check CBC with differential, BUN, CRE, ALT, AST, alk phos, T bili, and vancomycon trough weekly starting [2140-10-10]. fax results to [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 2505] at [Telephone/Fax (1) 1419] 38. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 6 days. 39. Vancomycin 1,000 mg Recon Soln Sig: 1000 (1000) mg Intravenous every twelve (12) hours for 6 days. 40. Aztreonam 1 g Recon Soln Sig: Two (2) grams Injection Q8H (every 8 hours) for 6 days. 41. Outpatient [Name (NI) ] Work PT, PTT, INR to be checked [2140-10-12] and eveyr third day until in therapeutic range of INR 2.0-2.5 Discharge Disposition: Extended Care Facility: [Hospital 745] Health Care Centre Discharge Diagnosis: Primary 1. Infected pannus hematoma 2. Atrial fibrillation 3. Pneumonia Secondary: 1. Type 2 diabetes 2. Obstructive sleep apnea 3. Hypertension 4. Hypercholesterolemia Discharge Condition: Afebrile, hemodynamically stable, therapeutic INR, HCT stable Discharge Instructions: If you have any increasing shortness of breath, chest pain, palpitations, fevers, chills or any other concerning symptoms you should contact your doctor or come to the emergency room. . 1. Take all of your medications as directed 2. Keep all of your follow up appointments 3. You are scheduled for a repeat CT scan on [10-18] to monitor the status of your hematoma Followup Instructions: Provider: [Name10 (NameIs) ] SCAN Phone:[Telephone/Fax (1) 327] Date/Time:[2140-10-18] 9:45. You should arrive for your CT scan at 8:45 am on the [Location (un) 470] of the [Hospital Unit Name ]. You should not eat or drink 3 hours prior to your arrival. Your results will be reviewed with you when you go to see Dr. [First Name (STitle) 2505] at the infectious disease clinic that same day at 12 pm. Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 4340], MD Phone:[Telephone/Fax (1) 457] Date/Time:[2140-10-18] 12:00 Provider: [First Name11 (Name Pattern1) 312] [Last Name (NamePattern4) 3015], M.D. Phone:[Telephone/Fax (1) 1803] Date/Time:[2140-10-24] 9:30 Provider: [Name10 (NameIs) ] INJECTIONS Date/Time:[2140-10-31] 8:30 Please call ([Telephone/Fax (1) 9000] to schedule an appointment with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] from the department of surgery in 2 weeks. At this time you should discuss seeing a plastic surgeon for further management. . You should also follow up with your primary doctor Dr. [Last Name (STitle) ] [Telephone/Fax (1) 250] after you finish rehab. [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 2158]	[ "530.81", "V58.67", "283.9", "285.1", "427.31", "250.00", "244.9", "482.41", "278.01", "458.9", "V12.51", "790.92", "276.50", "496", "682.2", "593.9", "571.8" ]	icd9cm	[ [ [] ] ]	[ "86.04", "38.93", "99.04", "93.90" ]	icd9pcs	[ [ [] ] ]	19761, 19825	4314, 11414	337, 399	20038, 20102	2482, 4291	20519, 21834	2023, 2041		12000, 19738		19846, 20017		11440, 11977			20126, 20496									2056, 2463																									291, 299									427, 1399																	1421, 1939	1955, 2007
16,913	120,594	50631	Discharge summary	report	Admission Date: [2181-5-9] Discharge Date: [2181-8-17] Date of Birth: [2122-10-22] Sex: M Service: MEDICINE Allergies: Ace Inhibitors Attending:[First Name3 (LF) 2181] Chief Complaint: Leg pain Major Surgical or Invasive Procedure: Parathyroidectomy FNA Thyroid History of Present Illness: Mr. [Known lastname ] is a 58 year old male with history of CAD s/p CABG ([2175]), hyperparathyrodism with parathyroid adenoma (dx'd [2175]), type 2 DM, CHF (EF 20%), "fast heart rate" and CKD who presents with leg pain. The patient presented to the ED after arising from his bed and hearing a 'snap' in his left leg. He subsequently he had difficulty moving the leg and was concerned that it broke. He also reported two similar episodes: first last [Month (only) ] he felt a painful click in his right forearm which developed into a soft mound and second on New Year's Eve he heard a snap in his right UE, followed by pain and ecchymosis which lasted for weeks. . In ED, plain film of his pelvis showed a possible chronic superior/inferior pubic rami fracture with lucencies/lytic lesions in long bones. He was evaluated by orthopedics in the ED. The plan was for CT of the pelvis and possible surgery. He refused both the surgery as well as the CT scan and was admitted to medicine for clearance. . Of note, he was also found to be hyperkalemic with a K of 6.2. He was given kayexalate and repeat K 5.3. Calcium on admission was 12.7 - per OMR this is chronic hypercalcemia [3-16] hyperparathyroidism. . Review of systems was negative for fevers, chills, night sweats, weight loss - in fact patient had 70lb wt gain over 2 years - chest pain, shortness of breath, lightheadedness, dizziness, palpitations. He had no dysuria, hematuria. Only complaint is pain in left leg. Sometimes feels as though wearing socks/shoes, poor movement of LE. Past Medical History: # CAD s/p CABG, [2175-7-6] - 3V CABG with a saphenous vein graft to the CMI, saphenous vein graft to the right posterior descending artery (with a proximal anastomosis from the diagonal), and a saphenous vein graft to the diagonal. # hyperparathyroidism (adenoma)- chronic hypercalcemia, ?bone pains, renal insuff, but has not undergone surgery. He was seen by Dr. [Last Name (STitle) ] in [2175], was recommended surgery, but patient did not follow up. # CHF- EF 20% pre-CABG, no recent ECHO on file # chronic knee pain # CKD- Cr 2.4; suspected secondary to hypercalcemia, DM # PAF Social History: The patient has a 15 pack year history. Quit smoking after CABG. Worked as bookmaker for sports gambling. No alcohol, no drugs. Family History: The patient's father died at age 86 of coronary artery disease and also had hypertension. The patient's mother died of stomach cancer. Patient is an only child. He has two children aged 18 and 19 who are alive and well. ? Father had paget's disease. No history of DM or thyroid disease. Physical Exam: vitals- T 96.4, BP 130/68, HR 96, RR 20, 99% RA gen- disheveled appearing, no acute distress heent- EOMI. MM dry. OP clear Neck: supple, no LAD, no palpable nodules pulm- CTA b/l. no r/r/w cv- irreg, nl s1 s2, no murmurs abd- obese, soft, NT/ND ext- 3+ pitting edema b/l LEs; limited movement left leg [3-16] pain; able to wiggle toes, strong plantar flexion. 2+ dp pulse and warm extremities; neuro- alert and oriented x 3 Pertinent Results: Admission Labs: [2181-5-9] 01:10PM BLOOD WBC-10.6 RBC-4.39* Hgb-10.0* Hct-33.1* MCV-75* MCH-22.7* MCHC-30.1* RDW-18.9* Plt Ct-271# [2181-5-9] 01:10PM BLOOD Neuts-91.5* Lymphs-5.1* Monos-3.0 Eos-0.3 Baso-0.2 [2181-5-9] 01:10PM BLOOD Plt Ct-271# [2181-5-9] 01:10PM BLOOD Glucose-169* UreaN-53* Creat-2.4* Na-141 K-6.2* Cl-112* HCO3-16* AnGap-19 [2181-5-17] 09:00AM BLOOD AlkPhos-354* [2181-5-18] 07:10AM BLOOD ALT-30 AST-16 LD(LDH)-139 AlkPhos-335* TotBili-0.4 [2181-5-9] 01:10PM BLOOD Calcium-12.7* Phos-3.6 Mg-1.4* [2181-5-10] 07:30PM BLOOD calTIBC-229* VitB12-622 Ferritn-254 TRF-176* [2181-5-10] 07:30PM BLOOD %HbA1c-7.6* [Hgb]-DONE [A1c]-DONE [2181-5-10] 07:30PM BLOOD PTH-1642* [2181-5-11] 06:20AM BLOOD PTH-1300* [2181-5-12] 06:15AM BLOOD PEP-NO SPECIFI Vitamin D <4 Discharge Labs: Reports: [2181-5-9] pelvis xray- IMPRESSION: 1. Fractures of the left superior and inferior pubic ramus of uncertain chronicity. 2. Curvilinear lucency in the left femoral head is suspicious for fracture. 3. Lytic lesion in the left femoral mid shaft may represent a brown tumor given the patient's history of aggressive hyperparathyroidism, however aggresive tumor such as metastasis or myeloma cannot be excluded. . CXR: neg for PNA/PTX . EKG: afib w/ ventricular rate 110's . [5-10] Echo: Conclusions: The left atrium is markedly dilated. The right atrium is markedly dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. Overall left ventricular systolic function is severely depressed (ejection fraction 20 percent) secondary to akinesis of the inferior wall and at least moderate hypokinesis of the rest of the left ventricle. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size is normal. Right ventricular systolic function appears depressed. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([2-13]+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is no pericardial effusion. . [2181-5-10] CT Pelvis:IMPRESSION: 1. Diffusely abnormal study with multifocal lytic expansile soft tissue density masses throughout the visualized pelvis. These masses may be related to very aggressive forms of brown tumors in the setting of longstanding hyperparathyroidism. However, given the nonspecific as well as heterogeneous appearance, metastatic malignancy musct also be considered. 2. Acute pathologic fracture involving the left femoral neck 3. Chronic appearing pathologic fractures involving the left superior and inferior pubic rami, also secondary to expansile soft tissue masses. 4. Lesion in diaphysis of left femur, with endosteal scalloping which creates risk for pathologic fx at this second site. 5. Multiple lesions with interrupted cortex, as described including lesion of the right anterior acetbulum/ramus, which represent, by definition, pathologic fractures. . [2181-5-10] CT Femur: 1. Soft tissue density mass within the mid femoral diaphysis causing significant endosteal scalloping, which may be at risk for pathologic fracture. 2. Redemonstration of pathologic fracture of the left femoral neck, as discussed on the CT of the pelvis. These lesions again may reflect aggressive form of brown tumors, though other metastatic lesion should be considered in the differential. . [2181-5-13] Renal US: IMPRESSION: Limited evaluation of the kidneys secondary to patient's increased body habitus and inability to comply with necessary maneuvers. No evidence of nephrocalcinosis or hydronephrosis identified. A small simple cyst is identified within the upper pole of the left kidney. Mass lesions on the right kidney cannot be completely ruled out on this study. . [2181-5-14] Thyroid US: IMPRESSION: 1. 3.9 x 3.8 x 3.2 cm nodule posterior and lateral to the inferior pole of the left thyroid lobe likely represents a parathyroid nodule. 2. Interval enlargement of the right thyroid lobe and isthmus nodules. 3. 1.4 x 0.8 x 0.9 cm hypoechogenic nodule adjacent to the lower pole of the left thyroid lobe cannot cannot distinct lymph node from another parathyroid adenoma. . Forearm film: MPRESSION: 1. Expansile osseous lesion of the distal right ulnar diaphysis with ill-defined margins, associated cortical destruction, and numerous bony trabeculations running through the center of the mass. Given the patient's history, the possibility of a brown tumor in this location must be considered. The appearance is nonspecific, however, an other considerations would include aneurysmal bone cyst or metastasis. 2. Indistinct areas of lucency more proximally within the ulna and in the radial diaphysis are nonspecific; attention to these areas on followup imaging is advised, particularly since they may represent additional lesions. . Parathyroid mass [2181-7-5]: Left parathyroid and left thyroid lobe and isthmus (A-T): a. Parathyroid carcinoma, 3.4 cm, with capsular invasion and vascular invasion (slide Q). The tumor extends to the inked resection margin. b. Papillary carcinoma, follicular variant, left thyroid lobe, 4 mm, not extending to inked margin. Tumor cells are positive for TTF-1 and thyroglobulin. . Thyroid FNA [2181-7-23]: Indeterminate for malignancy - follicular lesion with some features suggestive of, but not diagnostic for, papillary carcinoma with cystic degeneration. Hypocellular specimen with follicular cells in a few groups, some with crowding. Some of the follicular cells show Hurthle cell changes. Some of the follicular cells show powdery chromatin, nuclear enlargement, nuclear grooves, small prominent nucleoli and irregular nuclear membranes. . LENIs [8-2]: Both grayscale and color Doppler ultrasound examination of the left lower extremity was performed. There is normal compressibility, respiratory variation, and response to augmentation in the left common femoral, superficial femoral, and popliteal veins. No intraluminal filling defects are seen. IMPRESSION: No DVT. Brief Hospital Course: # Primary hyperparathyroidism/hypercalcemia: Mr. [Known lastname ] was initially diagnosed with a 3 cm parathyoird adenoma in [2175]. PTH at that time was 300s. He was referred to Dr. [Last Name (STitle) ] for removal of the adenoma however never followed up with the surgery. He was lost to follow up until [2180-2-13]. On admission he was noted to be hypercalcemic (12.7) and parathyroid hormone was 1600. He denied any symptoms of hypercalcemia - had never had renal stones. He was treated with lasix to help reduce his calcium levels, with good response initially. He was also started on Sensipar and Vitamin D supplementation. Endocrinology and endocrine surgery were called for help with management. A repeat thyroid US showed increased size of the adenoma: 3.9x3.8x3.2cm nodule post/lat to inferior pole L thyroid lobe and 1.4x0.8x0.9cm nodule adjacent to lower pole of L thyroid lobe. In terms of pre-op testing, initial part of MIBI done, however pt reports a bad rxn to dipyridamole and refused second part of MIBI. Radiologic studies showed lytic lesions which are consistent with Brown's tumors. Dr. [Last Name (STitle) ], who had seen the patient briefly in [2175], came to evaluate the patient and agreed to remove the adenoma. Psychiatry was consulted and deemed the patient to have capacity and understand the risks and benefits of his decisions. He was started on ativan, then changed to klonapin, and seroquel for anxiety.The patient underwent parathyroidectomy on [7-6]. The pathology report revealed papillary carcinoma thyroid. The pt underwent FNA of the R thyroid mass which was intermediate for papillary Ca thyroid. Dr [Last Name (STitle) 5182] from endocrine surgery will perform thyroid surgery in [9-18] at a specific time to be sheduled. During the patients stay calcium, phosphate, albumin, PTH were monitored daily. The patient was found to have elevated PTH and low calcium due to hungry bone syndrome, and the patient received calcitriol and vitamin D. In addition, during his stay, the PTH continued to rise with a normal calcium which was found to be a result of his hungry bone syndrome and not recurrance of parathyroid cancer at this time since the PTH supressed well with IV calcium supression test. # Hypthyroidism: The patient was found to have hypothyroidism during his hospital stay with TSH 6.6,Free T4 1.1. The patient was placed on Synthroid 112 mcg PO DAILY. TSH and free T4 were monitored weekly. # Pathologic pelvic fx/leg fracture: Once admitted to the floor and the patient's pain was appropriately managed, a CT pelvis was obtained which revealed left femoral neck fracture and soft tissue density mass within the mid femoral diaphysis. Skeletal survey showed multiple lytic lesions in femurs, pelvis, and humeri and pathologic subacute humerus fracture. Differential included brown's tumor vs. metastasis vs. myeloma vs. lymphoma. SPEP and UPEP were done and both were negative. Brown's tumor felt to be most likely given clinical history. Orthopedic oncology was following the patient. The patient decided that he is not willing to undergo femur repair at this time. Orthopedics thought that conservative management was the best option at this time. They suggested PT to work with pt. Pt has been working with PT daily since then. . # CAD s/p CABG: During this admission, patient had an episode of epigastric pain, not his anginal equivalent. He says that his anginal equivalent prior to CABG was shortness of breath with exertion and right shoulder pain. EKG was done with epigastric pain and was unchanged. No further chest pain. He also completed the first day of a two day stress test. The first portion showed severe inferior perfusion wall defect presumed to be fixed on these rest images and dilated LV and global hypokinesis. He refused the second portion as he says that he had a bad reaction to dipyridamole in the past. He was maintained on ASA, statin, b-blocker. Even without the second half of the stress test, his risk for both surgical procedures is high. Cardiology was consulted to clear the pt before the parathyroid surgery. If the pt needs to undergo repeat thyroid resection, may need to consult cards again. . # Afib with RVR: On admission, the patient reported a history of a fast HR. This admission he has had multiple episodes of RVR with ventricular rate in 140s. He has been treated with diltiazem and toprol, titrated to good rate control. During the initial episodes of rapid ventricular response he remained hemodynamically stable and asymptomatic with good response to IV diltizem; however due to uptitration of BB and CCB he had an episode of bradycardia and hypotension requiring transfer to the CCU for pressors briefly and then monitoring. His CCB was held and BB reduced with return of his RVR and therefore he was loaded with digoxin with good response. He was also started on a heparin drip which was stopped when therapeutic on coumadin (goal INR [3-17]). Then he was continued on coumadin and the INR was therapeutic. The coumadin was stopped before the FNA. It was restarted and we are uptitrating it till the INR becomes therapeutic. . # DM, type 2: Poorly controlled at home. He was not taking anything for DM as an outpatient. His A1c was 7.6%. Initially he was on glargine and HISS. His FSG were normal, and the glargine and subsequently the HISS were stopped. . # Systolic CHF, decompensated: Initial physical exam revealed 4+ pitting edema in legs bilaterally. Known to have EF 20%. Repeat echocardiogram confirmed this ejection fraction as well as moderate TR and moderate MR. [Name13 (STitle) ] presented with a weight of 150kg. After this time lasix was held and the patient continued to autodiurese. He was able to lie flat and required no supplemental O2. Cardiology was consulted and recommended transition from toprol XL to coreg which he tolerated well. ACEi was held due to hypotension and renal failure. He continued to have good O2 satts and no trouble breathing. However, on [8-2], increasing swelling on bilat LE was noted, and pt was started on lasix 40mg PO qdaily. The patient diuresed well with 1-1.5 L neg each day, a 20lb weight decrease and a significant reducion in lower extremety edema over two weeks. The patient was kept on a low sodium, heart heealthy diet. . # CKD, stage III/IV: The patient's renal function remains at baseline. Kidney disease is likely due to hypercalcemia and diabetes. A renal US was done which showed no evidence of nephrolithiasis or hydronephrosis. He was continued on a low dose ace inhibitor initially, but with high potassium and borderline BP, the ACE was held. The Sr Cr has remained stable. . # Anemia: Microcytic. Vit B12 was within normal limits. Low iron & TIBC, eleveated ferritin. Guaiac positive intermittently. [Month (only) 116] be mixed picture of ACD and iron deficiency. Started on epo 8000 units qMWF, iron supplements. Hct has been stable (range 26-28). . Medications on Admission: Lisinopril 5mg daily atenolol 50mg daily lipitor 20mg daily ASA 325 mg daily docusate 100mg [Hospital1 ] Discharge Medications: 1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 3. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). Disp:90 Refills:2 4. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. Disp:30 Tablet, Sublingual(s) Refills:0 5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. Disp:30 Tablet(s) Refills:0 9. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:30 Tablet(s) Refills:0 10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 11. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical DAILY (Daily) as needed. Disp:qs Refills:0 12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 13. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 14. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for anxiety. Disp:90 Tablet(s) Refills:0 15. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 16. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 17. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. Disp:240 Tablet(s) Refills:0 18. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). Disp:60 Tablet, Chewable(s) Refills:2 19. Calcitriol 0.5 mcg Capsule Sig: Five (5) Capsule PO DAILY (Daily). Disp:150 Capsule(s) Refills:2 20. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 21. 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. 22. Lorazepam 2 mg/mL Syringe Sig: One (1) Injection Q4H (every 4 hours) as needed for agitation/anxiety. Disp:120 Refills:0 Discharge Disposition: Extended Care Facility: [Location (un) 583] House Rehab and Nursing Center Discharge Diagnosis: Primary: Primary Hyperparathyroidism. Hypercalcemia. Pathological Left Pubic Ramus Fracture. Pathologic subacute right proximal humerus fracture. Pathological right proximal femoral fracture. Multiple lytic lesions throughout. 3.9 x 3.8 x 3.2 cm left inferior parathyroid adenoma. Multiple thyroid nodules. Decompensated Heart Failure. Non-sustained Ventricular Tachycardia Atrial Fibrillation with Rapid Ventricular Response Bradycardia - Secondary to Medications Enterococcal UTI Secondary: Severe Ischemic LVSD CAD Native Vessel s/p CABG SVG-OM1, SVG-D1, SVG rPDA. Resection left infraclavicular chest wall ulcer. Postoperative Hemothorax secondary to intercostal artery bleed. CKD Stage III Hypertension Anemia of CKD and Chronic Disease Discharge Condition: good Discharge Instructions: If you break any more bones, if you have pain in your lt leg, if you develop fever or chills, please return to the emergency room. Followup Instructions: Mr. [Known lastname ] coumadin has been held for elevated INR. Is INR is now 2.0. Coumadine was restarted at 3mg PO QD on [2181-8-17]. You will need to adjust dose for INR> You have the following appointments 1. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 250] , please call to make an appointment 2. [First Name4 (NamePattern1) 5627] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 1803], please call to make an appointment 3. [Doctor Last Name 105361] MD [Telephone/Fax (1) 5189], [2184-8-28]:15am Completed by:[2181-8-17]	[ "428.21", "308.0", "599.0", "585.3", "194.1", "584.9", "250.42", "285.21", "268.2", "733.19", "244.1", "403.90", "427.31", "252.01", "733.14", "198.89", "733.11", "V45.81", "564.00" ]	icd9cm	[ [ [] ] ]	[ "06.11", "06.89", "06.39" ]	icd9pcs	[ [ [] ] ]	19584, 19665	9785, 16813	284, 316	20452, 20459	3442, 3442	20639, 21258	2689, 2978		16973, 19561		19686, 20431		16839, 16950			20483, 20616	4280, 9762								2993, 3423																									236, 246									344, 1908						3458, 4263											1930, 2528	2544, 2673
26,523	136,457	6064	Discharge summary	report	Admission Date: [2193-3-3] Discharge Date: [2193-3-11] Date of Birth: [2130-7-8] Sex: F Service: MEDICINE Allergies: Compazine / Pepcid / Nitroglycerin / Dicloxacillin / Neurontin / Tape / Detrol / Ambien / Methadone Attending:[First Name3 (LF) 5301] Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: Endotracheal Intubation Placement of Dauboff Tube Lumbar Puncture History of Present Illness: This is a 62 yo F with multiple medical problems including HTN, DM, h/o one tonic clonic seizure in [2189], h/o recurrent UTI with E. Coli and Pseudomonas, chronic arachnoiditis, on chronic morphine PCA, with multiple recent admissions for altered mental status related to either infection or opiate intoxication from her morphine PCA. She was recently admitted at [Hospital1 18] on [4-26] for altered mental status and [Female First Name (un) ] albicans growing in her blood culture bottles from [Hospital1 ]. LP was unsuccessful during that admission and felt unlikely to be successful given her significant scarring. The pt at the time of that admission was septic, admitted to the ICU, and treated for fungemia. Her fungemia was treated with a 14 day course of caspofungin and her Hickman line was discontinued. Chest CT showed multiple nodular paranchymal lesions with tiny cavitations concerning for fungal infection, inflammatory process, or metastatic thyroid CA. PICC line was placed prior to completion of abx, and was d/c'd on [2193-2-26]. . Since the pts last discharge, she has been at [Hospital1 ]. She completed her course of caspofungin on [2193-3-1]. On night of this admssion the pt was found with altered sensorium with jerking movements. Her eyes were noted to be roving and there was question of seizure activity. She was given 0.4 m narcan without effect. She had noted neck stiffening and extension of the upper extremities, prompting administration of ativan 2 mg x1. She was then transferred to [Hospital1 18]. She was intubated for airway protection. She received Vanc, CTX. She was noted to have lactate of 5.5, tachycardia, and fever so code sepsis was called in the ED. Head CT on admission was negative for any acute change. When patient intitially presented to the MICU she was noticed to have tonic-clonic seizures which resolved after increased of propofol. Past Medical History: 1. MRSA 2. Metastatic thyroid CA s/p iodine and XRT and now on synthroid 3. Right lower extremity cellulitis 4. Nuerogenic bladder: Pt self catheterizes 5. Chronic low back pain: Pt is on continuous morphine PCA. 6. Depression 7. Type 2 DM 8. Chronic arachnoiditis 9. Esophageal dysmotility 10. DVT and PE s/p placement of IVC filter. Felt to be hypercoagulable 11. Chronic UTIs with pseudomonas/Klebsiella 12. Obstructive Sleep Apnea 13. Osteoarthritis 14. CHF now recovered. LVEF of 60%. 15. HTN 16. Anemia of chronic disease 17. Right ankle graft 18. Seizure [2190-8-14] 19. s/p Klebsiella line infection [12-31] 20. s/p ERCP for retained stone [12-31] 21. Hospitalized at [Hospital1 ] [6-30] with R thumb/forearm cellulitis s/p several courses of Vancomycin 22. Splenic cyst 23. Osteomyelitis of the right second toe with chronic ulceration s/p distal phalangectomy of the right second toe with ulcer excision 24. Peripheral vascular disease 25. Squamous Cell Carcinoma 26. s/p Cholecystectomy Social History: Married. Currently residing at [Hospital1 ] after recent [Hospital1 18] hospitalization. Cared for by husband at home. Pt has one son. Worked as a research chemist. No ETOH or tobacco use. Family History: Father has CAD, Mother with CVA Physical Exam: PE: 99.1, 158/70, 112, 20, 98RA Gen: NAD, AOx2 HEENT: MMM, R tongue lesion, PERRLA, EOMI, NC Neck: swollen, R hematoma, central induration , no JVD Chest: reduced BS with limited effort, no W/R/R CV: tachy, RR, S1 and S2 nl, no m/r/g Abd: obese, soft, NT, ND, +BS, well healed scars Ext: relatively atrophic, R foot s/p resection toes II,III Neuro: CN II-XII intact, LE strenght 2-3/5, decreased sensation feet b/l Skin: dry Pertinent Results: Admission labs: Na 135/K 4.2/Cl 97/HCO3 20/BUN 22/Cre 0.8/Gluc 314 ALT 17 AST 16 AP 113 TBil 0.3 [Doctor First Name ] 14 Lip 13 WBC 17.6/Hct 35.2/plt 394 . [2193-3-8] 06:45AM BLOOD WBC-6.6 RBC-3.34* Hgb-9.5* Hct-28.7* MCV-86 MCH-28.5 MCHC-33.2 RDW-15.8* Plt Ct-370 [2193-3-8] 06:45AM BLOOD Plt Ct-370 [2193-3-8] 06:45AM BLOOD Glucose-155* UreaN-6 Creat-0.5 Na-137 K-3.9 Cl-101 HCO3-29 AnGap-11 [2193-3-8] 06:45AM BLOOD TSH-0.65 [2193-3-8] 06:45AM BLOOD Free T4-1.4 [2193-3-3] 04:13PM BLOOD Phenyto-13.4 . VIDEO OROPHARYNGEAL SWALLOW [2193-3-7]: No aspiration demonstrated during the study. There is a mild amount of penetration before and during swallow. . Barium esophagram [2193-3-7]: 1. Nonspecific esophageal motility disorder characterized by weakened primary peristaltic waves and prominent tertiary activity also noted on study from [2190]. No strictures or masses are identified. Moderate-sized hiatal hernia. Suggestion of a schatzki's ring although a barium tablet was not administered per request of speech and swallow pathologist. . EGD [2193-3-8]: The esophagus appeared normal. The scope was easily able to pass into the upper esophagus. There were no esophageal strictures. Medium hiatal hernia. Erythema and erosions in the antrum compatible with gastritis. Normal EGD to stomach antrum . URINE CULTURE (Final [2193-3-5]): PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA \| CEFEPIME-------------- 8 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R IMIPENEM-------------- 4 S MEROPENEM------------- 0.5 S PIPERACILLIN---------- 8 S PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ =>16 R Brief Hospital Course: # Altered Mental Status/Seizure: The pt presented with altered sensorium after what appeared to be tonic clonic seizure activity at her rehab. She was likely post-ictal in the ER, and then presents with another witnessed tonic clonic seizure when in the ICU. She was also found to have a UTI which was felt that could have also contributed to her altered mental status. Patient was seen by neurology and underwent both LP and EEG. The LP came back negative for infection and her EEG did not show any evidence of seizure activity. However since patient had witness seizures in the hospital it was decided to load patient with Dilantin which was then transitioned to Keppra. Her mental status improved back to baseline as her UTI was treated and she was loaded with dilantin. She was briefly intubated for airway protection but was quickly extubated once her mental status improved. - Patient needs to contiue to be transitioned to Keppra. She was started on Keppra 500mg [Hospital1 ] on [2193-3-8], this should be increased to 1000mg [Hospital1 ] on [2193-3-14] and the dilantin should be decreased to 200mg daily. On [2193-3-20] Dilantin should be decreased to 100mg daily and then stopped on [2193-3-27]. The Keppra should be continued at 1000mg [Hospital1 ]. - She should follow up with her Neurologist Dr. [Last Name (STitle) ] [Name (STitle) ] on [3-13] @ 1:30pm; [Telephone/Fax (1) 23810] . # Urosepsis: When patient presented she had elevated WBC, fever, and was hypotensive. She was breifly on pressors for blood pressure support but this was stopped as patient was treated with antibiotics. She was initially treated with vancomycin and ceftazidime for empiric coverage. Her blood cultures came back negative but her urine culture came back positive for UTI with Pseudomonas that was sensitive to ceftaz. The vancomycin was discontinued and the ceftaz was continued which should be completed on [2193-3-13]. She had a PICC line that was removed upon admission. A new PICC line was placed on [2193-3-7] once patient was being treated for infection and no longer had fevers. . #Tachycardia: She had episode of SVT, responded to 5mg lopressor IV. The patient then continued to have low grade tachycardia. She was put on loppressor 10mg IV q4 as patient was not taking PO meds. Once patient able to take PO meds her IV lopressor was stopped and she was given PO metoprolol. . #Esophageal dysmotility: Patient with history of esophageal dysmotility and appeared to be aspiration risk when she arrived. However when patient's mental status improved it appeared her swallowing also improved. There was concern for upper esophageal stricture so she underwent EGD which showed normal esophagus with no stricture. She also had video swallow as well as braium swallow which was consistent with esophageal dismotility. Patient did not want PEG tube at this time and wanted to try taking PO food. She was started on a diet that was recommended by speech and swallow and her PO pills were restrarted. Her EGD did show gastritis and patient was given PPI [Hospital1 ]. . # DM: She was initially kept on insulin sliding scale, when she was able to take PO meds she was restarted on her metformin. . # Metastatic thyroid CA with recurrence s/p iodine and XRT: Patient was followed by endocrine while in the hospital. While she was unable to take PO medication she was put on levothyroxine 100mcg IV which was then switched back to Levoxyl 150mcg [Hospital1 ] when she was again able to take PO meds. Her TFTs were monitored as there was concern that she would require more levothyroxine since she was started on Dilantin. However now that she is being transitioned to Keppra she will most likely remain on Levoxyl 150mcg [Hospital1 ]. - She should have her TFTs monitored once weekly and if trending toward hypothyroidism her levoxyl dose should be adjusted. A TSH and free t4 should both be checked. She should be done until she is off dilantin. . # Hisotry of DVT and PE: Patient with IVC filter on lifelong coumadin. Coumadin was held as patient's INR supratheraputic. Her INR continued to trend up most likely secondary to malnutrition and being on Dilantin. Her INR should be checked regularly and once < 2 her coumadin should be restarted with careful monitoring while still on dilantin. . Medications on Admission: -Ferrous Sulfate 325 mg daily -Amitripytiline 50 mg qhs -HCTZ 12.5 mg qd -SSI -Synthroid 150 mcg [Hospital1 ] -Metformin 850 mg [Hospital1 ] -lopressor 50 mg tid -MS Contin 15 mg [Hospital1 ] -Coumadin 6 mg daily -Docusate Sodium 100 mg twice daily -Morphine 1mg q 3hr prn -Hydralazine 50 mg po q6 hr -Senna 8.6 mg [Hospital1 ] prn -Folic Acid 1 mg daily -Clonidine 0.2 mg/24 hr patch weekly (Thursday) Discharge Medications: 1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) Units Injection TID (3 times a day). 4. Hydrochlorothiazide 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): This medication is to be increased to 1000mg po BID on [2193-3-13] . 7. Dilantin 100 mg Capsule Sig: Three (3) Capsule PO once a day for 4 days: On WED [3-13]: decrease dose to 200mg PO QDAY . On WED [3-20]: decrease dose to 100mg PO QDAY . D/C on [2193-3-27]. 8. Pantoprazole 40 mg IV Q24H 9. Ceftazidime-Dextrose (Iso-osm) 2 g/50 mL Piggyback Sig: Two (2) grams Intravenous Q8H (every 8 hours) for 5 days. 10. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO every six (6) hours. 11. Insulin Regular Human 100 unit/mL Solution Sig: As directed UNITS Injection ASDIR (AS DIRECTED): See Sliding Scale. 12. Morphine 2 mg/mL Syringe Sig: 1-2 mg Injection every 2 hours as needed as needed: Please give for breakthrough pain. 13. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day. 14. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO at bedtime. 15. Levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO BID (2 times a day): To be adjusted by endocrinologist with follow up TSH and T4 levels. 16. Metformin 850 mg Tablet Sig: One (1) Tablet PO twice a day. 17. Warfarin 2 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Seizure Disorder Altered Mental Status Urinary Tract Infection Esophageal Dysmotility Diabetes Mellitus Discharge Condition: Tolerating POs with swallowing instructions. Sating well on room air. Discharge Instructions: Please take all medications as prescribed. Please attend all follow up appointments. You should contact your health care providers if you develop fever, nausea, vomitting, or if you develop altered mental status including seizures and confusion. It is important that you practice the swallowing techniques outlined by the speech and swallow therapists. Followup Instructions: It is recommended that you see your Primary Care Doctor - [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. please call to schedule an appointment @ [Telephone/Fax (1) 4775]. . You have a neurology follow up appointment with Provider: [Name10 (NameIs) ] [Name8 (MD) ], MD, PHD[MD Number(3) 708]:[Telephone/Fax (1) 1690] Date/Time:[2193-3-13] 1:30 . Endocrine Provider: [First Name11 (Name Pattern1) 312] [Last Name (NamePattern4) 3015], M.D. Phone:[Telephone/Fax (1) 1803] Date/Time:[2193-3-14] 11:00 Completed by:[2193-3-11]	[ "553.3", "250.00", "530.5", "599.0", "V58.61", "276.51", "707.15", "289.81", "V45.4", "596.54", "535.50", "327.23", "787.2", "V12.51", "518.81", "348.30", "244.0", "041.7", "V10.87", "785.0", "345.90", "263.9", "724.2", "995.91", "276.2", "401.9", "285.29", "311", "038.9" ]	icd9cm	[ [ [] ] ]	[ "96.71", "45.13", "03.31", "96.04", "38.93", "96.6" ]	icd9pcs	[ [ [] ] ]	12659, 12738	6140, 10521	380, 448	12886, 12957	4175, 4175	13358, 13947	3681, 3714		10991, 12636		12759, 12865		10547, 10968			12981, 13335									3729, 4156																									319, 342									476, 2405						4191, 6117											2427, 3449	3465, 3665
15,558	182,587	13028	Discharge summary	report	Admission Date: [2155-6-2] Discharge Date: [2155-6-14] Service: CHIEF COMPLAINT: Chest pain HISTORY OF PRESENT ILLNESS: The patient is an 89-year-old female with a history of coronary artery disease, status post myocardial infarction, atrial fibrillation and interstitial lung disease who presented to the [Hospital3 3834] on [2155-6-1] with a chief complaint of chest pain. The patient reported making her bed on the morning of [6-1] when she collapsed. The patient denied prodrome or loss of consciousness. She noted epigastric pain, nausea, but denied chest pain, shortness of breath, diaphoresis at the time. At the outside hospital, the patient had a creatinine of 1.7, CK of 138, MB of 12 with an index of 9.2 and a troponin of 2.54. Electrocardiogram showed ST elevations of 4 to 5 mm in leads 2, 3 as well as in the right sided leads. The patient had a Q wave in 4 and F. She was transferred to [Hospital6 1760] for catheter. In the catheter lab, she had elevated right sided pressures with a right atrial pressure of 13 and RVEDP of 13 and dip and plateau physiology. Ejection fraction was 45%. The patient had severe inferior hypokinesis. No lytics were given at the outside hospital. There was no intervention taken in the catheter lab. The patient was transferred to the C-Med floor and at 9 p.m. on the night of the procedure, the patient developed hypertension and bradycardia. She did not respond to atropine. She could not be paced transcutaneously and was started on dopamine and transferred to the CCU. PAST MEDICAL HISTORY: 1. Coronary artery disease, status post myocardial infarction 2. Atrial fibrillation 3. Interstitial lung disease 4. Hypertension 5. Status post tonsillectomy ALLERGIES: METOPROLOL WHICH CAUSES A RASH. MEDICATIONS: 1. Aspirin 2. Hydrochlorothiazide 3. Prempro SOCIAL HISTORY: The patient is a family physician. [Name10 (NameIs) ] lives with her [Age over 90 ]-year-old husband. Denies tobacco or alcohol use. FAMILY HISTORY: Noncontributory PHYSICAL EXAM: VITAL SIGNS: The patient's pulse was 70, blood pressure 133/50, respiratory rate of 21 and oxygen saturation of 98% on 100% nonrebreather. GENERAL: The patient was an ill appearing female in no apparent distress. She was agitated. HEAD, EARS, EYES, NOSE AND THROAT: Extraocular muscles are intact. Pupils equally round and reactive to light, moist mucous membranes. NECK: No lymphadenopathy. There was jugular venous distention that was difficult to assess. CARDIAC: Regular rate and rhythm, normal S1, S2 and no murmurs, rubs or gallops. PULMONARY: Lungs are clear to auscultation bilaterally. ABDOMEN: Soft, nontender, nondistended with normoactive bowel sounds. EXTREMITIES: No edema. The patient had 2+ DP pulses. RECTAL: Guaiac positive. NEUROLOGIC: Patient was agitated. She had a low hertz tremor of the upper extremities. She had movement in all four extremities. She had 2+ biceps, patellar and deep tendon reflexes and downgoing plantar reflexes. PERTINENT LABORATORY FINDINGS: The patient had a white blood cell count of 17.6 with a hematocrit of 33.2 and platelets of 240. Her creatinine was 1.1. The patient had an anion gap of 21. CK was 972 with an MB of 133 and an index of 13.7. This rose to 981 with an MB of 137. The patient had a lactate of 4.8. The patient had an initial arterial blood gases of pH 7.25, PCO2 of 33 and PAO2 of 393. Repeat revealed pH of 7.31, PCO2 of 33 and PAO2 of 368. Electrocardiogram revealed a junctional escape rhythm at 40 with normal axis, right bundle branch block and ST elevations in 3 and F and ST depressions in L. Cardiac catheterization revealed right atrial pressure of 13, RVDP of 13, LVEDP of 13. Cardiac output was 4.53 with a cardiac index to 2.63. The patient had a right dominant system with a mid LAD lesion of 50%, left circumflex OM lesion of 40% and a proximal RCA lesion of 50%. The patient had a diagonal 40% to 50% lesion and a distal PDA 80%. SUMMARY OF HOSPITAL COURSE: The patient is an 89-year-old female, past medical history of coronary artery disease, status post myocardial infarction, atrial fibrillation, hypertension and interstitial lung disease who presented with an IMI and RV extension and now with severe bradycardia and hypertension. 1. CARDIOVASCULAR: The patient presented with a history of coronary artery disease, status post myocardial infarction in the past, now with inferior myocardial infarction, severe RV extension with hypertension, bradycardia and cardiogenic shock. From a coronary artery disease standpoint, the patient had three vessel disease with suspected RCA culprit that had largely become patent by the time of the first catheterization and there was no intervention performed. The patient has symptomatic bradycardia and hypotension. On transfer to the unit, the patient continued to have episodes of bradycardia and hypotension despite dopamine. It was decided to take the patient back to the cardiac catheterization lab for a second look. There was no change. Electrophysiology was consulted and felt that the patient's bradycardia was likely related to AV dysfunction and that a temporary pacing wire was not indicated at that point. The patient was maintained on aspirin, Plavix and Aggrastat. From a myocardium standpoint, the patient had an IMI with RV extension and elevated right ventricular pressures. Because of the patient's hypertension and RV infarcts, the patient was aggressively volume resuscitated. Bedside echocardiogram was done and revealed RV hypokinesis and inferior hypokinesis, otherwise relatively normal LV function. From a conduction standpoint, the patient had a junctional escape rhythm likely secondary to her ischemic heart disease. She had an initial response to dopamine with increase in heart rate and blood pressure. It was not felt that the patient needed a temporary wire at that point. Electrophysiology followed the patient. The day after admission to the CCU, the patient continued to have hypotension and bradycardia not responding to inotropes and .........otropes. She had been switched from dopamine to dobutamine. Lactate continued to be elevated. EP decided to place a temporary pacing wire. The patient also had a PA catheter placed in order to monitor the patient and ensure a physiologic cardiac output. The patient required intubation for control of her acidosis. The day after temporary pacer placement, the patient's cardiac output had improved. It had become evident that the patient's pacemaker had not been capturing. The EP fellow had been called and the set rate was increased. The patient had episodes of nonsustained ventricular tachycardia thought to be secondary to dobutamine and this was weaned off. The patient's acid base status improved with an improved cardiac output. The patient was markedly hypertensive in the post infarct and was started on intravenous enalaprilat with little effect. This was then transitioned to intravenous hydralazine with excellent results. The temporary wire was removed. The patient had an episode of tachypnea and shortness of breath and a chest x-ray revealed some evidence of congestive heart failure likely related to vigorous volume resuscitation. The patient responded excellently with 20 mg intravenous of Lasix. The patient had episodes of nonsustained ventricular tachycardia in the setting of relative bradycardia after the temporary wire was removed. EP was reconsulted for possible placement of a new temporary pacing wire versus permanent pacemaker placement. The patient's rhythm changed to atrial fibrillation. She was started on low molecular weight heparin. Eventually, her hydralazine was switched to captopril which she responded very well to. The patient ultimately underwent permanent pacemaker placement. The pacemaker was complicated by episodes of ventricular tachycardia and ventricular fibrillation in the EP lab after administration of ibutilide. The patient was easily cardioverted with 200 joules. The patient had a repeat echocardiogram that had an ejection fraction of greater than 55%, pulmonary artery hypertension, severe global right ventricular hypokinesis, 1+ mitral regurgitation and 2+ tricuspid regurgitation. The patient was eventually transitioned to oral anticoagulation. She will need to follow up with her outpatient cardiologist, Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 11493], in the electrophysiology device clinic. The patient was started on amiodarone 400 mg po tid. 2. PULMONARY: The patient was intubated for worsening acid base status and overwhelming lactic acidosis. With improvement in her cardiac output, her acidosis improved markedly. She was able to be extubated within three days. She was found to have a left lower lobe Methicillin sensitive Staphylococcus aureus pneumonia and was started on oxacillin with excellent clinical response. 3. RENAL: The patient presented with lactic gap acidosis which resolved with mechanical ventilation and improved cardiac output. The patient's creatinine was elevated on presentation, but returned to baseline level of 0.6. 4. NEUROLOGIC: The patient presented with agitation, mental status changes which were thought to be secondary to poor perfusion from decreased cardiac output. It was also thought that sedation as well as the patient's acid base status had a role in her mental status changes. The patient, post extubation, had dysarthria without aphasia. Her neurologic exam showed no focal deficits. Neurology was consulted and recommended a CT. CT scan revealed an old left temporal cerebrovascular event. The patient underwent MRI with DWI which revealed a presence of a stroke in the left uncus which did not correlate with the patient's dysarthria. Neurology and the stroke team recommended that the patient be anticoagulated. She was started on low molecular weight heparin with the hope to transition her to Coumadin at the time of discharge. Her dysarthria improved slowly but steadily throughout the admission. 5. GASTROINTESTINAL: The patient presented with guaiac positive stools. The patient had a relatively stable hematocrit throughout her admission, although she did require 2 units of packed red blood cells on admission for anemia and then 1 unit of packed red blood cells after her pacemaker placement to keep her hematocrit greater than 30. She did not have any evidence of gastrointestinal bleed while in hospital. 6. HEMATOLOGIC: The patient presented with platelets of 181. After being started on intravenous heparin post catheterization, the patient had declined in her platelets to 104 from an initial platelet count of 240. The patient's heparin products were held and a heparin dependent platelet antibody was sent. There was no evidence of heparin induced thrombocytopenia. The patient's heparin related antibody was negative. She was started on low molecular weight heparin without any adverse effect to her platelets. Her platelet count returned to the 200s. DISCHARGE CONDITION: Stable DISCHARGE STATUS: The patient was discharged with follow up in device clinic, as well as follow up with her cardiologist, Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 11493], one to two weeks after discharge. She will likely have to go to acute rehabilitation. The patient was discharged on aspiration precautions and fall precautions. She will have a cardiac diet. The patient was evaluated by the speech and swallow team who recommended that she be kept on a soft consistency diet although able to take pills po. She will be re-evaluated near the end of her admission for her ability to swallow. The remainder of this discharge summary will be dictated by the intern that picks up this CCU service. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 8227] Dictated By:[Last Name (NamePattern1) 5246] MEDQUIST36 D: [2155-6-13] 11:29 T: [2155-6-13] 12:54 JOB#: [Job Number 39891] cc:[Last Name (NamePattern1) 39892]	[ "428.0", "410.41", "785.51", "276.2", "426.6", "482.41", "427.31", "434.11", "792.1" ]	icd9cm	[ [ [] ] ]	[ "37.72", "96.71", "37.23", "37.22", "36.01", "37.83", "88.53", "88.56" ]	icd9pcs	[ [ [] ] ]				11132, 12185			2046, 2063																		2078, 4020													4049, 11110												101, 113									142, 1574																	1596, 1868	1885, 2029
16,860	137,112	45142	Discharge summary	report	Admission Date: [2125-7-5] Discharge Date: [2125-7-10] Date of Birth: [2064-12-26] Sex: M Service: MEDICINE Allergies: Motrin / Glyburide / Glucophage / Robitussin-Dm Attending:[First Name3 (LF) 1845] Chief Complaint: Back Pain Major Surgical or Invasive Procedure: None History of Present Illness: This is a 60 year old male with a history of diabetes type II, endocarditis s/p [Hospital3 ] valve replacement, CRI who presents to the ED with back pain for three weeks. The pain is a crampy pain that occurs in his right gluteus area. It is a sharp pain. Over the past few weeks he has been working with his PCP to control the pain. On [7-4] the patients exam was notable for new spinal tenderness and some new warmth over his skin. PCP attempted to obtain MRI of spine at that time but this was recorded as an incomplete study. Patient had persistent pain and was reffered to the ED. In the ED, initial vs were: 98.2 94 119/60 20 100. A CT revealed a bleed in the psoas muscle on the right. Patient was given was given vitamin K 10mg, haldol 5mg, dilaudid, ativan. Surgery evaluated the patient and said there was no indication for surgery at this time and recommended IR if continued bleeding. A femoral line was placed for access. Patient was started on one unit of FFP. His vitals at the time of transfer 98.1, 139, 132/59, 18, 100% RA. Past Medical History: DM2 HTN hyperlipidemia CRI hearing loss Colonic Polyp Aortic valve replacement s/p endocarditis (MRSA) in [2119] Social History: Currently on disability. Lives at home with his wife, [Name (NI) ]. They have 2 grown children. Reports occasional cigar use. Denies alcohol, drugs, or tobacco. No pets. Family History: No hx of MI or CAD. Mom with DM. Physical Exam: Physical Exam: Vitals: T:98.6 BP:120/54 (110's-160's/40's-60's) P:90 (80-90's) R: 18 O2: 97% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, good dentition, no oralpharyngeal ulcer Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Midline surgical scar along sternum, Regular rate and rhythm, normal S1/S2, w/ holosystolic murmur heard best at the upper left sternal border, rubs, gallops, valve click heard Abdomen: large midline vertical surgical scar extending from xyphoid processsoft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place Ext: Pt has amputation below the knee on left and missing two lateral digits on RLE, warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [2125-7-4] 11:15PM BLOOD WBC-13.7* RBC-3.48* Hgb-7.5* Hct-24.8* MCV-71* MCH-21.7* MCHC-30.4* RDW-18.4* Plt Ct-663# [2125-7-10] 05:40AM BLOOD WBC-7.8 RBC-3.50 Hgb-8.6* Hct-26.7* MCV-76* MCH-24.5* MCHC-32.2 RDW-19.4* Plt Ct-398 [2125-7-4] 11:15PM BLOOD Neuts-81.0* Lymphs-13.2* Monos-4.4 Eos-1.2 Baso-0.2 [2125-7-8] 06:20AM BLOOD Neuts-74.9* Lymphs-15.0* Monos-5.6 Eos-4.3* Baso-0.3 [2125-7-4] 11:15PM BLOOD PT-72.1* PTT-108.8* INR(PT)-8.5* [2125-7-10] 05:40AM BLOOD PT-21.2* PTT-29.7 INR(PT)-2.0* [2125-7-4] 11:15PM BLOOD Glucose-241* UreaN-47* Creat-2.2* Na-134 K-5.2* Cl-103 HCO3-20* AnGap-16 [2125-7-10] 05:40AM BLOOD Glucose-106* UreaN-15 Creat-1.3* Na-133 K-4.5 Cl-101 HCO3-24 AnGap-13 [2125-7-5] 08:17AM BLOOD Calcium-8.8 Phos-3.3 Mg-2.8* [2125-7-10] 05:40AM BLOOD Calcium-8.6 Phos-3.0 Mg-2.0 [2125-7-7] 07:27PM BLOOD Vanco-15.3 Blood Culture, Routine (Final [2125-7-17]): CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). IDENTIFIED AS CORYNEBACTERIUM AURIMUCOSUM , Identified by [Hospital1 ] laboratories. FINAL SENSITIVITIES. Sensitivity testing performed by Sensititre. ERYTHROMYCIN > 4 MCG/ML. 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. 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 _________________________________________________________ CORYNEBACTERIUM SPECIES (DIPHTHEROIDS) \| STAPHYLOCOCCUS, COAGULASE NEGATIVE \| \| CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- R =>8 R GENTAMICIN------------ <=2 S <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 2 R PENICILLIN G---------- 0.25 S RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ <=1 S <=0.5 S Aerobic Bottle Gram Stain (Final [2125-7-6]): REPORTED BY PHONE TO DR. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] PAGER [Numeric Identifier 40112] @ 0655 ON [2125-7-6]. GRAM POSITIVE ROD(S). Anaerobic Bottle Gram Stain (Final [2125-7-6]): GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. [2125-7-5] 8:17 am BLOOD CULTURE Source: Line-RIJ #1. FINAL REPORT [2125-7-17] Blood Culture, Routine (Final [2125-7-8]): 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. 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. CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). SENSITIVITIES PERFORMED ON CULTURE # [Numeric Identifier 96490]([2125-7-5]). IDENTIFICATION PERFORMED ON CULTURE # [Numeric Identifier 96490] [2125-7-5]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE \| CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 1 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ 1 S Aerobic Bottle Gram Stain (Final [2125-7-6]): REPORTED BY PHONE TO DR. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] PAGER [Numeric Identifier 40112] @ 0655 ON [2125-7-6]. GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. GRAM POSITIVE ROD(S). Anaerobic Bottle Gram Stain (Final [2125-7-6]): GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. [2125-7-7] 5:10 pm BLOOD CULTURE FINAL REPORT [2125-7-13] Blood Culture, Routine (Final [2125-7-13]): NO GROWTH. [2125-7-7] 1:35 pm BLOOD CULTURE FINAL REPORT [2125-7-13] Blood Culture, Routine (Final [2125-7-13]): NO GROWTH. CT ABD/PELVIS [2125-7-5]: IMPRESSION: 1. Retroperitoneal hematoma within the right iliacus and psoas musculature. Active extravasation is not assessed without contrast. 2. Cholelithiasis without CT evidence of cholecystitis. 3. Poorly characterized thickening of the fundus of the stomach. Though similar in appearance to [2121-8-22], endoscopy is again recommended for further evaluation, if not already performed. 4. Thoracolumbar degenerative change, without fracture. ECHO [2125-7-5]: The left atrium is normal in size. Left ventricular wall thicknesses and cavity size are normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. A bileaflet aortic valve prosthesis is present. The transaortic gradient is higher than expected for this type of prosthesis. No masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. The left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the report of the prior study (images unavailable for review) of [2121-12-27], gradient across the prosthetic aortic valve is similarly high, trace aortic regurgitation is now seen. Cannot adequately assess prosthetic valve endocarditis by TTE. Brief Hospital Course: MICU COURSE [Date range (1) 21036]: 60 year old male who presents to the ED with PMH of AVR for endocarditis on coumadin, DM, HLD, CRI baseline Cr 1.5, who presented to ED with back pain for two weeks and was found to have a right psoas hematoma on CT scan in setting of supratherapeutic INR to 4 and acute on chronic renal failure. He was admitted to the ICU and his INR was reversed with iv vitamin K. his hct dropped from baseline of low 30's to 24. He recevied 2u RBC and 2u plts and his hct rose to 25 and was stable. His cardiologist was contact[Name (NI) ] and agreed with holding anticoagulation for several days in setting of bleed. Plan was to bridge with heparin to coumadin and monitor inpatient while bridging given bleed. His renal failure improved to baseline of 1.5. Echo done over concern of possible endocarditis given slight leukocytosis which showed no endocarditis (can't be fully ruled out on TTE). Patient is full code. # Right psoas hematoma: Patient likely developed this in the setting of supratherapeutic INR found to be 8.4 on admission. His INR was reversed by IV vitamin K in the ED and he was transferred to the MICU for monitoring. He received 2units of pRBC and 2 units of pltlts and pt stabilized. His anticoagulation was held in the setting of psoas bleed. His bleeding remained stbale and pt was transferred to the floor. While on the floor the patient did not require any transfusions. His vital signs were stable and he was increasingly able to move his right leg with minimal pain. At time of discharge pt had near normal range of motion of his right psoas with no pain when the psoas muscle was isolated and stressed on physical exam. He was discharged to home with close follow up. . # AVR: Pt anticoagulation for AVR was stopped secondary to supratherapuetic INR and psoas hematoma. After pt hematoma stabilized, vital signs were stable and patient was transferred to the floor he was started on a heparin drip and bridged over to coumadin. There were no complications related to the short discontinuation of his warfarin therapy and there were no complications with his AVR. # DMII: Patient on insulin at home. His home doses of insulin were continued in addition to a prandial insulin sliding scale. FS and blood sugars were checked and were well controlled through his hospital course. . # Acute on Chronic renal failure: Pt has a baseline Cr of 1.5 prior to admission and on admission it was elevated to 2.2. As pt was treated his Cr trended down back to baseline. This acute rise in Cr was likely secondary to hypovolemia in the setting of a large psoas hematoma. Pt was discharged to home therapuetic on heparin with close follow up with his PCP. Medications on Admission: AZELASTINE- 137 mcg Spray [12-23] sprays(s) CALCITRIOL - 0.25 mcg three times weekly CLINDAMYCIN PHOSPHATE 1 % Lotion [Hospital1 ] prn FOLIC ACID 1 mg daily LISINOPRIL - 5 mg once a day METOPROLOL TARTRATE - 25 mg twice a day OXYCODONE-ACETAMINOPHEN - 5 mg-325 mg 2 twice a day prn pain PANTOPRAZOLE 40 mg qHS SILDENAFIL 100 mg 20-30 minutes before sexual activity SIMVASTATIN 20 mg at bedtime WARFARIN 10mg four days a week and 7.5mg three times a week. ASPIRIN - 81 mg Tablet INSULIN NPH: 20U am, 10U pm. Humalin sliding scale Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. Disp:30 Tablet(s) Refills:0 3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Disp:2 Tablet(s) Refills:0 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice a day. 7. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 8. Outpatient Lab Work Patient should have INR drawn every other day with his first INR drawn tomorrow [2125-7-11] 9. Warfarin 5 mg Tablet Sig: 1.5 Tablets PO once a day. Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Psoas hematoma Discharge Condition: Pt is A&ox3, ambulatory with a walker and has been stable since transfer out of the intensive care unit. He is medically ready for discharge with follow up with Dr. [First Name (STitle) ] and Dr. [Last Name (STitle) ] on Friday [7-13]. [Company 191] warfarin clinic will also be made aware that he is being discharged. Discharge Instructions: You are being discharged from the hospital today. You were admitted because you were found to have a large collection of blood in your psoas, hip, muscle. This collection of blood caused the extreme pain you felt when you moved your right leg. This likely occurred because your INR was very high at 8.5. We want your INR between 2.5-3.5 in order to prevent clots on your valve. Somehow this value got out of control and it should be followed closely when you are discharged. You received 3 units of blood while you have been in the hospital. Initially, your blood cultures were positive. We initially treated you with IV antibiotics then switched you to oral antibiotics on discharge. In addition, you have an appt with Dr. [First Name (STitle) ] on Friday [7-13]. We will also have someone come to your house and check your INR tomorrow, [7-11]. You should continue on the following home meds: FOLIC ACID 1 mg daily LISINOPRIL - 5 mg once a day METOPROLOL TARTRATE - 25 mg twice a day OXYCODONE-ACETAMINOPHEN - 5 mg-325 mg 2 twice a day prn pain PANTOPRAZOLE 40 mg qHS SIMVASTATIN 20 mg at bedtime INSULIN NPH: 20U am, 10U pm. The following medication was changed: warfarin 10mg 4 days a week and 7.5 3 days a week --> warfarin 7.5mg 7 days a week. The following medication was added levofloxacin 500mg Q24hrs Followup Instructions: Department: [Hospital3 249] When: FRIDAY [2125-7-13] at 3:00 PM With: [First Name11 (Name Pattern1) 275] [Last Name (NamePattern4) 1849], M.D. [Telephone/Fax (1) 250] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: WEST [Hospital 2002] CLINIC When: FRIDAY [2125-7-13] at 11:30 AM With: [First Name11 (Name Pattern1) 177] [Last Name (NamePattern4) 720], M.D. [Telephone/Fax (1) 721] Building: De [Hospital1 ] Building ([Hospital Ward Name 121] Complex) [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage	[ "285.1", "V58.61", "403.90", "585.9", "790.92", "V43.3", "729.92", "584.9" ]	icd9cm	[ [ [] ] ]	[ "38.93" ]	icd9pcs	[ [ [] ] ]	13908, 13966	9775, 12498	318, 324	14025, 14364	2690, 9752	15746, 16445	1754, 1788		13086, 13885		13987, 14004		12524, 13063			14388, 15723									1818, 2671																									269, 280									352, 1405																	1427, 1546	1562, 1738
31,886	169,645	50995	Discharge summary	report	Admission Date: [2164-11-15] Discharge Date: [2164-11-18] Date of Birth: [2082-10-9] Sex: M Service: MEDICINE Allergies: Inderal Attending:[Last Name (NamePattern4) 290] Chief Complaint: traumatic fall Major Surgical or Invasive Procedure: arterial line History of Present Illness: The patient is an 82 year old man who was admitted in the afternoon of [2164-11-15] with a fall at home complicated by rib pain and found to have multiple rib fractures now transfered to the ICU for hypoxic and hypercarbic respiratory distress. . He is an 82 M with hx of CAD s/p DES x4, CABG, CHF with EF55%, hx of renal cell carcinoma, COPD, and CKD presents with severe L rib pain, SOB, and vomiting with exertion. On the morning of presentation (~9am)the patient slipped on ice landing on his R flank. He took an unknown amount of tylenol #3 prior to coming to hospital. HE denied LOC. Denies striking head. EMS called and pt refused transport. Denies neck, back pain but has noted severe, [9-12] pain with any inspiration over L flank. Large ecchymosis over area. Son reports pt s/p 2 episodes vomiting with exertion this pm, initially yellow. No hematemesis. Denies abd pain. Has chronic urinary incontinence. Per ED patient recently increased his furosemide dose. . In the ED he had a CXR that showed no infiltrate, edema, or pneumothorax. He had rib films that showed multiple rib fractures ([5-12]). He was admitted for pain control and evaluation of acute on chronic renal failure. On arrival to the medicine floor he was "lethargic and sleepy" was afebrile with repirations of 16 and O2sat 93%2L. He had received no pain medications since arrival to the medicine floor. At ~2:45 am he was found to be hypoxic with O2sat 71% on 2L. He received nebs and was able to wean his supplemental O2 to 2-3L. However at ~4am, he desatted again requiring a NRB and ICU transfer. Also he was found to have a bladder scan of ~500cc and a foley catheter was placed. . ROS: no nausea. no vomiting. no leg pain. no increase in leg swelling. left chest pain. Past Medical History: Hyperlipidemia hypertension CAD: (Outpatient cardiologist is Dr. [Last Name (STitle) ] - s/p CABG status post coronary artery bypass graft in [2138] SVG--> OM1 (last stented in [2162] x 3), SVG-->LAD (last stented in [2162]), SVG-->RCA (occluded) - MI [2151], multiple cardiac catherizations and stent placements. AV delay: - [Company 1543] pacer AV placed for AV delay/conduction disease in [2159]- interrogated last [10-10] CHF (diastolic dysfunction, LVH, EF 40-45%) COPD History renal cell carcinoma s/p nephrectomy [2149] Chronic Renal failure (baseline 2.4-3) Pernicious anemia AAA Diabetes Prostate cancer Lung nodules potentially from lung cancer vs mets (seen 2 years ago) Social History: retired furniture salesman. Married, has children, one daughter is a nurse and works at [Hospital1 18]. He currently lives with his son and grandson. They are very involved and very supportive. He has an extensive smoking history (stopped 25yrs ago) and admits to minimal EtOH. He denies use of illicit substances. Family History: noncontributory Physical Exam: Vitals: 98.3 82 142/66 15 99%NRB Gen: ill appearing. moaning in pain HEENT: dry MM. PERRL. EOMI. no battle sign or racoon eyes. no head bruising Neck: supple. no JVD seen Chest: ecchymotic patch to left flank CV: regular. S1/S2 w/o murmur or gallop Abd: adipose. soft. active bowel sounds Ext: venous harvest on right. chronic venous stasis bilat Skin: ecchymosis to left upper flank Neuro: -MS: alert. oriented to self, "[Hospital3 ]" "[2113]" -CN: pupils reactive. EOMI. face [Last Name (un) 36] intact. head turn intact -Motor: moving -DTR: -[Last Name (un) ]: light touch intact to face, arms, legs Pertinent Results: EKG: sinus. PR prolongation (stable from priors). right axis deviation. RBBB. slow R wave progression. no ST-T changes from prior . Studies: [2164-11-15] CXR Cardiomediastinal silhouette is grossly unchanged. Patient is status post median sternotomy with wires intact. A left basal nodule measures 13 mm. Right basal nodule is not well seen on today's study. There is no pneumothorax or focal consolidations. Pulmonary vascularity is normal. Left pleural thickening is stable since [2164-5-4]. Osseous structures are diffusely demineralized. There is no displaced fracture. . [2164-11-15] rib xray - There are nondisplaced and mildly displaced fractures of four contiguous left-sided ribs (the sixth through ninth ribs). There is increased pleural density in this region which could reflect associated hematoma. No pneumothorax is seen. Chest is unchanged in appearance with a [Month/Day/Year 4448] seen in the left anterior chest wall and prominent cardiomegaly. Subsegmental atelectasis is seen at the bases bilaterally. Osseous structures are otherwise unremarkable. . [2164-11-16] CXR - (unofficial) patchy rounded opacities in right mid lung field and left base potentially atelectasis vs infiltrate [2164-11-15] 04:36PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.016 [2164-11-15] 04:36PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2164-11-15] 04:36PM URINE RBC-1 WBC-0 BACTERIA-NONE YEAST-NONE EPI-0 [2164-11-15] 04:33PM GLUCOSE-140* UREA N-91* CREAT-3.4* SODIUM-141 POTASSIUM-5.4* CHLORIDE-105 TOTAL CO2-24 ANION GAP-17 [2164-11-15] 04:33PM CK(CPK)-66 [2164-11-15] 04:33PM CK-MB-NotDone cTropnT-0.02* [2164-11-15] 04:33PM CALCIUM-8.8 PHOSPHATE-7.6# MAGNESIUM-2.7 [2164-11-15] 02:23AM GLUCOSE-179* UREA N-85* CREAT-3.4* SODIUM-141 POTASSIUM-4.9 CHLORIDE-101 TOTAL CO2-29 ANION GAP-16 [2164-11-15] 02:23AM estGFR-Using this [2164-11-15] 02:23AM CK(CPK)-77 [2164-11-15] 02:23AM cTropnT-0.02* [2164-11-15] 02:23AM CK-MB-NotDone proBNP-4228* [2164-11-15] 02:23AM WBC-8.7 RBC-4.71# HGB-13.0# HCT-41.4# MCV-88 MCH-27.6 MCHC-31.5# RDW-15.1 [2164-11-15] 02:23AM NEUTS-91.1 LYMPHS-5.0* MONOS-3.6 EOS-0.3 BASOS-0.1 [2164-11-15] 02:23AM PLT COUNT-231 [2164-11-15] 02:23AM PT-12.4 PTT-26.4 INR(PT)-1.1 Brief Hospital Course: The patient is an 82 year old man with history of extensive CAD, CHF, DM2, COPD, RCC now presenting with rib fractures following a fall complicated by respiratory distress. The patient's daughter confirmed that he was DNR/DNI. He was placed on bipap to help with his breathing which was particularly difficult given the need to balance treatment of his fracture pain with adequate mentation and respiratory effort. An epidural could not be placed as the patient was taking clopidogrel. The patient remained significantly acidemic with pH 7.1 and elevated CO2. Family members concluded that he would want comfort care only and did not want to continue with invasive interventions. The patient was made CMO status and appeared comfortable. He received morphine boluses prior to moving him but otherwise did not require additional therapeutics. . HOSPITAL COURSE BY PROBLEM PRIOR TO CMO STATUS: # Respiratory Distress: likely secondary to pain with splinting from rib pain resulting in ventilation and oxygenation deficits. given normal or near normal serum bicarb likely not a significant CO2 retainer at baseline. no fever or evidence for infection however with vomiting and altered mental status could have aspirated. likely dehydrated as opposed to in CHF. no pneumothorax on imaging. other potentials could be PE however seems early in course for this and has no hemodynamic or ECG evidence for PE. - cycle cardiac enzymes: peaked at 0.04 - serial ABG: most recent 7.21/77/101 - Chest CT yesterday noted as above - NIPPV yesterday without signif improvement in PCo2. Still with myoclonus. Will re-attempt with higher PS today. - A-line for BP monitor and frequent ABG - CXR this am as above. Limit fluid today . # Altered mental status/myoclonus: non-focal neuro exam and altered mental status has waxed and waned with the respiratory distress (i.e. CO2 narcosis) which supports this as the primary disorder. however with recent trauma, SDH also possible. - serial ABG as above - CT head: negative - Mental status improved yesterday. Will target improving Co2 status to improve mental status and myoclonus. -DC'd lidoderm patch yesterday without change in myoclonus. . # Acute on chronic renal failure: likely pre-renal with component or post-renal given large bladder scan. - UA, urine lytes showing likely pre-renal etiology with high osmol and low urine Na. - renally dose meds - UOP improved this am. - Limit further fluids now that uOP increasing. . # Fall: likely mechanical secondary to slipping on ice at home. no evidence of head trauma per history or exam. - monitor as above - low dose dilaudid for pain given renal impairment if needed - Acute pain service: no epidural due to plavix. Recs tylenol, neurontin, prn dilaudid. . #DM: Sliding scale insulin with good coverage yesterday. . # CAD: no ischemic changes on EKG and negative enzymes x 2. however with new respiratory changes reasonable to re-cycle enzymes - cycle enzymes. Peaked at 0.04 - repeat EKG - continue aspirin/plavix/statin . # CHF: appears dehydrated as shown in Hct, Cr, and mucous membranes. - hold home diuretics - received gentle IVF on [11-16]. Limit further IVF [11-17]. - hold ACE for now - continue BB . #Lung mets from unknown primary, possible renal given history RCC. - no further eval at this time. Will discuss with daughter. . # FEN: Limit further IVF. Replace as needed. NPO for now. . # Prophy: hep sc, bowel regimen # Access: PIV # Code: DNR/DNI confirmed with daughter who corroborated with her 2 siblings. Will discuss DNI with daughter regarding possible temporary intubation for Co2 reduction. # Contact Info: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 27320] (daughter) cell: [Telephone/Fax (1) 103116] # Dispo: ICU Medications on Admission: ASA 325 mg QD Plavix 75 mg daily captopril 100 mg [Hospital1 ] atenolol 100 mg daily Lipitor 40 mg QD Norvasc 10 mg QD Lasix 40 mg [Hospital1 ] Imdur 120 mg doxazosin 8mg levothyroxine 50mg Spirva Zaroxolyn 5 mg daily albuterol prn epogen 3x/week Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: Primary: s/p fall hypoxic and hypercarbic respiratory distress Secondary: hyperlipidemia hypertension CAD s/p PPM CHF COPD chronic renal failure pernicious anemia AAA diabetes prostate cancer lung nodules Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292]	[ "197.0", "518.5", "V45.82", "V10.52", "V66.7", "585.9", "428.0", "276.51", "281.0", "333.2", "441.4", "428.42", "V45.81", "496", "414.00", "584.9", "272.4", "E885.9", "807.04", "780.97", "244.9", "V45.01", "518.0", "V10.46", "403.90", "250.00" ]	icd9cm	[ [ [] ] ]	[ "89.61" ]	icd9pcs	[ [ [] ] ]	10386, 10395	6289, 7702	292, 307	10644, 10653	3868, 6266	10709, 10855	3196, 3213		10354, 10363		10416, 10623		10074, 10331			10677, 10686									3228, 3849																						7719, 8275			238, 254									335, 2101		8284, 10048															2123, 2844	2860, 3180
29,268	119,534	34154	Discharge summary	report	Admission Date: [2120-4-11] Discharge Date: [2120-5-23] Date of Birth: [2082-3-15] Sex: M Service: MEDICINE Allergies: Compazine Attending:[First Name3 (LF) 613] Chief Complaint: endocarditis Major Surgical or Invasive Procedure: none History of Present Illness: 38 yo man with a h/o IVDA, TV endocarditis in [2117] s/p bioprosthetic valve replacement and recurrent endocarditis in [2118] (MRSA). He was in his usual state of health until 7 days ago when he began having fevers, chills, B foot pain, nausea and diarrhea. He presented to [Hospital1 1562] 4 days ago ([4-8]) and was found to have high-grade MSSA bacteremia. He was treated with IV Nafcillin and had an echo showing possible TV and MV endocarditis (although suboptimal study). CXR showed RML pneumonia. Possible RML pneumonia/septic emboli. He was felt to be clinically worsening with continued high-spiking fevers, bacteremia, worsening thrombocytopenia. His antibiotics were broadened to cefipime and flagyl prior to transfer. Of note he also was caught using cocaine and marijuania at [Hospital1 1562]. In the MICU pt was changed to IV nafcillin and gentamicin for synergy is now afebrile with VSS and comfortable without any complaints when seen. He had a TTE demonstrating multiple moderate-sized vegetations on the tricuspid valve leaflets, causing obstruction of transtricuspid flow, and moderate tricuspid stenosis. CT [Doctor First Name ] were consulted and determined him a poor surgical candidate given risk of repeat-sternotomy and his current drug abuse Past Medical History: Tricuspid valve endocarditis [1-13] MRSA in [2117]; s/p bioprosthetic TV at [Hospital1 2025] MSSA bacteremia/endocarditis, [2-/2119] HCV IVDA and polysubstance abuse # Tricuspid valve endocarditis [1-13] MRSA in [2117]; s/p bioprosthetic TV at [Hospital1 2025] # MSSA bacteremia/endocarditis, [2-/2119] # HCV # IVDA and polysubstance abuse # Asthma, mild and not on meds Social History: last IVDA 5 months ago. last cocaine/MJ at [Hospital ] hospital 2 days ago. unemployed. Family History: family healthy Physical Exam: (on admission) T 100.8 BP 113/79 HR 96 RR 30-36 96% on RA General: sleepy, tachypneic, no distress HEENT: NCAT, PERRL, EOMI, neck supple, w/o LAD, icteric sclera, no hemorrhage CV: tachy + systolic murmur at LLSB. ?S4 Pulm: scattered crackles and wheezing Abd: s/nd + RUQ and LUQ TTP. + liver edge, spleen non-palpable. no rebound/gaurding Ext: papular rash on RLE. no petechiae/splinter hemorrhage or [Last Name (un) ] lesions/osler nodes Pertinent Results: TTE ([2120-4-12]): The left atrium is mildly dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 70%) There is no ventricular septal defect. The aortic arch is moderately dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. A bioprosthetic tricuspid valve is present. The gradients are higher than expected for this type of prosthesis. The leaflets of the tricuspid prosthesis are thickened. There is are multiple moderate-sized vegetations on the tricuspid valve leaflets, causing obstruction of transtricuspid flow. There is moderate tricuspid stenosis (area 1.0-1.5cm2). There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: bioprosthesis tricuspid valve endocarditis; tricuspid valve prosthesis stenosis . CT head ([2120-4-11]): No CT evidence for septic emboli in the brain. . CT chest, abd, pelvis ([2120-4-11]): 1. Severe multifocal airspace opacities are identified within the lung parenchyma. This may represent multifocal infection possibly from septic emboli. 2. No evidence of intra- or extra-hepatic biliary dilatation. 3. Fusion of the right SI joint for which clinical correlation is recommended as detailed above. Gallbladder wall is mildly thickened and there is splenomegaly, free fluid, as well as enlarged perihepatic lymph nodes, which may all represent a sequela from underlying chronic liver disease. . TTE ([2120-4-26]): The left atrium is elongated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%) The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. Mitral valve leaflets are normal, with trivial mitral regurgitation. A bioprosthetic tricuspid valve is present. There is a large (2.0 x 1.1 cm), highly-mobile vegetation on the tricuspid prosthesis. There is no abscess of the tricuspid valve, and the sewing ring appears intact, without dehiscence or paravalvular regurgitation. The vegetation is partially obstructive to flow, resulting in functionally-moderate tricuspid stenosis (mean gradient 15 mmHg). No vegetation/mass is seen on the pulmonic valve. Estimated pulmonary pressures are normal. There is no pericardial effusion. IMPRESSION: Prosthetic tricuspid valve endocarditis with moderate functional tricuspid stenosis. . CT chest w/ contrast ([2120-4-25]): 1. Persistent multiple pulmonary septic emboli. 2. Hepatosplenomegaly. Decreased attenuation of the right lobe may represent focal fatty infiltration. 3. Fusion of the right SI joint, unchanged. 4. Increased sclerosis of the left pubic symphysis, unchanged. 5. Scattered mesenteric, retroperitoneal, and periportal lymph nodes, unchanged. Brief Hospital Course: 38 yo man with h/o TV endocarditis with prosthetic valve transferred from OSH on [4-11] w/ high-grade MSSA bacteremia, tricuspid prosthetic valve endocarditis, and septic pumonary emboli recovering on nafcillin, rifampin (s/p 2 wks of gent), now with budding yeast in [Month/Day (4) ] cx from [4-23] and new murmur over apex radiating into axilla. . # MSSA endocarditis In the MICU pt was changed to IV nafcillin and gentamicin for synergy and was afebrile with VSS and comfortable without any complaints when seen. He had a TTE demonstrating multiple moderate-sized vegetations on the tricuspid valve leaflets, causing obstruction of transtricuspid flow, and moderate tricuspid stenosis. CT [Doctor First Name ] were consulted and determined him a poor surgical candidate given risk of repeat-sternotomy and his current drug abuse. . Enlarged TV vegetation on top of tricuspid prosthetic valve MSSA bacteremia and endocarditis. CT torso without obvious signs of seeding, TTE with enlarged TV vegetation after fungemia, dilated fundoscopic exam by ophtho normal. Continued 6 week course of nafcillin+rifampin, from first neg bld cx ([4-11])m this was completed [5-23]. He was kept an inpatient to complete course due to history of IV drug use and inability to discharge to facility with PICC. He has a ESR and CRP drawn prior to discharge so that ID could repeat these labs at his follow up appointment to ensure resolution of his bacteremia. . # Candidemia Completed 2 week course of fluconazole, d/c on [5-8], repeat [Month/Year (2) ] cx 5 days later with no growth to date. . # Drug abuse - used cocaine and MJ at OSH, caught taking pain meds and mixing in needles at [Hospital1 18] - no pain meds - Social work and addiction medicine following - appears to sincerely intend to not use in future (but definitely at high risk) - states he will enter rehabilitation program once he leaves hospital - patient to follow up with psychiatry, was started on anti depressant inpatient . # Disposition Patient was scheduled follow up appointment with ID on [2120-6-12] for follow up and with a new PCP at [Name9 (PRE) 191] on [2120-6-17]. He was instructed of the importance to follow up at these appointments Medications on Admission: nafcillin cefipime flagyl ativan 1mg q 6 prn protonix albertrol Discharge Medications: 1. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp:30 Patch 24 hr(s) Refills:3 2. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. Disp:10 Tablet(s) Refills:0 3. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). Disp:28 Tablet Sustained Release(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: MSSA infective endocarditis Candidemia h/o polysubstance abuse Discharge Condition: Stable Discharge Instructions: You were admitted to the ICU initially for treatment of endocarditis of your prosthetic tricuspid valve. You also developed a fungal infection of the [Date Range ] 2 weeks later which was treated with a 2 week course of anti-fungal agents. You were kept in the hospital to complete a 6 week course of IV antibiotics to clear the infection with endocarditis. You have appointments scheduled to see Dr. [Last Name (STitle) ] of infectious diseases on [6-12] at 10am and Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1887] as your new primary care doctor [First Name (Titles) ] [6-17] at 3pm. You will also have an appointment with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 78730] of psychiatry. Please ensure you follow up at these appointments so you can be well established in the system. Make sure your insurance company knows you have switched to [Company 191] as your primary clinic. If you develop any fevers, chills, night sweats, chest pain, trouble breathing, back pain it is extremely important you go straight to the emergency room and tell them you have a prosthetic valve and recently had endocarditis. If you develop any concerning symptoms call [Hospital 191] clinic and request an appointment. Followup Instructions: Provider: [Last Name (NamePattern4) ]. [First Name (STitle) ] [First Name (STitle) 3143] Phone:[Telephone/Fax (1) 457] Date/Time:[2120-6-12] 10:00 Provider: [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) 6811] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2120-6-17] 3:00 [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 78730] of psychiatry at [Telephone/Fax (1) 78731] [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 617]	[ "112.5", "304.21", "253.6", "038.11", "304.01", "415.12", "287.5", "996.61" ]	icd9cm	[ [ [] ] ]	[ "38.93" ]	icd9pcs	[ [ [] ] ]	8452, 8458	5650, 7912	282, 288	8565, 8574	2659, 5627	9907, 10501	2163, 2179		8026, 8429		8479, 8544		7938, 8003			8598, 9884									2194, 2640																									230, 244									316, 1611																	1633, 2038	2054, 2147
80,344	102,906	54725	Discharge summary	report	Admission Date: [2193-5-9] Discharge Date: [2193-5-22] Date of Birth: [2161-1-29] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 983] Chief Complaint: Overdose Major Surgical or Invasive Procedure: - Flexible bronchoscopy with bronchoalveolar lavage and upper endoscopy [5-9] - Temporary HD line placed on [2193-5-13] - Permanent Right HD line placement on [2193-5-17] History of Present Illness: The patient is a 32 y/o M with unknown PMHx who was brought to OSH ED after being found altered at his apartment. Was found with suicide note as well as numerous empty Coridicin HBP packages (>100tabs). Febrile to 105 at OSH, agitated, delirious. Intubated at OSH and found to have elevated AST/ALT. Per MA/RI PCC, pt was started on NAC. Was also given vanc/ceftriaxone due to fever and Leukocytosis to 35 with bandemia. On arrival to [Hospital1 18] ED, toxicology was consulted. Recommended to continue NAC. Labs were significant for Na 150, Cl 114, HCO3 18, Cr 3.9. CK [Numeric Identifier 111890]. Ca 6.8. ALT 185, AST 1070. Lipase 95. Serum Osm 321 (Osmolar gap 1). WBC 17.9. Urine tox was positive opiates and cocaine. Serum tox was negative (including acetaminophen). Most recent ABG 7.23/50/114/22. CXR was unremarkable. CT head showed no acute intracranial process but did show soft tissue air in the right masticator, parapharyngeal and prevertebral space. CT neck and chest showed pneumomediastinum, bilateral pneumothoraces, as well as subcutaneous air. ETT noted to have cuff leak and was changed. On arrival to the MICU, the patient was intubated and sedated. ROS was unable to be obtained. (At the time of admission, patient's identity was [Last Name (un) 6722]) Past Medical History: - Bipolar Disorder II - Depression: H/o multiple suicide attempts and prior h/o dextromethorphan abuse and overdose in past. Recently hospitazied twice at [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] for depression. Since [93] yo had issues w/ etoh and marijuana; at 16 yo milatary academy; ICU 2x during college for dextramethorphan abuse; 10 years ago otc decongestant w/ ste/htn crisis 3 years manic depressive girlfriend broke up with - has been at [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] 3x (last time [Month (only) ] for depression; suicide attempt; od on adderal) -does not have outpatient psychiatrist Social History: Patient works as a professor [First Name (Titles) ] [Last Name (Titles) 21569] History at an online college program based in Cypress, [State 2690]. Has had job for 4 yrs. He also recently taught at Northshore Community College but lost his teaching contract in this Spring. Pt currently lives alone. - tobacco:+ 2 packs of cigarettes a day - etoh: 12 packs of beer/wk. - illicits: prior h/o dextromethorphan abuse, Patient uses Adderall one week per month. Stated occasional use of cocaine but "not often" because of cost. Last used it over the weekend. EtOH use: Smokes - housing: lives alone - employement: teaches history, graduate degree - family: father in [Location (un) 3844] ENT physician, [Name10 (NameIs) ] in [State 15946], one of 8 (oldest son) children Family History: No significant family history of kidney disease Physical Exam: ADMISSION Vitals: T: 97.2 BP: 133/95 P: 75 R: 22 O2: 100% General: sedated and intubated, no apparent distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, pupils dilated but reactive Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: Foley present, dark brown urine Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: sedated DISCHARGE Vitals: T 98.7 BP 170/98 HR 87 RR 18 pOx 95 on RA General: NAD HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI CV: rrr, normal S1 + S2, no murmurs, rubs, gallops CHEST: tunneled dialysis line (RIGHT IJ) in place non-erythematous Lungs: clear through out Abdomen: soft, non-tender no rebound or gaurding Ext: No clubbing/cyanosis/edema. NEURO: CN III-XII intact, motor 5/5 strength through out, tremulous w/ FNF no asterixis. PSYCH: Denies SI/HI, depressed mood with constricted affect Pertinent Results: ADMISSION LABS [2193-5-9] 12:00AM BLOOD WBC-17.9* RBC-3.64* Hgb-13.0* Hct-38.3* MCV-105* MCH-35.6* MCHC-33.8 RDW-14.0 Plt Ct-155 [2193-5-9] 12:00AM BLOOD Neuts-92* Bands-2 Lymphs-3* Monos-2 Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0 [2193-5-9] 12:00AM BLOOD Glucose-128* UreaN-35* Creat-3.9* Na-150* K-3.5 Cl-114* HCO3-18* AnGap-22* [2193-5-9] 12:00AM BLOOD ALT-185* AST-1070* CK(CPK)-[Numeric Identifier 111890]* AlkPhos-44 TotBili-0.3 [2193-5-9] 12:00AM BLOOD Albumin-3.9 Calcium-6.8* Phos-5.5* Mg-2.6 PERTINENT LABS: [2193-5-9] 12:00AM BLOOD Glucose-128* UreaN-35* Creat-3.9* Na-150* K-3.5 Cl-114* HCO3-18* AnGap-22* [2193-5-9] 12:00AM BLOOD ALT-185* AST-1070* CK(CPK)-[Numeric Identifier 111890]* AlkPhos-44 TotBili-0.3 [2193-5-9] 12:00AM BLOOD Lipase-95* [2193-5-9] 12:00AM BLOOD cTropnT-<0.01 [2193-5-9] 12:00AM BLOOD Lithium-LESS THAN [2193-5-9] 12:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2193-5-9] 12:04AM BLOOD pO2-227* pCO2-44 pH-7.26* calTCO2-21 Base XS--6 [2193-5-9] 12:36AM BLOOD Lactate-0.4* [2193-5-9] 03:00AM BLOOD O2 Sat-94 [2193-5-9] 06:06AM BLOOD freeCa-0.97* [2193-5-9] 12:00AM BLOOD Lithium-LESS THAN SEROLOGIES: [2193-5-13] 04:01PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE [2193-5-13] 04:01PM BLOOD HCV Ab-NEGATIVE CXR - FINDINGS: Comparison is made to previous study from [2190-12-13]. There is an endotracheal tube whose tip is 2.5 cm above the carina. This could be pulled back approximately 1 cm for more optimal placement. There is a nasogastric tube whose tip and side port are below the gastroesophageal junction. Lungs are grossly clear. There is scoliosis. There is normal heart size. No pneumothoraces are identified. NCHCT [2193-5-9]: 1. Normal brain CT. 2. Soft tissue air in the right masticator, parapharyngeal and prevertebral space of unknown etiology. CT of the neck and chest might be considered. CT CHEST [2193-5-9]: 1. Moderate pneumomediastinum and small bilateral pneumothoraces. 2. Small bilateral pleural effusions and bibasilar opacities, likely aspiration or atelectasis. 3. Bilateral supraclavicular soft tissue air. 4. Appropriately placed ET and OGT. No evidence of esophageal or tracheal injury on CT. 5. No fractures. CT NECK [2193-5-9]: 1. Moderate to large amount of soft tissue gas, most pronounced in the R>L supraclavicular regions, along the sternocleidomastoid muscles of the neck, the upper neck prevertebral soft tissues and the partially seen mediastinum. 2. Small, only partially seen left pneumothorax. 3. No large neck hematoma, and no fracture. RENAL US [2193-5-9]: 1. Echogenic renal parenchyma bilaterally, compatible with diffuse parenchymal disease. No hydronephrosis. 2. Trace right perinephric fluid. CT NECK [2193-5-11]: 1. Interval decrease in soft tissue gas involving mediastinum, bilateral supraclavicular regions, right sternocleidomastoid, and right masticator spaces. 2. New bilateral moderate-sized pleural effusions, right slightly greater than left, incompletely imaged. 3. Interval extubation. 4. Previously seen left apical pneumothorax is no longer visualized. CT CHEST [2193-5-11]: 1. Interval decrease in pneumomediastinum and supraclavicular subcutaneous soft tissue air. 2. Slight interval decrease in size of bilateral small pleural effusions. Associated atelectasis is also present. 3. Interval resolution of small bilateral pneumothoraces. BARIUM SWALLOW [2193-5-11]: Swallows of thin barium in the frontal, lateral, and oblique positions show normal swallow function without evidence of leak. The column of barium is seen extending through the esophagus to the stomach without evidence of leak in the esophagus. There is no definite motility dysfunction. The stomach fills normally. There is no evidence of obstruction at the gastroesophageal junction or elsewhere in the upper GI tract. IMPRESSION: No evidence of pharyngeal or esophageal leak with persistent pneumomediastinum and soft tissue gas. KUB [2193-5-12]: There is contrast material seen throughout the colon including the appendix. There are few air-filled loops of small bowel, however, there is no free intra-abdominal gas. Contrast in the stomach fundus is also seen. Bony structures are grossly intact. RUQ US [2193-5-14]: The liver is normal in size and appearance. No focal liver lesion is identified. No biliary dilatation is seen and the common duct measures 0.4 cm. The portal vein is patent with hepatopetal flow. The gallbladder is normal. The pancreas is unremarkable, but is only partially visualized due to overlying bowel gas. The spleen is at the upper limits of normal measuring 12.2 cm. No hydronephrosis is seen on limited views of the kidneys. The aorta is of normal caliber but is only minimally visualized. The intrahepatic portion of the IVC is unremarkable. No ascites is seen in the abdomen. A small right and left pleural effusion is noted. IMPRESSION: 1. No gallstones and no biliary dilatation. 2. Small bilateral pleural effusions. CXR [2193-5-15]: PA and lateral radiographs of the chest demonstrate interval resolution of pulmonary edema from the mid and upper lung field when compared to the study from three days ago. There are persistent bilateral lower lung opacities representing residual edema and/or atelectasis. Small pleural effusions are also present. The hilar and cardiomediastinal contours are normal. There is no pneumothorax. There is no evidence of residual pneumomediastinum. A right subclavian hemodialysis catheter has been placed and terminates at the expected location of the cavoatrial junction. IMPRESSION: 1. Interval improvement in pulmonary edema with some persistence in the bilateral lung bases. 2. Small bilateral pleural effusions and atelectasis. 3. No evidence of pneumomediastinum. NCHCT: FINDINGS: There is no evidence of hemorrhage, edema, mass, mass effect, or infarction. Specifically, regions of the posterior occipital lobes are unremarkable. The ventricles and sulci are normal in size and configuration for the patient's age. The basal cisterns are patent. There is preservation of [Doctor Last Name 352]-white matter differentiation. No fracture is identified. There is a small mucous retention cyst within the right maxillary sinus. The remainder of the visualized paranasal sinuses, mastoid air cells, and middle ear cavities is clear. The previously seen subcutaneous emphysema has resolved. IMPRESSION: No acute intracranial process. Specifically, no changes in the posterior occipital lobes suggestive of PRES syndrome. CXR [2193-5-20]: Lung volumes remain quite low and there is substantial bibasilar atelectasis which has not cleared over several days. Mild vascular congestion is new, small bilateral pleural effusions are stable. Small nodular opacities in the lungs are probably vessels on end and hazy opacification in the lower lungs is probably mild pulmonary edema. Dialysis catheters end in the right atrium. Small bilateral pleural effusions are slightly larger today than on [5-15]. No pneumothorax. Heart size top normal, unchanged. DISCHARGE LABS: [2193-5-22] 08:00AM BLOOD WBC-11.7* RBC-2.42* Hgb-8.3* Hct-24.8* MCV-103* MCH-34.4* MCHC-33.6 RDW-13.4 Plt Ct-238 [2193-5-22] 08:00AM BLOOD Glucose-80 UreaN-20 Creat-8.2# Na-137 K-3.9 Cl-98 HCO3-29 AnGap-14 [2193-5-21] 08:20AM BLOOD ALT-59 AST-91* AlkPhos-41 TotBili-0.3 [2193-5-20] 11:15AM BLOOD Lipase-298* [2193-5-22] 08:00AM BLOOD Calcium-8.2* Phos-4.1 Mg-1.9 MICROBIOLOGY: Urine culture [2193-5-9] negative Blood culture [2193-5-13] negative Blood cultures 06/15/-[5-22] pending (no growth to date) Brief Hospital Course: 32M with a history of bipolar disorder and depression who presented from an outside hospital with anuric renal failure due to rhabdomyolysis secondary to a toxic ingestion of cough syrup, acute hypoxemic respiratory failure s/p traumatic intubation resulting in pneumomediastinum. He is currently medically stable on chronic hemodialysis. #OVERDOSE: Patient was brought to [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] hospital ED where he was found to be febrile to 105, agitated, and delirious with elevated LFTs. He was intubated in setting of airway protection and hypoxemic respiratory failure, and empirically started on n-acetylcysteine (NAC)as well as vancomycin/ceftriaxone due to fever and leukocytosis to 35 with bandemia. Following transfer to [Hospital1 18] ED, toxicology was consulted. The patient was continued on NAC. Notable labs included Na 150, Cl 114, HCO3 18, Cr 3.9, and CK [Numeric Identifier 111890], Ca 6.8, ALT 185, and AST 1070, WBC 17.9. Per the initial toxicology recs, patient most likely experienced serotonin syndrome as a result of his ingestion (Coricidin contains dextromethorphan, chlorpheniramine, +/- acetaminophen). The patient's urine tox screen was also positive for cocaine and opiates, but his serum tox screen was negative for acetaminophen. Patient's LFTs continued to worsen in the setting of patient's significant rhabdomyolysis despite aggressive fluid hydration. His rhabdomyolysis resolved with CK and LFTs trending downward. #RHABDOMYOLYSIS: The patient's rhabdomyolysis was likely due to hyperthermia and his toxic ingestion. He received aggressive LR fluid hydration in the setting of hyperchloremia and hypernatremia. He was repleted with bicarb and 1 liter NS. Over the course of his hospitalization, the patient's CKs began to trend downwards and had normalized with the initiation of dialysis. #TRANSAMINITIS: The patient had a transaminitis on admission initially concerning for ischemia or tylenol use and was started on NAC treatment, though these were rapidly elminated from the differential. His transaminitis were felt to be secondary to rhabdomyolysis and began to improve over the course of his stay and with the initiation of dialysis. There was no evidence of hepatologic pathology, hepatitis serologies were sent and were negative. #ANURIC RENAL FAILURE: The [Initials (NamePattern4) 228] [Last Name (NamePattern4) ] was most likely [1-3] rhabdomyolysis. The patient was aggressive hydrated initially with LR in the setting of hyperchloremia/hypernatremia. Per renal consult's recs, LR was discontinued briefly because of transient hyperkalemia and the patient was switched to 1/2 NS and repleted with more bicarb. The patient was once more switched back to LR because of recurrent hyperchloremia and hypernatremia. The patient's Cr continued to trend up during his stay in the MICU, and urine output was minimal. Renal recommended a trial of Lasix 150 mg to help diuresis him, given his volume overload and anuria but he was not responsive. Patient continued to develop a worsening acidosis with compensatory tachypnea. A temporary dialysis catheter was placed by IR on [5-13] and the patient was started on dialysis with rapid correction in his acidosis and overall clinical status. As he tolerated dialysis well without recover of his urine output, ranging from 100 - 400 cc daily, he was transitioned to a tunneled HD catheter for chronic administration of hemodialysis. He did well on a MWF dialysis schedule and discharged with a plan to continue on this schedule for longterm. Of note, Hepatitis B and C serologies suggestive no history of hepatitis C and immunity to Hepatitis B. He also had a PPD that was < 2 mm induration. . SEDATION: The patient was initially sedated with propofol following admission to the MICU to avoid to avoid worsening his rhabdomyolysis. However, the patient was weaned off his propofol and self-extubated the day following admission. #PNEUMOMEDIASTINUM: The patient was evaluated by both Thoracic Surgery and ENT for his pneumomediastinum. Thoracic surgery performed bronchoscopy and endoscopy and noted no tear from the carina all the way up to the cricoid. ENT noted some bruising of his left lateral laryngeal wall (possible site of tear) and thought that the pneumomediastinum was likely [1-3] a traumatic intubation prior to admission at the OSH followed by bagging, causing air to track down his mediastinum. The patient was started on an empirical 7 day course of Unasyn and followed with serial physical exams. Chest Xray from [5-15] showed radiographic resolution of pneumomediastinum. #LEUKOCYTOSIS: Patient's WBC was elevated at 17.9 at admission, but quickly normalized following admission. His leukocytosis was likely [1-3] stress demargination. Patient was treated with Unasyn for 7 day course as prophylaxis for mediastinitis. He again developed a WBC late in his hospitalization and was evaluated for infectious causes with a negative CXR, urinalysis, urine culture and blood culture. His WBC count trended down over the course of his stay on the medical service without further concern for infection. #DEPRESSION: Patient was followed by psychiatry and social work during his hospitalization. He was started on hydroxazine 25 mg Q6H PRN for anxiety. Patient will be discharged to medical facility. #HYPERTENSION: On admission, the patient was transiently hypertensive to the 170s, felt to be secondary to volume overload and discomfort. Renal has been performing ultra filtration in an effort to decrease intravascular volume and started on labetalol 200 mg [Hospital1 ] for further control. As patient did not have existing hypertension prior to his toxic insult he was not felt to be at high risk for developing end organ damage and permissive blood pressures to the 160s were felt resonable as he was likely to further improve with ongoing dialysis. He did had a NCHCT to evaluate for evidence of PRES syndrome given his nausea and vomitting that developed late in his hospitalization, but there was no radiographic evidence of demylenation. His nausea and headache resolved with further dialysis treatments. At this juncture, he will continue on labetalol for renovascular hypertension. NAUSEA/ABDOMINAL PAIN: On [2193-5-18] the patient developed nasuea with vomitting, given his persistent hypertension a central cause was explored and no radiographic evidence of PRES syndrome was identified. The patient's symptoms were felt to be related to uremia secondary to 48 hours without dialysis. The patient resumed dialysis on [2193-5-20] per his usual schedule with improvement in his symptoms. It was also thought around [2193-5-18] that the patient could have developed pancreatitis given elevated lipase in setting of Carbamazepine re-initiation. His home Carbamazepine was subsequently held. This medication should be avoided in the future. His abdominal symptoms and nausea resolved with conservative measurements. TRANSITIONAL ISSUES - He will need to establish with a primary care doctor [First Name (Titles) ] [Last Name (Titles) 111891]n with repeat LFTs and CK on outpatient basis to trend to normalization as psychiatric discharge -MWF dilaysis -monitor urine output -full code - Contact: Father Dr. [Known firstname ] [Known lastname 111892] [Telephone/Fax (1) 111893], [Telephone/Fax (1) 111894]. Medications on Admission: Zyprexa 5mg daily Tegretol 200mg [Hospital1 ] (pt states both meds are from prescriptions he received after his hospitaliztion) Discharge Medications: 1. Calcium Carbonate 500 mg PO QID:PRN heartburn/indigestion 2. Docusate Sodium (Liquid) 100 mg PO BID 3. HydrOXYzine 25 mg PO Q6H:PRN anxiety hold for sedation, RR<10 4. OLANZapine 5 mg PO HS 5. Pantoprazole 40 mg PO Q24H 6. Artificial Tear Ointment 1 Appl BOTH EYES QID:PRN dry eyes 7. Labetalol 300 mg PO BID Discharge Disposition: Extended Care Discharge Diagnosis: Primary: - acute oliguric renal failure secondary to rhabdomyolysis - mood disorder NOS with suicide attempt - rhabdomyolysis - pancreatitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were transferred to [Hospital1 18] after overdosing on cough syrup in an attempt to kill yourself. As a result, you have injured your kidneys badly and require hemodialysis. You also had pneumomediastinum from a traumatic intubation, which has resolved. We also think that you developed briefly pancreatitis from your home medication (tegretol), which you should not take any more. Overall, you had a complex hospital course. You will need to remain on dialysis as your kidneys are still failing. You will be discharged to a psychiatric facility for further therapy. Followup Instructions: You should establish care with a primary care physician after psychiatric discharge. You should also establish care with a nephrologist (kidney doctor). If you need assistance with finding a doctor, please call 1-[Telephone/Fax (1) 70946]	[ "564.1", "296.89", "285.9", "787.02", "292.81", "333.99", "577.0", "518.81", "276.0", "288.60", "728.88", "305.00", "V74.1", "790.4", "998.81", "965.4", "E950.0", "305.20", "512.1", "E879.8", "530.81", "584.5", "401.9", "E950.4", "251.2", "963.0", "276.2", "975.4", "305.70", "784.0", "305.60", "276.9" ]	icd9cm	[ [ [] ] ]	[ "38.95", "96.71", "39.95", "45.13", "33.24" ]	icd9pcs	[ [ [] ] ]	20297, 20312	12302, 19777	312, 497	20497, 20497	4486, 5011	21248, 21496	3330, 3379		19960, 20274		20333, 20476		19803, 19937			20648, 21225	11739, 12279								3394, 4467																									263, 274									525, 1817										20512, 20624	5027, 11723						1839, 2506	2522, 3314
57,187	137,008	42881	Discharge summary	report	Admission Date: [2101-2-9] Discharge Date: [2101-2-16] Date of Birth: [2030-12-12] Sex: F Service: MEDICINE Allergies: Ancef / meropenem Attending:[First Name3 (LF) 4327] Chief Complaint: STEMI Major Surgical or Invasive Procedure: Intubation and extubation Intraaortic balloon pump removal LAD BMS stents x2 and proximal LCX Integrity 2.5 x 26 mm BMS. History of Present Illness: 70 year old woman with prior RCA stent three years ago, COPD, hypertension, hyperlipidemia and breast cancer, recently came off of plavix as she had been "feeling poorly on it", admitted on [2-7] with chest pain x several days for elective cath in LGH. Ruled out by troponins but EKGs did show depressions in the 'lateral leads'. . Pt was seen in office by cardiologist Dr [Last Name (STitle) 61478] w/ CP but no SOB other than baseline. No fevers, chills, n/v, no abdominal pain were reported. Last cath w/ stent 3 yrs back to RCA. She has been having on and off pain, not related to exertion, relieved w/o intervention, mostly in the back but radiating to the front as well. Statin was recently changed to gemfibrizil as pt felt lousy and pt had decided to stop taking plavix as it had been more than 2 years since last cath. Had stress test last month for evaluation for urethral stenting for hematuria which was negative, so she went on to have the surgery. . Underwent diagnostic cath today via left radial: RCA diffusely diseased with patent stent, patent OM but Cx occlusion more distally, LAD with 70% proximal LAD vessel. Just after LV gram around 11:15am, patient had severe chest and upper back pain with drop in systolic pressure to 80. Pt also became unconcious. LAD was found completely occluded. Attempts to get wire down LAD were unsuccessful. IABP was placed in RFA. Pt was intubated and currently on assist only. Ephedrine 10mg was given, and the pt was started on Neo at 50mcg/min and angiomax (bivalirudin). SBP 107. Nurse reported LV gram to be "poor". She was transferred straight to [Hospital1 18] cath lab via ground transport for attempt to open LAD. VS on transfer: 108/50, HR 90 SR, intubated w/ assist, "oxygenating well". . On review of systems, she denies any history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: CAD - RCA stent three years ago Hypertension Hyperlipidemia COPD on 1L home 02 in PM , Breast cancer in [2084], w/ malignancy site in brain. s/p lumpectomy and radiation Lyme Disease Hysterectomy Social History: lives w/ husband, smokes 5-10cigarettes / day, never been able to stop. no alcohol, drug use. Family History: CVA in the family Physical Exam: GENERAL: intubated. RASS -2. Withdrawing to pain. HEENT: Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple with JVP not assessed. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: Pt intubated. No chest wall deformities, scoliosis or kyphosis. Coarse breath sounds bilaterally. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. NEURO: intubated. No gross deficits evident. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ On discharge: GENERAL: AOX1, agitated and sedated HEENT: Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple with JVP not assessed. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. IABP hear throughout precordium, belly LUNGS: No chest wall deformities, scoliosis or kyphosis. CTAB anteriorly. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. NEURO: AOX1. No gross deficits evident. Pertinent Results: [2101-2-9] 02:59PM HGB-7.3* calcHCT-22 O2 SAT-96 [2101-2-9] 02:59PM TYPE-ART PO2-110* PCO2-56* PH-7.08* TOTAL CO2-18* BASE XS--13 -ASSIST/CON INTUBATED-INTUBATED [2101-2-9] 03:22PM HGB-9.7* calcHCT-29 O2 SAT-98 [2101-2-9] 03:22PM TYPE-ART RATES-26/ TIDAL VOL-450 PEEP-5 O2-100 PO2-155* PCO2-52* PH-7.23* TOTAL CO2-23 BASE XS--6 AADO2-510 REQ O2-85 -ASSIST/CON INTUBATED-INTUBATED [2101-2-9] 04:53PM HGB-9.1* calcHCT-27 O2 SAT-94 [2101-2-9] 04:53PM TYPE-ART PO2-87 PCO2-51* PH-7.17* TOTAL CO2-20* BASE XS--10 INTUBATED-INTUBATED On Admission: [2101-2-9] 06:29PM PT-40.3* PTT-150 * INR(PT)-4.0* [2101-2-9] 06:29PM PLT COUNT-369 [2101-2-9] 06:29PM NEUTS-93.0* LYMPHS-3.6* MONOS-3.1 EOS-0.1 BASOS-0.2 [2101-2-9] 06:29PM WBC-31.8* RBC-3.60* HGB-9.3* HCT-29.9* MCV-83 MCH-25.9* MCHC-31.1 RDW-17.1* [2101-2-9] 06:29PM ALBUMIN-3.6 CALCIUM-8.0* PHOSPHATE-4.3 MAGNESIUM-1.8 [2101-2-9] 06:29PM CK-MB->500 cTropnT-23.46* [2101-2-9] 06:29PM ALT(SGPT)-81* AST(SGOT)-490* LD(LDH)-1499* ALK PHOS-156* TOT BILI-0.2 [2101-2-9] 06:29PM estGFR-Using this [2101-2-9] 06:29PM GLUCOSE-198* UREA N-25* CREAT-0.7 SODIUM-140 POTASSIUM-4.6 CHLORIDE-113* TOTAL CO2-16* ANION GAP-16 [2101-2-9] 06:37PM O2 SAT-98 [2101-2-9] 06:37PM LACTATE-1.0 [2101-2-9] 06:37PM TYPE-ART PO2-137* PCO2-47* PH-7.20* TOTAL CO2-19* BASE XS--9 INTUBATED-INTUBATED VENT-CONTROLLED [2101-2-9] 09:40PM PT-15.5* PTT-56.7* INR(PT)-1.5* [2101-2-9] 09:40PM PLT COUNT-428 [2101-2-9] 09:40PM HCT-28.8* [2101-2-9] 09:46PM freeCa-1.08* [2101-2-9] 09:46PM O2 SAT-95 [2101-2-9] 09:46PM LACTATE-1.4 [2101-2-9] 09:46PM TYPE-ART TEMP-36.7 RATES-28/4 TIDAL VOL-440 PEEP-5 O2-60 PO2-83* PCO2-39 PH-7.29* TOTAL CO2-20* BASE XS--6 -ASSIST/CON INTUBATED-INTUBATED Cardiac Enzymes: [2101-2-9] 06:29PM BLOOD CK-MB->500 cTropnT-23.46* [2101-2-10] 12:34AM BLOOD CK-MB->500 cTropnT-23.02* [2101-2-10] 06:17AM BLOOD CK-MB-GREATER TH cTropnT-17.84* [2101-2-10] 03:16PM BLOOD CK-MB-228* MB Indx-5.5 cTropnT-13.40* Discharge Labs: [2101-2-15] 05:37AM BLOOD WBC-10.8 RBC-3.30* Hgb-9.5* Hct-26.7* MCV-81* MCH-28.6 MCHC-35.3* RDW-18.9* Plt Ct-267 [2101-2-14] 06:44AM BLOOD Neuts-80.3* Lymphs-8.3* Monos-6.6 Eos-4.3* Baso-0.4 [2101-2-15] 05:37AM BLOOD PT-13.5* INR(PT)-1.3* [2101-2-15] 05:37AM BLOOD Glucose-102* UreaN-56* Creat-2.4# Na-137 K-5.1 Cl-99 HCO3-27 AnGap-16 [2101-2-13] 01:45AM BLOOD ALT-49 AST-76* AlkPhos-137* TotBili-0.7 [2101-2-15] 05:37AM BLOOD Calcium-8.8 Phos-4.7* Mg-2.5 Studies: Cardiac Cath [2101-2-9]: 1. Cardiogenic shock, IABP in situ. [Hospital ] transfer from [Hospital1 5979]. Acutely occluded LAD with dissection following attempted PTA. 2. LAD wired with difficulty. Successful BMS x 2 to proximal and mid LAD. Plaque shift resulting in occluded proximal LCX. LCX successfully stented with BMS. Integrilin IC bolus. 3. Right heart cath - PA 41/25, RV 47/10, RA mean 15. AO 88/31. 4. Intubated, sedated, ventilated, pressor support on transfer to CCU. FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Successful PCI of occluded / dissected proximal and mid LAD using two Integrity 3.0 x 30 mm overlapping BMS stents. Plaque shift into proximal LCX which required additional Integrity 2.5 x 26 mm BMS. Overall good result with patent LAD and LCX with TIMI 3 flow and no apparent dissection. 3. Echocardiogram done during procedure to outrule pericardial effusion shows markedly depressed LV systolic function. 4. Transferred to CCU - intubated, sedated, ventilated, pressor support, IABP in situ. [1-/2018]: TTE: The left ventricular cavity size is normal. Overall left ventricular systolic function is severely depressed (LVEF= 15-20%). Right ventricular chamber size and free wall motion are normal. The right ventricular free wall is hypertrophied. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. [Due to acoustic shadowing, the severity of tricuspid regurgitation may be significantly UNDERestimated.] There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Severe LV systolic dysfunction. Only the basal to mid lateral and basal inferolateral segments have appreciable systolic function. Akinetic anterior wall and septum. Moderate tricuspid regurgitation and moderate pulmonary hypertension. [2-11] TTE: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is severely depressed (LVEF= 15 %) secondary to extensive apical and anteroseptal akinesis with varying degrees of hypokinesis of the rest of the left ventricle. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size is normal with extensive akinesis and edema of the apical half of the free wall. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. [2-13] CXR: ardiomegaly is stable. Left lower lobe atelectasis has markedly improved. If any, there are small bilateral pleural effusions. Right PICC tip is in the lower SVC. NG tube tip is out of view below the diaphragm. Intraaortic balloon pump is in standard position. Surgical clips project in the right axilla. Vascular congestion has improved, still asymmetric on the left. Brief Hospital Course: 70 year old female w/ CAD s/p RCA stent in [2097], HTN, HL, COPD on 1L home 02, who presented from OSH w/ abrupt occlusion of LAD during PCI that could not be crossed. Pt was transferred to [Hospital1 18], where perfusion was restored via stenting of LAD and Lcx. Pt was in cardiogenic shock and had IABP placed at OSH. Pt was initially on norepinephrine and phenylephrine here which was able to be weaned off. The IABP was able to be removed. Pt also was extubated. Pt's blood pressures remain soft ranging from 70s-100s systolic. After extensive discussion with family given patient's severe depression and poor quality of life before this event, family felt that discontinuation of all medications other than ones used for comfort would be in [Location (un) ] with patient's wishes given her worsening functional status, poor heart function after STEMI, and renal failure. . # Cardiogenic Shock: Pt became acutely hypotensive in the cath labs requiring pressors (Norepi and Phenylephrine). Pt got an echo during cath which showed an EF of 15-20%. Pt became volume overloaded due to her acute systolic heart failure and required diuresis. Given family and patient??????s goals of care, pt was weaned off pressors and IABP taken out. Her blood pressures remained low, ranging from 70s-100s systolic, with waxing mentation and poor urine output suggesting poor perfusion and oliguric renal failure. Due to goals of care, pt will use dilaudid for shortness of breath but no medications will be used for heart failure. . # STEMI: Pt presented w/ on and off CP and underwent elective cath. RCA stent was found to be patent, but Lcx was found to be occluded distally. During the procedure, LAD closed off abruptly, and the pt crashed. Was transferred w/ IABP, intubation, neo and bivalirudin gtt. Underwent cath, LAD was stented and the Lcx was stented and IC integrilin was used. The patient will continue on plavix and aspirin to prevent thrombosis. Her heart function was severely compromised with development of pulmonary edema and EF of 15%. . # Respiratory Failure: Pt was intubated after having acute total occlusion of LAD. Pt remained on assist control but was weaned to CPAP. Likely d/t severe hemodynamic compromise, and LOC. Pt was extubated successfully. Continue spiriva, xoponex, advair for comfort. . # Altered Mental Status/Comfort measures: Pt extubated and since then has been agitated likely secondary to poor perfusion and her baseline psych disease. Palliative care assisted us with development of a medicaton regimen: standing haldol 2mg and ativan 2 mg Q evening, haldol and ativan as needed for delirium and agitation, and dilaudid 1-2 mg Q3h prn for pain and respiratory distress. . # Leukocytosis/Fever: Pt had a WBC count of 31 on presentation w/ left shift. Likely stress related. Pt also had an asymmetric opacity in the lt lung, likely pulm edema, but unable to rule out pna. Given her morbid status, levofloxacin was started and completed for a 7 day course. Pt also spiked a fever and vancomycin was given for 3 days before being discontinued. The patient did not develop further fever and white count normalized. . # Anemia: unclear etiology. Likely multifactorial and related to poor production, stress response/shock, and possibly phlebotomy. [Month (only) 116] have some shearing from IABP as well. No evidence of bleeding. Pt maintained her hct/hgb. . # COPD: on home 02 1L at night. Continue on inhalers for comfort. . # Goals of care: Goals were confirmed as DNR/DNI/and comfort focused. Medications as above. . . TRANSITIONAL: For any acute change in status, such as dyspnea or pain, please contact hospice nurse before coming to ED Medications on Admission: diovan 80mg asa 81mg spiriva qd xopnenex advair100/50 nicotine patch protonix 40mg lorazepam prn coumadin (on hold per pt) gemfibrizil Discharge Medications: 1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 5. haloperidol 2 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for agitation or nausea. 6. haloperidol 1 mg Tablet Sig: Two (2) Tablet PO daily at 5 pm. 7. lorazepam 1 mg Tablet Sig: Two (2) Tablet PO daily at 5 pm. 8. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 9. lorazepam 1 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for agitation/nausea. 10. hydromorphone 2 mg Tablet Sig: 0.5-1 Tablet PO Q3H (every 3 hours) as needed for SOB/Pain. 11. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) inhalation Inhalation once a day. 12. Xopenex HFA 45 mcg/actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 13. Advair Diskus 100-50 mcg/dose Disk with Device Sig: One (1) inh Inhalation twice a day. 14. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 15. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for pruritus. Disp:1 bottle Refills:0 Discharge Disposition: Home With Service Facility: [Hospital3 ]Hospice Discharge Diagnosis: Primary: STEMI, Cardiogenic shock, Acute renal failure Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. [Known lastname 92591], . You were admitted for a large heart attack with shock. You had an intraaortic balloon pump placed to maintain your blood pressure and stents were placed into your coronary arteries. You initially had your blood pressure supported with intravenous medications. These were able to be discontinued as was your balloon pump. You were also initially intubated to help you breathe and protect your airway. You were able to be weaned from this. However, your renal function declined. . You and your family decided that you wanted to focus on comfort measures only. Thus, treatments were withdrawn other than those to keep you comfortable. You will be going home with hospice services. . The following changes were made to your medications: - INCREASE Aspirin to 325 mg - START Bisacodyl for constipation - START Senna for constipation - START Plavix for stent - START Haloperidol for agitation or nausea - START Ativan for anxiety - START hydromorphone for pain - STOP Warfarin - STOP Diovan - STOP Gemfibrozil Followup Instructions: None Completed by:[2101-2-16]	[ "584.9", "496", "E879.0", "785.51", "414.01", "E849.7", "V10.3", "410.81", "305.1", "599.70", "428.0", "V49.86", "414.12", "780.09", "997.1", "428.23", "518.81", "V66.7", "285.9" ]	icd9cm	[ [ [] ] ]	[ "96.71", "00.66", "38.97", "00.47", "88.52", "00.17", "37.21", "36.06", "00.41", "88.56" ]	icd9pcs	[ [ [] ] ]	15777, 15831	10367, 14069	284, 407	15930, 15930	4515, 5079	17182, 17217	3066, 3085		14255, 15754		15852, 15909		14095, 14232		7637, 10344	16110, 17159	6634, 7620								3100, 3853																	3867, 4496					6376, 6618			239, 246									435, 2715								5093, 6359		15945, 16086							2737, 2939	2955, 3050
3,337	156,911	20455	Discharge summary	report	Admission Date: [2120-3-13] Discharge Date: [2120-3-20] Date of Birth: [2044-11-22] Sex: F Service: TRAUMA HISTORY OF PRESENT ILLNESS: The patient is a 75-year-old, Portuguese female, with a past medical history of hypertension, who presented to the Trauma Service as a Trauma plus on [2120-3-13]. This was activated secondary to the fact that the patient's mechanism of injury was a large tree branch that had fallen and struck her head hitting her in the back of her head and knocking her down. She had an obvious open left ankle fracture, as well as a deformed left forearm confirming radius and ulnar fractures. She was minimally responsive in the field, was intubated, and brought in by [Location (un) ]. PAST MEDICAL HISTORY: Notable for just hypertension. MEDICATIONS ON ADMISSION: Diltiazem SR 360 mg p.o. q.d., Potassium supplement. ALLERGIES: NO KNOWN DRUG ALLERGIES. SOCIAL HISTORY: She lives with her daughter. She is widowed. She has multiple children. She is otherwise high functioning at baseline. She does not smoke or drink. FAMILY HISTORY: Noncontributory. REVIEW OF SYSTEMS: Otherwise unremarkable and not obtainable at the time of this discharge note; she was well however up until the timing of this event. PHYSICAL EXAMINATION: Vital signs: On presentation temperature was 98.5??????, heart rate 83, blood pressure 130/60, she was vented with an oxygen saturation of 100% on the vent. HEENT: Pupils were [1-23] and sluggish and reactive. Her midface was stable. She had an obvious large scalp deformity. Oropharynx was otherwise satisfactory with endotracheal tube in place 21 cm at the lip. Trachea was midline. There was no neck crepitus. Chest: Stable. There was no stepoff deformity. She had equal breath sounds bilaterally. Abdomen: Soft. Could not assess tenderness. Her FAST exam in the trauma bay was otherwise negative. Extremities: Pelvis was stable. She had an obvious open fracture with the tibia exposed of the tibiotalar joint complex at the left ankle. There was no active bleeding. She did have a palpable but thready distal dorsalis pedis pulse. Her posterior tibial pulse however was not obtainable. The foot was somewhat cool however was not cyanotic. Capillary refill was somewhat delayed at 3-4 sec. Her left upper extremity had an obvious deformity; however, her radius and ulnar arteries were easily palpable. Her fingers were a little bit dusky, but capillary refill again delayed. All extremities were somewhat cool, and she was somewhat clamped. Upon rolling, she had multiple abrasions but no stepoff or deformity. She had abrasions across the kyphotic upper thoracic spine noted. Rectal: Loose tone. No mass. Guaiac negative. Genitourinary: Unremarkable. A Foley catheter had been placed. The patient thereafter was brought to the Operating Room where an emergent scalp laceration repair and exploration was done. Prior to going to scan, she did get a CT of her head, at which time she actually began to move more. Her initial GCS was 3T in the trauma bay. This rapidly improved to a 10T while in the CT scanner. She was able to localize and follow commands and open her eyes spontaneously. CT scan of the head revealed no intracranial injury or fracture. She had an obvious hematoma and laceration to her scalp noted by these films. CT of her cervical spine was somewhat limited by motion but was otherwise negative. A TLS survey was initially read as possible wedge compression fracture of T11. CT of chest and abdomen were without any obvious visceral injury. Catalog of her injuries at this time showed that she had what looked like a large occipital scalp avulsion/laceration, no active exsanguination. She had an obvious left arm deformity confirmed by plain films to show a distal radius and ulnar fracture, but this was a closed fracture. She had an obvious open fracture of the left lower extremity at the tibia and fibula involving the tibiocalcaneal complex of the left ankle. This was reduced and splinted in the trauma bay by the Orthopedic Service. She was then whisked off to the Operating Room where her left ankle was washed out. She had previously received Tetanus, Kefzol, and Gentamicin. Her scalp flap was also washed and repaired. She received a two-layer closure, interrupted to the deep suturing to the galea aponeurotica and then skin staples thereafter. The orthopedic portion of the procedure was open reduction and internal fixation of her left upper extremity and lower extremity were completed. Please refer to Dr.[Name (NI) 42858] dictation noted for further details regarding that procedure. She was left intubated and sent back to the Trauma Intensive Care Unit over night. She required some volume. She had been transfused at least 2 U of packed red blood cells on [2120-3-13]. She did not require any further transfusions. By postoperative day #1, hospital day #2, she was on Kefzol and Gentamicin periprocedurally per the Orthopedic Service. Repeat CT of the head was done on the following day which again showed no evidence of bleeding or intracranial injury. At this time she was moving all four extremities and actually following commands. We opted to extubate the patient at this time. She did quite well and progressed quite well. Her cervical collar was then cleared over the next 48 hours. She was kept on logroll precautions, and follow-up MRS [Last Name (STitle) ] the cervical spine revealed in fact a possible acute compression fracture at T11. At this time consultants with Dr. [Last Name (STitle) 25918] of the Neurosurgical Service recommended a fitting and TLSO bracing. She did have some mild degree of agitation within the first 24 hours on the floor requiring a 1:1 sitter and intermittent Haldol; however, her mental status rapidly improved to the point of where she was discontinued from her sitter. She was only receiving p.r.n. Tylenol and Percocet for pain control. She was placed on an aggressive bowel regimen. She was placed back on her Diltiazem 360 mg SR q.d. for blood pressure maintenance. Her fractures were healing well, and the Orthopedic Service was following for dressing care to her left lower extremity. She ultimately received a short-leg cast on [2120-3-18]. Her weightbearing status was determined to be nonweightbearing on the left lower extremity and upper extremity. She may bear weight on her left elbow. Her right upper and lower extremity were full weightbearing. She was participating with Physical Therapy and wearing a TLSO brace per the recommendations of the Neurosurgical Spine consultation with Dr. [Last Name (STitle) 25918]. She was deemed appropriate and stable for discharge on [2120-3-20]. Prior to her discharge, her lab test on [2120-3-18], revealed a white count of 7.5, hematocrit 28.3, and platelet count 269. This was otherwise stable. Her chemistries at this time were a sodium of 138, potassium 3.9, chloride 102, bicarb 29, BUN and creatinine 11 and 0.6, glucose 102, magnesium 2.0. She had received EKGs during her hospitalization which were otherwise normal. She was on telemetry during her Intensive Care Unit stay and for several days on the floor, and there was no apparent electrocardiogram activity. She otherwise looked quite well clinically and was discharged to acute rehabilitation. DISCHARGE MEDICATIONS: Diltiazem SR 360 mg p.o. q.d., Lovenox 30 mg subcue q.12 while in rehabilitation, Protonix 40 mg p.o. q.d., Colace 100 mg p.o. b.i.d., Tylenol 325 mg [11-24] p.o. q.[2-27] p.r.n., Percocet 5/325 [11-24] p.o. q.[2-27] p.r.n., she should be on a sliding scale Insulin regimen as well to check her fingersticks, as she did have some mild stress-induced hyperglycemia, it was unclear of whether or normal the patient had some undiagnosed type 2 diabetes, however, this did not come with her admission information from her family, and she was not on any outpatient Insulin regimens or oral hypoglycemics. DISCHARGE DIAGNOSIS: Status post tree branch falling on head and back with long bone fractures, possible closed head injury with concussion only, no obvious intracranial lesion by CT scans times two, massive occipital scalp laceration and avulsion status post washout and repair on [2120-3-13], closed left radius and ulnar fracture status post open reduction and internal fixation on [2120-3-13], with Dr. [First Name (STitle) ] of the Orthopedic Surgery Service, status post washout and stabilization of left open tibial and fibula fracture of left lower extremity, possible recent acute compression fracture of T11 vertebra which is stable. MAJOR INVASIVE PROCEDURES: 1. Exploration and washout of the occipital scalp laceration and avulsion with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] of the Trauma Surgical Service; please see the dictation of the operative note for further details. 2. Status post washout and stabilization of left lower extremity open tibia and fibula fracture with Dr. [First Name (STitle) ]. 3. Status post open reduction and internal fixation of left upper extremity radius and ulnar fracture. TREATMENTS AND FREQUENCY: She will require aggressive physical therapy, feeding assistance, and Occupational Therapy evaluation as a rehabilitation patient. Her diet should be as tolerated. She has no evidence of clinical aspiration. FOLLOW-UP: 1. She will be seen in the Trauma Clinic one week from the time of discharge for skin clip removal from her scalp laceration; call [Telephone/Fax (1) 274] for outpatient clinic appointment. 2. She should call Dr.[Name (NI) 54786] Neurosurgical Service and be seen in [12-27] weeks for her T11 compression fracture, wear her TLSO brace in the interim. It is not clear if the patient will require any further imaging as an outpatient. This can be coordinated with her follow-up plan with Dr. [Last Name (STitle) 25918] by calling the office at [Telephone/Fax (1) 1669]. 3. The patient is to follow-up with Dr. [First Name (STitle) ] of the Orthopedic Trauma Service; follow-up is in [12-27] weeks; call [Telephone/Fax (1) 1113]. DISCHARGE INSTRUCTIONS: The patient at this time is deemed appropriate for discharge. She will be discharged and follow-up as noted above. Her weightbearing activity will be nonweightbearing to the left lower extremity, nonweightbearing to the left upper extremity; however, she may weightbear on the left elbow. She will wear her TLSO brace for her T11 compression fracture. She has full weightbearing privileges of right upper and lower extremity. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2213], M.D. [MD Number(1) 2214] Dictated By:[Last Name (NamePattern4) 3204] MEDQUIST36 D: [2120-3-19] 10:14 T: [2120-3-19] 10:19 JOB#: [Job Number 54787]	[ "813.83", "780.09", "E916", "599.0", "401.9", "873.0", "824.5" ]	icd9cm	[ [ [] ] ]	[ "86.59", "79.36", "79.32", "79.66" ]	icd9pcs	[ [ [] ] ]							1117, 1135		7448, 8065		8087, 10252		838, 930			10277, 10986																								1313, 7424						1155, 1290													169, 756																	779, 811	947, 1100
23,731	191,760	17264	Discharge summary	report	Admission Date: [2119-5-16] Discharge Date: [2119-5-26] Date of Birth: [2046-9-4] Sex: F Service: CARDIOTHORACIC HISTORY OF PRESENT ILLNESS: Mrs. [Known firstname ] [Known lastname 13534] is a 73 year-old female with a past medical history remarkable for chronic obstructive pulmonary disease and coronary artery disease and type 2 diabetes who has been experiencing worsening exertional angina for the past several years. The patient has noted that the pain is currently occurring once monthly with exertion typically located midsternal and radiating to the back. A stress test that was done on [2119-5-11] showed the patient had [Street Address(2) 48360] depressions during stage 2 exercise while the patient developed chest pain consistent with prior anginal symptoms. Imaging during this period revealed an inferolateral and apical ischemia with an EF of 78%. At this time the patient underwent cardiac catheterization for further evaluation for coronary revascularization. The patient's left anterior descending coronary artery showed 80% compromise, LCX showed 80% compromise and right coronary artery showed 80% compromise with an EF of 60%. Given these findings the decision was made to take the patient back to the Operating Room for three vessel disease coronary artery bypass graft on [5-18] with Dr. [Last Name (STitle) 70]. PAST MEDICAL HISTORY: 1. Chronic obstructive pulmonary disease. 2. Gastritis. 3. Irritable bowel syndrome. 4. Cerebrovascular accident with decrease in left eye vision. 5. Psoriasis. 6. Arthritis. 7. Type 2 diabetes. 8. Asthma. 9. Hypercholesterolemia. PAST SURGICAL HISTORY: 1. Bilateral hip replacement. 2. Left knee replacement. 3. Hysterectomy. 4. Bilateral leg stripping. SOCIAL HISTORY: The patient has been married living with her husband, two children. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Plavix 75 mg po q.d. 2. Glucotrol 10 mg po b.i.d. 3. Folate 1 q.d. 4. Lipitor 10 mg po q.d. 5. Vitamin E 400 international units q.d. 6. Monopril 5 mg po q.d. 7. Coreg 3.125 po b.i.d. 8. Albuterol prn. PHYSICAL EXAMINATION: At the time of discharge the patient's temperature 98.9, pulse 63, blood pressure 112/37, respirations 18, 97% on room air. The patient is a well developed, well nourished female in no acute distress at the time of discharge. HEENT sclera anicteric. Cranial nerves II through XII intact. No cervical lymphadenopathy. Mucous membranes are moist. No evidence of oral ulcers. Chest clear to auscultation bilaterally. Regular rate and rhythm. Sternotomy site without any evidence of erythema and no evidence of serosanguinous drainage. Abdomen soft, nontender, nondistended with positive bowel sounds and no evidence of inguinal lymphadenopathy. Lower extremity had no evidence of edema and graft site shows good healing without any evidence of ulceration, erythema or serosanguinous drainage. LABORATORY: CBC white blood cell count 9.8, hematocrit 31.1, platelets 217, sodium 143, potassium 4.3, chloride 105, bicarb 26, BUN 27, creatinine 1.2, glucose 133. Magnesium 1.9. The laboratory values were of [2119-5-26]. HOSPITAL COURSE: The patient is a 73 year-old female with a past medical history remarkable for coronary artery disease, type 2 diabetes and worsening anginal symptoms with cardiac catheterization to find three vessel disease of left anterior descending coronary artery, LCX, right coronary artery. On [2119-5-19] the patient underwent coronary artery bypass graft times two with left internal mammary coronary artery to left anterior descending coronary artery, saphenous vein graft to right posterior descending coronary artery (lesser saphenous) without complications. Postoperatively, the patient was taken to TSRU for close observation and extubated on postoperative day number one and was saturating well. On postoperative day number two the patient developed acute agitation, which required 40 mg of Haldol to maintain the patient sedated. Because the patient's confusion status correlated well with narcotic administration all narcotics and benzodiazepines were discontinued at this time. A few hours thereafter the patient's confusion status resolved and the patient continued to improve postoperatively. By postoperative day number three the decision was made to transfer the patient to the floor since the patient's mental status had returned back to baseline and no additional Haldol was necessary. Furthermore the patient's Lopressor was initiated successfully maintaining the heart rate at 60s to 70s without resulting in significant compromise of the blood pressure. The patient was also restarted on Plavix and Glucotrol along with diet as tolerated. On postoperative day number four the patient was evaluated by physical therapy and was deemed to have achieved level five. Shortly thereafter the patient's cardiac rhythm became irregular and the patient developed atrial fibrillation with rapid ventricular response. 20 mg of Lopressor along with total of 300 mg of Amiodarone bolus was administered. Approximately three hours after the atrial fibrillation began rate was controlled and the rhythm spontaneously reverted back to normal sinus. By postoperative day number seven the decision was made to discharge the patient to home in good condition, because the patient had not had any arrhythmias for 48 hours after spontaneously reverting to normal sinus rhythm. DISCHARGE STATUS: To home. DISCHARGE CONDITION: Good. DISCHARGE DIAGNOSIS: Status post coronary artery bypass graft with saphenous vein graft to right posterior descending coronary artery (lesser saphenous). DISCHARGE MEDICATIONS: 1. Lasix 20 mg po q.d. times seven days. 2. Potassium chloride 20 meq po q.d. times seven days. 3. Plavix 75 mg po q.d. 4. Glipizide 10 mg po b.i.d. 5. Amiodarone 400 mg po q.d. 6. Metoprolol 75 mg po b.i.d. 7. Vioxx 12.5 mg po q.d. FOLLOW UP PLANS: The patient was instructed to follow up with Dr. [Last Name (STitle) 70] in six weeks and her cardiologist Dr. [Last Name (STitle) 48361] in one week. [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 75] Dictated By:[Last Name (NamePattern1) 48362] MEDQUIST36 D: [2119-5-26] 11:34 T: [2119-5-26] 12:12 JOB#: [Job Number 48363] cc:[Last Name (STitle) 48364]	[ "493.20", "E878.2", "427.31", "411.1", "414.01", "292.81", "272.0", "998.11", "250.00" ]	icd9cm	[ [ [] ] ]	[ "39.61", "36.11", "36.15", "88.53", "88.55", "37.22" ]	icd9pcs	[ [ [] ] ]				5550, 5557					5735, 6495		5578, 5712			3217, 5528										1687, 1793																2167, 3199																			175, 1401																	1423, 1664	1810, 2144
30,999	172,506	33612	Discharge summary	report	Admission Date: [2153-9-4] Discharge Date: [2153-9-24] Date of Birth: [2097-3-23] Sex: F Service: MEDICINE Allergies: Valium Attending:[First Name3 (LF) 2009] Chief Complaint: Right charcot foot with chronic ulceration Major Surgical or Invasive Procedure: 1. Complex Charcot reconstruction with extensive internal fixation. 2. Medial Plantar artery based Fasciocutaneous tissue flap 3. Flexor Digitorum Brevis Muscle flap right foot. 3. Split-thickness skin graft. 4. Excisional debridement of plantar cuboid ulcer. 5. Percutaneous tendon Achilles lengthening. 6. Placement of external fixator 7. Placement of PICC [2153-9-5] 8. Epidural 9. Arterial line History of Present Illness: 56F with DM, HTN with severe Charcot feet admitted post-operatively following right foot Charcot reconstruction, medial artery flap and STSG. Pt has had a chronic ulceration plantar to her cuboid for approximately two years and states that she had a bump on the bottom of her foot that required surgery after the bump burst about 1.5 years ago. Subsequently, she has had numerous treatments including surgery as well as 55 dives in hyperbaric oxygen chamber. She also had an exostectomy and resection of an infected cuboid with application of an external fixator. A BK amputation had been proposed however the patient elects to go forth with a limb salvage procedure and reconstruction. Past Medical History: MRSA hx EKG with inferior q's 3, avf noted on prior Dyslipidemia Hypertension DM2 with neuropathy nephropathy gastritis glaucoma Previous Surgeries 1. left ovarian cystectomy [2119] 2. cholecystectomy [2120] 3. c-sections x 5 4. toe amputation [2132] 5. multiple right foot surgeries Social History: denies tobacco, EtOH lives with her husband in [Name2 (NI) ] Family History: n/c Physical Exam: Appearance: obese, anxious woman HEENT: EOMI, PERLLA Heart: RRR, ns s1 s2, no murmurs Lungs: Clear to Auscultation bilaterally Abdomen: NT/ND, +BS Neuro: CN 2-12 grossly intact LE: VASCULAR Pedal Pulses: [x] weakly palpable [] Non-palpable Sub-Papillary VFT: [x] < 3 sec. [] > 3 sec. [] Immediate Extremities: [x] pitting edema [] non-pitting edema [ ] Anasarca NEUROLOGICAL Sensation: [] Intact [x] Absent Proprioception: [] Intact [x] Absent Dressings: Clean/dry intact since OR procedure Pertinent Results: Admission Labs: [2153-9-5] 06:05AM BLOOD WBC-9.4 RBC-3.22* Hgb-10.6* Hct-30.8* MCV-96 MCH-32.9* MCHC-34.4 RDW-13.0 Plt Ct-301 [2153-9-5] 06:05AM BLOOD Glucose-50* UreaN-16 Creat-1.0 Na-142 K-4.7 Cl-108 HCO3-29 AnGap-10 [2153-9-5] 06:05AM BLOOD Albumin-2.5* Calcium-8.5 Phos-4.1 Mg-1.7 [2153-9-5] 06:05AM BLOOD %HbA1c-11.4* Discharge labs- [2153-9-24] WBC- 9.6 H/H- 3.9/28 PLTS- 469 Other labs- Glucose UreaN Creat Na K Cl HCO3 AnGap [2153-9-24] 05:57AM 118* 14 1.5* 142 4.7 104 29 14 Source: Line-PICC [2153-9-23] 05:29AM 133* 17 1.5* 140 4.7 105 30 10 [2113-9-12]* 25* 2.3* 137 5.3* 105 24 13 ALT AST LD CK AlkPhos [2153-9-19] 05:13AM 10 10 189 115 0.2 HEMATOLOGIC calTIBC Ferritn TRF [2153-9-15] 05:32AM 176* 184* 135* DIABETES MONITORING %HbA1c [2153-9-5] 06:05AM 11.4* PITUITARY TSH [2153-9-13] 05:52AM 3.5 OTHER ENDOCRINE Cortsol [2153-9-13] 05:52AM 29.31 . [2153-9-4] 9:40 am TISSUE BONE RIGHT FOOT. FINAL REPORT [2153-9-8]* GRAM STAIN (Final [2153-9-4]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. TISSUE (Final [2153-9-8]): REPORTED BY PHONE TO [First Name8 (NamePattern2) 77870] [Last Name (NamePattern1) ] [2153-9-5] @ 1:25 PM. THIS IS A CORRECTED REPORT [2153-9-8]. REPORTED BY PHONE TO DR [Last Name (NamePattern4) ] [2153-9-8] 1145AM. Due to mixed bacterial types (>=3) an abbreviated workup is performed; P.aeruginosa, S.aureus and beta strep. are reported if present. Susceptibility will be performed on P.aeruginosa and S.aureus if sparse growth or greater.. STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH. PREVIOUSLY REPORTED AS STAPH AUREUS COAG + ([2153-9-5]). ANAEROBIC CULTURE (Final [2153-9-8]): NO ANAEROBES ISOLATED. . [2153-9-13] 7:42 am SWAB Source: right heel. FINAL REPORT [2153-9-17] GRAM STAIN (Final [2153-9-13]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). WOUND CULTURE (Final [2153-9-16]): MORGANELLA MORGANII. MODERATE GROWTH. KLEBSIELLA PNEUMONIAE. MODERATE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ MORGANELLA MORGANII \| KLEBSIELLA PNEUMONIAE \| \| AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CEFUROXIME------------ <=1 S CIPROFLOXACIN---------<=0.25 S <=0.25 S GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- 16 S <=4 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S ANAEROBIC CULTURE (Final [2153-9-17]): NO ANAEROBES ISOLATED. . [2153-9-15] 7:25 am SWAB Source: R foot. FINAL REPORT [2153-9-19] GRAM STAIN (Final [2153-9-15]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [2153-9-19]): Due to mixed bacterial types (>=3) an abbreviated workup is performed; P.aeruginosa, S.aureus and beta strep. are reported if present. Susceptibility will be performed on P.aeruginosa and S.aureus if sparse growth or greater.. ANAEROBIC CULTURE (Final [2153-9-19]): NO ANAEROBES ISOLATED. . EKG: sinus brady vs wandering atrial pacemaker @ 41. nl axis and intervals. Q III, avF, no ischemic ST-T deviations. compared with [2153-8-27] Q waves are old and P wave voltage smaller. CXR - Since [2153-9-9], there is no vascular engorgement. Subsegmental retrocardiac atelectasis persists and right basilar atelectasis slightly decreased. Heart size is unchanged, seems enlarged. The aorta is mildly tortuous. Right PICC ends in mid SVC. TTE - The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. The right atrial pressure is indeterminate. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). There is no ventricular septal defect. The right ventricular cavity is mildly dilated with normal free wall contractility. There is abnormal septal motion/position. 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. There is no mitral valve prolapse. 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. . V/Q scan: poor quality study. matched perfusion and ventilation defects. low prob for PE but cannot exclude. . [2153-9-15] renal ultrasound FINDINGS: The right kidney is normal in size and appearance, measuring 10.0 cm. The left kidney is normal in size and appearance, measuring 10.1 cm. There is no nephrolithiasis or hydronephrosis. Limited visualization of the surrounding soft tissues is within normal limits. IMPRESSION: Normal appearance of the kidneys bilaterally. Specifically, no hydronephrosis seen. . [2153-9-14] u/s LE bilateral IMPRESSION: No evidence of DVT. - CXR [2153-9-24] Portable [First Name9 (NamePattern2) ] [Location (un) 1131]- no significant changes, bilateraly basilar atelecatsis. Brief Hospital Course: # Charcot foot reconstruction/wound infection: Admitted for right Charcot foot reconstruction with external fixation. The patient tolerated the procedures and anesthesia well without complications (see op report for full details). The acute pain service was made aware of this patient for pre & post-op pain management. An epidural was placed and MS contin and MSIR with a PCA. The PCA was discontinued on [2153-9-5]. On [2153-9-9] the epidural was d/c'ed and the patient had adequate pain control with the MS contin & MSIR. On [2153-9-11] the patient had her first dressing change. The skin graft had taken. At discharge her pain was controlled to Morphine IR and tylenol with close observation for sedation. Podiatry followed patient post operativley. She had been intermittent febrile in excess of 101F daily on [8-29]/08. She developed a wound infection, started on vanco and zosyn, then culture showed Klebsiella and Morganella, changed to Cipro [2153-9-17] for 14 day course. Also [9-22] started on Clindamycin since second wound culure showed mixed flora. Will also need 14 course. Podiatry created a drain for wound due to a fluid collection. Then recommended every other day dressing changes for wound care. Will need Podiatry follow up in 2 weeks. Sutures removed [2153-9-23]. # Hypotension/Bradycardia: Developed hypotension on AM [2153-9-12] afer going to commode. HR 40s, bp 62/40. She was bolused with IVF and an EKG was obtained that showed sinus bradycardia without acute ischemic changes. Had only transient improvement to the sbp >100s over the next several hours with IVF. Her Coreg was last given on [2153-9-11] at 9am. Also of note, decreased urine output during this period. She was sent to ICU. Possible etiologies for bradycardia included primary cardiac event, pneumonia, PE, shock, sick sinus, med side effect, or vagal effect. EP consult felt vagal effect was more likely either from infection, neuropathy, or foot pain. It was felt unlikely to be either an MI or a PE- no significant ischemic ST-T changes. V/Q scan low probability but poor image. LE Dopplers negative for DVT. Required dopamine drip. On the morning of [9-14], she was no longer bradycardic. Her rate acutely increased from 40s to 70s and her BP also increased. Dopamine was discontinued. This episode is possibly explained by sepsis, since foot culture was growing GNR. Patient was initially placed on ASA 325 but discharged on 81mg for cardio protection. # Acute on chronic renal failure: baseline Cr appears ~1 but she was elevated to 2.3 on admission Creatinine improved to around 2.0. This was felt to be likely pre-renal +/- post-obstructive (relieved with Foley placement). After hypotension episode post-op Cr rose again, likely from ATN, peak of 2.3. Improved by discharge to 1.3-1.5. # Hypertension: Coreg was stopped during hypotensive event above. Once patient became hypertensive to 150-160's again, she was started on ACE-I, due to hx of DM. BP was well controlled. This medication dose may need to be adjusted if BP increases again. Her Lasix was held during her ARF, and was not restarted. # Anemia: Felt to be multifactorial anemia from CKD, anemia of chronic disease, mild blood loss from procedures. Normocytic anemia, no evidence of active bleeding. Iron studies did not show iron deficiency. # Diabetes mellitus type 2 with complication of neuropathy: Was continued on Lantus and SSI. Had blood sugars in 60-100 [9-13]. Lantus was decreased to glargine 30 QHS and placed on less aggressive sliding scale. Byetta was given at first and then held after hypoglycemia and patient ran out of this medication (she was taking her own). Last AIC was 11.4%. # Patient was on Protonix while in hospital but stopped before discharge. She was on first on Heparin SC and then Lovenox SC for DVT prophylaxis. [Initials (NamePattern4) ] [Last Name (NamePattern4) 77871], Elavil, and Phenergan were held. She may need to restart these medications if needed. # Hypoxia: During her hospital course the patient had intermittent hypoxia, while in the ICU she was ruled out for a PE with a VQ scan with low probability and a bilaterally Doppler of the lower extremities with no DVT. She was on Heparin SC initially then changed to Lovenox 40mg SC. She has a known dx of sleep apnea and has been unwilling to use CPAP. Her oxygen saturation the night before discharge was 91% on 2L, in the AM she had saturation in the 80s on RA, but with deep breathing it increased to 98%on RA within 1-2 minutes. Patient is asymptomatic during these periods and not SOB. Appears to have hypoxia [2-10] hypoventilation, likely worsen by obesity and sleep apnea. She had a CXR before discharge that showed only bibasilar atelecatsis, with some improvment from prior cxr on [2153-9-14]. She may require oxygen to keep saturations >92%. She needs to continue to use her spirometer 10 times per hour and be encouraged to take deep slow breaths. She may need a further work up as an out patient. She will be discharged to a rehab facility in NY state where she lives. She will have follow up with Podiatry and her primary care doctor. Medications on Admission: Carvedilol [Coreg] (6.25 mg twice daily) Crestor (Rosovastatin) (40 mg daily) Elavil (Amitriptyline)(25 mg daily) Furosemide [Lasix] (20 mg daily) Insulin (byetta 10 mg twice daily, lantus 35 units morning and evening, humalog sliding scale) Morphine Oxycontin 45 mg twice daily Phenergan (Promethazine 25 mg three times daily) Zetia (Ezetimibe) (10 mg daily) Gabapentin 600 mg three times daily soma 350 mg daily minocycline 100 mg twice daily lortab 75 mg as needed Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever or pain: max 4 grams per day. Disp:qs Tablet(s) Refills:0 3. Lantus 100 unit/mL Solution Sig: Thirty (30) units Subcutaneous once a day: give at dinner time. 4. Humalog 100 unit/mL Solution Sig: One (1) Subcutaneous three times a day: sliding scale sent from hosptial. 5. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous DAILY (Daily): continue while in rehab. 6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 7. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 8. Morphine 15 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for prn pain: hold for sedation. rr<12. 9. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): hold for loose stool. 12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): hold for sbp<100 . 13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed for constipation. 14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 15. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS): start giving when done with Cipro (antibiotic). 16. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. 17. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days: last day of treatment [2153-9-30]. 18. Clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours) for 12 days: Give for total of 14 days, first day on [2153-9-22]. Discharge Disposition: Extended Care Facility: [Hospital1 ] Health Nursing & Rehab Discharge Diagnosis: -Charcot foot repair -Diabetes Type II -Hypertension -Mixed Flora wound infection -Acute renal failure, secondary to ATN from hypotension, resolving -Anemia, multifactoral -Sleep Apnea Discharge Condition: hemodynamically stable, afebrile, foot in external fixation. Discharge Instructions: You were admitted to [Hospital1 18] for foot surgery. After your sugery you developed a low blood pressure and slow heart rate this required a stay in the ICU. You have an infection in your foot. You are on two antibiotics for this infection. You will need every other day dressing changes for your foot. You will be going to a rehab center to care for your foot. You were started on a new medicaion for your blood pressure. Please keep your follow up appointments. You will need to see the Podiatrist and your PCP. Please take your medications as instructed. Several of your medicaions have been changed. If you have chest pain, shortness of breath, fever, increased drainage from your foot, or any other concerning symptom please seek medical attention or go to the ER. Followup Instructions: Podiatry, please call to make a follow up appointment with Dr. [Last Name (STitle) ] in 2 weeks. ([Telephone/Fax (1) 4335] Please call your PCP to make [Name Initial (PRE) ] follow-up appointment as soon as you leave the hospital, discuss your stay, she may adjust your lisinopril dose. PCP: [Name10 (NameIs) ],[Name11 (NameIs) ] [Name Initial (NameIs) ]. [Telephone/Fax (1) 77872] Completed by:[2153-9-24]	[ "707.14", "285.9", "403.90", "250.60", "780.57", "998.59", "585.9", "440.24", "584.9", "736.72", "997.1", "713.5" ]	icd9cm	[ [ [] ] ]	[ "86.69", "38.93", "78.19", "78.59", "38.91", "83.82", "83.85", "77.69" ]	icd9pcs	[ [ [] ] ]	16237, 16303	8475, 13678	309, 713	16532, 16595	2452, 2452	17422, 17864	1853, 1858		14197, 16214		16324, 16511		13704, 14174			16619, 17399									1873, 2433																									227, 271									741, 1433						2468, 8452											1455, 1754	1770, 1837
20,033	139,208	47099	Discharge summary	report	Admission Date: [2194-7-16] Discharge Date: [2194-7-18] Date of Birth: [2139-1-31] Sex: M Service: Mr. [Known lastname 7474] was in the hospital for 24 hours. He came from [Hospital3 1196] with a history of alcoholic hepatitis C, Child-C cirrhosis. He came into [Location (un) ] [Hospital ] Hospital with peritoneal signs, where he had a peritoneal tap. He was subsequently transferred to [Hospital1 1444] to GI service, where he underwent a tap which showed a fecalith aspirate. He had a CT scan showed which showed massive free air. Consent was obtained. He was taken to the operating room, where he is found to have a hostile abdomen and necrotic portion of terminal small bowel and cecum, which were resected. A decision was made with conjunction of the family to make comfort measures only. Patient expired at 3:20 pm on [2194-7-18]. Dictated By:[Last Name (NamePattern1) 99839] MEDQUIST36 D: [2194-7-18] 18:10 T: [2194-7-22] 11:26 JOB#: [Job Number 99840] cc:[Name8 (MD) 99841]	[ "567.2", "070.54", "569.83", "571.1", "557.0" ]	icd9cm	[ [ [] ] ]	[ "99.15", "45.79" ]	icd9pcs	[ [ [] ] ]
42,612	162,699	41800	Discharge summary	report	Admission Date: [2153-12-7] Discharge Date: [2153-12-8] Date of Birth: [2096-2-1] Sex: F Service: MEDICINE Allergies: Levaquin / lisinopril / clonidine / Hydralazine / Terazosin / Lasix / Hytrin / amlodipine / ibuprofen / Celexa / Bactrim / Relpax Attending:[First Name3 (LF) 69390] Chief Complaint: transfer for cath and ASA desensitization Major Surgical or Invasive Procedure: 1. Cardiac catheterization with drug eluting stent to left circumflex artery - Attending Physician: [Name10 (NameIs) ] [Name11 (NameIs) 33746], MD History of Present Illness: 57yo F PMHx morbid obesity, DM, HTN, HLD, asthma, history of ASA allergy (induced cough, worsened asthma symptoms) who was initially admitted to [Hospital6 33] [12-3] w L arm pain, found to have Lcx lesion, now transferred to [Hospital1 18] for cardiac catheterization and ASA desensitization protocol. Per patient report, on day of admission to [Hospital1 34], she developed acute onset L arm pain in the setting of doing her morning stretches, described as "severe", exertional, without associated chest pain, shortness of breath. Given comorbidities, coronary CTA was ordered to better risk-stratify based on her coronary disease, which was reportedly abnormal (no report available at this time). This prompted cardiac catherization that demonstrated 3VD w mild RCA and LAD disease, as well as critical mid LCx lesion. Patient was transferred for further intervention. . At [Hospital1 18] patient underwent cardiac cath via L radial, underwent placement of DES to mid-Cx without complication. Given history of reported ASA allergy (1 year ago [Male First Name (un) ] worsening wheezing / asthma symptoms in past after 3d aspirin, with symptom improvement after ASA cessation), patient was transferred to CCU for post-cath for ASA desensitization protocol. . On arrival to the floor, patient was without complaint, denied shortness of breath, chest pain, arm pain. Denied dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: - CABG: - PERCUTANEOUS CORONARY INTERVENTIONS: - PACING/ICD: 3. OTHER PAST MEDICAL HISTORY: - Asthma - Thrombocytosis on hydroxyurea - Esophagitis w schatski's ring - Cervicalgia - Morbid Obesity Social History: Lives in [Location 10022] w husband. Retired teacher. Denies tobacco, etoh, illicits. Family History: Father w h/o HTN, MI, CVA. Mother w h/o HTN, AAA, Lymphoma. Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS: 97.3 71 120/56 11 97%RA GENERAL: NAD, comfortable HEENT: NCAT, PERRL, EOMI NECK: Supple, unable to assess JVP 2/2 habitus CARDIAC: RRR, normal S1, S2. No m/r/g. LUNGS: Resp unlabored, no accessory muscle use, quiet breath sounds bilaterally w/o crackles, wheezes or rhonchi ABDOMEN: Soft, obese, nontender EXTREMITIES: No c/c/e. Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ . DISCHARGE PHYSICAL EXAM: VS: 98.2 77 113/65 15 99%RA GENERAL: NAD, comfortable HEENT: NCAT, PERRL, EOMI NECK: Supple, unable to assess JVP 2/2 habitus CARDIAC: RRR, normal S1, S2. No m/r/g. LUNGS: Resp unlabored, no accessory muscle use, quiet breath sounds bilaterally w/o crackles, wheezes or rhonchi ABDOMEN: Soft, obese, nontender EXTREMITIES: No c/c/e. Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ Pertinent Results: ADMISSION LABS: . [2153-12-7] 07:57PM BLOOD WBC-9.2 RBC-3.08* Hgb-8.7* Hct-26.8* MCV-87 MCH-28.2 MCHC-32.3 RDW-15.8* Plt Ct-457* [2153-12-7] 07:57PM BLOOD Neuts-72.2* Lymphs-21.7 Monos-3.4 Eos-2.2 Baso-0.5 [2153-12-7] 07:57PM BLOOD Glucose-107* UreaN-11 Creat-0.8 Na-141 K-3.2* Cl-100 HCO3-30 AnGap-14 [2153-12-7] 07:57PM BLOOD Calcium-8.8 Phos-3.7 Mg-1.9 . PERTINENT LABS: . [2153-12-8] 05:31AM BLOOD CK-MB-3 . DISCHARGE LABS: . [2153-12-8] 05:31AM BLOOD Hct-31.6* Plt Ct-372 . MICRO/PATH: MRSA Screen: negative . IMAGING/STUDIES: . C.CATH [2153-12-7]: FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Successful PCI of the LCx with DES. 3. Aspirin desensitization immediately on arrival to CCU, then continue aspirin daily indefinitely. 4. Plavix 75 mg daily. 5. Integrilin IV gtt x 18 hours. 6. After discharge, the patient to follow up with Dr. [Last Name (STitle) ], [Hospital ] Medical Cardiology. Brief Hospital Course: 57yo F PMHx morbid obesity, DM, HTN, HLD, asthma, history of ASA allergy (induced cough, worsened asthma symptoms) transfered for critical Lcx lesion, now s/p [Hospital ] transferred to ICU for ASA desensitization protocol. . ACTIVE DIAGNOSES: . # 3 Vessel Coronary Artery Disease s/p PCI with Stent: She was transferred to [Hospital1 18] for evaluation and treatment of critical stenosis of her mid left circumflex coronary artery. On catheterization she was found to have significant 3-vessel disease (please see report for full details) and had placements of DES to mid LCx lesion. She was treated with plavix, carvedilol, pravastatin, and integrillin and underwent aspirin desensitization as below. Her course was otherwise unremarkable and she was discharged with follow-up appointments in cardiology and with her PCP. . # Aspirin Allergy/Desensitization: This patient with significant history of allergies and atopy had a reported history of reactive airways secondary to aspirin in the past. Following stent placement, treatment with aspirin became a priority and in consultation with the allergy and immunology team, she underwent a 6 hour desensitization protocol involving montelukast prior to initiation and frequent, escalating doses of aspirin with serial peak flow measurements and close monitoring on tele for possibility of developing a severe reaction. She was quite anxious during this testing but tolerated the protocol well without complications. She was discharged on aspirin and with instructions to seek urgent medical care if she developed concerning symptoms. . CHRONIC DIAGNOSES: . # HTN: Stable. She was continued on her home HCTZ and diltiazem. . # Asthma / Chronic Cough: Stable. In addition to the protocol medications, she was continued on her home advair, mucinex, and zyrtec. . # Seasonal Allergies: Stable. She was continued on her home nasarel. . # DM: Stable. She was continued on her standing NPH and regular insulin sliding scale. . # Thrombocytosis: Stable with PLT counts in the high 300's to mid 400's. Her hydrea was held overnight on the day of admission and restarted on discharge. . # GERD: Stable. She was continued on her home ranitidine. . TRANSITIONAL ISSUES: . #This patient would likely benefit from an outpatient ECHO to assess her cardiac function in [4-25] weeks . #She underwent aspirin desensitization protocol while admitted here. She was instructed to seek care from her PCP for minor symptoms or a local ED if her symptoms are more concerning with the possbility of transfer back to [Hospital1 18] if warranted. Medications on Admission: Zertec 10mg daily Ranitidine 300mg [Hospital1 ] Mucinex 600mg [Hospital1 ] Clotrimazole Suppositories 500mg twice weekly HCTZ 25mg [Hospital1 ] KCl 10meq QID Plavix 75mg daily Insulin Hydrea 500mg TID three days/week, 500mg [Hospital1 ] two days/week Advair 500/50 1 puff [Hospital1 ] Nasarel 2 sprays [Hospital1 ] Clobetasol prn Carvedilol 25mg QID Diltiazem 240mg daily Pravastatin 20mg daily Discharge Medications: 1. Zyrtec 10 mg Capsule Sig: One (1) Capsule PO once a day. 2. ranitidine HCl 300 mg Capsule Sig: One (1) Capsule PO twice a day. 3. Mucinex 600 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO twice a day. 4. clotrimazole Vaginal 5. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO twice a day. 6. potassium chloride 10 mEq Tablet Extended Release Sig: One (1) Tablet Extended Release PO QID (4 times a day). 7. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 9. Hydrea 500 mg Capsule Sig: [2-22] Capsules PO once a day: Please take three times daily three days per week, and twice daily two days per week. . 10. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 11. clobetasol Topical 12. flunisolide Nasal 13. carvedilol 25 mg Tablet Sig: Two (2) Tablet PO twice a day. 14. Diltzac ER 240 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO three times a day. 15. pravastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 16. NPH insulin human recomb 100 unit/mL Suspension Sig: as directed units Subcutaneous twice a day: 26 units in the morning and 12 units at night. 17. insulin regular human 100 unit/mL Solution Sig: as directed units Injection twice a day: 10 units with breakfast and 14 units with dinner. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Coronary Artery Disease, Aspirin Desensitization, Asthma Secondary Diagnosis: Diabetes, Dyslipidemia, Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Left arm pain free. Discharge Instructions: It was a pleasure taking care of you during your stay here at [Hospital1 18]. You were admitted for left arm pain. A cardiac catheterization was performed via the left radial artery with placement of a drug eluting stent in your left circumflex coronary artery. Your left arm pain subsequently resolved. Given your history of wheezing and worsening of your asthma after prior aspirin therapy, you were admitted to the CCU after the procedure for aspirin densensitization. You were given increasing doses of aspirin until the goal of 325mg was given. Your asthma was monitored with peak flow measurements and was stable throughout the desensitization. *You will need to continue taking your aspirin every day without exception.* If you miss more than three days of aspirin therapy you will need to be desensitized again. Please do not stop taking your aspirin or plavix unless your cardiologist instructs you to do so. The following changes were made to your medication regimen: START aspirin 325mg daily Your attending physician during your stay was Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 6512]. Followup Instructions: Please call to make an appointment with your PCP [First Name4 (NamePattern1) 30564] [Last Name (NamePattern1) ] at [Telephone/Fax (1) 90786] within one - two weeks of discharge. Please call to make an appointment with your cardiologist, Dr. [Last Name (STitle) 25731], within one month. You will need a repeat EKG and Echocardiogram at this visit. [First Name8 (NamePattern2) 20] [Last Name (NamePattern1) ] MD [MD Number(1) 69391] Completed by:[2153-12-11]	[ "428.32", "428.0", "278.01", "V58.66", "272.4", "414.01", "493.90", "250.00", "401.9", "V07.1" ]	icd9cm	[ [ [] ] ]	[ "00.45", "00.66", "37.22", "36.07", "88.56", "99.20", "00.40" ]	icd9pcs	[ [ [] ] ]	9046, 9052	4426, 4656	432, 588	9229, 9229	3450, 3450	10565, 11087	2550, 2612		7483, 9023		9073, 9073		7040, 7460		4049, 4403	9399, 10542	3898, 4032								2627, 2637				2228, 2289											2659, 3033			6643, 7014							351, 394									616, 2121			9170, 9208			3466, 3824	9092, 9149			9244, 9375	3840, 3882	2320, 2425			4674, 6622		2143, 2208	2441, 2534			3058, 3431
44,890	187,443	25756	Discharge summary	report	Admission Date: [2129-3-28] Discharge Date: [2129-4-11] Date of Birth: [2055-10-28] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2009] Chief Complaint: coffee ground emesis Major Surgical or Invasive Procedure: EGD ICU monitoring History of Present Illness: 73 yo M with a history of CAD, DM2, CRI, and alcohol abuse who was admitted from the ED for weakness and coffee ground emesis. He initially presented to the ED after his VNA found he had fallen to the floor from his bed secondary to weakness, no LOC. The patient had vomited "purple liquid" after drinking purple juice the day prior to admission. The patient reported some labored breathing on admission, but denied abdominal or chest pain, nausea, melena, fevers, chills, or nightsweats. In the ED, the patient had witnessed coffee ground emesis and guaiac positive stools, however no gross blood per rectum. His vital signs were stable with BP 130/80 and HR 110s. He refused NG lavage, was started on an octreotide drip for presumed variceal bleed, and IV PPI. He received 500mL of IV fluids. GI was consulted who recommended continuing IV PPI, potentially octreotide gtt given potential for variceal bleed, transfusion of 2 units PRBCs. . The patient was transfered to the MICU for close monitoring. During his short MICU stay, the patient remained hemodynamically stable and Hct remained stable. GI did not believe the patient needed to be emergently scoped, thus was postponed. As the patient did not have further episodes of coffee ground emesis, octreotide drip was discontinued and PPI was continued. As the patient has a large diabetic foot ulcer, the patient was given vancomycin and zosyn empirically, podiatry was consulted. Past Medical History: 1. CAD: s/p MI in [2120] w/ stent 2. CRI: baseline Cr 1.5-2.2 3. Chronic R foot ulcerations/infections: s/p R metatarsal head resection on [2125-12-13], followed by podiatry 4. DM 2: c/b neuropathy, nephropathy, and chronic R foot infections. h/o microalbuminuria 5. h/o DVT w/ L filter 6. PVD 7. h/o squamous cell CA of left posterior auricular area (s/p removal by derm) 8. EtOH abuse w/ alcoholic hepatitis 9. h/o CVA [2122] with residual left foot weakness; MRI in [2125] Likely small acute cortical infarcts involving the right frontal lobe. Extensive chronic small vessel infarcts. Old right cerebellar infarct. 10. Odontoid fracture in [2125] with traumatic Horner syndrome L Social History: 4 oz of vodka every night, 2ppd x60 years, retired builder. Patient has never had DTs, seizures, or passed out as a result of drinking. He left rehab facility against medical advice and states he lives alone. Takes medications on his own with assistance of his visiting nurse (question of whether he has been compliant). As per nurse patient is non compliant with foot care and often walks on open ulcerated foot with no socks. Family History: DM-mother, stroke-mother, [Name (NI) 64167] Physical Exam: VS - T 96.9 HR 76 BP 131/65 RR 16 O2 sat 100% on RA Gen- Well nourished, NAD HEENT- NCAT. EOMI. Oropharynx clear. No cervical [Doctor First Name ]. MMM CV- RRR. No murmurs. Chest- CTAB. No wheezes or crackles. poor respiratory effort Abd- Soft, NT, ND. No masses. No rebound or guarding. No hepatosplenomegaly Ext- WWP. No edema. Right foot, under first phalynx, large open area, probes to bone. No eschar. Cool LE. Skin- No [Location (un) ] erythema or spider angiomas. No jaundice or scleral icterus. Neuro: alert oriented x3 Pertinent Results: Studies: EGD [2129-3-31]: Impression: Congestion, erythema and granularity in the gastroesophageal junction compatible with possible barrets esophagus (biopsy) Ulcers in the antrum and pylorus (biopsy) The duodenal periampullary region appeared abnormal. I recommend evaluation with ERCP to evaluate for possible neoplastic change. Otherwise normal EGD to third part of the duodenum Recommendations: Please call my office in [12-3] weeks in order to obtain the results of your biopsies. Please begin Prilosec 20 mg po twice a day for 3 months. Please start Carafate 1 gm by mouth three times a day for 3 months. We will need to repeat an upper endoscopy in 8 weeks, . EGD [2129-4-4]: Impression: Abnormal mucosa in the esophagus Ulcers in the middle third of the esophagus Small hiatal hernia Ulcers in the antrum and stomach body Ulcers in the first part of the duodenum Otherwise normal EGD to third part of the duodenum Recommendations: follow up biopsy results from the recent EGD. Avoid all NSAIDS and [Doctor Last Name ]-2 inhibitors. [Hospital1 ] PPI. recommend prep today for colonoscopy in am for further work up of persistent melena. Carafate 1 gram QID for esophagitis. will need a repeat EGD in 8 weeks for f/u gastric ulcers and biopsy of the GE junction . Colonoscopy: [2129-4-6]: Impression: Erythema and possible pseudomembrane in the sigmoid colon and descending colon (biopsy) Blood in the cecum - bleeding site could not be identified. Poor bowel prep obscured 25% of mucosal view. Diverticulosis of the sigmoid colon and descending colon Otherwise normal colonoscopy to cecum Recommendations: Follow-up with inpatient consult team. . CT Abd: IMPRESSION: 1. Severe diverticulosis of the sigmoid colon, with mild prominence of the wall and folds of the sigmoid colon. This may be related to hypertrophy. However, there is a trace amount of fluid adjacent to the sigmoid colon. If clinically concordant, this can be seen with diverticulitis. 2. Infrarenal abdominal aortic aneurysm with extensive atherosclerotic calcifications. 3. Rounded hypodensity in the interpolar region of the right kidney, too small to characterize, likely reflects a cyst. 4. Tiny gallstones, without evidence of cholecystitis. 5. Honeycombing and pulmonary fibrosis within the visualized lung bases, similar to Chest CT [2129-2-21]. . Tagged RBC scan: IMPRESSION: 1. Rectal bleeding likely due to hemmorhoids at 72 minutes. Bleeding likely started earlier, although the deep pelvis was not imaged during the first 60 minutes. No other areas of bleeding identified within the abdomen or pelvis. Findings discussed with Dr. [Last Name (STitle) 12769]. . CXR: FINDINGS: In comparison with study of [4-4], there has been placement of a nasogastric tube with its tip in the upper stomach. The side hole is in the region of the esophagogastric junction. Little change in the appearance of the heart and lungs with stable diffuse chronic interstitial disease and mild cardiomegaly. . Foot X-ray: IMPRESSION: Prominent soft tissue defect at both the plantar and medial soft tissues about the first MTP joint with an associated lucency and ossific fragment along the medial aspect of the base of proximal first phalanx that is highly concerning for osteomyelitis from adjacent known soft tissue ulcer. . CXR: IMPRESSION: Limited study. No gross acute cardiopulmonary process with unchanged diffuse chronic interstitial lung disease and right-sided volume loss. . Lab results: [2129-3-28] 05:09PM BLOOD WBC-22.0# RBC-3.53# Hgb-10.4# Hct-32.4# MCV-92 MCH-29.5 MCHC-32.2 RDW-17.4* Plt Ct-678# [2129-3-28] 09:21PM BLOOD WBC-21.6 RBC-3.29* Hgb-9.7* Hct-29.8* MCV-91 MCH-29.5 MCHC-32.6 RDW-16.7* Plt Ct-610* [2129-3-29] 06:30AM BLOOD WBC-19.2* RBC-3.39* Hgb-9.9* Hct-30.0* MCV-88 MCH-29.2 MCHC-33.1 RDW-16.8* Plt Ct-506* [2129-3-30] 05:05AM BLOOD WBC-26.2* RBC-3.25* Hgb-9.6* Hct-28.8* MCV-89 MCH-29.5 MCHC-33.3 RDW-16.9* Plt Ct-460* [2129-3-31] 06:40AM BLOOD WBC-24.4* RBC-3.47* Hgb-10.1* Hct-30.7* MCV-88 MCH-29.1 MCHC-33.0 RDW-17.0* Plt Ct-431 [2129-4-1] 06:30AM BLOOD WBC-25.8* RBC-3.46* Hgb-10.2* Hct-31.5* MCV-91 MCH-29.6 MCHC-32.5 RDW-17.4* Plt Ct-459* [2129-4-2] 06:30AM BLOOD WBC-22.1* RBC-3.09* Hgb-8.9* Hct-27.4* MCV-89 MCH-28.8 MCHC-32.4 RDW-16.9* Plt Ct-464* [2129-4-3] 06:30AM BLOOD WBC-19.8* RBC-3.25* Hgb-9.6* Hct-29.0* MCV-89 MCH-29.6 MCHC-33.2 RDW-16.9* Plt Ct-486* [2129-4-4] 06:30AM BLOOD WBC-20.2* RBC-2.70* Hgb-8.0* Hct-23.7* MCV-88 MCH-29.5 MCHC-33.6 RDW-16.5* Plt Ct-470* [2129-4-5] 05:19AM BLOOD WBC-11.6* RBC-2.95* Hgb-8.7* Hct-25.3* MCV-86 MCH-29.4 MCHC-34.3 RDW-16.7* Plt Ct-436 [2129-4-6] 05:56AM BLOOD WBC-11.9* RBC-3.29* Hgb-9.6* Hct-27.8* MCV-85 MCH-29.3 MCHC-34.6 RDW-16.5* Plt Ct-373 [2129-4-7] 06:42AM BLOOD WBC-13.4* RBC-2.95* Hgb-8.8* Hct-25.7* MCV-87 MCH-29.7 MCHC-34.2 RDW-16.3* Plt Ct-347 [2129-4-8] 05:48AM BLOOD WBC-13.6* RBC-3.39* Hgb-10.2* Hct-29.4* MCV-87 MCH-30.2 MCHC-34.8 RDW-17.1* Plt Ct-343 [2129-4-9] 05:38AM BLOOD WBC-12.7* RBC-3.44* Hgb-10.0* Hct-30.0* MCV-87 MCH-29.2 MCHC-33.5 RDW-17.0* Plt Ct-326 [2129-4-10] 09:00AM BLOOD WBC-9.0 RBC-3.20* Hgb-9.5* Hct-27.9* MCV-87 MCH-29.8 MCHC-34.1 RDW-16.5* Plt Ct-325 [2129-4-11] 06:09AM BLOOD WBC-9.1 RBC-3.00* Hgb-8.8* Hct-26.1* MCV-87 MCH-29.2 MCHC-33.6 RDW-16.7* Plt Ct-334 [2129-4-4] 02:02PM BLOOD PT-16.0* PTT-35.8* INR(PT)-1.4* [2129-4-5] 09:26PM BLOOD PT-14.7* PTT-33.0 INR(PT)-1.3* [2129-4-6] 05:56AM BLOOD PT-15.1* PTT-34.2 INR(PT)-1.3* [2129-4-8] 05:48AM BLOOD PT-14.5* PTT-32.5 INR(PT)-1.3* [2129-4-8] 03:55PM BLOOD PT-14.2* PTT-31.7 INR(PT)-1.2* [2129-4-10] 03:45PM BLOOD PT-14.1* PTT-30.7 INR(PT)-1.2* [2129-3-28] 05:09PM BLOOD UreaN-69* Creat-2.7# Na-138 K-5.1 Cl-105 HCO3-17 AnGap-21* [2129-3-28] 09:21PM BLOOD Glucose-181* UreaN-71* Creat-2.8* Na-138 K-5.6* Cl-106 HCO3-22 AnGap-16 [2129-3-29] 06:30AM BLOOD Glucose-110* UreaN-66* Creat-2.7* Na-141 K-5.2* Cl-110* HCO3-20* AnGap-16 [2129-3-30] 05:05AM BLOOD Glucose-70 UreaN-57* Creat-2.3* Na-143 K-4.3 Cl-114* HCO3-21* AnGap-12 [2129-3-31] 06:40AM BLOOD Glucose-60* UreaN-41* Creat-1.7* Na-144 K-4.1 Cl-115* HCO3-20* AnGap-13 [2129-4-1] 06:30AM BLOOD Glucose-66* UreaN-34* Creat-1.7* Na-143 K-3.9 Cl-113* HCO3-20* AnGap-14 [2129-4-2] 06:30AM BLOOD Glucose-109* UreaN-30* Creat-1.8* Na-142 K-3.9 Cl-113* HCO3-20* AnGap-13 [2129-4-3] 06:30AM BLOOD Glucose-127* UreaN-25* Creat-1.8* Na-141 K-3.8 Cl-113* HCO3-19* AnGap-13 [2129-4-4] 06:30AM BLOOD Glucose-133* UreaN-24* Creat-1.9* Na-139 K-4.2 Cl-111* HCO3-18* AnGap-14 [2129-4-5] 05:19AM BLOOD Glucose-137* UreaN-22* Creat-1.8* Na-141 K-4.2 Cl-114* HCO3-20* AnGap-11 [2129-4-6] 05:56AM BLOOD Glucose-126* UreaN-16 Creat-1.5* Na-143 K-3.5 Cl-115* HCO3-21* AnGap-11 [2129-4-7] 06:42AM BLOOD Glucose-117* UreaN-16 Creat-1.5* Na-144 K-3.7 Cl-116* HCO3-21* AnGap-11 [2129-4-7] 06:42AM BLOOD Glucose-117* UreaN-16 Creat-1.5* Na-144 K-3.7 Cl-116* HCO3-21* AnGap-11 [2129-4-8] 05:48AM BLOOD Glucose-87 UreaN-14 Creat-1.4* Na-143 K-3.5 Cl-116* HCO3-21* AnGap-10 [2129-4-9] 05:38AM BLOOD Glucose-106* UreaN-11 Creat-1.2 Na-142 K-3.2* Cl-113* HCO3-20* AnGap-12 [2129-4-9] 05:38AM BLOOD Glucose-106* UreaN-11 Creat-1.2 Na-142 K-3.2* Cl-113* HCO3-20* AnGap-12 [2129-4-10] 09:00AM BLOOD Glucose-142* UreaN-11 Creat-1.4* Na-141 K-3.9 Cl-115* HCO3-19* AnGap-11 [2129-4-11] 06:09AM BLOOD Glucose-168* UreaN-11 Creat-1.2 Na-144 K-4.3 Cl-117* HCO3-19* AnGap-12 [2129-3-28] 09:21PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Brief Hospital Course: 73 yo M with a history of DM type 2, CAD, CRI, CVA, alcohol abuse, but no known history of liver disease, who presented for a GI bleed. . # GI bleed: Likely upper GI bleed as source of bleed given coffee ground emesis and brown guaiac positive stool, developed into melena during hospital course. Over the course of the hospitalization the patient had melena daily with daily Hct drops requiring a total of 10 untis of PRBCs, the last of which he received on [2129-4-7]. However the patient's blood pressure remained stable during hospitalization. The patient had multiple diagnostic studies done during the hospitalization included two EGDs, a colonoscopy, CT abd/pelvis, and tagged red blood cell scan. The two EGDs showed peptic ulcer disease, gastritis, possible Barrett's esophagus and a lesion at in the duodenal periampullary region concerning for malignancy. None of these lesions were bleeding during either EGD. As neither of these EGDs showed evidence of active bleeding, a colonoscopy was done the following week which showed pseudomembranes and diverticulosis, as well as blood in the cecum, but no clear source of bleeding. The patient was thought to possibly have a small bowel source of bleeding, and was referred for capsule endoscopy, however the patient was unable to swallow the capsule. Instead the patient had a tagged red blood cell scan and CT abdomen/pelvis which did not show conclusive evidence of acute bleeding. The presumed source was then determined to be multifactorial from the patient's peptic ulcer disease, gastritis and c diff colitis. The patient was hemodynamically stable without evidence of persistent melena for four days prior to discharge. His hct reached a baseline of high 20s to low 30s and did not change during this time. The patient will need to be seen by GI in four weeks to discuss possible repeat EGD and ERCP to evaluate periampullary duodenal mass. The patient was continued on sucralfate 1gm TID and pantoprazole 40mg [Hospital1 ], he should continue on these medications on discharge. . # C difficile colitis: Diagnosed on [2129-3-30]. The patient had significant leukocytosis on admission and large loose stools. The patient had been empirically started on flagyl for his left foot osteomyelitis given previous history of infection with anaerobic bacteria. When the C diff toxin came back positive the flagyl was changed to PO. The patient should be continued on flagyl for 7 days following the discontinuation of his antibiotic course for osteomyelitis. End date [2129-5-16]. . # Osteomyelitis: Patient had a large ulcerated lesion on R first metatarsal where the joint capsule and bone was exposed, with some drainage on admission. Podiatry was consulted during admission. He was last seen by podiatry 2 weeks ago, where he was noted to have exposed joint capsule, and poor wound care. The did not believe the joint had an acute infection, however X-ray showed evidence of osteomyelitis. On [4-25] Patient was admitted with R hallux infection, then wound culture grew out Enterobacter cloacae and was treated with Cipro and Vancomycin. Has a history of chronic foot infections, non compliance with antibiotics and wound care. The patient was treated with vancomycin and zosyn initially, then changed to vanc/cipro/flagyl for coverage of MRSA and GNR in wound. As the GNR turned out to be E coli which was resistant to cipro, the patient was changed to ceftriaxone. The staph species was found to be sensitive to penicillin, but given his history of MRSA, he was continued on vancomycin. As the patient has a history of renal insufficiency, vancomycin levels were monitored. He was only supratherapeutic on two occassions. These leves should be monitored periodically during his stay at rehab and his dose adjusted accordingly. The end date for the vancomycin and ceftriaxone should be [2129-4-25]. At that time he should change to bactrim 1DS PO BID and cefpodoxime 400 mg PO BID for an additional 14 days (end date [2129-5-9]). . # Acute on chronic renal failure: Cr on admission 2.7. Baseline 1.6-2.0. Likely prerenal in etiology given GI bleed. FeNa was 4%, consistent with ATN or diabetic nephropathy. The renal failure improved with fluids. It was stable prior to discharge. . # Alcohol abuse: As an outpatient the patient drinks 4oz of vodka daily. No history of DTs, seizures, black outs. The patient was managed on Ativan PRN CIWA score >10 initially, but was discontinued the first week of his hospitalization. He was also initially placed on seizure and aspiration precautions. He was started on a MVI, folate, thiamine daily. He was given trazodone as needed for insomnia. Social work was consulted. . # Hyperkalemia: The patient has a history of hyperkalemia. This was likely secondary to the patient's acute on chronic renal failure, and ACE I therapy. The patient's ACE-I was discontinued and his hyperkalemia resolved. He should not be restarted on an ACE-I as an outpatient. . # CAD: history of MI in [2120] with stent placed. The patient's ASA, BB and lisinopril were all held in the setting of a GI bleed. The patient was continued on Atorvastatin. He was able to be restarted on metoprolol 12.5mg [Hospital1 ] without a drop in his blood pressure. ACE-I should not be restarted given hyperkalemia. . # Type 2 Diabetes mellitus: The patient has uncontrolled DM, complicated by neuropathy, nephropathy, chronic foot infections. The patient takes glipizide at home, however was discontinued during his hospital stay. The patient was managed on humalog insulin sliding scale instead with decent control of his blood sugars. . Medications on Admission: Glipizide 2.5 mg po daily Metoprolol 50mg po bid ASA 81mg po daily Atorvastatin 20mg po daily Pantoprazole 40mg po daily Cilostazol 100mg po bid Lisinopril 5mg po daily Unclear whether patient is to be taking Abx for right foot chronic infection Discharge Medications: 1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 3. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed. 6. B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. 9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours): Please continue until [2129-5-16] . Tablet(s) 10. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) Intravenous Q 24H (Every 24 Hours): Please continue for until [2129-4-25]. Please check a vancomycin trough twice a week and adjust dose accordingly. 11. Ceftriaxone in Dextrose,Iso-os 1 gram/50 mL Piggyback Sig: One (1) Intravenous Q24H (every 24 hours): Please continue until [2129-4-25]. 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day): Hold for SBP < 90, HR < 50. 14. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale Subcutaneous four times a day. 15. Outpatient Lab Work results, goal should be > 25. Please check vancomycin trough twice a week. Please contact on [Name8 (MD) 138] MD with results. Goal should be < 20. 16. Clarithromycin 500 mg Tablet Sig: One (1) Tablet PO twice a day for 10 days: For H Pylori infection. Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Primary Diagnoses: Upper GI Bleed secondary to peptic ulcer disease, H pylori gastritis C diff colitis Osteomyelitis . Secondary Diagnoses: Type 2 Diabetes Mellitus Coronary artery disease [Last Name (un) ] renal insufficiency Peripheral vascular disease Alcohol Abuse History of CVA Discharge Condition: The patient was alert and oriented, hemodynamically stable and afebrile prior to discharge. Discharge Instructions: You were admitted to [Hospital1 18] for evaluation of vomiting blood. You were found to have an ulcer in your intestines and inflammation of the lining of your stomach. These were determined to likely be the cause of your bleeding. You also were found to have an infection in your colon called C difficile. You were put on antibiotics for this infection. You were also found to have an infection called H pylori in your stomach, you will be treated for this infection as well. You were also found to have an infection in the bone of your foot. You were treated with antibiotics for this as well. . You will have to continue the IV and by mouth antibiotics for some time following discharge: Flagyl 500mg three times a day End date [5-16] Ciprofloxacin 500mg twice a day IV End date [4-25] Vancomycin 1gm once a day, dosed renally by level End Date [4-25] Clarithromycin 500mg twice a day End date [4-21] . These other medications were added: Sucralfate 1gm three times a day Pantoprazole 40mg twice a day . These medications were stopped: Aspirin Lisinopril Glipizide . These medications were changed: Metoprolol decreased to 12.5mg twice a day . If you experience bright red blood per rectum, dark or black stools, abdominal pain, fever, chills, chest pain or any other worrisome symptoms please seek medical attention. Followup Instructions: Please follow up with your primary care physician [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) 636] [Last Name (NamePattern1) 64168] in the next 1-2 weeks. The phone number to her office is [Telephone/Fax (1) 64169]. . Please follow up with the GI physician, [Last Name (NamePattern4) ]. [First Name (STitle) ] [Name (STitle) ], on Friday [2132-5-13]:45pm on the [Hospital Ward Name 516] on the [Location (un) 453] of the [Hospital Unit Name ]. The number to reschedule this appointment is ([Telephone/Fax (1) 2233]. . Please follow up with Dr. [Last Name (STitle) ] in podiatry on [4-20] at 1:10pm. The number to reschedule the appointment is ([Telephone/Fax (1) 19882] Completed by:[2129-4-12]	[ "530.85", "583.81", "443.9", "041.86", "585.9", "250.42", "730.07", "707.15", "531.40", "438.89", "571.1", "V12.51", "250.72", "403.90", "V58.66", "303.91", "276.7", "584.9", "041.4", "250.62", "414.01", "008.45", "357.2", "V10.83", "V45.82", "412", "440.23" ]	icd9cm	[ [ [] ] ]	[ "45.25", "99.04", "77.68", "38.93", "45.16" ]	icd9pcs	[ [ [] ] ]	19087, 19166	11304, 16991	337, 358	19498, 19592	3636, 11281	20987, 21763	3015, 3064		17288, 19064		19187, 19306		17017, 17265			19616, 20964									3079, 3617			19327, 19477																						277, 299									386, 1826																	1848, 2554	2570, 2999
41,897	193,853	45127	Discharge summary	report	Admission Date: [2144-7-26] Discharge Date: [2144-8-4] Date of Birth: [2071-9-8] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 2279] Chief Complaint: Hematemesis Major Surgical or Invasive Procedure: Upper endoscopy with clip placement History of Present Illness: 72yo M with PMHx of ESRD secondary to lithium exposure and interstitial nephritis, diabetes insipidus (lithium toxicity), normal pressure hydrocephalus s/p drain placement ([2138]), hypertension, anemia of chronic disease, h/o endocarditis, pulmonary lymphadenopathy and BPH who presents with hematemsis. Patient was in his normal state of health when he developed 4 episodes of coffee ground emesis on the day of admission. He reports that this occurred after drinking a cup of Ginger Ale. He denies abdominal pain. He also denies abdomianl pain, melena, hematochezia, or BRBPR. The patient denies chest pain, chest tightness, shortness of breath, dizziness. In the ED, the patient was noted to have a HCT of 19.8 with Hgb 6.0 and MCV 113. INR 1.4 with lactate 3.3. Creatinine notable to be 3.8. CXR in the ED notable for moderate left-sided pleural effusion , possible cardiomegaly, and infiltrate in the RLL. Serum tox screen was negative. EKG w/ NSR at 96 bpm with RBBB and ST segement depressions in V1-V3 with TWI in V1-V3. GI was consulted in the ED who felt that scope could wait until AM. Per veral sign out, the patient was mentating appropriately through his ED course despite low SBPs. On arrival to the MICU, the patient is annoyed; he denies nausea, vomiting, and abdominal pain. Past Medical History: -ESRD [2-20] lithium exposure and chronic interstitial nephritis on HD (Tue/[Doctor First Name ]/Sat) -Thrombosis of the LUE fistula/graft, catheter associated thrombus in RIJ -DI from Lithium toxicity -Normal pressure hydrocephalus s/p drain at [Hospital1 112] in [2138] -Hypertension -Anemia of chronic disease -H/o endocarditis -Pulmonary lymphadenopathy -BPH -CAD s/p CABG . Past Surgical History: -PPM without ICD for complete heart block [2144-4-14] -Left AVG placement [1-/2144] -CABG x 4, resection of tumor from left ventricular outflow tract [2141-1-27] -Left brachiocephalic AV fistula placed [2139-9-23] -Left forearm radiocephalic AV fistula [2139-5-12] -Left LUE graft -Left tunneled dialysis catheter placement due to LUE graft thrombosis [2144-6-18] -Appendectomy -Tonsillectomy . Past Psychiatric History: - MDD vs BPAD type 1 - Previous trials of lithium (was helpful but caused kidney toxicity), depakote (was discontinued) - Several ([4-23]) hospitalizations in lifetime, no suicide attempts Social History: Formerly worked at the MFA as a security guard. Had lived alone in [Location (un) 2030], now living at [Hospital 169] Center. Never married, no children. Never smoker. Denies alcohol use and illicits. Family History: Patient denies history of heart disease, diabetes, or cancer. Does not know of any other medical problems in his family. History of depression in his father. Physical Exam: Admission: 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, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, LUE fistula in place Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact Discharge: Pertinent Results: Admission: [2144-7-26] 08:23PM [Month/Day/Year 3143] WBC-6.6 RBC-1.75* Hgb-6.0* Hct-19.8* MCV-113* MCH-34.0* MCHC-30.1* RDW-19.4* Plt Ct-273 [2144-7-26] 08:40PM [Month/Day/Year 3143] PT-15.0* PTT-26.6 INR(PT)-1.4* [2144-7-27] 04:30AM [Month/Day/Year 3143] Glucose-106* UreaN-68* Creat-3.9* Na-139 K-5.1 Cl-103 HCO3-26 AnGap-15 [2144-7-30] 01:13AM [Month/Day/Year 3143] ALT-12 AST-17 LD(LDH)-177 AlkPhos-56 TotBili-0.2 [2144-7-26] 08:23PM [Month/Day/Year 3143] Lipase-18 [2144-7-27] 04:30AM [Month/Day/Year 3143] Calcium-9.1 Phos-3.2 Mg-2.0 [2144-7-30] 01:13AM [Month/Day/Year 3143] Hapto-80 [2144-7-26] 08:23PM [Month/Day/Year 3143] [Month/Day/Year ]-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2144-7-26] 08:36PM [Month/Day/Year 3143] Glucose-119* Lactate-3.3* Na-137 K-4.6 Cl-100 calHCO3-31* [2144-7-27] 05:54PM [Month/Day/Year 3143] Lactate-1.5 [2144-7-27] 11:22AM [Month/Day/Year 3143] IgG-663* [2144-7-27] H. pylori negative Discharge: [2144-8-4] 05:50AM [Month/Day/Year 3143] WBC-5.5 RBC-3.26* Hgb-10.5* Hct-33.2* MCV-102* MCH-32.2* MCHC-31.5 RDW-22.1* Plt Ct-193 [2144-8-4] 05:50AM [Month/Day/Year 3143] Plt Ct-193 [2144-8-4] 05:50AM [Month/Day/Year 3143] Glucose-77 UreaN-44* Creat-5.0* Na-132* K-4.7 Cl-94* HCO3-30 AnGap-13 [2144-8-4] 05:50AM [Month/Day/Year 3143] Calcium-8.1* Phos-3.6 Mg-2.2 [2144-7-29] 12:03AM [Month/Day/Year 3143] Lactate-1.9 [2144-7-26] 08:36PM [Month/Day/Year 3143] freeCa-1.26 Reports: [7-27] EGD: Erosions in the duodenal bulb Old [Month/Day (4) ] was found in the stomach but no active [Month/Day (4) ] was seen Diffuse esophageal ulcers and severe esophagitis were noted in the lower third of the esophagus. There was also a mix of fresh [Month/Day (4) ] and thick adherent clot within the moderate sized hiatal hernia. The area was suctioned and irrigated. A few ulcers were noted and two large [Doctor First Name 329] [Doctor Last Name ] tears were noted. A total of three clips were applied. two to the larger tear and one to the smaller tear with successful hemostasis. We were unable to remove the adherent clot. No further [Doctor Last Name ] was noted. Medium hiatal hernia Esophagitis in the lower third of the esophagus Otherwise normal EGD to second part of the duodenum CXR: The patient is status post coronary artery bypass graft surgery. A right-sided pacemaker device has been placed, terminating in the right ventricle. There is a moderate pleural effusion on the left with associated opacity, probably due to atelectasis, including volume loss and mild leftward shift of mediastinal structures. Aside from streaky and band-like opacities in the right lower lung suggesting minor atelectasis, the right lung appears clear. There is no pleural effusion of the right or pneumothorax. There is no definite evidence for free air. IMPRESSION: Moderate left-sided pleural effusion with substantial suspected atelectasis. No evidence for free air. Micro: HELICOBACTER PYLORI ANTIBODY TEST (Final [2144-7-29]): NEGATIVE BY EIA. Brief Hospital Course: 72yo M with PMHx of ESRD secondary to lithium exposure and interstitial nephritis, diabetes insipidus (lithium toxicity), normal pressure hydrocephalus s/p drain placement ([2138]), hypertension, anemia of chronic disease, h/o endocarditis, pulmonary lymphadenopathy and BPH who presents to the ED with likely upper GI bleed found to have HCT 19.8 with MCV 113 for whom GI was consulted admitted for further HD monitoring in light of GI bleed. # GI Bleed: Patient with GI bleed with evidence of coffee ground emesis prior to ED presentation as well as on lavage in the ED. Patient volume resuscitated in the ED with 2L of NS and 1 unit of pRBCs was started. Upon arrival to the ICU, the patient with SBPs in the high 100 to 110s, and not tachycardic. The patient currently denies nausea, vomiting, and abdominal pain. NGT with evidence small (approximately 15cc) of [Year (4 digits) ] in the canister. GI is following the patient. Review of endoscopy reports from [2143] showing esophagitis, gastritis, and duodenitis. No evidence of varices on last EGD. Of note, patient previously hospitalized in early [Month (only) ] with gastro-occult positive emesis. He underwent EGD on [7-27] which showed [Doctor First Name 329] [Doctor Last Name ] tear within hiatal hernia and 3 clips were placed. He was transitioned from PPI drip to [Hospital1 ] dosing. H. pylori serology negative. Aspiration precautions ordered. He was transfused a total of 5u PRBCs and had no additional [Hospital1 ]. NGT was removed when EGD done. He should have repeat EGD in [8-30] weeks as an outpatient to ensure resolution. Patient with stable hematocrit for several days following last transfusion on [2143-7-28] and no episodes of additional hematemesis. [Date Range ] pressures stable in the 100s-120s on the floor. Metoprolol was held given soft BPs, and should be titrated back at rehab when his BP tolerates (below). [Date Range ] was held by GI following bleed and it was restarted prior to discharge, per their recommendations. # Hypotension: Patient noted to be hypotensive on morning after admission, trauma line placed. BP improved with PRBC and crystalloid infusions. Noted to have systolics in the 70s during HD, asymptomatic, improved to baseline of 95-105 systolic once fluid given back. Systolic BPs stable in 95-100 range prior to floor transfer. On the floor, BPs stable in the 100s-130s. Metoprolol held initially given soft BPs in the ICU and was titrated back as BPs returned to baseline. # Pleural effusion: First noted [2142], tapped by IP, transudative, no growth. He should have continued outpatient work up given loculation on CT. # IV access: Patient is a difficult peripheral stick and unable to get IV access to LUE in light of fistula. IO was placed and then removed and femoral trauma line placed, changed over to CVL for rest of hospitalization given inability to place central line in IJ or subclavian given known vasculopathy. His right femoral triple lumen line was removed prior to discharge. # Upper extremity edema: Patient has chronic upper extremity edema. Has been stable throughout admission. This has been extensively worked up in the past. On his last admission, CTA without SVA syndrome and RUE ultrasound did not show thrombus formation. Venogram showed uncomplicated right subclavian and central venography. No significant stenosis or venous collaterals. During the current admission, a left upper extremity ultrasound was performed which showed normal flow, compressibility and augmentation. Wall-to-wall color flow is seen within the graft throughout. # Lactatemia: Patient with lactate 3.3 upon presentation, suggesting end organ ischemia in the setting of acute GI bleed. Trended down to 1.9 as he was volume resuscitated. # ESRD: Tuesday, Thurdsay, Saturday HD schedule. Patient did go to HD on Saturday prior to admission per HCP report. [Name2 (NI) ] was continued on his usual HD schedule but was noted to have asymptomatic hypotension with systolics in the 70s at times when trying to remove fluid, improved to baseline 90s with fluid given back. Continued nephrocaps, renvela, sensipar. # Psyhciatric history: Patient with an extensive psychiatric history that includes depression requiring ECT as well as episodes of mania. Psych meds (valproate, haldol) initially transitioned to IV, back to PO once diet advanced along with quetiapine. He had no s/s of mania. # History of CAD: Patient CP free despite low HCT at admission. EKG in the ED is unchanged from prior EKGs. [Name2 (NI) ] and beta blocker initially held in setting of GIB. # History of HTN: Held metoprolol initially given hypotension secondary to acute bleed. This was restarted while in the hospital at 12.5 mg PO BID. This should be should be held on dialysis days as he tends to be hypotensive (asymptomatic during dialysis. # History of BPH: Held doxazosin in light of acute bleed and should be restarted at rehab as [Name2 (NI) ] pressure tolerates (as above). # Transitional issues: - Patient's doxazosin was held given low BPs, should be restarted at rehab as BP tolerates - Patient continued on home HD schedule (Tu Th Sat) and should resume at rehab - Scheduled for GI and PCP follow up - Patient should hold metoprolol on dialysis days as he tends to become hypotensive, albeit asymptomatic - He should have continued outpatient work up for pleural effusion given loculation on CT Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Assissted living facility records . 1. Doxazosin 8 mg PO HS 2. Metoprolol Tartrate 12.5 mg PO BID HOLD for SBP < 100, HR < 60 3. Haloperidol 0.5 mg PO BID 4. Haloperidol 0.5 mg PO PRN aggitation 5. Quetiapine Fumarate 25 mg PO QHS 6. Aspirin 81 mg PO DAILY 7. Acetaminophen 325 mg PO Q6H:PRN fever, pain 8. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain HOLD for sedation, RR < 12 9. Docusate Sodium 100 mg PO BID 10. Divalproex (DELayed Release) 500 mg PO BID 11. Nephrocaps 1 CAP PO DAILY 12. Omeprazole 40 mg PO DAILY 13. sevelamer CARBONATE 2400 mg PO TID W/MEALS 14. Senna 1 TAB PO BID:PRN constipation 15. Cinacalcet 30 mg PO DAILY Discharge Medications: 1. Acetaminophen 325 mg PO Q6H:PRN fever, pain 2. Cinacalcet 30 mg PO DAILY 3. Divalproex (DELayed Release) 500 mg PO BID 4. Haloperidol 0.5 mg PO BID 5. Haloperidol 0.5 mg PO PRN aggitation 6. Nephrocaps 1 CAP PO DAILY 7. Omeprazole 40 mg PO BID 8. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain HOLD for sedation, RR < 12 9. Quetiapine Fumarate 25 mg PO QHS 10. Senna 1 TAB PO BID:PRN constipation 11. sevelamer CARBONATE 1600 mg PO TID W/MEALS 12. Aspirin 81 mg PO DAILY 13. Docusate Sodium 100 mg PO BID 14. Metoprolol Tartrate 12.5 mg PO BID HOLD for SBP < 100, HR < 60. DO NOT GIVE ON DIALYSIS DAYS Discharge Disposition: Extended Care Facility: [Hospital ] Healthcare Center - [Location (un) ] Discharge Diagnosis: Primary diagnoses: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] Tear Acute [Last Name (NamePattern1) ] loss anemia Secondary diagnoses: ESRD on hemodialysis CAD, hypertension Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname ], You were admitted to the hospital because you were vomiting large amounts of [Known lastname ]. You spent time in the intensive care unit where you were transfused 5 units of [Known lastname ]. The GI doctors [Name5 (PTitle) ] two [Name5 (PTitle) ] vessels in your esophagus and placed clips to stop the [Name5 (PTitle) ]. You continued to have your regular dialysis treatments while in the hospital. You were transferred to the general medicine floor and you continued to improve. Your [Name5 (PTitle) ] counts remained stable and you did not have any additional episodes of bloody vomit. Your [Name5 (PTitle) ] pressure was low each time you went to dialysis, so you should not take your metoprolol ([Name5 (PTitle) ] pressure medicine) on days that you have dialysis. Followup Instructions: Department: GASTROENTEROLOGY When: FRIDAY [2144-8-28] at 9:00 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 51379], MD [Telephone/Fax (1) 1983] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) 858] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: ADVANCED VASC. CARE CNT When: WEDNESDAY [2144-9-30] at 11:00 AM With: [Name6 (MD) 5536] [Name8 (MD) ], MD [Telephone/Fax (1) 5537] Building: [Street Address(2) 7298] ([Location (un) 583], MA) [Location (un) ] Campus: OFF CAMPUS Best Parking: Free Parking on Site Department: CARDIAC SERVICES When: WEDNESDAY [2145-1-20] at 2:00 PM With: DEVICE CLINIC [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 2285] Completed by:[2144-8-5]	[ "511.89", "532.90", "600.00", "585.6", "782.3", "796.9", "V45.81", "414.00", "530.10", "530.7", "789.00", "582.89", "401.9", "296.80", "E939.8", "253.5", "V45.11", "285.29", "530.20", "458.9", "331.5", "285.1", "787.02", "553.3" ]	icd9cm	[ [ [] ] ]	[ "39.95", "38.97", "44.43", "38.93" ]	icd9pcs	[ [ [] ] ]	13916, 13999	7010, 12060	282, 319	14244, 14244	3807, 6987	15263, 16332	2974, 3134		13275, 13893		14020, 14161		12512, 13252			14397, 15240								2090, 2731	3149, 3788			14182, 14223																						231, 244									347, 1650										14259, 14373			12083, 12486				1672, 2067	2747, 2958
31,605	127,805	32213	Discharge summary	report	Admission Date: [2128-3-5] Discharge Date: [2128-3-15] Date of Birth: [2046-5-15] Sex: M Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamides) / Ciprofloxacin / Levaquin Attending:[Last Name (NamePattern4) 290] Chief Complaint: Bright red blood per rectum Major Surgical or Invasive Procedure: none History of Present Illness: 81 yo M with history of prior GIB from duodenal lesion 6 wks ago, recurrent C.diff, HTN, CAD admitted to [Hospital ] hospital with c/o diarrhea on [2-27], course complicated by [Hospital 39700] transferred to [Hospital1 ] MICU for GI bleed. He was initially admitted to the OSH ICU with shock on dopamine, treated with cefepime, po vanc, and po flagyl. His course was complicated by an NSTEMI, with his Troponin I peaking at 5.8; cardiology advised medical mgmt (IV heparin, stopping dopamine [3-13] tachycardia, and increasing ASA to 325 daily). Echocardiogram showed EF 25-30% with multiple regional wall motion abnormalities. Speech and swallow eval on [3-3] showed significant aspiration risk, and he was started on NG tube feeds. While evaluating him for J-tube placement, he was ntoed to have BRBPR with large clot. NG lavage was negative. GI was consulted and recommended transfer to [Hospital1 18]. Labs at OSH prior to transfer WBC 15.3 HCT 35.4 PLT 104 Cr 2.3. Portable CXR with moderate pulmonary edema. Blood Cx [2-27] negative, C.diff positive [2-28]. At [Hospital1 18], he recently had an EGD on [2128-2-11] showing: 1.Deformed duodenal bulb. 2.Adenomatous polyp measuring 2 cm was seen in the second part of the duodenum possibly arising from the ampulla. Otherwise normal EGD to third part of the duodenum . On arrival to the ICU, he endorses productive cough, nausea, and weight loss (unsure how much). He denies chest pain, SOB, palpitations, dizziness/LH, fever or chills, abdominal pain, vomiting. He reports that his diarrhea is improving. Past Medical History: -CAD- old anteroapical MI, NSTEMI [12-17] in setting of GIB, NSTEMI last week -recurrent C.diff infections (most recently positive [2-28]) -recurrent UTI -s/p AAA repair [2120] -s/p bilateral iliac aneurysm repair -s/p L renal bypass surgery -h/o Bladder tumor -s/p TURP -minimal C3/C4 spondylolisthesis -CHF ([2-29] Echo: EF 25-30% with multiple regional wall motion abnormalities, mild MR and mild TR) -CKD (baseline Cr 2.5, atrophic L kidney) Social History: married lives with wife and grandson in [Name (NI) 14663], smoking history, quit > 10 years ago, denies ETOH Family History: NC Physical Exam: VS: Temp: 96.9 BP: 136/78 HR: 75 RR: 21 SpO2 98% on 2L NC GEN: cachectic, pale-appearing, pleasant, comfortable, NAD; coughing with productive sputum, alert and oriented x3 HEENT: PERRL, EOMI, anicteric, MMM, op without lesions NECK: RIJ in place, site without erythema, no JVD RESP: crackles to bilateral bases, otherwise CTAB CV: RR, S1 and S2 wnl, 2/6 systolic murmur. PMI laterally displaced. ABD: +b/s, soft, nt/nd, no hepatosplenomegaly, large LUQ incisional hernia which is soft and reducible. EXT: no LE edema, extremities cool to palpation, femoral pulses by doppler SKIN: no rashes/ no jaundice Pertinent Results: [2128-3-5] 08:52PM BLOOD WBC-14.9* RBC-3.72* Hgb-11.0* Hct-34.7* MCV-93 MCH-29.6 MCHC-31.8 RDW-16.2* Plt Ct-114* [2128-3-7] 05:02AM BLOOD WBC-11.7* RBC-3.36* Hgb-10.1* Hct-31.6* MCV-94 MCH-30.0 MCHC-31.9 RDW-16.1* Plt Ct-107* [2128-3-7] 11:31AM BLOOD Hct-29.4* [2128-3-8] 04:53AM BLOOD WBC-11.1* RBC-3.92* Hgb-12.0* Hct-35.8* MCV-91 MCH-30.5 MCHC-33.4 RDW-16.7* Plt Ct-111* [2128-3-10] 09:40PM BLOOD Hct-29.5* [2128-3-12] 05:28AM BLOOD WBC-12.9* RBC-3.60* Hgb-11.1* Hct-34.0* MCV-94 MCH-30.9 MCHC-32.7 RDW-16.6* Plt Ct-200 [2128-3-13] 06:55PM BLOOD Hct-29.8* [2128-3-14] 04:47AM BLOOD WBC-12.2* RBC-3.56* Hgb-11.3* Hct-33.9* MCV-95 MCH-31.9 MCHC-33.5 RDW-16.4* Plt Ct-138* [2128-3-5] 08:52PM BLOOD PT-17.4* PTT-39.3* INR(PT)-1.6* [2128-3-14] 04:47AM BLOOD PT-15.0* PTT-33.6 INR(PT)-1.3* [2128-3-5] 08:52PM BLOOD Glucose-74 UreaN-35* Creat-2.1* Na-148* K-3.8 Cl-121* HCO3-19* AnGap-12 [2128-3-11] 04:33AM BLOOD Glucose-55* UreaN-36* Creat-1.8* Na-141 K-4.0 Cl-112* HCO3-19* AnGap-14 [2128-3-14] 04:47AM BLOOD Glucose-104 UreaN-45* Creat-1.7* Na-148* K-3.8 Cl-117* HCO3-25 AnGap-10 [2128-3-5] 08:52PM BLOOD ALT-9 AST-17 LD(LDH)-146 CK(CPK)-12* AlkPhos-138* TotBili-0.4 [2128-3-6] 04:59AM BLOOD CK(CPK)-13* [2128-3-6] 12:44PM BLOOD CK(CPK)-15* [2128-3-6] 10:41PM BLOOD CK(CPK)-15* [2128-3-11] 04:33AM BLOOD LD(LDH)-197 CK(CPK)-21* TotBili-1.3 [2128-3-5] 08:52PM BLOOD CK-MB-4 cTropnT-2.82* [2128-3-6] 04:59AM BLOOD CK-MB-4 cTropnT-2.54* [2128-3-6] 12:44PM BLOOD CK-MB-4 cTropnT-2.27* [2128-3-6] 10:41PM BLOOD CK-MB-4 cTropnT-2.59* [2128-3-8] 04:53AM BLOOD CK-MB-5 cTropnT-2.24* [2128-3-9] 11:14PM BLOOD CK-MB-4 cTropnT-1.84* [2128-3-10] 04:23AM BLOOD CK-MB-4 cTropnT-1.81* [2128-3-10] 03:00PM BLOOD CK-MB-4 cTropnT-1.70* [2128-3-11] 04:33AM BLOOD CK-MB-5 cTropnT-1.47* [2128-3-10] 09:40PM BLOOD Hapto-69 [2128-3-6] 11:01AM BLOOD Lactate-1.0 [2128-3-14] 04:47AM BLOOD Calcium-7.9* Phos-3.5 Mg-1.9 Imaging: CXR [3-5]: Findings suggestive of worsening congestive heart failure and moderate bilateral pleural effusions. EKG [3-6]: Sinus rhythm. Possible prior anteroseptal myocardial infarction. Low QRS voltage. No previous tracing available for comparison. Video Swallow: Aspiration with nectar-thickened and thin barium, primarily due to lack of normal opening of the upper esophageal sphincter. EKG [2128-3-13]: Sinus rhythm. Probable prior anteroseptal myocardial infarction, age undetermined. Lateral ST-T wave changes raise consideration of myocardial ischemia. Clinical correlation is suggested. Compared to the previous tracing of [2128-3-12] the lateral ST-T wave changes are new. Brief Hospital Course: 81 yo M with PMH of recent GIB, recurrent C.diff, and NSTEMI within the past week transferred from OSH for episode of BRPBR. In the [Hospital Unit Name 153], was started on [Hospital1 ] PPI, ASA was held, and serial HCTs were stable in the low 30s. GI was consulted and planned for colonoscopy after prep. Was called out to the wards where he received prep and 2 units of pRBCs on [3-7] for HCT dipping to 29. Bumped appropriately to 35. Given many comorbidities including cardiac disease and ongoign C Diff colitis, GI decided to defer endoscopy unless patient had evidence of increased bleeding. On early AM [3-10] pt triggered for SOB, CP. Got nebs, ASA 325mg, SL nitro x 2, IV metoprolol x 2, and lasix 40mg IV with good diuretic effect. CXR showed pulmonary edema. Cards evaluated EKG and saw no acute changes, rec continued medical management. Pt's sxs resolved. However, later in the day, he had 2 large BR BM's and c/o CP. An EKG was without changes and repeat cardiac enzymes were sent. HCT was 31.8 from 33.4. Was transferred back to [Hospital Unit Name 153] for GIB and in setting of recent pulm edema. On re-arrival to the [Hospital Unit Name 153] he denied chest pain, SOB, palpitations, dizziness/LH, fever or chills, abdominal pain, vomiting. He reports that his diarrhea is improving. He was receiving a unit of pRBCs released emergently by blood bank in setting of BRBPR without active T+S. Blood bank called to report patient cross-reactivity with E-antigen contained in that unit. Unit was immediately d/c'ed. Hemolysis and Renal function tests were both checked and were serially negative. A subsequent CXR did not reveal evidence of TRALI or ARDS. Patient had no symptoms of transfusion reaction. He was transfused 2 units of appropriately T+C'ed PRBCs overnight on [12-16], each of which was given with 40mg IV Lasix. He did have recurrent SOB and some CP during that night, which was treated successfully with SL nitrates and IV metoprolol. EKG was unchanged. HCT bumped appropriately to the transfusion. GI felt that it was too risky to scope him. To optimize his heart failure medical regimen, we maintained his [Last Name (un) ], uptitrated his metoprolol, and diuresed him daily. Nevertheless, the patient's clinical status continued to worsen. His nutrition status was poor and he continued to have chest pain and episodes of GI bleeding. After discussing the matter with the patient and his family, they opted to make him DNR/DNI and Comfort Measures Only. He was made comfortable on a fentanyl patch, and his chest pain was treated with small doses of morphine. He expired on [2128-3-15]. Medications on Admission: Medications on Transfer: metoprolol 50mg [Hospital1 ] flagyl 500mg IV Q8 nitro patch 0.4mg/hr protonix 40mg qday zocor 40mg qhs duonebs q6hrs prn morphine 1-2mg IV q2hr prn zofran 4mg IV q6 -aspirin 81mg daily (held at OSH) -iron sulfate 65mg daily (held at OSH) -avapro 75mg daily (held at OSH) -wellbutrin 75mg daily (held at OSH) Discharge Medications: Deceased Discharge Disposition: Expired Discharge Diagnosis: Deceased Discharge Condition: Deceased Discharge Instructions: Deceased Followup Instructions: Deceased [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292] Completed by:[2128-3-20]	[ "410.71", "578.9", "428.33", "414.01", "428.0", "285.1", "585.9", "008.45", "403.90", "584.9" ]	icd9cm	[ [ [] ] ]	[ "96.6" ]	icd9pcs	[ [ [] ] ]	9114, 9123	6025, 8693	356, 362	9175, 9185	3277, 6002	9242, 9417	2632, 2636		9081, 9091		9144, 9154		8719, 8719			9209, 9219									2651, 3258																									289, 318									390, 2001																8744, 9058	2023, 2486	2502, 2616
69,079	171,339	3161	Discharge summary	report	Admission Date: [2142-2-18] Discharge Date: [2142-2-24] Date of Birth: [2079-2-25] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1943] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: ERCP x 2 Hemodialysis on regular Tuesday, Thursday, Saturday schedule History of Present Illness: 62 year old male nursing-home resident ([Hospital1 1562] Care and Rehab) with history of CAD and ESRD on HD who presents with GIB and right upper quadrant pain. Patient had an ERCP on [2-14] with biliary stone removal and sphincterotomy. The procedure was without immediate complication, and the patient was sent home with 7 days of antibiotics and recommendation for cholecystectomy in future. Last night, he began to have maroon stools that have continued today. Symptoms are associated with continued RUQ abdominal pain with slight progression over the past day. The patient also endorses nausea, no vomiting. He presented to an OSH, where he was noted to have continued abdominal pain, maroon stools and hypotension to SBP 90. Hematocrit 34. He underwent CT abdomen that showed a distended gallbladder with dense material; dense focus in R hepatic bile duct; pneumobilia (as expected). In ER at [Hospital1 1562], he received morphine 10 mg, protonix 40 mg, pepcid 20 mg, and unasyn 3 grams. The patient was transferred to [Hospital1 18] for further management. In the [Hospital1 18] ED inital vitals were, 98.2 79 115/57 18 97% 2L. The patient had a tender right upper quadrant and positive [Doctor Last Name ] sign. Labs significant for HCT 28.2 from 34, WBC count 8.3, and mildly elevated transaminases and alk phos. A RUQ U/S was equivocal for acute cholecystitis. The patient had a bowel movement of maroon, pudding-consistency stool. GI and the ERCP team were consulted, and recommended a repeat scope in the ICU. An NG lavage was attempted but unable to be completed secondary to intermittent aggression. The patient received 1 unit PRBCs, dilaudid, and protonix 40mg bolus and drip. He was transferred to the ICU. Currently, the patient is in no acute distress. Abdomen tender to palpation. The patient is unable to provide a thorough history. Past Medical History: - Diabetes mellitus on insulin dependent - Chronic obstructive pulmonary disease with obesity hypoventilation syndrome - Coronary artery disease: Cardiac cath [3-/2140] showed severe three vessel disease not amenable to intervention and moderate ischemic cardiomyopathy - Chronic diastolic and systolic heart failure (Echo [5-/2140] EF 35% w/out sig valvular heart disease - Renal failure on dialysis (T/Th/S) - Chronic back pain - Depression - Anxiety - Memory loss - Obstructive sleep apnea (on bipap x 15yrs) - Cervical myelopathy / spinal stenosis - Recurrent upper respiratory infections (MRSA / VRE) - Hypertension - Anemia of chronic disease - Cervical myelopathy - Multiple decubitus ulcers - Legally blind Social History: Divorced, with two children with whom he is very close. Former heavy equipment operator. Lives in [Hospital1 1562] Care and Rehab. Former smoker, quit 10 years ago. Denies ETOH or recreational drugs. Family History: Non-contributory Physical Exam: Admission Exam: VS: afebrile, 68 114/44 100%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops; distant heart sounds Abdomen: soft, obese, bowel sounds present, no rebound tenderness or guarding, tenderness to palpation in RUQ; equivocal [Doctor Last Name ] sign; no organomegaly, no CVA tenderness GU: chronic suprapubic catheter Skin: stage II decub ulcer on sacrum Ext: warm, well perfused, palpable distal pulses, no clubbing, cyanosis, trace edema b/l Discharge Exam: VS - 98.3 120/80 66 18 100%RA GENERAL - chronically ill-appering man in NAD, comfortable, appropriate HEENT - sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - CTA bilat, no r/rh/wh, good air movement HEART - Normal S1, S2; 2/6 systolic murmur ABDOMEN - Obese, NABS, soft/NT/ND, no masses or HSM, no rebound/guarding; suprapubic catheter in place EXTREMITIES - WWP, 1+ edema to mid-calf, 1+ DPs NEURO - awake, A&Ox3, muscle strength 4-/5 in right upper extremity; [1-18] in left hand intrinsics SKIN: stage II decub ulcer on sacrum Pertinent Results: Admission Labs: [2142-2-18] 08:30PM BLOOD WBC-8.3 RBC-2.93* Hgb-8.9* Hct-28.2* MCV-96 MCH-30.4 MCHC-31.6 RDW-16.1* Plt Ct-299 [2142-2-18] 08:30PM BLOOD Neuts-77.6* Lymphs-12.2* Monos-5.1 Eos-4.1* Baso-1.0 [2142-2-18] 08:30PM BLOOD PT-11.5 PTT-26.6 INR(PT)-1.1 [2142-2-18] 08:30PM BLOOD Glucose-79 UreaN-47* Creat-2.2* Na-138 K-4.2 Cl-101 HCO3-27 AnGap-14 [2142-2-18] 08:30PM BLOOD ALT-55* AST-36 CK(CPK)-21* AlkPhos-278* TotBili-1.8* [2142-2-19] 05:54AM BLOOD Lactate-0.7 Cardiac Enzyme Trend: [2142-2-18] 08:30PM BLOOD CK-MB-3 cTropnT-0.77* [2142-2-19] 02:34AM BLOOD CK-MB-3 cTropnT-0.75* [2142-2-21] 05:21AM BLOOD CK-MB-2 cTropnT-0.66* [2142-2-22] 04:49AM BLOOD CK-MB-2 cTropnT-0.60* Discharge Labs: [2142-2-24] 05:32AM BLOOD WBC-9.1 RBC-3.32* Hgb-10.0* Hct-31.4* MCV-95 MCH-30.2 MCHC-31.9 RDW-16.4* Plt Ct-287 [2142-2-24] 05:32AM BLOOD Glucose-109* UreaN-25* Creat-3.3* Na-133 K-4.5 Cl-96 HCO3-30 AnGap-12 [2142-2-21] 05:21AM BLOOD ALT-31 AST-20 LD(LDH)-128 CK(CPK)-20* AlkPhos-182* TotBili-1.2 [2142-2-24] 05:32AM BLOOD Calcium-9.2 Phos-5.3* Mg-2.1 MICRO: [2142-2-18] 8:30 pm BLOOD CULTURE/Aerobic Bottle: STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. Blood Cultures ([2-19], [2-21], [2-22]): No growth [2142-2-23] 11:35 am URINE CULTURE FROM CATHETER: YEAST >100,000 ORGANISMS/ML. ERCP [2142-2-14]: Normal major papilla. Thick bile noted to drain. Cannulation of the biliary duct was successful and deep after a guidewire was placed. The common bile duct, common hepatic duct, right and left hepatic ducts, biliary radicles and cystic duct were filled with contrast and well visualized. The course and caliber of the structures are normal with no evidence of extrinsic compression, no ductal abnormalities, and no filling defects. Given elevated LFTs and HIDA scan findings, a sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. 3 small stones extracted successfully using a balloon. RUQ U/S ([2-18]): Distended gallbladder with sludge. Pneumobilia is likely secondary to recent ERCP. Upper abdominal pain does not localize to the gallbladder son[Name (NI) 5326]. [Name2 (NI) ] pericholecystic fluid. These findings are equivocal for acute cholecystitis. If indicated, a HIDA scan could be performed for further evaluation. CT Abd w/out contrast ([2-18]): 1. Distended gallbladder with dense material, likely reflecting sludge or prior ERCP contrast; questionable gallbladder wall edema/pericholecystic fluid; trace right lower quadrant free fluid - early acute cholecystitis is a concern, and ultrasound follow-up may be considered. 2. Bibasilar pulmonary infiltrates, more prominent on the left than the right - may represent atelectasis, aspiration, or early pneumonia. 3. No peripancreatic fluid collection or inflammation. CXR ([12-19]): FINDINGS: No previous images. The left subclavian PICC line extends to the mid-to-lower portion of the SVC. There may be minimal streaks of atelectasis at the left base, but otherwise the lungs are clear without evidence of pneumonia or vascular congestion. CXR ([12-20]): In comparison with study of [2-18], the tip of the PICC line is in the lower SVC just above the cavoatrial junction. There is slightly lower lung volume. This may account for the apparent crowding of vessels at the bases, though some atelectatic change would have to be considered. Echo ([12-20]): Poor image quality. The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function iappearsmildly depressed (LVEF= 45-50 %) with infero-lateral hypokinesis suggested. The distal LV/apex is not well seen. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. There is no aortic valve stenosis. No aortic regurgitation is seen. No mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. ERCP [2142-2-19]: Mild oozing of blood was noted at the major papilla suggestive of bleeding from the sphincterotomy site. Bile duct was successfully cannulated. Cholangiogram revealed normal appearance of the common bile duct, common hepatic duct, right and left hepatic ducts with no evidence of extrinsic compression, no ductal abnormalities, and no filling defects. Multiple balloon sweeps were performed using a balloon and no stone or sludge were extracted. [Hospital1 ]-CAP electrocautery was applied for hemostasis successfully at the sphincterotomy site. An epinephrine injection (3 ml) was applied for hemostasis successfully at the sphincterotomy site. No bleeding/oozing was noted after bicap and epinephrine injection. Otherwise normal ERCP to third part of the duodenum. Brief Hospital Course: 62 year old man with history of DM, CAD, ESRD who is 4 days s/p ERCP with stone removal admitted with maroon colored stools and abdominal pain. # Post-sphincterotomy bleed: The patient was admitted to the ICU with abdominal pain and maroon stools on [2142-2-18] following previous ERCP [2142-2-14] for possible choledocholithiasis. Hematocrit on admission 28 from baseline of 34. The patient was stabilized with three units of packed red blood cells. He underwent repeat ERCP that showed mild oozing around the site of prior ERCP. Hemostasis was achieved with electrocautery and epinephrine. Patient had further dark stools, but Hct remained stable, > 30, throughout remainder of stay. # Abdominal Pain: Patient was admitted from an OSH with RUQ pain, found to have gallbladder wall thickening, known gallstones, and equivocal ultrasound findings for cholecystitis vs. choledocholithiasis. Pain resolved s/p repeat ERCP with sphincterotomy and stone removal on [2142-2-19]. The patient completed a 7-day course of vancomycin, Zosyn, and ciprofloxacin to cover for a biliary source. He was followed by the ERCP team and surgery throughout admission for his likely cholecystitis. He should follow up with surgery in [3-25] for workup of future cholecystectomy. # CAD/Chronic systolic CHF EF 35%: Patient has history of severe 3VD not amenable to CABG or PCI. Echo from [5-/2140] demonstrates EF 35% w/out significant valvular heart disease. The patient's admission was complicated by demand ischemia in the setting of GI bleed. Troponin peaked at 0.77 with normal MB fraction and without acute EKG changes. With resuscitation, troponin trended down without further intervention. Following acute stabilization, the patient was resumed on home plavix, carvedilol, and norvasc. Home aspirin was decreased to 81 mg daily, as he is concurrently on plavix. The patient is not on a statin or ACEI at home. It is recommended that a statin and ACEI be initiated as an outpatient pending stable electrolytes and liver enzymes. # Urinary tract infection: Prior to discharge, the patient was noted to have pyuria. His suprapubic catheter was exchanged on [2142-2-22]. Following exchange of suprapubic catheter, the patient's urine culture returned positive for > 100,000 yeast. His catheter was again replaced on [2142-2-24]. The patient should undergo repeat urine culture within a week of discharge. Pending persistent yeast, the patient should undergo outpatient renal ultrasound to evaluate for fungal-related structural damage. # ESRD: The patient is on chronic Tuesday, Thursday, Saturday dialysis. His is oligouric with a chronic suprapubic catheter. The patient was continued on dialysis per regular schedule throughout admission. He was continued on home sevelamer. # DM II: The patient remained normoglycemic throughout admission. Home lantus was held throughout admission, and his AM blood glucoses remained borderline low (60-80, asymptomatic). The patient was maintained on home insulin sliding scale. Lantus was held at discharge. The patient should continue to have QID fingersticks with insulin sliding scale. Lantus may be re-initiated pending persistent hyperglycemia. # Hypothyroidism: Chronic. The patient was continued on home levothyroxine. # Constipation: Chronic. On admission, the patient had a large amount of stool appreciated in colon on CT scan. However, he passed several melanotic stools in the setting of GI bleed. Following cessation of GI bleed, the patient was resumed on his home bowel regimen. # Chronic pain: Due to lower back pain and skin wounds. Pain was well controlled throughout admission on home baclofen. Methadone was decreased to 5mg TID due to presence of intermittent visual hallucinations (chronic for 6 weeks per patient). # Depression/anxiety: Stable. However, patient endorses recent visual hallucinations of unclear etiology. The patient's mood was intact throughout admission. He was continued on cymbalta, remeron, ativan. # Code: Full code, confirmed with patient. ========================================================= TRANSITIONAL ISSUES: # Given systolic CHF with EF 35%, consider starting ACEI and statin as outpatient pending repeat electrolyte and liver enzyme check # Patient should have repeat urine culture within a week of discharge. If he has persistent yeast, would consider outpatient renal ultrasound to evaluate for structural effects of yeast Medications on Admission: Ativan 0.5mg Q6h prn Pepcid 20mg daily Synthroid 125mcg daily Asa 325mg daily Senokot 8.6mg daily Norvasc 10mg daily Methadone 10mg [Hospital1 ] (STARTED A FEW DAYS AGO) Bisacodyl 5mg prn Vit C 250mg [Hospital1 ] Ultram 50mg Q6h PRN Albuterol 2.5 Q2H PRn Flomax 0.4mg daily HISS (150-199 2units; 200-250 4units; 250-300 6 units) Lantus 10 units daily Baclofen 5mg tid prn Lactulose 20mg daily Tylenol 500mg prn Nitrostat prn Zofran 4mg prn Coreg 25mg [Hospital1 ] Lyrica 25mg tid Imdur 90mg daily (held) Renvela 800mg tid Dialysis day Remeron 15mg qhs Colace 100mg [Hospital1 ] Ampicillin-sulbactam 1.5g [Hospital1 ], changed to tigacycline Cymbalta 60mg daily Discharge Medications: 1. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO four times a day as needed for anxiety. 3. Pepcid 20 mg Tablet Sig: One (1) Tablet PO once a day. 4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. methadone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. bisacodyl 5 mg Tablet Sig: One (1) Tablet PO once a day as needed for constipation. 9. Vitamin C 250 mg Tablet Sig: One (1) Tablet PO twice a day. 10. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation every four (4) hours as needed for shortness of breath or wheezing. 12. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 13. insulin lispro 100 unit/mL Solution Sig: as directed units Subcutaneous four times a day: BS 150-199 2 units; 200-250 4 units; 250-300 6 units. 14. baclofen 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day) as needed for pain. 15. Tylenol 325 mg Tablet Sig: One (1) Tablet PO four times a day as needed for pain. 16. Nitrostat 0.3 mg Tablet, Sublingual Sig: One (1) tablet Sublingual once a day as needed for chest pain: take q5 min x 3 if chest pain; call Dr. [Last Name (STitle) ] use this med. 17. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. 18. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day. 19. pregabalin 25 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 20. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 21. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 22. Cymbalta 60 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 23. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 24. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 25. lactulose 20 gram Packet Sig: One (1) PO once a day. Discharge Disposition: Extended Care Facility: [Location (un) ]-[Hospital1 1562] Discharge Diagnosis: PRIMARY DIAGNOSIS: post-sphincterotomy bleed, cholecystitis, asymptomatic candiduria SECONDARY DIAGNOSIS: end-stage renal disease on HD, coronary artery disease, type II diabetes, constipation, chronic pain Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: Mr. [Known lastname 6330], You were admitted to the hospital with a gastrointestinal bleed following a procedure to help cure an infection in your gallbladder. You underwent a repeat procedure to stop the bleeding, and were given blood transfusions. Your blood counts remained stable. With the repeat procedure, your abdominal pain resolved. For your gallbladder infection, you were given antibiotics. You were re-started on your home medications without complication. You should follow up with surgeons in [Month (only) 958] (as below) to discuss removing your gallbladder following infection. During your admission, you were noted to have inflammatory cells in your urine. Urine culture showed yeast. Your supra-pubic catheter was changed. Please follow up with your doctor for a repeat urine culture within a week of discharge. Medications changed this admission: STOP unasyn DECREASE aspirin to 81 mg daily HOLD lantus, as your blood sugars have not been high during hospitalization Followup Instructions: Please follow up with your primary care physician [Name Initial (PRE) 176] 1 week of discharge. Call [Telephone/Fax (1) 14916] for an appointment. Please follow-up in the [Hospital 2536] Clinic the first week of [Month (only) 958] to discuss possible cholecystectomy. Call [Telephone/Fax (1) 600] to schedule.	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41,902	121,103	5268	Discharge summary	report	Admission Date: [2103-8-30] Discharge Date: [2103-8-31] Date of Birth: [2034-9-5] Sex: M Service: MEDICINE Allergies: Atenolol / Iodine; Iodine Containing / Ibuprofen / Bactrim Attending:[First Name3 (LF) 106] Chief Complaint: L main artery dissection during elective cardiac cath Major Surgical or Invasive Procedure: Elective Cardiac catheterization [8-30] History of Present Illness: 68 yo Guatemalan Spanish speaking male with history of CAD, HTN, HL, NHL s/p rituxan is admitted from cath lab following dissection of left main during elective cardiac catheterization. . Patient states that since [Month (only) 547] he has been experiencing worsening left sided chest pain that radiates to his arm and diaphoresis. He is able to walk ~5min before pain starts. Today, pain was elicited on his walk from the parking lot to the front door of the hospital. He denies LE swelling, but has PND. He has stable 2-pillow orthopnea. . He had a recent stress MIBI, 9min, had [8-21] CP w/ 0.5mm horizontal STD II, III, avf, v5-6, new partial reversible defect at the distal anterior wall and apex 2, stable severe apical and moderate septal fixed defects and global hypokinesis with LVEF of 37%. . Pt underwent cath today w/ promus stent to prox LAD. Upon stent deployment the LMCA was dissected, pt c/o CP and nausea had sbp of 75. A second stent was crossed and his symptoms resolved. He had 3rd stent placed in distal LAD. On transfer he was hemodynamically stable and in no distress/pain. . On the floor, his vitals were BP157/91 HR85 RR19 O2sat 99%RA. He denied any chest pain, sob, or discomfort. His daughter was at bedside. . On review of systems, s/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. S/he denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems notable for 2 pillow orthopnea, DOE, and diaphoresis. Cardiac review of systems is notable for absence of ankle edema, palpitations, syncope or presyncope. Past Medical History: PMH: 1. Burkitt's-like lymphoma: Followed by Dr. [Last Name (STitle) 410] and Dr. [Last Name (STitle) 18619] in onc clinic. s/p 5 cycles R-[Hospital1 ], 2 cycles R-ICE, 4 doses high dose MTX. Now getting maintenance treatment with 3rd cycle of rituxan, last infusion being on [2100-7-2] 2. CAD s/p anterior MI [2090], s/p LAD and OM1 stents [2093]. ETT MIBI [5-/2093] with stable severe fixed defect at distal anterior wall, mod fixed septal defect 3. CHF - EF 30-35% [2099-2-2] echo 4. hypertension 5. peptic ulcer disease 6. hyperlipidemia 7. h/o positive PPD 8. diverticulosis on colonoscopy [10-16] 9. colonic polyps 10. hemorrhoidal bleeding Social History: The patient lives with his wife, daughter, and 2 grandchildren. Retired, former tailor. Originally from [Country 7192]. Tob: 30 pack-years, quit [2078]. H/o previous EtOH, quit [2089]. Family History: Sister - leukemia Mother - died of PNA in [2080] Physical Exam: GENERAL: WDWN hispanic 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. No xanthalesma. NECK: Supple, no jvd CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. No femoral bruits. R groin site c/d/i, bandaged SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: [2103-8-30] 05:18PM SODIUM-140 POTASSIUM-3.9 CHLORIDE-104 [2103-8-30] 05:18PM CK(CPK)-66 [2103-8-30] 05:18PM CK-MB-4 [2103-8-30] 05:18PM PLT COUNT-156 [2103-8-30] 01:07PM VoidSpec-SPECIMEN C [2103-8-30] 12:30PM GLUCOSE-136* UREA N-11 CREAT-0.8 SODIUM-139 POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-26 ANION GAP-14 [2103-8-30] 12:30PM estGFR-Using this [2103-8-30] 12:30PM CALCIUM-9.7 PHOSPHATE-2.7 MAGNESIUM-2.0 [2103-8-30] 12:30PM WBC-5.8 RBC-4.67 HGB-14.3 HCT-40.6 MCV-87 MCH-30.6 MCHC-35.1* RDW-13.9 [2103-8-30] 12:30PM NEUTS-78.9* LYMPHS-14.1* MONOS-6.5 EOS-0.1 BASOS-0.3 [2103-8-30] 12:30PM PLT COUNT-187 Brief Hospital Course: Mr. [Known lastname ] is a 68yo spanish speaking male w h/o CAD, HTN, HL, NHL s/p rituxan admitted from cath lab following dissection of left main during elective cardiac catheterization [8-30]. Pt admitted to CCU for monitoring - hemodynamically stable on admission. . # CORONARIES: Patient with known CAD p/w worsening sx and reversible defect in the distal anterior wall on perfusion scan s/p 2 promus stent to prox and distal LAD and 1 stent to LM. Patient hemodynamically stable without any complaints. Started ASA 325mg and Plavix 75mg. Continued home carvedilol and lisinopril. Continued home statin. Discontinued home PPI and started H2 blocker since pt on plavix. . # PUMP: Patient w/ EF of 35%. Appears euvolemic on exam. Continued carvedilol/lisinopril as BP tolerates. Repeated Echocardiogram (LVEF= 45 %, see report below) . # RHYTHM: in sinus, no history of arrhythmias. . # BACK PAIN: Continued gabapentin, percocet prn . # Hyperlipidemia: Continued home statin . #. Non Hodgkin's Lymphoma: Has completed most recent course of maintenance Rituxan was in [2103-2-12]. Outpatient followup. [8-30] TTE: The estimated right atrial pressure is 0-5 mmHg. There is symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded in addition to distal left ventricular hypokinesis. Overall left ventricular systolic function is mildly depressed (LVEF= 45 %). Right ventricular chamber size and free wall motion are normal. The right ventricular free wall is hypertrophied. The aortic valve leaflets 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 a trivial/physiologic pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. CARDIAC CATH: [8-30] FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Significant systemic hypertension. 3. Successful stenting of the proximal LAD with a Promus 3.5x12mm drug-eluting stent (DES) post-dilated with a 3.5mm balloon. Emergent PTCA/stenting of the unprotected LMCA due to dissection secondary to guiding catheter with a Promus OTW 3.5x12mm [Name Prefix (Prefixes) ] [Last Name (Prefixes) ]-dilated with a 4.0 then 4.5 balloon. Intravascular ultrasound confirmed the LMCA-LAD stent to be well opposed with no uncovered dissection (see PTCA comments for further details). 4. ASA indefinitely 5. Plavix (clopidogrel) 75mg daily for 12months. 6. Relook angiography at LMCA in 3months. Medications on Admission: Carvedilol 12.5 mg [Hospital1 ] Gabapentin 300 mg TID Lisinopril 40 mg daily Omeprazole 20 mg [Hospital1 ] Percocet 1 tablet q6h prn pain Prednisone 40 mg [Hospital1 ] - [8-29] pm and [8-30] AM pre cardiac cath for dye allergy Simvastatin 80 mg daily Aspirin 81 mg daily Benadryl 25 mg qHS - [8-29] x 1 pre cardiac cath for dye allergy Ranitidine 150 mg [Hospital1 ] - on [8-29] PM and [8-30] AM pre cath Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 5. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO q6 prn as needed for pain. Discharge Disposition: Home Discharge Diagnosis: L main dissection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname ], It was a pleasure taking care of you. You were admitted to the CCU after your cardiac catheterization procedure. Your heart artery was injured during the procedure and your blood pressure decreased as a result. We wanted to observe you overnight in the CCU to make sure you were stable and comfortable to discharge to home. Your heart enzymes were normal which tells us that your heart did not suffer prolonged injury as a result of the procedure. Your vitals were stable overnight and you had no chest pain, shortness of breath, or difficulty walking around. . The following changes were made to your medications: START Ranitidine 150mg daily to decrease your stomach acid and treat your reflux INCREASED Aspirin 325mg daily to protect your heart Continue Plavix 75mg daily to protect your heart STOPPED Aspirin 81mg daily, please take the increased dose STOPPED Omeprazole (prilosec), this medication interferes with your Plavix and decreases its protective effects. . Please follow up with your doctors as listed below: Followup Instructions: Please keep the following appointments: PCP [Name Initial (PRE) ]: Walk-in-Clinic Mon.through Fri. 8am to 5pm, Sat.7am to 1pm With:[Known firstname ] [Name8 (MD) 21526],MD Address: [Apartment Address(1) 14920], [Location (un) ],[Numeric Identifier 6809] Phone: [Telephone/Fax (1) 14918] * Please see Dr. [Last Name (STitle) ] between next Monday, the 23rd and Sat. the 28th as requested by your hospital doctor for hospital follow up.* Department: CARDIAC SERVICES When: TUESDAY [2103-10-16] at 10:00 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4511], MD [Telephone/Fax (1) 62] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "533.90", "998.2", "272.4", "473.9", "795.5", "V45.82", "412", "414.01", "200.20", "E870.6", "414.12", "715.90", "E849.7", "401.9", "530.81" ]	icd9cm	[ [ [] ] ]	[ "00.66", "00.47", "36.07", "00.41", "37.22" ]	icd9pcs	[ [ [] ] ]	8590, 8596	4739, 6723	371, 417	8658, 8658	4045, 4716	9890, 10673	3177, 3232		7907, 8567		8617, 8637		7442, 7884		6740, 7416	8809, 9867									3247, 4026																									278, 333									445, 2238										8673, 8785							2260, 2946	2962, 3161
67,348	187,991	48048+59053	Discharge summary	report+addendum	Admission Date: [2182-7-15] [Month/Day/Year ] Date: [2182-7-23] Date of Birth: [2103-1-20] Sex: M Service: MEDICINE Allergies: Penicillins / Cephalosporins / ciprofloxacin Attending:[Doctor First Name 3290] Chief Complaint: GI Bleed Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [Known lastname 57554] is a 79 year old man with a medical history notable for atrial fibrillation on coumadin, severe aortic regurgitation s/p bioprosthetic AVR on [6-27], PCKD s/p cadaveric renal transplant in [2155], and diverticulosis noted in [2174], who presents from his nursing home with 5 episodes of BRBPR over the past 2 days. The patient underwent an uncomplciated AVR on [6-27] and was discharged on ASA/coumadin. He had been doing well at his nursing home until [7-14], 1 day PTA, when he had diarrhea with BRBPR throughout the night. He denied abdominal pain, nausea, and vomiting. He had one episode of dizziness but denied presyncope or syncope. The BRBPR continued until the morning. He was transferred to the ED. In the ED, initial VS were: HR 86, 122/72. He denied nausea/vomiding and abdominal pain. On exam, he had BRB in rectal vault. His labs were notable for a HCT of 31 (at baseline), Cr 1.3 (baseline 1.6), and an NTproBNP of [Numeric Identifier 101333]. During his ED stay, his HR increased to 110 and his SBP decreased to 110. Cardiac surgery was curbsided and recommended vitamin K and 2U FFP. They cautioned against giving fluid boluses. Past Medical History: - Moderate-to-severe aortic insufficiency with dilated LV (LVEF 50-55%), s/p bioprosthetic AVR on [2182-6-27] - Recent cardiac catheterization showing no obstructive coronary artery disease, however, found to have elevated filling pressures, requiring diuresis - Atrial fibrillation, currently on Coumadin for thromboembolic prophylaxis - Hypertension - Kidney transplant in [2155] due to PCKD, the baseline creatinine approximately 1.6 - Hyperlipidemia - Peripheral neuropathy - Diverticulitis - Pseudogout - Osteoporosis Social History: Patient previously worked as an engineer for channel 5. He currently lives in a house himself. His wife passed away 9 years ago. Prior history of 3 ppd X 20 years, quitting 34 years ago. Occasional ETOH (few beers per week). No illicits. His daughters ([Doctor First Name ] (daughter) - ([Telephone/Fax (1) 101330], [Female First Name (un) ] (daughter) [0-0-]) are very involved. Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL. Conjunctiva pale Neck: supple, no LAD CV: Irregular, normal S1 + S2, no murmurs. JVP 15cm. 2+ DP/PT pulses. Lungs: Decreased breath sounds but clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding GU: no foley Ext: 2+ edema to hips bilaterally. Warm, well perfused, 2+ pulses, no clubbing, cyanosis Neuro: CNII-XII intact, grossly normal sensation and motor function, gait deferred. Pertinent Results: [2182-7-15] 01:43PM WBC-10.1# RBC-3.20* HGB-9.7* HCT-31.0* MCV-97 MCH-30.4 MCHC-31.4 RDW-17.0* [2182-7-15] 01:43PM proBNP-[Numeric Identifier 101333]* [2182-7-15] 04:11PM PT-34.6* PTT-29.8 INR(PT)-3.4* . TTE [2182-7-19] The left atrium is mildly dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild to moderate global left ventricular hypokinesis (LVEF = 35-40%). The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. The aortic root is moderately dilated at the sinus level. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. A bioprosthetic aortic valve prosthesis is present. The aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is a moderate sized circumferential pericardial effusion without signs of tamponade physiology. IMPRESSION: Mild to moderate global left ventricular systolic dysfunction. Mild right ventricular systolic dysfunction. Normally-functioning aortic valve bioprosthesis. Mild mitral regurgitation. Moderate circumferential pericardial effusion. [7-22] echo The left ventricular cavity size is normal. There is mild to moderate global left ventricular hypokinesis (LVEF = 35-40%). Right ventricular chamber size is normal. with mild global free wall hypokinesis. A bioprosthetic aortic valve prosthesis is present. The aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is borderline pulmonary artery systolic hypertension. There is a moderate sized pericardial effusion. The effusion appears circumferential. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [2182-7-19], the findings are similar. On both echoes, there is a moderate circumferential pericardial effusion. There is no clear-cut evidence of tamponade physiology on either echo. Mitral valve and tricuspid valve inflows show variability which is partly due to atrial fibrillation. . [2182-7-17] CXR IMPRESSION: Small right pleural effusion with no evidence of pulmonary vascular congestion. . [2182-7-18] 5:30 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. MICROSPORIDIA STAIN (Preliminary): CYCLOSPORA STAIN (Final [2182-7-19]): NO CYCLOSPORA SEEN. C. difficile DNA amplification assay (Final [2182-7-19]): Reported to and read back by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [8-/3923] [2182-7-19] 11:20AM. CLOSTRIDIUM DIFFICILE. Positive for toxigenic C. difficile by the Illumigene DNA amplification. (Reference Range-Negative). FECAL CULTURE (Final [2182-7-20]): NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [2182-7-21]): NO CAMPYLOBACTER FOUND. FECAL CULTURE - R/O VIBRIO (Final [2182-7-21]): NO VIBRIO FOUND. FECAL CULTURE - R/O YERSINIA (Final [2182-7-21]): NO YERSINIA FOUND. FECAL CULTURE - R/O E.COLI 0157:H7 (Final [2182-7-20]): NO E.COLI 0157:H7 FOUND. Cryptosporidium/Giardia (DFA) (Final [2182-7-19]): NO CRYPTOSPORIDIUM OR GIARDIA SEEN. . [2182-7-23] 05:45AM BLOOD WBC-9.1 RBC-3.32* Hgb-10.3* Hct-32.1* MCV-97 MCH-30.9 MCHC-31.9 RDW-18.4* Plt Ct-186 [2182-7-22] 04:15PM BLOOD PT-23.9* PTT-35.8 INR(PT)-2.3* [2182-7-22] 09:30AM BLOOD Glucose-162* UreaN-46* Creat-1.4* Na-138 K-3.5 Cl-100 HCO3-28 AnGap-14 Brief Hospital Course: 79 yo M with a PMHx of moderate to severe AI with decreased EF s/p bioprosthetic AVR [2182-6-27] and discharged to rehab on [7-2] on coumadin and ASA, AF, HTN, renal transplant [2155] [1-17] to PCKD and diverticulitis noted on c-scope in [2174] who p/f rehab with BRBPR who was intially admitted to the [Hospital Unit Name 153] for observation and sent to the floor when showed no signs of clinical bleeding, course c/b AF with RVR, moderate sized pericardial effusion and c. difficile colitis . # LGI BLEED: GI bleeding resolved spontaneously. We suspect that this was likely a diverticular bleed given his known diverticuli. No colonoscopy done this admission. # C. dificile colitis Patient and family endorse months to years of intermitent mucousy output from his rectum and new in onset (for the past several weeks) incontinence. The patient has stool studies sent in house for further work up of opportunistic infectious etiologies of these symptoms and c. diff came back positive. This was considered an atypical presentation (vs. detection of an asymptomatic carrier) as the patient was not having diarrhea, leukocytosis or fevers. Since the patient was having other symptoms, as above, that could be attributed to this, it was decided to treat c. diff with 2 weeks of metronidazole. Flagyl course will be completed on [2182-8-2] # Fecal incontinence: SYmptoms improved in the hospital, but not completely resolved. Scheduling GI followup to reassess. He was started on cholestyramine by prior rehab doctors. Unclear if it is helping. Can consider trial off medication. # Pericardial Effusion: Echo noted moderate pericardial effusion without signs of tamponade. It was done on [7-19] and was repeated on [7-22], and was found to be unchanged at that time. We suspect that this effusion is a sequelae of his valve surgery. He will have follow up with his CT surgeon. . # ATRIAL FIBRILLATION with RVR: The etiology of the patient difficult to control AF was multifactorial related to LGIB, d/c of diltiazem and untreated c. difficile. CHADS2 score of 3, on coumadin at home. INR supratherapeutic on admission, initially reversed with vitamin K and FFP, but continued home metoprolol for rate cotrol. After further discussion with the patients Cardiologist, ASA was discontinued because the patient had a normal catheterization. His anticoagulation was resumed after his GI bleeding was resolved, and his INR was in the therapeutic range on day of [Month/Day (4) ]. The patient was trialed on single [Doctor Last Name 360] metoprolol in house for rate control but this was not effective with HR in the 110-130 range without symptoms. The inpatient Cardiology team was consulted and they ultimately recommended diliazem 120 CD which improved his rate control. His heart rate was controlled with diltiazem CD 120 mg po daily and metoprolol tartrate 75 mg po daily. He had occasional PVCs, so please check his potassium and magnesium at least twice a week (can be done with cyclosporine labs) . # VOLUME OVERLOAD with a h/o sCHF with recent EF 35-40%: Patient had elevated JVP and periperhal edema, suggestive of elevated R filling pressures. Lasix, HCTZ were held, however, in context of recent bleed. Once the patient showed no further episode of GIB, Cardiology was consulted and they rec'd IV diuresis. This helped improve the patient AF control and he was transitioned to his home dose of lasix. He should not continue hydrochlorothiazide. . # S/P RENAL TRANSPLANT: Renal consulted re immunosuppression regimen. He was continued on cyclosporine 100 mg po daily and prednisone 5 mg po daily. Per the renal staff, diltiazem can interact with cyclosporine, so if that medicine is discontinued or changed, cyclosporine levels need to be followed closely. The transplant team recommends that his cyclosporine levels be checked twice a week, in addition to his renal function. Please fax the results to his nephrologist, Dr [First Name4 (NamePattern1) 429] [Last Name (NamePattern1) 118], at [Telephone/Fax (1) 9420]. Creatinine ws 1.4 on [Telephone/Fax (1) ]; baseline is 1.6. PLEASE MAKE SURE THAT CYCLOSPORINE LEVEL IS CHECKED JUST BEFORE HE TAKES HIS CYCLOSPORINE. # Dysthymia: Patient acknowledged stress of prolonged illness and sadness that has resulted from death of wife and son. [Name (NI) ] met with our social worker, and it was felt that Mr [Name (NI) 57554] may benefit from psychotherapy. This should be discussed with his primary care doctor [First Name (Titles) ] [Last Name (Titles) ]. Medications on Admission: Alendronate Sodium 70 mg PO QSUN Aspirin EC 81 mg PO DAILY Benzonatate 100 mg PO TID:PRN cough CycloSPORINE (Sandimmune) 100 mg PO DAILY Fluticasone Propionate 110mcg 1 PUFF IH [Hospital1 ] Furosemide 40 mg PO BID Metoprolol Tartrate 100 mg PO TID PredniSONE 5 mg PO DAILY Warfarin 2.5 mg PO daily Acetaminophen 650 mg PO Q4H:PRN pain Lovastatin NF 20 mg ORAL DAILY Potassium Chloride ER 20 mEq PO DAILY Fluticasone-Salmeterol Diskus (100/50) 2 INH IH [Hospital1 ] Guaifenesin [4-25] mL PO Q6H:PRN cough Multivitamins 1 TAB PO DAILY Hydrochlorothiazide 12.5 mg PO DAILY Ferrous sulfate 325mg PO daily cholestyramine 1 packet daily uloric 40mg PO daily [Month/Year (2) ] Disposition: Extended Care Facility: [Hospital6 459] for the Aged - [Location (un) 550] [Location (un) ] Diagnosis: lower GI bleeding likely related to known diverticula Clostridium dificile infection poorly controlled atrial fibrillation bioprosthetic aortic valve replacement [Location (un) ] Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). [Location (un) ] Instructions: You were admitted to [Hospital1 18] with complaints of bloody diarrhea. You were observed in the ICU and then sent to the floor when you had no repeat episodes of bleeding. Your course in the hospital was complicated by poorly controlled atrial fibrillation and your were found to have an infection in your colon called Clostridium Dificile (C diff). You were started on an antibiotic for this, which you need to take for two weeks. You will be sent to the [Hospital 100] Rehab. You were also found to have fluid around your heart (pericardial effusion). We suspect that this occurred after your valve surgery, and that it will resolve with time. . You no longer need to take aspirin (this was discussed with your cardiologist). Take flagyl for the C diff infection for two weeks. COntinue metoprolol and diltiazem for your rapid heart rate. Followup Instructions: Please follow up with: Department: CARDIAC SERVICES When: WEDNESDAY [2182-7-31] at 2:20 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2908], MD [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: CARDIAC SURGERY When: WEDNESDAY [2182-8-21] at 1 PM With: [Name6 (MD) ] [Name8 (MD) 6144], MD [Telephone/Fax (1) 170] Building: LM [Hospital Unit Name ] [Location (un) 551] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: CARDIAC SERVICES When: WEDNESDAY [2182-8-28] at 2:00 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2908], MD [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Name: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 5080], MD Specialty: Primary Care Location: [Hospital1 ] HEALTHCARE - [Location (un) ] Address: [Location (un) ], [Apartment Address(1) 6850], [Location (un) ],[Numeric Identifier 1700] Phone: [Telephone/Fax (1) 3329] Please discuss with the staff at the facility a follow up appointment with your PCP when you are ready for [Telephone/Fax (1) ]. Department: DIV. OF GASTROENTEROLOGY When: WEDNESDAY [2182-8-14] at 2:00 PM With: [Name6 (MD) ] [Last Name (NamePattern4) 79190], 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 Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 349] has retired and will no longer see patients in the office. He will only be doing procedures. You will see one of the physicians that saw you while you were in the hospital, Dr. [Last Name (STitle) ] for this visit. Dr[Name (NI) 433] office will call you to schedule a followup appointment. Name: [Known lastname 16276],[Known firstname ] Unit No: [Numeric Identifier 16277] Admission Date: [2182-7-15] Discharge Date: [2182-7-23] Date of Birth: [2103-1-20] Sex: M Service: MEDICINE Allergies: Penicillins / Cephalosporins / ciprofloxacin Attending:[Doctor First Name 376] Addendum: Gout: Patient with recent gout flare. Had been started on febuxostat (uloric); this was held when his creatinine increased to 2.4, but then when his creatinine returned to baseline, it was resumed. Discharge Disposition: Extended Care Facility: [Hospital6 609] for the Aged - [Location (un) 1409] [Name6 (MD) ] [Last Name (NamePattern4) 377] MD [MD Number(2) 378] Completed by:[2182-7-23]	[ "733.00", "562.12", "356.9", "401.9", "428.0", "753.12", "788.20", "272.4", "V58.61", "427.31", "V42.2", "V42.0", "423.9", "787.60", "008.45", "274.01", "285.1", "428.23" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	16853, 17076	7399, 12015	327, 334		3322, 7376	14133, 16830	2553, 2670						12041, 12830												2685, 3303																								12862, 13026	279, 289			13058, 13058	13252, 14110					362, 1566										13073, 13217							1588, 2121	2137, 2537
6,153	140,244	24886	Discharge summary	report	Admission Date: [2163-11-5] Discharge Date: [2163-11-8] Date of Birth: [2113-3-25] Sex: M Service: MEDICINE Allergies: No Drug Allergy Information on File Attending:[First Name3 (LF) 2297] Chief Complaint: Liver failure, pneumonia Major Surgical or Invasive Procedure: Paracentesis History of Present Illness: 50 yo male with history of alcohol abuse who was transferred from OSH with alcoholic hepatitis. He has had worsening ascites, increasing LFTs and shortness of breath. THis started in [Month (only) 216] of [2163] when tbili was up to 14.8. He was started on prednisolone, lasix and aldactone for presumed alcholic hepatiits. He was admitted to [Hospital 5871] Hosp on [11-1] with SOB. MRCP showed intrahepatic ductal dialtion and there was concern for sepsis and SBP and started on ceftriaxone and levaquin. However, paracentesis on [11-1] was negative for SBP. One day of transfer he syncopized from hypotension started on levophed and transferred to [Hospital1 18]. Past Medical History: Alcoholic hepatitis Hypertension Afib Arthritis Social History: Married, 3 children, +ETOPH abuse, quit 4 years ago, relapsed 8 mos ago, quit 2 mos ago. Recently quit tobacco but had smoke 2 PPD for most of life. Family History: Noncontributory Physical Exam: PE 91.9, 70's, 121/70 (on levophed and dopamine), 24, 95%NRB GENL: mildly agitated, jaundiced HEENT: OP clear, +scleral icterus CV: RRR no MRG Lungs: coarse bs diffusely Abd: distended, sl tense, hypoactive bs Ext: no edema, 1+pedal pulses Pertinent Results: [2163-11-8] 09:34AM BLOOD WBC-24.3* RBC-1.96* Hgb-7.0* Hct-20.6* MCV-105* MCH-35.5* MCHC-33.8 RDW-17.9* Plt Ct-46* [2163-11-6] 12:07AM BLOOD WBC-16.0* RBC-3.73* Hgb-14.0 Hct-41.2 MCV-110* MCH-37.6* MCHC-34.0 RDW-16.5* Plt Ct-93* [2163-11-8] 09:34AM BLOOD Neuts-30* Bands-49* Lymphs-7* Monos-4 Eos-1 Baso-0 Atyps-0 Metas-6* Myelos-3* NRBC-5* [2163-11-6] 12:07AM BLOOD Neuts-62 Bands-24* Lymphs-2* Monos-4 Eos-0 Baso-0 Atyps-2* Metas-3* Myelos-3* [2163-11-8] 09:34AM BLOOD Plt Ct-46* [2163-11-8] 09:34AM BLOOD PT-13.5* PTT-90.3* INR(PT)-1.2 [2163-11-6] 12:07AM BLOOD PT-29.5* PTT-91.9* INR(PT)-6.5 [2163-11-8] 09:34AM BLOOD Fibrino-110* [2163-11-8] 09:34AM BLOOD Glucose-240* UreaN-47* Creat-4.2* Na-118* K-7.2* Cl-71* HCO3-10* AnGap-44* [2163-11-6] 12:07AM BLOOD Glucose-104 UreaN-40* Creat-1.8* Na-120* K-5.1 Cl-90* HCO3-13* AnGap-22* [2163-11-8] 05:42AM BLOOD ALT-531* AST-1340* LD(LDH)-773* AlkPhos-139* Amylase-85 TotBili-16.8* [2163-11-6] 12:07AM BLOOD ALT-201* AST-257* LD(LDH)-495* CK(CPK)-593* AlkPhos-407* Amylase-332* TotBili-25.3* DirBili-16.4* IndBili-8.9 [2163-11-8] 05:42AM BLOOD Lipase-36 [2163-11-6] 12:07AM BLOOD Lipase-433* GGT-158* [2163-11-6] 12:07AM BLOOD CK-MB-17* MB Indx-2.9 cTropnT-<0.01 [2163-11-8] 09:34AM BLOOD Calcium-8.2* Phos-12.8* Mg-2.3 [2163-11-6] 12:07AM BLOOD Albumin-2.0* Calcium-6.7* Phos-8.2* Mg-2.2 [2163-11-6] 12:07AM BLOOD Triglyc-65 [2163-11-6] 12:07AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE [2163-11-6] 05:10AM BLOOD AMA-NEGATIVE Smooth-POSITIVE [2163-11-6] 12:07AM BLOOD AFP-<1.0 [2163-11-6] 05:10AM BLOOD IgG-857 [2163-11-7] 08:38PM BLOOD Vanco-17.2* [2163-11-6] 12:07AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-8.0 Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2163-11-6] 12:07AM BLOOD HCV Ab-NEGATIVE [2163-11-8] 09:55AM BLOOD Type-ART Temp-34.4 Rates-[7-31] Tidal V-500 PEEP-10 FiO2-70 pO2-80* pCO2-32* pH-7.21* calHCO3-13* Base XS--14 Intubat-INTUBATED [2163-11-6] 12:00AM BLOOD Type-ART pO2-113* pCO2-41 pH-7.10* calHCO3-13* Base XS--16 [2163-11-8] 09:55AM BLOOD Lactate-27.7* K-6.8* [2163-11-6] 12:00AM BLOOD Lactate-8.7* K-5.2 Brief Hospital Course: He was admitted with liver failure secondary to alcoholic cirrhosis, sepsis, and respiratory distress. He was intubated shortly after arrival to the ICU for respiratory distress. Liver Failure: He was started on solumedrol, treated with zopsyn and cipro for SBP. He was also given folate, thiamine, nutritional support, lactulose, vitamin K, urosdiol. Liver team was consulted. Followed fibrinogen and coags for possible DIC. Goal fibrinogen was >150, INR<10, plt>20. U/S negative for PV thrombosis. Peritoneal fluid positive for SBP. He was not a transplant candidate given history of relapse of alcohol use. Sepsis: Source unclear - SBP versus pneumonia, covered with zosyn and cipro for SBP and vanco for ?MRSA pneumonia. Continued vasopressin and levophed Acute Renal Failure: ATN versus hepatorenal versus obstruction. Renal team consulted but given grave prognosis, dialysis felt to be futile. Octreotide and midodrine and albumin started for to treat hepatorenal syndrome if that was the cause. Bladder pressure was elevated at 17 and paracentesis performed to decreased intra-abd pressure to 8 with noimprovement in renal function. His condition worsened and he became profoundly acidotic and with multiorgan failure. Prognosis was discussed with family. Renal team felt CVVH would not be able to reverse his acidemia and hyperkalemia fast enough. He was made comfort measure only on [2163-11-8] and died with his family by his side. Medications on Admission: Levophed gtt Pepcid Zosyn Lacutlose vancomycin Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: Deceased Discharge Condition: Deceased Discharge Instructions: N/A Followup Instructions: N/A	[ "572.4", "303.90", "276.1", "427.31", "038.9", "567.23", "286.9", "789.5", "584.9", "276.2", "577.0", "571.2", "995.92", "401.9", "785.52", "570", "518.81", "571.1" ]	icd9cm	[ [ [] ] ]	[ "96.04", "54.91", "38.93", "96.71" ]	icd9pcs	[ [ [] ] ]	5407, 5416	3835, 5282	321, 335	5468, 5478	1600, 3812	5530, 5536	1308, 1325		5379, 5384		5437, 5447		5308, 5356			5502, 5507									1340, 1581																									257, 283									363, 1055																	1077, 1126	1142, 1292
10,646	113,678	28214	Discharge summary	report	Admission Date: [2148-10-20] Discharge Date: [2148-10-28] Date of Birth: [2098-6-19] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1974] Chief Complaint: headache Major Surgical or Invasive Procedure: none History of Present Illness: Patient has h/o chronic headche but complains of acute worsening today. She describes constant [11-5] right sided throbbing headahce that does not radiate. Denies photophobia but did complain of some mild blurry vision. She took excedrin as usual but did not help. Of note, patient is from DC and is here for visiting her family. She had not been taking her anti-hypertensive for 2 weeks. She never had such severe headache before. Patient had not seen her PCP [Name Initial (PRE) ] 2 years. . On arrival to ED, her initial VS T98.3 P110 BP 246/116 R17 99%on RA. She received 20mg labetalol x1, 20mg hydralazine x1, labetolol infusion, aspirin. She is currently on labetalol 1.5mg/min with BP in 160s/110s on transfer. She continues to complain of HA, vomited x2 and received anzemet, phenergan 25mg IVP, morphine 4mg and dilaudid 2mg. EKG show TWI V3-V6 and inferior leads, ST depression inferior leads, repeat show resolution of ST depression in inf leads. . Currently, patient denies chest pain, palpitation, shortness of breath, abdominal pain. She does complain of nausea from narcotic. She still complains of right sided headahce albeit less. . Past Medical History: diabetes on insulin hypertension chronic headahce s/p head injury [12-1] s/p hysterectomy Social History: denies smoking/alcohol/drugs . Family History: noncontributory Physical Exam: T 97 BP153/80 P73 R8 100% on 2L Gen- sleepy, otherwise no apparent distress, African American obese female HEENT- anciteric, pin point pupils 1-2mm, reactive bilaterally, EOMI, fundoscopic exam impossible because of pinpoint pupils, no sinus tenderness, dry mucus membrane, no JVD at 45 degrees, neck supple CV- regular, no murmurs/gallop, PMI not displaced RESP- clear bilaterally, no crackles ABDOMEN- soft, nontender, nondistended, obese abdomen, hypoactive bowel sounds EXT- trace pedal edema, pedal pulses equal bilaterally NEURO- A+O x3, CNII-XII intact, muscles strength 5/5 grossly, sensation grossly intact, reflexes deferred. SKin- no rashes/bruises Pertinent Results: [2148-10-20] 02:30PM WBC-8.6 RBC-3.86* HGB-10.5* HCT-30.8* MCV-80* MCH-27.1 MCHC-33.9 RDW-14.5 [2148-10-20] 02:30PM PLT COUNT-324 [2148-10-20] 04:38PM GLUCOSE-170* UREA N-30* CREAT-2.5* SODIUM-139 POTASSIUM-4.5 CHLORIDE-107 TOTAL CO2-22 ANION GAP-15 [2148-10-20] 02:30PM URINE BLOOD-TR NITRITE-NEG PROTEIN-500 GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [2148-10-20] 02:30PM URINE RBC-0-2 WBC-[3-31] BACTERIA-MOD YEAST-NONE EPI-0-2 [2148-10-20] 11:15PM CK-MB-2 cTropnT-<0.01 [2148-10-20] 02:30PM CK-MB-2 cTropnT-<0.01 [2148-10-21]: serum/urine tox: [2148-10-21]: serum erythopoietin: . [2148-10-20]: CT head: There is no evidence of hemorrhage, mass effect, shift of normally midline structures, hydrocephalus, or acute major vascular territorial infarction. The ventricles and sulci are normal in size. The [Doctor Last Name 352]-white matter differentiation is preserved. The visualized paranasal sinuses show opacification of the right mastoid air cells and a small mucus retention cyst in the right sphenoid sinus. Otherwise, the surrounding osseous and soft tissue structures are unremarkable. There is a nasopharyngeal mass on the right, perhaps crossing the midline. The opacification of the mastoid air cells suggests that this has been present for an extended period of time- i.e. unlikely to be inflammatory nodal enlargement. These findings are most concerning for nasopharyngeal carcinoma or other malignancy. .. MRI HEAD: Lobulated right-sided nasopharyngeal soft tissue mass lesion, which is highly suspicious for an underlying neoplastic process or carcinoma as indicated on the patient's prior CT from [10-20] and 25, [2148]. No acute territorial infarct seen within the brain. Right-sided mastoiditis. Brief Hospital Course: 1) HYPERTENSIVE EMERGENCY: Pt was admitted to ICU. She was tried on multiple BP regimens. At discharge, she is on lopressor, ACEI, amlodipine, and HCTZ. On this regimen, her BP is within her short term goal though not ideally controlled. There was also one measurement of BP in her 2 arms that was different. This was concerning for aortic dissection, but CXR showed no widening of mediastinum. Repeat simultaneous b/l UE BP measurements were equal so no further imaging was pursued. . 2) RENAL FAILURE: Creatinine ranged from 2.6-3.0 while in hospital but did not change significantly. Baseline is unknown but is possible she has CKD from DM and HTN. She did have proteinuria. Renal US was suboptimal quality but did not show definitive RAS or other pathology. Pt will require outpt renal f/u. . 3) DM: Seen by [Last Name (un) ]. Regimen adjusted and now on NPH with SSI. . 4) NASOPHARYNGEAL MASS: Incidental finding on head CT and MRI. ENT consulted who stated these are usually benign but should have outpt biopsy in next few months once acute issues resolved. Biopsy not practical as inpatient given issues with hypertension. . 5) ANEMIA: Hct ranged widely but settled in low 20s. Baseline unknown. [Month (only) 116] be due to chronic kidney failure. Should have outpt w/u including colonoscopy given age. Medications on Admission: insulin 70/30 actos lipitor aspirin blood pressure medicines (2) excedrin migraine 3x/day Discharge Medications: 1. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:7 Tablet(s) Refills:2 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:7 Tablet(s) Refills:2 3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:7 Tablet(s) Refills:2 4. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:21 Tablet(s) Refills:2 5. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:2 6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:7 Tablet(s) Refills:2 7. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:7 Tablet(s) Refills:2 8. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Sixteen (16) units Subcutaneous daily at breakfast. Disp:10 mL Refills:2 9. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: per SLIDING SCALE units Subcutaneous QACHS. Disp:3 ML Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary: Malignant Hypertension . Secondary: Chronic renal failure Diabetes mellitus type 2 Nasopharyngeal mass Obesity Hyperlipidemia Urinary Tract infection Anemia Discharge Condition: Good. blood pressure at short term goal. ambulating without assist. tolerating oral medications and nutrition. Discharge Instructions: You have been evaluated and treated for very high blood pressure, headaches, and acute kidney disease. While in the hospital your blood pressure was controlled with a combination of multiple medications. Your headaches improved with better control of the headaches. Also, the kidney disease improved as well but remains abnormal and needs to followed closely. . While you were in the hospital, we found that there is an abnormal mass inside your sinuses. We did not complete all the necessary testing as these should be done as an outpatient. The mass could be something unimportant, but it also could be very serious like a cancer. You should see the Ear-Nose-Throat doctors as described below. . Also, while you were in the hospital, we found that you had a urinary tract infection. You completed a 3 days cours of antibiotics . The most important next step is for you to get regular medical care. You must go see your primary doctor as soon as possible in [State 12000]. I have given you enough prescriptions to last you for about one week and we have arrange money for you to pay for that, but beyond the one week you should discuss with Dr. [Last Name (STitle) 22650] on how to obtain medications and care. . It is absolutely essential that you take your blood pressure pills as prescribed. . When you meet with the doctors at the community health center please give them this list of medical problems which is below. . After you meet with your new doctor, ask them to help arrange for a follow-up appointment with the Ear-Nose-Throat doctors here at [Hospital3 ] Deaconness, to discuss the nasal mass. If you have any trouble obtaining your medications, experience recurrent HA, neurological symptoms, chest pain or any other symptoms of concern to you, call Dr. [Last Name (STitle) 22650] or go to the nearest ER. Followup Instructions: You need to follow-up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 22650] in [State ] within one week. Call [Telephone/Fax (1) 68544] to make an appointment. He should be able to help you get access to your medications, monitor your medical issues and make you the appropriate referrals (see below). . You should have an appointment with the Ear-Nose-Throat doctors [Last Name (NamePattern4) ] [3-1] weeks to evaluate the mass inside your nose. The appointment can be with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] at [Hospital3 ] Deaconness the telephone number is [Telephone/Fax (1) 41]. If you return to [State 12000], please ask Dr. [Last Name (STitle) 22650] to refer you to ENT. You also need to see a kidney doctor. Ask Dr. [Last Name (STitle) 22650] to refer you.	[ "478.20", "041.4", "403.00", "585.9", "584.9", "250.02", "285.9", "599.0" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	6714, 6720	4254, 5588	326, 333	6930, 7043	2418, 3098	8937, 9810	1705, 1722		5728, 6691		6741, 6909		5614, 5705			7067, 8914									1737, 2399																									278, 288									361, 1522		3107, 4231															1544, 1640	1656, 1689
65,412	137,761	42652	Discharge summary	report	Admission Date: [2160-4-22] Discharge Date: [2160-5-15] Date of Birth: [2100-4-16] Sex: F Service: MEDICINE Allergies: [Doctor First Name ] Attending:[Last Name (NamePattern4) 290] Chief Complaint: MDS transformed to acute leukemia Major Surgical or Invasive Procedure: Bone marrow biopsy [2160-4-23] Lumbar puncture [2160-5-1] Skin punch biopsy [2160-5-2] History of Present Illness: 66 yo F with history of DMII, bipolar disorder, right eye blindness, and MDS now s/p 2 cycles of decitabine with revlamid presenting with worsening pancytopenia and concern for acute leukemia on bone marrow biopsy. Patient was admitted from [Date range (1) 92228]/12 where bone marrow biopsy showed evidence of MDS (in comparison to prior biopsy which was concerning for erythroleukemia). She was treated with 2 cycles of decitabine and revlimid (2/20-2/29), and was transfusion dependent throughout admission. Course was also complicated by ?acute on chronic renal failure, pneumonia, and hyperglycemia. She was readmitted [Date range (1) 29682]/12 with anemia, and had a repeat bone marrow biopsy at that time. As above, marrow was concerning for acute leukemia, however, there was not enough marrow obtained. Patient was seen in clinic today and was pancytopenic Past Medical History: Diabetes Type II Glaucoma with blindness in right eye Obesity Bipolar disorder TAH in the [2128] for uterine cancer [2128] Left eye with cataract surgery Back operation [2138] R knee replacement [2158] Social History: Prior to illness, was living alone, no siblings. Quit smoking a long time ago. No alcohol or drugs. Worked at [Name (NI) 10936] Brothers bakery in the past. Since diagnosis, was hospitalized and discharged to [Hospital3 ]. Family History: Dad with MI ([1-/2160]) Mom died of brain tumor in [2118] Brother with alcoholic liver disease ([Month (only) ]) Physical Exam: Admission Physical Exam: VS- T 98.1 BP 110/76 HR 69 RR 20 O2 100% RA Gen- Obese female in NAD HEENT- Right eye opaque and mostly closed, left pupil nonreactive to light, c/w past cataract surgery, no scleral icterus. Poor oral dentition, no mucosal lesions, erythema, thrush or petechia Neck- No lymphadenopathy CV- RRR, normal S1/S2, no m/r/g Pulm- CTA bilaterally, no w/r/r Abd- +BS, soft, NTND, +splenomegaly, no hepatomegaly Ext- WWP, no cyanosis or edema Skin- no rashes, lesions or petechia Neuro- A+O x3, right eye blindness, post cataract pupillary changes, CN otherwise intact, resting tremor in hands, strength [6-14] in upper and lower extremities Discharge Physical Exam: Pertinent Results: Admission Labs: WBC 1.6 Hgb 7.4 Hct 21.1 Plts 20 N:36 Band:0 L:53 M:7 E:2 Bas:0 Atyps: 2 . BUN 35 Cr 1.0 . ALT: 77 AST: 26 AP: 350 Tbili: 1.0 LDH: 291 . Anti-TPO antibody [5-2]- pending . Microbiology: CSF [4-30]- Protein 54 Glucose 75 LD(LDH): 34 WBC 0 RBC 42 Poly 4 Lymph 83 Mono 13 EOs 0 GRAM STAIN (Final [2160-4-30]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN Culture- no growth Viral culture- no virus isolated (preliminary0 AFB- pending Cryptococcal antigen- not detected HSV PCR- pending Blood culture [5-1]- no growth to date, pending x 2 Tissue (right thigh) [5-2]- 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Preliminary): NO GROWTH. ANAEROBIC CULTURE (Preliminary): FUNGAL CULTURE (Preliminary): ACID FAST SMEAR (Preliminary): ACID FAST CULTURE (Preliminary): . Imaging: CXR [4-22]- As compared to the previous radiograph, the PICC line is not well visible. The tip is likely to be at the level of the lower aspect of the superior vena cava. No evidence of complications, notably no pneumothorax. Normal appearance of the lung parenchyma. . Transthoracic echocardiogram [4-23]- 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%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2160-2-23], the findings are similar. Bone marrow biopsy [4-23]- Markedly hypercellular marrow with trilineage dysplasia in keeping with persistent involvement by patient's known myelodysplastic syndrome, with increased pronormoblasts worrisome for an evolving pure erythroleukemia (see note). Note: Increased abnormal early pronormoblasts are seen comprising approximately 40% of aspirate differential and nearly 60% of core cellularity. There is background trilineage dysplasia seen. No increase in CD34-immunoreactive myeloid blasts is seen. Overall, although the numeric count does not meet WHO criteria for erythroleukemia, the cytomorphologic findings are worrisome for evolving pure erythroleukemia. Compared to a prior biopsy (S12-2277W dated [2160-2-24]) the current marrow shows a greater proportion of erythroid precursors with an increased relative proportion of early pronormoblasts. . MRI w/contrast [4-25]- No acute abnormality. Mild pachymeningeal enhancement which could represent sequela of recent LP. Right globe abnormality could represent sequela of prior hemorrhage. No evidence for acute ischemia or hydrocephalus. Hypointense marrow reflecting underlying AML. . CXR [4-28]- Right PIC line ends in the low SVC. Lungs clear. Heart size normal. No pleural abnormality or evidence of central lymph node enlargement. . EEG [4-30]- This is an abnormal awake and drowsy EEG because of intermittent focal slowing in the left anterior quadrant. There is also moderate diffuse background slowing and a slow alpha rhythm. These findings are indicative of focal cerebral dysfunction in the left anterior quadrant and a moderate diffuse encephalopathy which is etiologically non-specific. No epileptiform discharges were present. . CT chest/abd/pelvis [5-1]- 1. No evidence of infectious process within the chest, abdomen and pelvis. 2. Interval resolution of previously seen ground-glass opacities in both upper lobes. 3. Unchanged splenomegaly. 4. Stable multinodular goiter. 5. Small uncomplicated bowel-containing umbilical hernia. . Brief Hospital Course: 60 yo F with h/o bipolar disorder, obesity, DM, right eye blindness, and MDS presenting with worsening pancytopenia. . # MDS, transformed to acute leukemia: s/p 2 cycles decitabine and revlimid (5q- cytogenetics) with evidence of transformation to acute erythroblastic leukemia with 60% erythroblastic core. TTE performed to establish baseline prior to chemotherapy and was unchanged from prior. 7+3 was deferred in the setting of acute delirium (see below). The patient was continued on ciprofloxacin and fluconazole prophylaxis initially, but both were discontinued in case they were precipitating delirium. She was started on acyclovir prophylaxis. She required intermittent transfusions throughout admission to maintain hct>21 and plts>10. . # Mental status change: Patient had acute change in mental status on [4-24]. Patient was slower to respond to questions, more irritable, listless. She was intermittently disoriented as well. Infectious work-up was negative (blood, urine cultures, CT torso). MRI had no acute abnormalities. 20 min EEG showed no epileptiform discharges or seizure activity, however there was some focality in left lobe, that may have been representative of seizure activity. Per neurology's recommendations, a continuous video EEG was initiated which showed encephalopathy. Neurology also recommended checking anti-TPO antibody (despite normal TSH/T3) for concern for Hashimoto's encephalopathy that returned normal. An LP was performed on [4-30] and was not consistent with infection. No malignant cells were seen. Cultures returned negative. Psych was also consulted and felt that patient was acutely delirious, not depressed or psychotic. However, patient's lithium and fluphenazine had both been decreased during last admission, so there was concern that these medication changes may have precipitated change in mental status. Lithium was titrated up to 300 mg qAM and 150qAM. Her lithium level remained normal throughout admission. . # Abdominal pain: During admission, the patient developed acute abdominal pain. She was passing gas and without peritoneal signs. KUB and upright without free air under diaphragm or enlarged loops of bowel concerning for obstruction. CT abdomen was without acute pathology. The patient did have chronically elevated AST/ALT, alkaline phosphatase, and normal bilirubin, but no evidence of acute liver pathology. Pain resolved without intervention. . # Left upper thigh lesion: Crusted, papular non erythematous lesion on left upper thigh noted on [5-1]. Patient denied pruritus or pain at site, and was not sure how it developed. Dermatology consulted and felt that lesion was less likely leukemia cutis, more likely a ruptured cyst or follicle with granulomatous response. Punch biopsy showed ruptured folliculitis. . # Renal insufficiency: Likely chronic disease, with estimated GFR of 45% during last admission. Creatinine has been stable; diagnosed with 24 hr creatinine/urea and cystatin C. Renal followed patient during last admission and did not feel that lithium was contributing to renal disease. 24hr urine performed on admission and GFR calculated at 55-60% which is consistent with Cr. Medications were dosed for EGFR 55-60. Nephrotoxic medications were avoided throughout admission. . # Bipolar disorder: Patient on lithium, fluphenazine and trihexyphenidyl. Lithium level appropriate (0.6) on day of admission. The patient was up titrated to Li 300mg qAM, 150mg qPM. Level remained therapeutic. For delirium fluphenazine was halved to 5mg qhs and trihexyphenidyl was halved to 1mg po BID for extrapyramidal symptoms. She remained without EPS. . # DM2: BS well controlled during last hospitalization on glargine [Hospital1 ] and ISS. BS well controlled now in house. The patient was continued on lispro sliding scale. She was continued on glargine qAM and qHS for basal coverage. . # Glaucoma: continued timolol . # ICU course- Upon arrival to the ICU the pt was persistently delirious unable to communicate to the staff. She continued to require frequent PRBC and platelet transfusions to maintain a hematocrit >21 and plt >10. The Heme/Onc team closely followed while in the ICU and felt that she may have developed HLH. She was given Dexamethasone without any improvement in her mental status. After several meetings with her HCP and no significant improvement in her mental status the decision was made to transition this pt to comfort measures only. She peacefully passed away less than 24hrs. Medications on Admission: 1. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 2. propranolol 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. trihexyphenidyl 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. fluphenazine HCl 10 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 6. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea/anxiety/insomnia. 7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for sob/wheezing. 8. nifedipine 30 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO DAILY (Daily). 9. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 11. lithium carbonate 150 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed for itching. 13. insulin Insulin SC (per Insulin Flowsheet) Sliding Scale & Fixed Dose 14. insulin glargine 100 unit/mL Cartridge Sig: Forty (40) units Subcutaneous at bedtime. 15. insulin glargine 100 unit/mL Cartridge Sig: Fifteen (15) units Subcutaneous qam. 16. insulin lispro 100 unit/mL Cartridge Sig: per sliding scale Subcutaneous see attached. 17. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) Powder in Packet PO DAILY (Daily). 18. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 19. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed for cough. 20. acetaminophen 650 mg/20.3 mL Solution Sig: Six [Age over 90 1230]y (650) mg PO Q6H (every 6 hours) as needed for fever/pain. 21. codeine-guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. 22. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 23. Ondansetron 8 mg IV Q8H:PRN nausea 24. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen. Discharge Medications: patient is deceased Discharge Disposition: Expired Discharge Diagnosis: patient is deceased Discharge Condition: patient is deceased Discharge Instructions: patient is deceased Followup Instructions: patient is deceased [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292]	[ "205.00", "799.02", "250.00", "284.19", "278.00", "289.4", "780.09", "575.0", "780.60", "348.30", "585.3", "553.20", "584.9", "296.80", "V49.86", "365.9", "369.60", "V43.65", "401.9", "704.8" ]	icd9cm	[ [ [] ] ]	[ "86.11", "03.31", "41.31" ]	icd9pcs	[ [ [] ] ]	13613, 13622	6718, 11243	326, 427	13685, 13706	2698, 2698	13774, 13932	1845, 1972		13569, 13590		13643, 13664		11269, 13546			13730, 13751									2012, 2652						3637, 6695			3570, 3604																253, 288									455, 1338						2714, 3501			3537, 3537								1360, 1580	1596, 1829			2679, 2679
75,305	121,636	30469	Discharge summary	report	Admission Date: [2147-12-27] Discharge Date: [2148-1-6] Date of Birth: [2095-9-11] Sex: F Service: MEDICINE Allergies: Iodine; Iodine Containing / Optiray 350 Attending:[First Name3 (LF) 8115] Chief Complaint: Vomiting Major Surgical or Invasive Procedure: DC Cardioversion History of Present Illness: [First Name3 (LF) 3390]: [Name10 (NameIs) ],[Name11 (NameIs) ] is primary ONC HPI: 52 F in ER with HA for 2 weeks, nausea x 1 week, and intractable vomiting x 2 days. She has also noticed some increasing cough and sinus pressure the last few days along with cough in the morning. Also started having diarrhea yesterday which has now stopped. She denies any f/c, SOB, chest pain. No changes in her vision, no numbness, weakness. In ER: Got symptomatic therapy. Omed fellow recommended CT of head which did not reveal any mets. had an abd CT with no abd pathology. 2L IVF given. Zofran given without success, patient still vomiting. ROS: -Constitutional: []WNL []Weight loss [x]Fatigue/Malaise []Fever []Chills/Rigors []Nightweats []Anorexia -Cardiac: [x]WNL []Chest pain []Palpitations []LE edema []Orthopnea/PND []DOE -Respiratory: []WNL []SOB []Pleuritic pain []Hemoptysis [x]Cough -Gastrointestinal: []WNL [x]Nausea [x]Vomiting []Abdominal pain []Abdominal Swelling [x]Diarrhea []Constipation []Hematemesis []Hematochezia []Melena -Musculoskeletal: [x]WNL []Myalgias []Arthralgias []Back pain -Neurological: [ ]WNL []Numbness of extremities []Weakness of extremities []Parasthesias []Dizziness/Lightheaded []Vertigo []Confusion [x]Headache Past Medical History: 1. Melanoma that was resected in [2140], it was a right shoulder melanoma w/ sentinel lymph node biopsy neg and no chemo given. Presented with hemoptysis [2145-3-5] found to have lung metastasis causing post obstructive PNA but was evaluated by IP for stent and found to have no obstruction. Also had a right sided pleurex catheter place for malignant effusion which has since been removed. She had recurrent hemoptysis so had bronchial artery embolization on [4-8] and then started on XRT. also found to have bilateral PE's despite lovenox and IVC filter and was discharged to rehab on [4-30]. She was then admitted [Date range (1) 72403] for cisplatin, dacarbazine and vinblastine regimen. 2. HTN 3. SVT vs ? paroxysmal atrial fibrillation, recent hospitalization thought to have AVNRT 4. Lower extremity DVT initially on coumadin but recieved IVC filter with recurrent hemoptysis and subsequent PE despite lovenox and filter 5. C-section x3 6. CCY 7. tonsillectomy/adenoidectomy Social History: Married w/ three children. She is a housewife. She quit smoking 29 years ago 1.5 ppd for 2 yrs and she reports no EtOH. Family History: Brother - melanoma in 20s. Mother with HTN, breast cancer @ 65 and has DMII. Father with MI in 60s Physical Exam: (Per Admitting Resident) VS: 98.2 113/65 127 20 95RA Gen: no acute distress, awake, alert, appropriate, and oriented x 3 Skin: warm to touch, no apparent rashes. HEENT: No conjunctival pallor, no scleral jaundice, OP clear CV: RRR but tachy, no audible m/r/g Lungs: clear to auscultation Abd: soft, NT, normal BS Ext: No C/C/E Neuro: Gait, strength and sensation intact bilaterally. Pertinent Results: Admission Labs [2147-12-27] 11:35AM BLOOD PT-13.2 PTT-26.8 INR(PT)-1.1 [2147-12-27] 11:35AM BLOOD Glucose-141* UreaN-7 Creat-1.0 Na-139 K-3.7 Cl-101 HCO3-20* AnGap-22* [2147-12-27] 11:35AM BLOOD ALT-81* AST-38 AlkPhos-118* TotBili-0.5 [2147-12-27] 11:35AM BLOOD Lipase-26 [2147-12-28] 05:03PM BLOOD CK-MB-2 cTropnT-<0.01 [2147-12-27] 11:35AM BLOOD Calcium-9.7 Phos-2.6* Mg-1.5* [2147-12-27] 11:43AM BLOOD Lactate-2.6* Na-141 Discharge Labs [2148-1-6] 05:31AM BLOOD WBC-10.9 RBC-3.57* Hgb-11.0* Hct-33.0* MCV-93 MCH-30.9 MCHC-33.4 RDW-14.7 Plt Ct-333 [2148-1-6] 03:48PM BLOOD Glucose-247* UreaN-15 Creat-1.1 Na-137 K-5.1 Cl-100 HCO3-29 AnGap-13 [2148-1-6] 03:48PM BLOOD Calcium-8.5 Phos-2.9 Mg-2.3 Other Labs [2148-1-1] 04:19AM BLOOD Prolact-5.8 TSH-0.059* [2148-1-1] 04:19AM BLOOD Free T4-0.91* [2148-1-3] 04:11AM BLOOD FSH-5.5 LH-1.7* [2148-1-5] 07:30AM BLOOD TSH-0.33 [2148-1-5] 07:30AM BLOOD T4-4.6 T3-43* Free T4-0.72* Blood and Urine Cx - Negative RADIOLOGY CT A/P ([12-27]) - IMPRESSION: 1. No acute intra-abdominal or pelvic pathology to explain the patient's symptoms. 2. Left lower lobe vague nodular opacity for which the differential includes infectious versus neoplastic etiology. Attention on followup recommended. 3. Mild decrease in size of right retroperitoneal/retrocaval mass. 4. Colonic diverticulosis without evidence of acute diverticulitis. CT Head ([12-27]) - IMPRESSION: No evidence of metastatic disease on this limited non-contrast evaluation. Cutaneous nodules on the right are unchanged. ECHO ([12-29]) - IMPRESSION: Suboptimal image quality. IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes with preserved global biventricular systolic function. No valvular pathology or pathologic flow identified. Bilateral Lower Ext U/S ([12-30]) - IMPRESSION: Limited exam of the distal superficial femoral veins bilaterally due to body habitus, but no evidence of DVT of either lower extremity. CT Chest ([1-1]) - IMPRESSION: 1. Increased size of large right mediastinal and hilar masses, with increased mass effect on the trachea, and worsening obstruction of the right middle lobe bronchus, and segmental right lower lobe bronchi. 2. Findings most consistent with mild pulmonary edema, including new small bilateral pleural effusions, scattered areas of ground-glass opacity, and mild interlobular septal thickening. CT Head ([1-4]) - IMPRESSION: Limited evaluation of the pituitary gland. Possible enlargement of the pituitary gland currently measuring 10 x 10 mm and previously measuring 7 x 10 mm on prior MR [First Name (Titles) 27533] [2146-9-30]. Brief Hospital Course: 52 y.o. Female with h.o. metastatic Melanoma to lungs, h.o. DVT on Lovenox, presents with N/V/D and developed atrial flutter with RVR. # N/V: Pt endorsed nausea over the past 2 weeks which lead to her admission as well as emesis x 3 days. Pt also endorses 3 days of diarrhea, which resolved. Most likely dx is viral gastroenteritis. Head CT was negative for any masses. CT abd/pelvis was negative for any signs of intra-abdominal pathology such as ileus, extrinsic compression. Abdominal exam was benign. Symptoms of nausea/vomiting resolved early in course, however she was severely anorexic and was not taking any POs. She was treated prn with Reglan, Compazine, Zofran however these did not help with appetite. Nutrition consult was consulted and followed the patient. By the time of transfer to the oncology service and subsequent discharge, the patient was tolerating PO well. # A. flutter with RVR: Pt had history of SVT vs AVNRT vs A. flutter with RVR. Pt noted to have SVT on [2147-12-27] and showed A. flutter with RVR after receiving Adenosine x 2. Patient was noted to be hypotensive, likely rate related. Patient received IVF, since she was volume depleted [1-23] N/V/D. Given volume depletion, her home doses of PO metoprolol and diltiazem had been held, and were restarted in setting of RVR. Atrial flutter remained refractory to PO meds. Patient was treated with diltiazem drip, and amiodarone IV bolus and drip, with no improvement in rate. Patient was DC cardioverted with return of sinus tachycardia. Pt was continued on PO amiodarone to maintain sinus rhythm. Cause of sinus tachycardia was unclear, patient was afebrile, not in pain, and not anxious. LENIs were negative for DVT and patient had IVC filter in place. CTA was not done given contrast allergy, and patient was already on therapeutic Lovenox. It remained possible that tachycardia was due to spread of underlying malignancy as evidenced on chest CT. After she was loaded on amiodarone, she was continued on a once daily regimen of PO amiodarone. She was discharged with instructions to arrange cardiology follow-up. By the time of discharge, the patient's tachycardia was improving. # Panhypopituitarism: Patient was noted to have low random cortisol. She is on Ipilimumab, which can cause panhypopit. TSH and free T4 were also low. PRL was borderline low. Endocrine was consulted, and recommended treating empirically for adrenal insufficiency. Tests will need to be repeated when patient is off pain medications, since these can also suppress the HPA axis. The patient was placed on oral prednisone with plans to taper after discharge. She was also started on levothyroxine. At the time of discharge, the patient was given instructions to follow-up at the [Hospital ] clinic for teaching about home glucose monitoring. She was also given instructions to follow-up with endocrinology for further work-up of her questionable panhypopituitarism. # Metastatic Melanoma: Pt had known mets to the lung and is currently being followed by Dr. [Last Name (STitle) ]. She is currently on Ipilimumab as part of the compassionate trial for Monotherapy in Subjects with Unresectable Stage III or IV Melanoma. The ICU team communicated with Dr. [Last Name (STitle) ]. Patient underwent chest CT to evaluate disease progression, which did show increased size of large right mediastinal and hilar masses, with increased mass effect on the trachea, and worsening obstruction of the right middle lobe bronchus, and segmental right lower lobe bronchi. Patient may be candidate for new study drug once outpatient. # SIADH: Patient had normal serum sodium on admission, however patient was volume depleted from N/V/D x 2 weeks. Upon rehydration, Na decreased. Urine studies were consistent with SIADH, and sodium corrected with 1.5L fluid restriction. SIADH is likely due to metastatic lung disease. # Sinusitis: Pt was started on Ceftriaxone for tx of acute Sinusitis that was thought to be related to her admission HA. On review of CT scan no signs of sinusitis and CTX was D/Ced. However, patient continued to have mild headaches, sinus pressure and leukocytosis that began rising after abx stopped. Patient was treated with 5 day course of levaquin. # 02 requirement/wheezing: Patient had wheezing on exam and new 02 requirement noted after atrial flutter with RVR, likely due to pulmonary edema and worsened with IVF hydration in an attempt to control tachycardia. Patient improved with diuresis. # h.o.PE: Pt has history of P. Embolism even on Lovenox, has IVC filter. Pt was previously on Coumadin for her A. fib however this appears to have been discontinued after her episodes of hemoptysis. Given patient's weight, her home Lovenox dose was inadequate, and she was increased to 150 mg [Hospital1 ]. LENIs were negative for PE as above. # Transaminitis: Pt noted to some mild transaminitis on admission, with ALT trending down 81->71, AST increased from 38->50. Alk Phose elevated in 110s. In the past pt has been noted to have high Alk Phos, pt is s/p CCY, abd not tender on exam. Transaminitis may be med related, ie Ceftriaxone. Medications on Admission: DILTIAZEM HCL - (Prescribed by Other Provider) - 90 mg Tablet - take 1 (one) tablet four times a day ENOXAPARIN [LOVENOX] - 100 mg/mL Syringe - SC twice a day HYDROCODONE-ACETAMINOPHEN [VICODIN] - (Prescribed by Other Provider: [Name Initial (NameIs) 3390]) - 5 mg-500 mg Tablet - 1 Tablet(s) by mouth 4-6 hours as needed for pain METOCLOPRAMIDE [REGLAN] - (Prescribed by Other Provider) - 10 mg Tablet - 1 Tablet(s) by mouth two times a day METOPROLOL TARTRATE - 50 mg Tablet - 1 Tablet(s) by mouth twice a day MIRTAZAPINE [REMERON] - (Prescribed by Other Provider) - 30 mg Tablet - 1 Tablet(s) by mouth once a day PANTOPRAZOLE [PROTONIX] - (On Hold ) - 40 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day POTASSIUM PHOSPHATE, MONOBASIC [K-PHOS ORIGINAL] - 500 mg Tablet, Soluble - 2 Tablet(s) by mouth twice a day Discharge Medications: 1. Prednisone 10 mg Tablet Sig: As directed Tablet PO once a day: Take 4 tabs daily starting on [1-7], then decrease to 3 tabs daily starting [2148-1-9]. Disp:90 Tablet(s) Refills:0 2. Mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. K-Phos Original 500 mg Tablet, Soluble Sig: Two (2) Tablet, Soluble PO twice a day. 5. Reglan 10 mg Tablet Sig: One (1) Tablet PO twice a day as needed for nausea. 6. Vicodin 5-500 mg Tablet Sig: One (1) Tablet PO every [3-26] hours as needed for pain. 7. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 9. Enoxaparin 150 mg/mL Syringe Sig: One (1) 150 mg injection Subcutaneous Q12HRS (). Disp:1 month's supply Refills:2 10. Glucometer Patient needs a glucometer. She should record her fasting blood sugar in the morning and her blood sugar 2 hours after each meal. She should bring these glucose values to her [Hospital ] clinic appointment on Tuesday, [2148-1-9]. Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Primary Hypopituitarism Metastatic Melanoma Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: You were admitted for headache, nausea, and vomiting. These symptoms improved over time. However, your course was complicated by an irregular heart rhythm called atrial flutter which required a transfer to the ICU. As your heart rate was not controlled by medications alone, you underwent cardioversion in the ICU. Your heart rhtyhm is regular again although still a little fast. It is improving. Your other work up has focused on the question of whether you have a condition called hypopituitarism. Endocrine was consulted, and recommended a steroid taper, which you will continue at home. The steroids did cause your blood sugars levels to be high, so you will need to be on insulin for now. Lastly, you are completing a course of antibiotics for sinusitis. The following changes were made to your medications: - START amiodarone for heart rhythm abnormality - START prednisone for low steroid levels - START levothyroxine for low thyroid levels - STOP diltiazem - STOP metoprolol - CHANGE lovenox to 150 mg injected twice a day Please take all medications as prescribed. You should record your fasting blood sugar in the morning and her blood sugar 2 hours after each meal. You should bring these glucose values to your [Hospital ] clinic appointment on Tuesday, [2148-1-9]. Please avoid foods that will increase your blood sugar, such as candy, cake, cookies, and juice. It was a pleasure to take part in your medical care. Followup Instructions: Please follow up at [Last Name (un) ] at 1pm on Tuesday with [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], NP for teaching about how to check blood sugars. You are scheduled to follow up with Dr. [Last Name (STitle) ] at [Last Name (un) ] at 1:30pm on the same day. If you cannot make this appointment, please [Telephone/Fax (1) 2378]. The endocrine clinic will also be contacting you to make a follow-up appointment to see Dr. [First Name8 (NamePattern2) ] [Name (STitle) 8473] for further management of your hypopituitarism. If you have any questions about this appointment, please call [Telephone/Fax (1) 2378] as well. You should also follow-up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] in the cardiology clinic for further management of your fast heart rate. You can call the cardiology clinic at [Telephone/Fax (1) 62] to schedule this appointment. You should also follow-up with your [Telephone/Fax (1) 3390], [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], within 1-2 weeks of discharge. You can call her office at [Telephone/Fax (1) 7164] to set up your appointment. [Name6 (MD) ] [Name8 (MD) 4908] MD [MD Number(2) 8116]	[ "799.02", "V10.82", "253.6", "253.7", "008.8", "E933.1", "276.2", "427.32", "461.9", "458.9", "427.31", "V58.61", "V58.65", "401.9", "V15.3", "V12.51", "196.2", "197.0", "783.0", "511.81" ]	icd9cm	[ [ [] ] ]	[ "99.61" ]	icd9pcs	[ [ [] ] ]	13319, 13376	6035, 11181	309, 328	13464, 13464	3314, 6012	15075, 16402	2795, 2895		12075, 13296		13397, 13443		11207, 12052			13609, 15052									2910, 3295																									261, 271									356, 1616										13478, 13585							1638, 2641	2657, 2779
26,471	141,447	27217	Discharge summary	report	Admission Date: [2111-3-26] Discharge Date: [2111-3-29] Date of Birth: [2037-1-10] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2186] Chief Complaint: Transfered for w/u for surgery for thoracic aortic aneurysm. No surgery indicated. Pt tx'd to ICU for syncope. Major Surgical or Invasive Procedure: None History of Present Illness: 74 yo c hx of hypertension, hyperlipidemia, CAD s/p RCA stent [2-26], paroxysmal atrial fibrillation, and aortic root aneurysm who developed intermittent periods of lightheadedness over the last month. He reports feeling dizzy with vague symptoms of vertigo; these occured at random without association with positional changes. He does not describe a clear prodrome to these episodes. Had CT of chest to workup these symptoms and noted to have significant coronary calcifications. Catheterization showed distal RCA occlusion stented. Following cath, had episodes of dizziness, now accompanied with some confusion to orientation quickly clearing. Admitted to OSH with persistent symptoms and noted to have orthostatic hypotension; continued to have symptoms c fluid resuscitation and w/u for adrenal insufficiency initiated. Started on fludricortisone at OSH. Transfered to [Hospital1 18] for surgical evaluation of aortic root aneursym and medical evaluation of orthostatic hypotension. . In CSRU, had SBP to 160s and started on nitroglycerin drip; no dissection noted and no emergent surgery performed. Morning of transfer, pt. had episode of questionable loss of consciousness while rising from a seated position to urinate. Arose from bed, stood up at side of bed to urinate, had dizziness/vertigo, fell to bed c no trauma to head. Found unresponsive briefly and noted to have decreased respirations; bag valve mask used briefly and pt. returned to [Location 213] respirations. Nitro drip stopped. Sinus rhythm in 50s and SBP 112/60. Underwent ECHO showing normal valvular function and transfered to medical ICU. . Past Medical History: CAD-s/p cypher stent to RCA [2111-3-16] HTN PAF Hypercholesterolemia Aortic root aneurysm - ascending aorta, 5.2 cm s/p colon resection for benign polyps s/p hernia repair Social History: SOCHX: Lives with wife in [Name (NI) 3844]. Drinks 1-2 drinks of scotch a night. 25-50 pack year smoking history, quit recently . FAMHX: No hx autoimmune disease Family History: N/C Physical Exam: VITALS: Tc 97.1, HR 64, BP 105/61, RR 23, 94% RA BP Pulse Supine 127/65 62 Sitting 104/68 69 Standing 105/61 76 GEN: Elderly man lying in bed in NAD HEENT: OP clear, MMM, no LAD CV: RRR, S1, S2, distant heart sounds LUNGS: Decrease breath sounds at L base c decrease fremitus and dullness to percussion over area. No wheeze, crackles, rhonchi BACK: Unremarkable ABD: Obese, soft, NT, ND, BS+ EXT: WWP, no cce, good capillary refill NEURO: AO3, CN 2-12 fxn intact, [3-27] MS throughout. No nystagmus. Pertinent Results: ADMISSION LABS: [2111-3-26] 09:39PM BLOOD WBC-7.4 RBC-3.43* Hgb-11.2* Hct-32.5* MCV-95 MCH-32.6* MCHC-34.5 RDW-13.6 Plt Ct-319# [2111-3-28] 06:02AM BLOOD Neuts-73.4* Lymphs-20.2 Monos-4.9 Eos-1.1 Baso-0.3 [2111-3-26] 09:39PM BLOOD PT-12.1 PTT-24.9 INR(PT)-1.0 [2111-3-26] 09:39PM BLOOD Glucose-91 UreaN-12 Creat-1.0 Na-140 K-3.7 Cl-107 HCO3-24 AnGap-13 [2111-3-26] 09:39PM BLOOD ALT-21 AST-19 AlkPhos-86 Amylase-56 TotBili-0.3 [2111-3-26] 09:39PM BLOOD Mg-2.0 [2111-3-27] 07:54AM BLOOD Cortsol-9.9 [2111-3-27] 10:01AM BLOOD Cortsol-19.8 . OTHER DATA: [3-27] ECHO - 1.The left atrium is elongated. 2.Left ventricular wall thicknesses and cavity size are normal. 3. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). 4. Right ventricular chamber size and free wall motion are normal. 5.The aortic root is moderately dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. 6. The mitral valve appears structurally normal with trivial mitral regurgitation. 7. The estimated pulmonary artery systolic pressure is normal. 8. There is no pericardial effusion. . [3-26] CT 1. Right hypodense subcentimeter renal structure, that may represent a cyst, but a comparison with outside CTs is recommended. Alternatively, an MR can be performed to evaluate this lesion. 2. Densely atherosclerotic aorta, but no evidence for acute aortic injury. Within the distal aorta is a very small focal area of dilation with a possible ulcerated plaque. Brief Hospital Course: BRIEF OVERVIEW: 74-year-old male xfr'd to [Hospital1 18] for eval for CT [Doctor First Name ] for aortic aneurysm but not a current candidate. Had a syncopal episode in the CSRU and transfered to the [Hospital Unit Name 153]. On history, he was found to have had orthostatic symptoms at home over the past ~1 month since starting flomax. He had self d/c'd this medication and felt better. He was on nitro gtt in the CSRU and was urinating when his syncope occurred there. On xfr to the [Hospital Unit Name 153] he had mild orthostatic hypotension that was symptomatic originally, but asx after a fluid bolus of 1L. The following day he was symptom free. The leading dx for his syncope was felt to be medication effect from flomax/nitroglycerin. Other diagnostic possibilities included bradycardia (? [12-25] amiodarone), volume depletion, vasovagal syncope (micturition). Adrenal fxn was found to be normal on a cosyntropin stim test. He was felt to be stable at this point in the workup and was transferred to the medical floor for further workup. On the floor, the following problems were addressed. . 1. Dizziness - His dizziness was worked up as above in the ICU. He had a normal ECHO w/out significant valvular disease and was monitored on telemetry w/out events noted. He was able to ambulate w/out any problems on the floor and was d/c on the day after admission [12-25] patient request. Further diagnostic possibilities that could be followed up as an outpatient include: 1) CT/MRI of head to exclude stroke in setting of stenting of calcific coronary arteries 2) tilt table test 3) Neurological evaluation for more rare causes such as shy [Last Name (un) ] syndrome. . 2. CAD - continued [Last Name (LF) 4532], [First Name3 (LF) ] in setting of recent RCA stenting. held off on bblocker or ace considering his orthostatic hypotension but these could be considered as an outpatient if his symptoms resolve . 3. Afib - should be on coumadin based on ACC recommendations; defer decision to anticoagulate to PCP . 4. Aneurysm - evaluated by surgery and decided to not pursue surgery at this time. Medications on Admission: amio 200' zocor 40' mvi glucosamine [First Name3 (LF) ] ambien 10 nexium 75 [First Name3 (LF) 4532] 75 Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 6. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 7. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary: Orthostatic hypotension likely [12-25] medication side effect . Secondary: CAD, HTN, hypercholesterolemia Discharge Condition: Stable; tolerating PO and ambulating independently Discharge Instructions: Please take your medications as directed Please keep your follow-up appointments Please return to the ER or call your PCP [Name Initial (PRE) ]: 1. chest pain 2. fever to 101 3. shortness of breath 4. fainting/severe dizziness Please make sure to not rise quickly from a sitting or lying position. When awaking in the morning or getting up at night, please remain sitting for 1-2 minutes before rising to a standing position Followup Instructions: Please follow up with your primary care physician [Name Initial (PRE) 176] [11-24] weeks Completed by:[2111-3-29]	[ "V45.82", "496", "E941.3", "276.52", "441.2", "401.9", "458.0", "427.31", "272.0", "414.01" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	7509, 7515	4664, 6818	428, 434	7678, 7731	3041, 3041	8209, 8337	2494, 2499		6980, 7486		7536, 7657		6844, 6957			7755, 8186									2514, 3022																									276, 390									462, 2094						3057, 4641											2116, 2294	2310, 2478
32,135	104,481	51228	Discharge summary	report	Admission Date: [2162-7-8] Discharge Date: [2162-7-13] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 425] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: None History of Present Illness: 85yo woman with h/o CAD s/p MI in [2134] and HTN who presents with complaint of chest pain. The patient reports episodes of substernal chest pain over the last week. She describes shooting pain that "pulled from side to side," not associated with exertion. She thought the pain was indigestion and did not seek care. The night prior to admission, she was feeling stressed after seeing her husband at rehab, where he has been staying since an MI treated at [Hospital1 18] in the CCU 02/[2162]. She went home and ate a hot dog with relish, then had a chocolate bar and fried [Last Name (un) 106277]. When she went to bed, she started having severe right-sided chest pain, which she variably describes as being under her right breast vs just to the right of her sternum. No associated nausea, dyspnea, or diaphoresis. Not pleuritic. She tried some tylenol and then smoked a cigarette, but without any relief. After taking some nasal spray (azelastine), she began feeling palpitations and shortness of breath. In the morning, she called her daughter, who brought her to see her PCP. [Name10 (NameIs) ] her PCP's office at 10:30am, she felt fine; the chest pain and dyspnea had resolved on their own. Her PCP noted EKG changes and sent her to the ED. In the ED, initial VS were: 97.1 67 146/76 19 95% on ??. There were no acute EKG changes noted, and she was given ASA 324mg, SL NTG. She was going to be admitted to [Hospital Unit Name 196] for rule out when she developed acute respiratory distress with SBP up to 170s and sat's down into the 80s. CXR demonstrated significant pulmonary edema, and she was given lasix 40mg IV as well as put on a nitro gtt. She was placed on CPAP at 8 and admitted to the CCU. Upon arrival to the CCU, she was breathing comfortably on 4L by nasal cannula and chest pain free. Nitro gtt at 0.78. The patient reports having poor energy for the last couple of months. She has also had poor appetite. She has 4 pillow orthopnea but denies PND. She endorses some minor LE edema x 1 week but no weight gain. Past Medical History: CAD s/p MI in the [2134]; reports she had a second minor MI shortly after, both medically managed. HTN GERD h/o Choledocholithiasis [2153] s/p ERCP and sphincterotomy h/o Acute cholecystitis [2156] s/p cholecystostomy tube, followed by open CCY c/b wound infection, epigastric hernia Gout h/o GI bleed in [2148], ?? due to diverticulosis h/o transfusion reaction s/p appendectomy s/p Open reduction and internal fixation of left hip. s/p C section. PCP: [Name10 (NameIs) ],[Name11 (NameIs) 569] [Name Initial (NameIs) ]. [Telephone/Fax (1) 133] ALLERGIES: NKDA Social History: Social history is significant for the presence of current tobacco use. She has smoked 1 pack per week x 70 years. She denies alcohol abuse. She had been living with her husband until [Month (only) 956], when he had his MI. He has been in and out of hospitals/rehab since then. She has 2 children in [Location (un) 86] and in [Hospital1 614]. She walks with a cane since a hip fracture. She does not have a visiting nurse, but a woman comes to help clean from time to time. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: VS: T 97.1, BP 143/80, HR 96, RR 26, O2 96% on 4L Gen: Pleasant elderly woman, mildly tachypneic when talking but able to complete full sentences; somewhat tearful when talking about changes in her life. Oriented x3. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with JVP of 5cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. +systolic murmur at apex. No S4, no S3. Chest: No chest wall deformities, scoliosis or kyphosis. Faint crackles at bases b/l, no wheeze or rhonchi. Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: Left > right LE edema. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Carotids 2+ without bruit; distal pulses dopplerable b/l Pertinent Results: EKG on admission demonstrated NSR with normal axis and incomplete BBB with old inferior Q waves and T wave flattening in I, aVL, and V5-V6. As compared with prior from [2161], prominent R wave in V2 has disappeared and lateral T wave flattening is new. CXR [2162-7-8] (dictated): Lateral right hemithorax cut off. No definite pneumonia. Central hilar prominence suggestive of congestion. No large pleural effusion on left [Month/Day/Year ] [11/2160] The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with basal inferior and inferolateral akinesis. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened, without prolapse. Moderate (2+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The estimated pulmonary artery systolic pressure is normal. IMPRESSION: Mild regional left ventricular systolic dysfunction. Moderate mitral regurgitation. Bedside TTE in CCU [2162-7-8]: The left atrium is normal in size. There is severe regional left ventricular systolic dysfunction with extensive inferior, inferolateral and lateral akinesis (LCx distribution). There is mild hypokinesis of the remaining segments (LVEF = 25-30%). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Severe (4+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Severe regional left ventricular systolic dysfunction, c/w CAD. Severe mitral regurgitation. Moderate pulmonary hypertension. pMIBI [2161-5-13]: 84 yo woman (h/o MI) was referred to evaluate an atypical chest discomfort and fatigue. Due to a limited ability to exercise (prior hip fx) and limited hemodynamic response to exercise without ECG changes or symptoms, a persantine-MIBI was performed. The patient was administered 0.142 mg/kg/min of persantine over 4 minutes. No chest, back, neck or arm discomforts were reported by the patient during the procedure. No significant ST segment changes were noted from baseline. The rhythm was sinus with frequent aea and infrequent vea. The hemodynamic response to the persantine infusion was appropriate. Three min post-MIBI, the patient was administered 125 mg aminophylline IV. IMPRESSION: Limited functional exercise tolerance secondary to orthopedic limitations; persantine MIBI performed. No anginal symptoms or ECG changes from baseline. Nuclear report sent separately. Laboratory Data [2162-7-13] WBC-5.2 RBC-3.20* Hgb-10.0* Hct-29.3* MCV-92 MCH-31.3 MCHC-34.1 RDW-16.6* Plt Ct-184 [2162-7-8] Glucose-111* UreaN-41* Creat-2.5* Na-137 K-4.7 Cl-107 HCO3-17* AnGap-18 [2162-7-13] Glucose-104 UreaN-62* Creat-3.2* Na-134 K-4.3 Cl-104 HCO3-18* AnGap-16 [2162-7-13] Calcium-8.3* Phos-4.3 Mg-2.0 [2162-7-9] TSH-1.8 [2162-7-8] 12:05PM BLOOD CK(CPK)-90 [2162-7-8] 08:44PM BLOOD CK(CPK)-114 [2162-7-9] 06:04AM BLOOD CK(CPK)-83 [2162-7-10] 05:52AM BLOOD CK(CPK)-62 [2162-7-12] 07:00AM BLOOD CK(CPK)-44 [2162-7-8] 12:05PM BLOOD CK-MB-NotDone proBNP-[Numeric Identifier 106278]* [2162-7-8] 12:05PM BLOOD cTropnT-1.90* [2162-7-8] 08:44PM BLOOD CK-MB-21* MB Indx-18.4* cTropnT-2.09* [2162-7-9] 06:04AM BLOOD cTropnT-1.86* [2162-7-10] 05:52AM BLOOD cTropnT-1.88* [2162-7-12] 07:00AM BLOOD CK-MB-5 cTropnT-1.42* [2162-7-9] Triglyc-127 HDL-35 CHOL/HD-5.0 LDLcalc-115 Brief Hospital Course: Mrs. [Known lastname 1557] is an 85 yo woman with CAD s/p remote MI admitted with chest pain and acute pulmonary edema, found to have new inferolateral wall motion abnormality and 4+ MR [First Name (Titles) ] [Last Name (Titles) ] concerning for subacute ischemic event. . # CAD/Ischemia [Last Name (Titles) ] was found to have new inferolateral wall (LCx distribution) motion abnormality, EF of 25-35% in remaining areas, and 4+ MR (increased from 2+) on [Last Name (Titles) 113] since [2160]. Pt likely had MI in past week or so leading up to admission since at presentation, troponins were elevated but trending down, CKs negative, non-evolving EKGs. During hospital course, the pt complained of "chest soreness" associated with episodes of acute pulmonary edema, but her EKGs were unchanged from baseline and her cardiac markers continued trending down so a new ischemic event is not likely. The pt was managed medically rather than invasively in light of her age and comordities; home aspirin was continued and she was started on a statin. Metoprolol was increased as tolerated instead of giving home nifedipine for increased cardiac benefit. She was not started on an ACE I during this admission due to acute renal failure but would benefit from it once her renal function stabilizes. She was also given a nicotine patch for tobacco cessation. The need for tobacco cessation was readressed at discharged. . # Acute Systolic Heart Failure (EF 25-35%) Patient likely had acute pulmonary edema due to transient stiffening of her LV vs worsening mitral regurgitation. Her respiratory status improved with lasix, nitro gtt, and oxygenation in the ED. Her nitro gtt was weaned off and hydralazine and imdur were started for afterload reduction. The pt had acute pulmonary edema several more times which was triggered by exertion and possibly elevated BP. This resolved with lasix prn. Patient was subsequently started on a standing dose of lasix 40 mg po daily . # Acute renal failure on chronic renal insufficiency: Baseline Cr 1.8-2.1. The pt noted to have decreased urine output at admission. She had urine lytes with a FeUrea of 30.5, an unremarkable UA, and urine output that was responsive to increased po fluid intake all of which suggest a prerenal etiology. This was most likely due to poor forward flow in setting of heart failure. Nephrotoxic agents, including ACE I, were avoided. However, as the patient continued to develop acute pulmonary edema, she was gently diuresed with lasix while her fluid status was closely monitored. She had a Cr of 3.5 on discharge. . # Anemia: Her Hct was stable at 29.3 on discharge. She has a baseline Hct of 33-38. The pt has a h/o BRBPR in [2148]. Her stool was guiac negative. She reports a recent outpatient colonoscopy (in past 6mos) as normal. . # Gout: The pt was on home med of allopurinol 300 mg daily for gout prophylaxis. As pt had ARF her dose was decreased to 100 mg daily. Medications on Admission: Atenolol 100mg Isosorbide 20mg daily Nifedical XL 60mg daily Allopurinol 300mg daily Prilosec Azelastine nasal spray Discharge Medications: 1. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:100 Tablet(s) Refills:2 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:2 4. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:30 Tablet Sustained Release 24 hr(s) Refills:2 5. Outpatient Lab Work For visiting nurse to draw: Please draw BUN, creatinine and CBC on [7-15] and forward results to Dr. [Last Name (STitle) 172] 6. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:30 Tablet Sustained Release 24 hr(s) Refills:2 7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 9. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 10. Azelastine Nasal Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary Diagnosis: 1. Coronary artery disease s/p Myocardial Infarction 2. Acute systolic heart failure Secondary Diagnoses: 1. Acute systolic heart failure 2. Acute pulmonary edema 3. Mitral regurgitation 4. Acute renal failure 5. Chronic renal insufficiency 6. Hypertension Discharge Condition: Stable vital signs. Ambulating with wheeled walker. Tolerating oral medication and nutrition. Discharge Instructions: You were admitted with chest pain and shortness of breath. We found evidence for a recent heart attack and adjusted your medications to optimize your heart function. 1. Please take all medications as prescribed. *Medication changes:* New medications: - Aspirin 325 mg daily - Atorvastatin 80 mg at night - Hydralazine 50 mg three times a day - Furosemide 40 mg daily Changed medications: - Isosorbide was increased to 30 mg daily - Allopurinol was decreased to 100 mg daily - Atenolol was changed to Toprol XL (metoprolol succinate) 100 mg daily Discontinued medications: - Nifedical XL 60mg daily 2. Please attend all follow-up appointments listed below. The two new doctors [First Name (Titles) ] [Last Name (Titles) 32607] in the heart and kidney disease. 3. Please call your doctor or return to the hospital if you develop chest pain, shortness of breath, palpitations, lightheadedness, fevers, or any other concerning symptom. 4. Please stop smoking. Information was given to you on admission regarding smoking cessation. 5. Please weigh yourself every day and tell Dr. [Last Name (STitle) 172] if you gain more than 3 pounds in 1 day or 6 pounds in 3 days. Please follow a low sodium diet. Information was given to you regarding heart failure, diet and exercise on discharge. Followup Instructions: 1. PCP: [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 172] [2162-7-22] at 9:30am. Please call [Telephone/Fax (1) 133] with questions. 2. Cardiology clinic: You have a follow up appointment with Dr. [Last Name (STitle) ] on Monday [7-26] at 3:20pm 3. [Hospital 10701] Clinic: Dr. [First Name4 (NamePattern1) 429] [Last Name (NamePattern1) 118] on [2162-8-3] at 11:30am in the [Hospital Ward Name 23] Center [Location (un) 436]. Please call [Telephone/Fax (1) 60] with questions. Completed by:[2162-7-21]	[ "428.21", "285.9", "403.90", "585.9", "416.0", "410.71", "428.0", "584.9", "530.81" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	12752, 12810	8431, 11417	271, 277	13131, 13227	4442, 8408	14579, 15186	3502, 3584		11584, 12729		12831, 12831		11443, 11561			13251, 13468									3599, 4423			12957, 13110																				13487, 14556		221, 233									305, 2366							12850, 12936										2388, 2984	3000, 3486
54,735	136,085	48046	Discharge summary	report	Admission Date: [2145-10-29] Discharge Date: [2145-11-8] Date of Birth: [2076-7-31] Sex: F Service: CARDIOTHORACIC Allergies: Bee stings Attending:[First Name3 (LF) 1505] Chief Complaint: Critical symptomatic aortic stenosis. Major Surgical or Invasive Procedure: Aortic Valve Replacement (21mm pericardiac valve)[10-29] History of Present Illness: The patient is a 69-year-old female with worsening symptoms related to critical aortic stenosis presenting for aortic valve replacement. Past Medical History: Aortic Stenosis, s/p Aortic Valve Replacement [2145-10-29] PMHx: Asthma, Hypertension, Anxiety, Arthritis, Vertigo, Bilateral total Knee Replacements, Tonsillectomy, Left breast biopsy, C section Social History: Patient is the primary care taker of her husband who has [Name (NI) 2481]. Patient is a retired speech and language therapist for early childhood education. -Tobacco history: 7 years 1/2ppd quit at age 23 -ETOH: None -Illicit drugs: None Family History: Mother: MI at age 53, died of CHF at age 57 Father - DM, CVA, Died at age 50 MGM - DM Physical Exam: Physical Exam: VS: T=97.4 BP=131/89 HR=130 RR=18 O2 sat=95%RA GENERAL: NAD, pleasant affect, laying comfortably in bed HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP appears to be 4cm above clavicle CARDIAC: Tachy, regular rate, [3-7] crescendo decrescendo murmur loudest over aortic window, no radiation to carotids, no carotid bruits LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Mild crackles at the bases. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Trace edema in the lower extremities. Large hematoma at R catheterization site, stable, no bruit auscultated PULSES: Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+ Pertinent Results: [2145-10-29] Intra-op TEE Conclusions PRE-BYPASS: The left atrium is dilated. 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 moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Dr. [Last Name (STitle) ] was notified in person of the results before surgical incision. Post_Bypass: Preserved biventricular systolic function. LVEF55%. The bioprosthesis in the native aortic position is stable, functioning well. No perivalvular aortic regurgitation. The residual peak gradient is 35 and mean gradient is 20mm of Hg. Intact thoracic aorta. [2145-11-8] 06:07AM BLOOD WBC-8.4 RBC-3.67* Hgb-10.6* Hct-31.5* MCV-86 MCH-28.8 MCHC-33.5 RDW-14.1 Plt Ct-280 [2145-11-7] 12:33PM BLOOD WBC-8.6 RBC-3.88* Hgb-11.1* Hct-33.3* MCV-86 MCH-28.5 MCHC-33.2 RDW-14.2 Plt Ct-292 [2145-11-8] 06:07AM BLOOD Glucose-128* UreaN-35* Creat-0.8 Na-141 K-3.4 Cl-95* HCO3-38* AnGap-11 [2145-11-7] 12:33PM BLOOD UreaN-42* Creat-0.8 Na-141 K-3.6 Cl-95* [2145-11-6] 05:38AM BLOOD Glucose-119* UreaN-51* Creat-1.0 Na-142 K-3.4 Cl-101 HCO3-34* AnGap-10 Brief Hospital Course: The patient was brought to the operating room on [2145-10-29] where the patient underwent Aortic valve replacement with 21-mm Magna Ease [Last Name (un) 3843]-[Doctor Last Name ] tissue valve. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact. She remained on milrinone for pulmonary hypertension and was diuresed wiht IV lasix. Beta blocker was initiated. Acute Kidney Injury developed and Toradol was discontinued. The patient continued to make adequate urine and Creatinine returned to baseline quickly. She developed a brief episode of post-op atrial fibrillation, which converted to Sinus Rhythm with Amiodarone and DC Cardioversion. She continued to vascilate between Sinus Rhythm and A-Fib and was started on Coumadin. Chest tubes and pacing wires were discontinued without complication. The patient was transferred to the telemetry floor for further recovery. 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, yet deconditioned. The wound was healing and pain was controlled with oral analgesics. The patient was discharged to [Doctor Last Name 11622] House Rehab in good condition with appropriate follow up instructions. She will remain on Coumadin for AFib. INR should be closely monitored and Chemistries should be repeated at the end of the week in light of her recent kidney injury. Medications on Admission: ALBUTEROL SULFATE [PROAIR HFA] 90 mcg HFA 2 qid, FLUTICASONE SALMETEROL 500 mcg-50 mcg/Dose 1 inhale [Hospital1 ], HYDROCHLOROTHIAZIDE 25 mg daily, LABETALOL 100 mg daily, LOSARTAN 100 mg daily, SERTRALINE 50 mg daily, VITAMIN D 2 TABS daily, ASPIRIN 81 mg daily, CETIRIZINE 10 mg daily, FERROUS SULFATE 325 mg daily Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for temperature >38.0. 2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 6. losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheeze. 10. sodium chloride 0.65 % Aerosol, Spray Sig: [1-3] Sprays Nasal [Hospital1 ] (2 times a day) as needed for nasal dryness. 11. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 12. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 13. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheeze. 14. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 16. hydralazine 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours). 17. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days: re-assess need for ongoing diuresis following 1 week course. 18. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. Outpatient Lab Work - Chem 7 on [2145-11-12] - PT/INR, Coumadin for AFib Goal INR 2-2.5 First draw [2145-11-9], Then please do INR checks Monday, Wednesday, and Friday for 2 weeks then decrease as directed by MD 20. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO DAILY (Daily) as needed for constipation. 21. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 22. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. Disp:20 Tablet(s) Refills:0 23. diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for itching. 24. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: MD to dose daily for goal INR 2-2.5, dx: afib. 25. potassium chloride 20 mEq Packet Sig: One (1) Packet PO twice a day for 1 weeks. Discharge Disposition: Extended Care Facility: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] at [Doctor Last Name 5749] [Doctor Last Name ] Village - [Location (un) ] Discharge Diagnosis: Aortic Stenosis, s/p Aortic Valve Replacement [2145-10-29] PMHx: Asthma, Hypertension, Anxiety, Arthritis, Vertigo, Bilateral total Knee Replacements, Tonsillectomy, Left breast biopsy, C section Discharge Condition: Alert and oriented x3 nonfocal Ambulating, deconditioned Incisional pain managed with Ultram Incisions: Sternal - healing well, no erythema or drainage Edema 1+ Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] 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: Provider: [Name10 (NameIs) ] [Name8 (MD) 6144], MD Phone:[Telephone/Fax (1) 170] Date/Time:[2145-12-8] 1:00 Cardiologist: Dr [First Name4 (NamePattern1) 122] [Last Name (NamePattern1) ], [12-9] at 10:00am Please call to schedule appointments with your Primary Care Dr [Last Name (STitle) ],[First Name3 (LF) ] K. [Telephone/Fax (1) 2205] in [4-6] weeks Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours PT/INR, Coumadin for AFib Goal INR 2-2.5 First draw [2145-11-9], Then please do INR checks Monday, Wednesday, and Friday for 2 weeks then decrease as directed by MD Completed by:[2145-11-8]	[ "997.5", "300.00", "V15.82", "V43.65", "285.9", "428.32", "278.00", "V85.41", "584.9", "424.0", "428.0", "997.1", "401.9", "493.90", "416.8", "E878.2", "427.31" ]	icd9cm	[ [ [] ] ]	[ "35.21", "39.61", "99.61" ]	icd9pcs	[ [ [] ] ]	8541, 8719	3922, 5588	317, 380	8963, 9126	2141, 3899	10050, 10871	1046, 1133		5959, 8518		8740, 8942		5614, 5936			9150, 10027									1163, 2122																									239, 279									408, 547																	569, 771	787, 1030
923	190,712	44627	Discharge summary	report	Admission Date: [2137-7-19] Discharge Date: [2137-7-25] Date of Birth: [2088-4-13] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5790] Chief Complaint: 48M Left upper lobe lung nodule Stage IIIa Non small cell lung cancer, s/p chemo/radiation therapy Major Surgical or Invasive Procedure: [7-19] bronchoscopy, Video assisted thoracoscopy Left upper lobectomy c/b Left pulmonary artery laceration converted to anterior thoracotomy, 1L EBL, EKG changes. History of Present Illness: 49-year-old gentleman who was found to have a left upper lobe non-small cell lung cancer and a positive level 5 lymph node. For this, he underwent induction chemoradiotherapy and his re-staging CT scans showed an improvement in the size of the primary mass and the nodal metastases. Past Medical History: Hypertension, Diabetes Mellitus 2, Hyperlipidemia, Coronary artery disease s/p CABG [1-25], Stage IIIa non small-cell lung CA left upper lobe, low back pain, mult. herniated disks s/p chemotherapy and radiation therapy Social History: From prior note. Lives in [Location 86] with his wife. [Name (NI) ] three children. Prior tobacco abuse of [2-22] ppd x 34 years; currently smoking one to [1-21] pack cigarettes/day. Originally from [Country ] [Country ], moved to US in [2122]. Previously worked at a paper recycling factory but stopped approximately 10 years ago after a work related injury. Denies etoh and recreational drug use. Family History: not elicited Pertinent Results: Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2137-7-22] 12:46AM 5.3 3.03* 9.8* 27.6* 91 32.5* 35.7* 20.2* 153 BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT) [2137-7-22] 12:46AM 153 [2137-7-22] 12:46AM 12.6 24.6 1.1 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [2137-7-22] 12:46AM 115* 11 0.7 137 4.1 98 33* 10 ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili IndBili [2137-7-22] 12:46AM 47* 78* 1066* 56 1.9* 0.9* 1.0 CPK ISOENZYMES CK-MB MB Indx cTropnT [2137-7-22] 12:46AM 14* 1.3 0.731 1 CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [2137-7-22] 12:46AM 9.4 2.9 1.8 Brief Hospital Course: 48M LUL Stage IIIa NSCLC, s/p chemo/XRT admitted same day on [7-19] for bronchoscopy, mediastinoscopy, LUL lobectomy by VATS converted to anterior thoracotomy due to tear in superior branch of pulmonary artery. Patient transfused w/ 2UPRBC intra-op, stabilized, tolerated procedure, transferred to PACU extubated, CT to suction, on Neo gtt. Post-op EKG> changes>NSTEMI. CPK/MB--1066/14, T=.73. Started on B- blocker post-op. POD#1<[2137-7-20]>- Bronchoscopy for moderate secretions POD#3 <[2137-7-22]>- rhonchi, minimal CT output (50/10/5), CT placed to waterseal, and left CT(#2) d/c in afternoon. CXRY w/ small hydropneumothorax. Pt transferred to floor. Loperssor increased 75mg [Hospital1 ], diuresed w/ lasix 20 mg IV. Clear liqs started. POD#[4-24] decreased drainage from blakes -blakes d/c'd. CXR stable. [Last Name (un) 1815] po pain med. POD#6- Patient stable, tolerating po pain rx, moved bowels prior to d/c. Pt discharged in stable condition late in afternoon in company of son to home. Discharge instructions given and reviewed w/ patient and [Name6 (MD) ] by RN. Medications on Admission: Nexium 40', atenolol 100", ECASA 81', actos 30', gemfibrozil 600', cxycontin 20'';perc 2q4h Discharge Medications: 1. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 2. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day): DO NOT TAKE YOUR ATENOLOL WHILE TAKING THIS MEDICATION. Disp:180 Tablet(s)* Refills:2 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 7. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). Disp:90 Tablet(s) Refills:2 8. Oxycodone 20 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO Q8H (every 8 hours) as needed for pain. Disp:60 Tablet Sustained Release 12HR(s) Refills:0 9. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for breakthrough pain. Disp:60 Tablet(s) Refills:0 10. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for increaased/thickened sputum. 11. Actos 30 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: PMH: Hypertension, Diabetes Mellitus 2, Hyperlipidemia, Coronary artery disease s/p CABG [1-25], Stage IIIa non small-cell lung CA left upper lobe, low back pain, mult. herniated disks s/p chemotherapy and radiation therapy Discharge Condition: good Discharge Instructions: Call Dr.[Name (NI) 2347]/Thoracic Surgery office [Telephone/Fax (1) 170] for: fever, shortness of breath, chest pain, excessive foul smelling drainage from incision sites. Take previous medications as stated on discharge instructions. Take new medications as directed and as needed. You may shower on friday. Remove CT dressing after showering and change daily as needed w/ bandaid or guaze. No tub baths or swimming for 3-4 weeks. Followup Instructions: Call Dr.[Name (NI) 2347]/Thoracic Surgery office [Telephone/Fax (1) 170] for a follow-up appointment. Completed by:[2137-7-29]	[ "997.3", "414.00", "518.0", "V45.81", "401.9", "272.4", "250.00", "998.2", "162.3" ]	icd9cm	[ [ [] ] ]	[ "39.31", "34.22", "32.4", "96.05", "33.22", "40.11" ]	icd9pcs	[ [ [] ] ]	4952, 4958	2463, 3577	421, 590	5230, 5237	1644, 2440	5725, 5867	1610, 1625		3719, 4929		4979, 5209		3603, 3696			5261, 5702																																		282, 382									618, 903																	925, 1149	1165, 1594
60,994	174,197	40999	Discharge summary	report	Admission Date: [2119-7-13] Discharge Date: [2119-7-22] Date of Birth: [2055-4-10] Sex: M Service: CARDIOTHORACIC Allergies: Beta-Blockers (Beta-Adrenergic Blocking Agts) / Alpha 2 Adrenergic Agonist Attending:[First Name3 (LF) 1406] Chief Complaint: New onset throat pain with shortness of breath Major Surgical or Invasive Procedure: [2119-7-17] Coronary artery bypass graft x 4 (left internal mammary artery > left anterior descending, saphenous vein graft > obtuse marginal 1, saphenous vein graft > obtuse marginal 2, saphenous vein graft > posterior descending artery) History of Present Illness: 64 year old male seen by PCP for routine [Name9 (PRE) 16574] and mentioned that he was having throat pain for over a period of a week. He evaluated by cardiology and given his cardiac risk factors he was admitted to the hospital and underwent cardiac catheterization which revealed significant CAD with 60% LM. He was therefore transferred to [Hospital1 18] for surgical evaluation. Past Medical History: HTN dyslipidemia severe RA anxiety disorder chronic back pain muscular dystrophy COPD glaucoma bil cataracts retinal detachment left eye with vision loss BPH R knee replacement x2 left knee replacement x1 left nephrectomy in his 20's 2nd to trauma exp laprascopic abd surgery ventral surgery [Last Name (un) ] inguinal surgery vasectomy bilateral rotator cuff repairs Social History: Lives with:wife Occupation:Disabled Tobacco:smokes 1ppd x 40 yrs ETOH:none Family History: + CAD Physical Exam: Pulse:70's Resp: [11-22] O2 sat: 98% B/P Right:131/96 Left: 140/94 Height:6ft Weight:250lbs General: Skin: Dry [] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [] Neuro: Grossly intact Pulses: Femoral Right:trace Left:Trace DP Right: Trace Left:Trace PT [Name (NI) 167]: Trace Left:Trace Radial Right: +2 Left:+2 Carotid Bruit Right: none Left:None Pertinent Results: [2119-7-13] 03:10PM BLOOD WBC-6.5 RBC-5.03 Hgb-15.5 Hct-44.2 MCV-88 MCH-30.8 MCHC-35.0 RDW-14.7 Plt Ct-243 [2119-7-13] 03:10PM BLOOD PT-11.5 PTT-22.9 INR(PT)-1.0 [2119-7-13] 03:10PM BLOOD Plt Ct-243 [2119-7-13] 03:10PM BLOOD Glucose-91 UreaN-17 Creat-1.4* Na-141 K-4.8 Cl-103 HCO3-30 AnGap-13 [2119-7-13] 03:10PM BLOOD ALT-33 AST-24 LD(LDH)-202 AlkPhos-72 Amylase-56 TotBili-0.3 [2119-7-13] 03:10PM BLOOD Albumin-4.7 [2119-7-18] 01:16AM BLOOD Calcium-8.2* Phos-3.7 Mg-2.1 [2119-7-13] 03:10PM BLOOD %HbA1c-6.3* eAG-134* Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 3.5 cm <= 4.0 cm Right Atrium - Four Chamber Length: 5.0 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 5.4 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 55% to 60% >= 55% Left Ventricle - Lateral Peak E': 0.11 m/s > 0.08 m/s Left Ventricle - Septal Peak E': 0.07 m/s > 0.08 m/s Left Ventricle - Ratio E/E': 4 < 15 Aorta - Sinus Level: 4.6 cm <= 3.6 cm Aorta - Ascending: 4.3 cm <= 3.4 cm Aorta - Arch: 3.4 cm <= 3.0 cm Aortic Valve - Peak Velocity: 1.3 m/sec <= 2.0 m/sec Aortic Valve - LVOT diam: 2.2 cm Mitral Valve - E Wave: 0.4 m/sec Mitral Valve - A Wave: 0.6 m/sec Mitral Valve - E/A ratio: 0.67 Mitral Valve - E Wave deceleration time: 260 ms 140-250 ms TR Gradient (+ RA = PASP): <= 25 mm Hg <= 25 mm Hg Findings LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic function (LVEF>55%). Suboptimal technical quality, a focal LV wall motion abnorality cannot be fully excluded. No resting LVOT gradient. No VSD. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Moderately dilated aorta at sinus level. Mildly dilated ascending aorta. Mildly dilated aortic arch. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No MS. Trivial MR. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No TS. Physiologic TR. Normal PA systolic pressure. GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal image quality as the patient was difficult to position. Suboptimal image quality - patient unable to cooperate. Conclusions The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is moderately 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. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. Brief Hospital Course: Transferred in from outside hospital for surgical evaluation. Underwent preoperative work up and on [7-17] was brought to the operating room for coronary artery bypass graft surgery. See operative report for further details. He received cefazolin and vancomycin for perioperative antibiotics and was transferred to the intensive care unit for post operative management. That evening he was weaned off sedation, awoke neurologically intact and was extubated without complications. On post operative day one he was started on betablockers and diuretics. Additionally he was transferred to the floor. Chest tubes and epicardial wires were removed per protocol. Physical therapy worked with him on strength and mobility however his chronic back pain was a limiting factor. He also had pulmonary congestion which was treated with nebs, CPT and pulmonary hygiene. He was maintained on on his home dose of vicodin and ativan. He continued to progress and was ready for discharge to rehab at [Hospital 100] rehab on post operative day #5. Medications on Admission: Ativan 2mg tid crestor 10mg daily lisinopril 10mg [Hospital1 ] hydrocodone tid cyclobenzaprine 10mg tid asprin 325mg daily MVI daily fish oil daily [Doctor First Name 130] daily Discharge Medications: 1. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 2. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 3. rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 5. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever, pain. 7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. lorazepam 1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for anxiety. Disp:45 Tablet(s)* Refills:0 10. diltiazem HCl 180 mg Capsule, Extended Release Sig: Two (2) Capsule, Extended Release PO DAILY (Daily). 11. hydrocodone-acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:75 Tablet(s) Refills:0 12. Lasix 40 mg Tablet Sig: Two (2) Tablet PO three times a day for 10 days. Tablet(s) 13. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO Q12H (every 12 hours) for 10 days. 14. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours). 15. acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) neb Miscellaneous Q6H (every 6 hours). Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Coronary artery disease s/p CABG Hypertension dyslipidemia Anxiety Rheumatoid arthritis chronic back pain muscular dystrophy Chronic obstructive pulmonary disease Glaucoma Bilateral cataracts retinal detachment left eye with vision loss Benign prostatic hypertrophy Left nephrectomy ventral hernia inguinal hernia 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 Leg Left - healing well, no erythema or drainage. Edema 1+ Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon: Dr [Last Name (STitle) ] on [8-9] at 1:15pm in the [Hospital ] medical office building [Hospital Unit Name ] [Telephone/Fax (1) 10651] Cardiologist: Dr [Last Name (STitle) 4922] on [8-28] at 9:45am Please call to schedule appointments with your Primary Care Dr [Last Name (STitle) 89437] in [5-16] 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 Completed by:[2119-7-22]	[ "V43.65", "365.9", "714.0", "305.1", "359.1", "300.00", "600.00", "414.01", "366.9", "496", "338.29", "724.5", "V45.73", "272.4", "401.9" ]	icd9cm	[ [ [] ] ]	[ "36.15", "36.13", "39.61" ]	icd9pcs	[ [ [] ] ]	8488, 8554	5679, 6724	389, 634	8912, 9136	2248, 5656	9977, 10570	1560, 1568		6961, 8465		8575, 8891		6750, 6938			9160, 9954									1583, 2229																									302, 351									662, 1056																	1078, 1451	1467, 1544
25,916	153,916	25025	Discharge summary	report	Admission Date: [2119-3-13] Discharge Date: [2119-3-22] Date of Birth: [2069-4-7] Sex: M Service: Liver Transplant Surgery Service ADMISSION DIAGNOSIS: Hepatitis C cirrhosis. HISTORY OF PRESENT ILLNESS: The patient is a 49 year-old man with hepatitis C cirrhosis complicated by encephalopathy, positive esophageal varices, now with worsening confusion and lethargy. The patient has been admitted 5 x in the past to [Hospital1 18] since [11-12] for encephalopathy. Most recently admitted on [2119-3-1] to [2119-3-4]. Infectious work-up was negative. Trazodone stopped. Patient was started on Lactulose and Rifaximine which improved his mental status. Today, on [2119-2-13], the patient was seen in clinic with increased lethargy, confusion. Wife reports that the patient has a history of lethargy and confusion, similar to the symptoms for which the patient was recently admitted. The patient also reports that he has had "yellowish eyes, some shaking and his breath smelled more like ammonia over the past 3 days." The patient has been compliant with his medications. He has had one bowel movement today which is on [2119-3-13]. He has had night sweats for the past 2 weeks. He denies any abdominal pain. He gets cold easily but denies fevers. His stools have been brown to green. PAST MEDICAL HISTORY: HCV cirrhosis. Underwent treatment with Interferon 10 years ago. He stopped secondary to aggressive behavior. History of hepatic encephalopathy. Esophageal varices. EGD on [2118-11-20] demonstrated 5 cores of varices, grade 1 to 2 at the lower third of the esophagus. Four bands were placed without difficulty. Also, the patient has a past medical history of hypertension, glucose intolerance, peripheral neuropathy. The patient was taken off of Neurontin because it started to worsen his mental status. MEDICATIONS ON ADMISSION: Nadolol 20 mg q. Day. Protonix 20 mg q. 24 hours. Osamine 200 mg t.i.d. Lactulose 30 mg q.i.d. Lasix 40 mg q. Day. Insulin regular. Amlodipine 5 mg q. Day. Retazepine 50 mg q h.s. Testosterone 4 mg q. 24 hours. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient is married and lives with his wife. Previously employed as a security guard at a nuclear power plant. Quit tobacco 20 years ago and currently denies any cigarette. Alcohol: No alcohol use. The patient contracted HCV 20 years ago secondary to IV drug use. FAMILY HISTORY: Father died of metastatic colon cancer. Mother died of end stage renal disease. PHYSICAL EXAMINATION: Vital signs were stable. Weight was 122.5. General: Patient is in no acute distress. Lethargic, occasionally falling asleep. HEENT: Pupils equal, round and reactive to light. Sclera mildly icteric. Neck: No LAD. Lungs clear to auscultation bilaterally. CV: Regular rate and rhythm. Normal S1 and S2 without murmurs or rubs. Positive gynecomastia. Abdomen: Positive bowel sounds, soft, nondistended, nontender. Obvious ascites. 1+ edema bilaterally. Neurologic: Awake, alert and oriented x3. Cranial nerves 2 through 12 intact. There was mild asterixis. HOSPITAL COURSE: The patient was admitted. Patient continued on Lactulose. The goal was 3 to 4 stools per day. Continue on Rifaximine. Continue Lasix. Physical therapy was consulted on [2119-3-14]. On [2119-3-15], the patient was awake, alert and oriented, taking Lactulose. Difficulty with word finding at times. Denies any pain or discomfort. Abdomen: Slightly distended, nontender. Positive bowel sounds. Positive flatus. Good op site. Ultrasound was performed on [2119-3-14] demonstrating severe portal hypertension with massive peri splenic varices and splenorenal shunt. Portal vein was fully patent. Repeat hepato fungal flare. On [2119-3-17], the transplant service was consulted because the patient was possibly going to the operating room for transplant on [2119-3-17]. The patient did go to operating room on [2119-3-17] and the patient had cadaveric liver transplant performed by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 816]. Please see detailed operative note for more information about the procedure. Postoperatively, the patient was transferred to the ICU. The patient received MMF 1 gram b.i.d., Flagyl 500 mg IV x1. The patient also received Unasyn for 2 days, Fluconazole, heparin, Protonix, insulin, morphine, Bactrim. The patient was on Propofol for 2 days. LABORATORY DATA: On [2119-3-17], labs were as follows: WBC of 8.3; hematocrit of 30.6; platelets 69; sodium 132; 3.9, 102, 22, serum creatinine of 13 and 1.1. Glucose 114. AST 87. ALT 44. Alkaline phosphatase 169. PT of 20.6. PTT of 38.7. INR of 2.0. On postoperative day number 1, duplex ultrasound of the patient's liver was performed demonstrating normal appearing portal veins and hepatic arteries. There was normal flow within the middle hepatic vein. There appears to be a decreased and sluggish flow within the right and left hepatic veins with loss of normal respiratory variations, wave forms and the intrahepatic portion. Additionally, there is diminished color flow with confluence of the hepatic veins. These findings may reflect thrombus within the left and right hepatic veins. Caval narrowing is seen, most likely correlation to clinical history is recommended and further evaluation of the CT or short-term ultrasounds for follow-up was recommended. The [Initials (NamePattern4) 228] [Last Name (NamePattern4) 1661]-[Location (un) 1662] drain on postoperative day number demonstrated medial output of 780 with lateral output of 150. Patient went to the floor and patient was on the floor on [2119-3-20]. Patient continued getting Acyclovir, Prednisone, MMF one gram b.i.d. The patient was on FK 2 and 2 that was started on postoperative day number 2. Diet was advanced. Patient was ambulating. [Location (un) 1661]-[Location (un) 1662] drains put out on the 13th 620 and 380. Physical therapy was re consulted. [Last Name (un) ] was consulted on [2119-3-21] for better glucose control since the patient was on steroids. Social work was consulted. Patient continued to do very well, ambulating, following the diet. Patient was transfused 1 unit of platelets on [2119-3-21] for platelet count of 66. A heparin independent antibody was sent off on [2119-3-20] which was unremarkable. On [2119-3-22], patient continued to do very well, ambulating, tolerating a diet, urinating without difficulty. Drains continued to put out significant amount of fluid. Patient's labs from [2119-3-23] were the following: 7.1, hematocrit of 30.8, platelets 90. Sodium of 138; potassium 3.5; 106, 28, 31, 1.0, glucose 134. AST 82. ALT 176. Alkaline phosphatase 78 which all have significantly decreased since postoperative day number 1. Total bilirubin was 0.9. On [2119-3-22], FK level was 10.3. Patient left on [2119-3-22] with VNA to home. DISCHARGE MEDICATIONS: Protonix 40 mg q. 24. Moltipine 5 mg q. Day. Fluconazole 400 mg q. 24 hours. Prednisone 20 mg q. Day. MMF 1000 mg b.i.d.. Lopressor 50 m b.i.d. Percocet 1 to 2 tabs q. 4 to 6 hours prn. Colace 100 mg b.i.d. Bactrim SS 1 tab q. Day. Tacrolimus 3 mg b.i.d. Lasix 20 mg b.i.d. Valcyte 900 mg q. Day. Patient is on insulin sliding scale with fixed dose. FOLLOW UP: The patient is to follow-up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 816] on the following dates: [2119-3-27] at 9 a.m., [2119-4-6] at 10:20 a.m. and [2119-4-13] at 10:20 a.m. If the patient can not make those appointments or has any questions about the appointments, please call [Telephone/Fax (1) 673]. The patient is to call [Telephone/Fax (1) 673] if any fevers, chills, nausea and vomiting, abdominal pain, inability to take medications, inability to eat or drink. Patient needs to have labs every Monday and Thursday including a CBC, chem-10, AST, ALT, alkaline phosphatase, albumin, total bilirubin and Prograf level need to be obtained. Please fax results to [Telephone/Fax (1) 697]. All cultures have been unremarkable. Cultures were obtained on [2119-3-13]. Urine culture and blood culture have been unremarkable on [2119-3-16]. Hepatitis viral load was 76,500. Pathology demonstrates that the pathology results of the liver were not finalized. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], MD,PHD[MD Number(3) ] Dictated By:[Last Name (NamePattern1) 4835] MEDQUIST36 D: [2119-3-24] 14:30:39 T: [2119-3-24] 15:05:40 Job#: [Job Number 62835]	[ "572.2", "572.3", "789.5", "571.5", "070.70", "401.9" ]	icd9cm	[ [ [] ] ]	[ "00.93", "50.59" ]	icd9pcs	[ [ [] ] ]							2473, 2554		7044, 7405				1909, 2167	3166, 7020																					7417, 8711					2577, 3148	186, 210																		239, 1347																	1370, 1882	2184, 2456
2,784	101,477	26782	Discharge summary	report	Admission Date: [2173-10-4] Discharge Date: [2173-10-6] Date of Birth: [2104-4-12] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 99] Chief Complaint: observation following bronchoscopy Major Surgical or Invasive Procedure: fiberoptic bronchoscopy History of Present Illness: Ms. [Known lastname ] is a 69 year old Cambodian woman with a history of cardioresp arrest secondary neck mass (thyroid ca) - resected, c/b tracheal stenosis - tracheostomy which stenosed - was changed to a T tube 3 weeks ago - presented today from rehab hospital for f/u bronch. The patient's history dates back to [2173-3-10] when she was found unresponsive at home. She recovered and was found to have papillary thyroid cancer, and in [Month (only) 958] her cancer had an extensive resection involving a sternotomy. Subsequently, her course was complicated by subglotic edema, requiring a trach, and multiple vent-acquired PNA's. Most recently, for progessive tracheal stenosis, she was changed to a t-tube about three weeks ago. Of note, she has also had several episodes of respiratory arrest thought due to mucus plugging and respiratory compromise at [Hospital1 18] and rehab. Today, she presented to IP for a followup bronchoscopy. Following sedation after initiation of the bronch, the patient desaturated and developed resp. arrest. After some manual ventilation she was resuscitated but she has had frequent ectopy (PVC's) on the cardiac monitor (this was also noted following her cardiac arrest in [Month (only) 205]). The IP team requested that she be admitted to the MICU for observation given the respiratory arrest and the frequent ectopy. Past Medical History: 1. Mult episodes of cardiac and respiratory arrest prompting inpatient hospitalizations here [4-12] and [9-12]; most recently s/p VAP with respiratory difficulties and Cardiac arrest [9-2] at OSH 2. thyroid cancer dx in [3-/2173]- Papillary cancer with positive nodes status post sternotomy and partial right and total left 3. thyroidectomy on [2173-4-12]. 3. IDDM 4. HTN 5. Hiatal hernia 6. B12 defic 7. B cell lymphoma-s/p chemo 8. h/o acinetobacter and enterobacter pneumonias at [Hospital1 18] [4-12] 9. a flutter 10. tracheomalacia, subglottic stenosis, and infra and superior glottic swelling seen on bronch [8-/2173] Social History: The pt has six children living in the area, 2 children living in [Country ]. She is from [Country ] and speaks Cantonese. She understands some English. Apparently she was independent with mobility and basic ADL prior to her last hospitalization. Her functional capacity recently has been the need for maximal assistance to total dependency in most areas Family History: Noncontributory Physical Exam: VS: T 98.6 HR 67 BP 100/57 RR 13 Sat 100% 4L trach collar GEN: Pleasant woman in bed in no apparent distress. HEENT: MMM, sclerae anicteric, NC/AT. NECK: T-tube in trach, JVP no elevated COR: Normal s1/s2, RRR, no m/r/g appreciated PULM: Scattered rhonchi ABD: Soft, NT, ND +BS. +Gtube EXT: No edema, FROM NEURO: Awake, alert. Pertinent Results: [2173-10-4] 12:49PM GLUCOSE-128* UREA N-14 CREAT-0.8 SODIUM-133 POTASSIUM-6.6* CHLORIDE-101 TOTAL CO2-23 ANION GAP-16 [2173-10-4] 12:49PM TSH-13* [2173-10-4] 12:49PM FREE T4-1.4 [2173-10-4] 12:49PM WBC-4.3 RBC-3.95* HGB-12.2# HCT-35.2# MCV-89 MCH-30.8 MCHC-34.6 RDW-15.3 [2173-10-4] 12:28PM TYPE-ART PO2-44 PCO2-47* PH-7.34* TOTAL CO2-26 BASE XS-0 [2173-10-4] 12:28PM K+-5.2 Brief Hospital Course: 69 year old woman with history of papillary thyroid ca s/p resection, complicated by tracheal stenosis. Here today for elective bronch complicated by respiratory arrest. 1) For her respiratory failure, the patient s/p respiratory arrest after bronch, s/p t-tube for tracheomalacia. The most likely etiology was a combination of over-sedation and mucus plugging. On arrival to the MICU the patient was satting very well on trach collar and was comfortable. 2) For her frequent ectopy, s/p respiratory arrest during the bronch. It is unclear how much ectopy she had prior to the bronch, but according to old [Hospital1 18] records, she had this during her previous hospitalizations. She responds very well to her beta-blockade. Her LDL was 73 and HDL was 66 so a statin was not started. 3) For f/en, the pt has a history of aspiration, with a g-tube in place. She did past a speech & swalllow eval during her previous admit. Her most recent diet here was diabetic/Consistent carbohydrate, consistency: Ground; w/ Nectar prethickened liquids with aspiration precautions and this was continued. 4) Endocrine: h/o DM, h/o thyroid resection, cont RISS and thyroid hormone replacement 5) Code is full 6) Communication is with her daughter, [Name (NI) ] [Name (NI) ] [Telephone/Fax (1) 65849], pt also understands some english 7) Access: PIVS 8) Disposition: to [Hospital ] Rehab. Medications on Admission: 1. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Docusate Sodium 150 mg/15 mL Liquid Sig: Seven (7) ml PO BID (2 times a day). 3. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) PO DAILY (Daily). 4. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 5. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 6. Calcium Carbonate 500 mg Tablet, Chewable Sig: 2.5 Tablet, Chewables PO BID (2 times a day). 7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): last dose [2173-9-27]. 10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 11. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [Hospital1 ] (2 times a day). 13. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day) as needed for secretions. 14. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 15. Acetylcysteine 20 % (200 mg/mL) Solution Sig: Three (3) ml Miscell. [Hospital1 ] (2 times a day). 16. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours): last dose [2173-9-27]. 17. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 5 days: last dose [2173-9-28]. 18. regular insulin per sliding scale finger sticks. 19. T-Tube cap cap T-Tube during day and uncap at noc and provide humidified oxygen 20. NPH insulin 20 units NPH Sq qam and 17 units NPH Sq qpm 21. Decadron 0.5 mg Tablet Sig: Two (2) Tablet PO twice a day for 7 days: then decrease to 0.5mg x 7days then d/c Discharge Medications: 1. Guaifenesin 600 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO BID (2 times a day). 2. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day) as needed. 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 5. Calcium Carbonate 1,250 mg (500 mg) Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 10. Insulin Regular Human 100 unit/mL Solution Sig: Sliding Scale Injection ASDIR (AS DIRECTED). 11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 12. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty (30) mg PO once a day. Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Respiratory failure s/p bronchoscopy Discharge Condition: Stable Discharge Instructions: Please seek medical attention for fevers > 101.4, or for anything else concerning. Followup Instructions: Provider: [Last Name (NamePattern4) ]. [Last Name (STitle) 12647] [Name (STitle) ] Phone:[Telephone/Fax (1) 1803] Date/Time:[2173-10-15] 2:30 (Endocrinology)	[ "933.1", "518.81", "V10.87", "530.81", "427.89", "401.9", "553.3", "E912", "V10.79", "244.1", "519.02", "250.00", "V58.67", "997.3", "519.1", "478.6" ]	icd9cm	[ [ [] ] ]	[ "33.24" ]	icd9pcs	[ [ [] ] ]	8132, 8211	3673, 5081	348, 373	8291, 8299	3236, 3650	8430, 8611	2856, 2873		7037, 8109		8232, 8270		5107, 7014			8323, 8407									2888, 3217																									274, 310									401, 1780																	1802, 2461	2477, 2840
17,882	151,927	8868	Discharge summary	report	Admission Date: [2148-1-15] Discharge Date: [2148-1-22] Date of Birth: [2083-2-4] Sex: M Service: MEDICINE Allergies: Percocet Attending:[First Name3 (LF) 5606] Chief Complaint: Shortness of breath, fever Major Surgical or Invasive Procedure: none History of Present Illness: 64M with COPD on 4L NC home O2, bipap at night, nebs prior to meals, OSA, pHTN, HTN, HLD, DM, and PVD presents from nursing home with SOB x 3 days and fever to 101F. S/P R-BKA 1 month ago, had been at rehab x3 weeks then d/c'ed to nursing home 5 days prior to admission. He developed SOB and anxiety 3 days ago and was febrile overnight to 101. Of note, he has a tenuous respiratory status at baseline with minimum 4L NC baseline requirment and need for BiPAP at night and with nebulized treatments before eating. . In the ED, initial VS were: 99.2 90 151/65 26 100% 6L nc CXR showed evidence of LLL or possible bibasilar opacities concerning for pneumonia, and was febrile to 101. The patient also became anxious and dyspneic, and desaturated to 74% on 6L NC. He was started on bipap and given Vancomycin, Levofloxacin, and Methylprednisolone as well as duo-nebs. He was admitted to the MICU for further management. . Labs significant for WBC 17.1, Hgb 9.3, Plt 317 with diff N 91 %. Chemistry panel significant for Na 134, K 4, Cl 83, HCO3 44 (HCO3 usually mid 30s), BUN 43, Cr 1.5 (baseline 1.4-1.6) Glc 239. . Coags significant for INR 4.5, PTT 36.9. . UA significant for cloudy appearance with large leukocytes, WBC > 182, RBC > 182, many bacteria, and no epis . Most recent vitals: 99.6 86 143/77 100% on 10L via bipap. . On arrival to the MICU, the patient appeared somulent not responding initially till provocated repeatedly. He was able to follow command. ABG was performed noting: 7.45/70/56 on 6L bipap 12/8. . 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: Past Medical History (per [First Name3 (LF) ]): Appendiceal abscess in [2140] treated with IR drain, recurrent appendicitis Insulin-dependent Diabetes Mellitus COPD Peripheral vascular disease Right fem-[Doctor Last Name ] bypass graft x 2 ([2115]'s) CVA ([2-/2139]) - mild dysarthria/mild left facial weakness Hepatomagaly Pulmonary hypertension History of DVT GERD Hypercholesterolemia Hypertension Obstructive Sleep Apnea Osteoporosis Depression Social History: -Tobacco history: Former smoker, quit 8-10 years ago. -ETOH: 2-3 beers/day. -Illicit drugs: None. Family History: Mother with lung carcinoma. No family history of heart disease, HTN, or DM. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 97.2 HR80 BP144/65 RR24 Sat 95% on bipap General: solument, follow command HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: poor breath sounds, but no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, distented, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: s/p right bka, warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [2148-1-18] 08:00AM BLOOD WBC-11.2* RBC-3.31* Hgb-10.1* Hct-29.4* MCV-89 MCH-30.6 MCHC-34.5 RDW-12.8 Plt Ct-382 [2148-1-17] 04:16AM BLOOD WBC-16.4* RBC-3.34* Hgb-9.9* Hct-29.5* MCV-88 MCH-29.7 MCHC-33.8 RDW-12.8 Plt Ct-392 [2148-1-16] 03:30AM BLOOD WBC-13.7* RBC-3.25* Hgb-9.9* Hct-29.4* MCV-90 MCH-30.4 MCHC-33.7 RDW-12.6 Plt Ct-337 [2148-1-15] 04:47PM BLOOD WBC-15.5* RBC-3.22* Hgb-9.8* Hct-28.9* MCV-90 MCH-30.5 MCHC-34.0 RDW-13.0 Plt Ct-304 [2148-1-15] 10:30AM BLOOD WBC-17.1# RBC-3.16# Hgb-9.3* Hct-28.3* MCV-90 MCH-29.5 MCHC-32.9 RDW-12.6 Plt Ct-317 [2148-1-17] 04:16AM BLOOD Neuts-85.7* Lymphs-6.9* Monos-7.1 Eos-0.2 Baso-0.1 [2148-1-18] 08:00AM BLOOD Plt Ct-382 [2148-1-18] 08:00AM BLOOD PT-16.8* PTT-25.3 INR(PT)-1.6* [2148-1-17] 04:16AM BLOOD Plt Ct-392 [2148-1-17] 04:16AM BLOOD PT-31.5* PTT-30.4 INR(PT)-3.1* [2148-1-16] 03:30AM BLOOD Plt Ct-337 [2148-1-16] 03:30AM BLOOD PT-54.6* PTT-38.7* INR(PT)-5.4* [2148-1-15] 04:47PM BLOOD Plt Ct-304 [2148-1-15] 04:47PM BLOOD PT-52.1* PTT-41.4* INR(PT)-5.2* [2148-1-15] 10:30AM BLOOD Plt Ct-317 [2148-1-15] 10:30AM BLOOD PT-45.5* PTT-36.9* INR(PT)-4.5* [2148-1-18] 08:00AM BLOOD Glucose-320* UreaN-37* Creat-1.2 Na-135 K-4.3 Cl-87* HCO3-41* AnGap-11 [2148-1-17] 04:16AM BLOOD Glucose-198* UreaN-42* Creat-1.3* Na-138 K-3.3 Cl-88* HCO3-43* AnGap-10 [2148-1-16] 03:30AM BLOOD Glucose-282* UreaN-46* Creat-1.4* Na-138 K-4.1 Cl-88* HCO3-42* AnGap-12 [2148-1-15] 04:47PM BLOOD Glucose-292* UreaN-43* Creat-1.4* Na-135 K-4.3 Cl-84* HCO3-42* AnGap-13 [2148-1-15] 10:30AM BLOOD Glucose-239* UreaN-43* Creat-1.5* Na-134 K-4.0 Cl-83* HCO3-44* AnGap-11 [2148-1-18] 08:00AM BLOOD ALT-64* AST-29 AlkPhos-128 TotBili-0.2 [2148-1-17] 04:16AM BLOOD ALT-65* AST-32 AlkPhos-145* TotBili-0.2 [2148-1-16] 03:30AM BLOOD ALT-91* AST-47* CK(CPK)-105 AlkPhos-179* TotBili-0.2 [2148-1-18] 08:00AM BLOOD Calcium-9.5 Phos-3.3 Mg-2.2 Iron-96 [2148-1-17] 04:16AM BLOOD Albumin-3.3* Calcium-9.2 Phos-2.4* Mg-2.3 [2148-1-16] 03:30AM BLOOD Calcium-9.3 Phos-2.7 Mg-2.3 [2148-1-15] 04:47PM BLOOD Calcium-9.5 Phos-3.3 Mg-2.1 [2148-1-18] 08:00AM BLOOD calTIBC-247* VitB12-827 Folate-19.1 Ferritn-180 TRF-190* [2148-1-16] 03:21PM BLOOD Type-ART pO2-72* pCO2-64* pH-7.49* calTCO2-50* Base XS-21 [2148-1-15] 04:23PM BLOOD Type-ART pO2-56* pCO2-70* pH-7.45 calTCO2-50* Base XS-19 [2148-1-15] 04:14PM BLOOD Type-ART pO2-55* pCO2-66* pH-7.48* calTCO2-51* Base XS-21 [2148-1-15] 10:36AM BLOOD Glucose-224* Lactate-1.2 K-3.9 Cl-75* [2148-1-16] 03:21PM BLOOD O2 Sat-94 . EKG: Sinus rhythm and frequent ventricular ectopy. Diffuse low voltage. Compared to the previous tracing of [2147-12-7] the sinus rate and the frequency of ventricular ectopy have increased. Otherwise, no apparent diagnostic interim change. . CXR [1-15]: IMPRESSION: Bilateral lung base opacity concerning for pneumonia . CXR [1-16]: IMPRESSION: AP chest compared to [1-15]: The patient would not cooperate for standard positioning. Lateral aspect of the left hemithorax is excluded from the examination. Mild opacification at the base of the right lung could be due to recent aspiration. Abnormality is more severe at the left lung base, more concerning for pneumonia. Pleural effusion on the right is minimal. Left cannot be assessed because the sulcus is excluded from the examination but there is no large left pleural effusion. Right PIC line ends close to the superior cavoatrial junction. Heart is not enlarged. No pneumothorax along the imaged pleural surfaces. . [1-17]: CXR Comparison is made with prior study, [1-16]. The lateral base of the left hemithorax was not included on the film. Bibasilar consolidations left greater than right are stable. There are no new lung abnormalities. Cardiomediastinal contours are unchanged . [2148-1-17] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2148-1-16] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2148-1-16] CATHETER TIP-IV WOUND CULTURE-FINAL INPATIENT [2148-1-16] URINE Legionella Urinary Antigen -FINAL INPATIENT [2148-1-16] URINE URINE CULTURE-FINAL INPATIENT [2148-1-15] BLOOD CULTURE Blood Culture, Routine-PRELIMINARY {ESCHERICHIA COLI}; Anaerobic Bottle Gram Stain-FINAL EMERGENCY [Hospital1 ] [2148-1-15] BLOOD CULTURE Blood Culture, Routine-FINAL {ESCHERICHIA COLI}; Anaerobic Bottle Gram Stain-FINAL; Aerobic Bottle Gram Stain-FINAL EMERGENCY [Hospital1 ] AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- 0.5 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R URINE CULTURE (Final [2148-1-18]): 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.. 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-- =>32 R CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- 0.5 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 32 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R Repeat urine culture negative. Repeat blood cultures negative thus far. legionella urinary antigen negative Brief Hospital Course: 64yoM severe COPD, DM, HTN, DLP, recent R BKA presenting with dyspnea and fever, found to have e. coli UTI and bacteremia. #. Respiratory failure: Patient presented with fever, leukocytosis and dyspnea and had suspicion of pneumonia on CXR. Transferred to the [Hospital Unit Name 153] for respiratory distress. Initially treated for COPD exacerbation and HCAP given recent hospitalization with nebs, a pulse of steroids and vanc/cefepime/ciprofloxacin. Patient's oxygen requirement returned to baseline on the day of admission. Upon transer he was on his baseline O2 of 4L NC and satting in the mid-high 90s. He was found to have a UTI, antibiotics were narrowed to cefepime. Respiratory failure was likely due to sepsis from UTI, as well as possible HCAP and resolved prior to transfer to the floor. The patient has had a bedside suction for secretions prn and specifically requests to continue this at rehab. . #COPD: the patient was on prednisone 5 mg po daily. He received IV steroids while in the ICU and was transitioned to a prednisone taper. He is currently on a prednisone taper of 20 mg po daily which we recomend for 2 days, then 15 mg po daily x 2 days with a taper to his 5 mg po daily. He is on Bactrim prophylactically. He is also on standing nebulizers. . #.UROSEPSIS: The patient was found to have gross hematuria and significant pyuria on UA in the ED. Subsequently, his urine and blood cultures (x2) grew e.coli. Patient was covered initially with Vanc, cefepime, and ciprofloxacin however these were narrowed to cefepime once speciation and sensitivities returned. He received 5 days of cefepime and was transitioned to levofloxacin. He remained afebrile afterwards. He does continue to have a mild leukocytosis but is also receiving steroids. ID felt that the patient could continue on a total of 14 days of antibiotics and to continue to the levofloxacin. Last day [1-29]. . # Elevated INR: Warfarin was initially held and the patient was given a small dose of vitamin K 2.5mg IV, and restarted warfarin at 5mg when INR fell. Pt became subtherapeutic and lovenox bridging was initiated. . # Metabolic alkalosis with Respiratory acidosis: Given lung disease, patient is a CO2 retainer at baseline and has compensated by retaining bicarbonate. Pt is also on diuretic therapy. . # CKD: Cr rose slightly during hospitalization. He had no signs of volume overload so his metalozone was d/ced. . # DM: Continue ISS and Glargine. [Last Name (un) ] consulted at family's request and Insulin regimen was titrated according to their recommendations. He blood sugars fluctuated drastically. The patient was not compliant with a diabetic diet and insisted on ordering additional items. He will require close monitoring and continued nutrition education. Can consider addition of ACEI therapy and evaluation for microalbuminuria as outpatient. . # PVD/s/p BKA- Continued metoprolol, atorva, aspirin. Vascular surgery saw the patient and did not feel that there were any acute post-op issues. His prosthetic device was delivered today. He will continue with Physical therapy. . # History of DVT: Warfarin inititially held for elevated INR, but restarted when INR fell. Bridged with lovenox. . # Anemia: Probably multifactorial in etiology secondary to CKD. - last colonoscopy in [2140] was normal. Iron studies show ACD. . #Chronic R sided heart failure: Continued outpatient diuretic regimen with discontinuation of the metalozone. Continue BB, CPAP for OSA. Please monitor strict I/Os and daily weights given the discontinuation of metalozone and titrate his diuretics prn. # OSA: Continued on bipap. Medications on Admission: - Albuterol nebulization q4h prn dyspnea - Atenolol 50 mg daily - Atorvastatin 20 mg daily - Budesonide 0.5mg/2ml nebulization [Hospital1 ] - Citalopram 20 mg daily - Prednisone 5 mg daily - Tiotropium 18 mcg Capsule inhalation daily - Aspirin 81 mg daily - Docusate 100 mg [Hospital1 ] - Senna 8.6 mg [Hospital1 ] - Metolazone 2.5 mg daily - Furosemide 80 mg daily - Ketoconazole 2 % Shampoo as directed - Omeprazole 40 mg daily - Hydromorphone 2 mg q3h prn pain - Warfarin 5-10 mg Tablet daily - Lantus 44 units qAM - sliding scale insulin - Vitamin D 600 mg po BID Discharge Medications: 1. atorvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 8. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours). 11. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day) as needed. 13. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 14. sodium chloride 0.65 % Aerosol, Spray Sig: [12-25] Sprays Nasal QID (4 times a day) as needed for dry nose . 15. enoxaparin 100 mg/mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours). 16. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO QMOWEFR (Monday -Wednesday-Friday). 17. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. guaifenesin 600 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO TID (3 times a day). 19. prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Taper to 15 mg po daily in 2 days, then 10 mg x 2 days, then 10mg daily x2d then 5mg daily per pulmonologist recommendations. . 20. cholecalciferol (vitamin D3) 400 unit Tablet Sig: 1.5 Tablets PO BID (2 times a day). 21. Lantus 100 unit/mL Solution Sig: One (1) 25 Subcutaneous twice a day. 22. Humalog 100 unit/mL Cartridge Sig: One (1) sliding scale Subcutaneous once a day: BS <71 hypoglycemia protocol; 71-79 2 units 80-120 6 units 121-160 8 units 161-200 10 units 201-240 12 units 241-280 14 units 281-320 16 units 321-400 18 units >400 notify MD. Discharge Disposition: Extended Care Facility: [Hospital6 979] - [Location (un) 246] Discharge Diagnosis: COPD exacerbation E.coli bacteremia and UTI nosocomial PNA h.o DVT on coumadin PVD DM HTN OSA Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted for evaluation of fever. You were initially admitted to the ICU and found to have a pneumonia, bacteria in your blood, as well as a urinary tract infection. For this, you were given antibiotics with improvement. The vascular surgeons evaluated your R.leg and felt that your wound was well healed. . Please take all of your medications as prescribed and follow up with the appointments below. Your blood sugars fluctuated. Please adhere to a diabetic and heart healthy diet. You should have your blood sugars checked regularly. Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. Followup Instructions: You should follow up with your PCP [Last Name (NamePattern4) ] [12-25] weeks. [Last Name (un) ] will contact you about following up for your diabetes. You can also reach them at [Telephone/Fax (1) 30895]. Department: PULMONARY FUNCTION LAB When: TUESDAY [2148-2-13] at 7:40 AM With: PULMONARY FUNCTION LAB [Telephone/Fax (1) 609] Building: [Hospital6 29] [Location (un) ] [Location (un) ]: EAST Best Parking: [Hospital Ward Name 23] Garage Department: MEDICAL SPECIALTIES When: TUESDAY [2148-2-13] at 8:00 AM With: [First Name11 (Name Pattern1) 1569] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. [Telephone/Fax (1) 612] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] [Location (un) ]: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "583.81", "428.0", "038.42", "585.3", "V58.67", "250.42", "790.92", "311", "285.21", "041.49", "438.13", "416.8", "E934.2", "300.00", "486", "276.4", "733.00", "491.21", "530.81", "995.92", "443.9", "518.84", "599.0", "327.23", "403.90", "272.4", "V49.86", "V49.75" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	16152, 16224	9623, 13269	295, 302	16362, 16362	3560, 9600	17200, 18061	2949, 3026		13899, 16129		16245, 16341		13295, 13876			16538, 17177									3066, 3541																					1877, 2325				229, 257									330, 1858										16377, 16514							2347, 2818	2834, 2933
12,497	175,114	45613	Discharge summary	report	Admission Date: [2123-3-1] Discharge Date: [2123-3-18] Date of Birth: [2061-4-6] Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 7141] Chief Complaint: progressively worsening abdominal distention Major Surgical or Invasive Procedure: exam under anesthesia, exploratory laparotomy, tumor debulking, BSO, omentectomy, sigmoid resection w/ sigmoid-rectal end to end reanastomosis History of Present Illness: 61 yo W w/ho GERD/hiatal hernia, hemorrhoids, IBS admitted for increased abdominal distention and CT showing peritoneal carcinomatosis and sigmoid compression, likely due to ovarian primary. Pt reports she was in her USOH until [12-31] wks ago when she noted progressively increasing abdonminal girth. She denies any associated abdominal pain, nausea, vomiting, fever, chills, but does note pencil stools and increased frequency of loose stools, BRB on her TP (which she attributed to hemorrhoidal bleeding) as well as increased satiety and anorexia. She has not had any weight loss or urinary symptoms. Pt spoke with Dr. [Last Name (STitle) 1940] who suggested she increase her zelnorm dose and follow-up with him this week for these symptoms, but the symptoms persisted, so she came to the ED. In the ED, she was HD stable, and CT showed large amount of asites with omental, peritoneal, and mesenteric implants, concerning for carcinomatosis. Past Medical History: PMH: GERD/hiatal hernia,IBS,htn, hypercholesterolemia, ^triglycerides, migraines, hemorrhoids, depression PSH: TAH, hemorrhoid rubber banding ([2-12]), B breast reduction, wrist ganglion cyst OB: P2 Gyn: nl [Last Name (un) 3907], no abnl pap Social History: no tobacco/EtOH/ilicits Was a clothes saleswoman in [Country 18084]. Family History: No ovarian, colon, endometrial, breast ca Physical Exam: 99.5 128-140/70 82-85 18 96%RA GEN: Lying in bed, NAD HEENT: PERRL, OP clear Neck: No JVD, no LAD CVS: RRR, no M/R/G Chest: CTA bilat Abd: NT, moderately distended, no rebound/guardind, no HSM, NABS Ext: on c/c/e Skin: No [Last Name (un) ] Neuro: Non-focal Pertinent Results: [2123-3-2] 05:20AM BLOOD WBC-7.1 RBC-4.08* Hgb-12.7 Hct-37.4 MCV-92 MCH-31.1 MCHC-33.9 RDW-12.6 Plt Ct-424 [2123-3-2] 05:20AM BLOOD Plt Ct-424 [2123-3-2] 05:20AM BLOOD PT-12.8 PTT-27.4 INR(PT)-1.0 [2123-3-1] 03:04PM BLOOD Glucose-101 UreaN-13 Creat-0.7 Na-137 K-4.5 Cl-100 HCO3-31* AnGap-11 [2123-3-1] 03:04PM BLOOD ALT-33 AST-37 AlkPhos-78 Amylase-37 TotBili-0.2 [2123-3-1] 03:04PM BLOOD Lipase-25 [2123-3-1] 03:04PM BLOOD Albumin-4.1 [2123-3-1] 03:04PM BLOOD CEA-1.7 CA125-922* CT pelvis: 1) Large amount of ascites with omental, peritoneal, and mesenteric soft tissue implants suggestive of carcinomatosis. 2) Soft tissue structures in the expected location of the ovaries. If indicated, further evaluation may be performed by ultrasound. 3) 10-cm segment of narrowing in the sigmoid colon, without evidence of mechanical obstruction. While no infiltrating mass is detected, it cannot be excluded. Brief Hospital Course: The patient was initially admitted to the general medicine service. She was transferred to gyn oncology on [3-2] for further management of bowel obstruction and likely metastatic ovarian cancer. She was started on IV fluid and given nothing by mouth. She also had initial consultation with medical oncology service. She was taken to the OR on [3-5] for staging, cytoreduction, and relief of obstruction. Her surgery was notable for extensive tumor debulking and 6L of ascites requiring prolonged surgery. She was admitted to the SICU post operatively for post op volume management. Her ICU course was notable for a blood transfusion of 1 unit to increase oncotic pressure. Otherwise she had no acute events and was transferred to the floor on post op day 1. The remainder of her post operative course is as follows: 1) GI: The pt's postop course was complicated by post-op ileus. She was kept NPO with IVF. Her IV access was lost on [2123-3-9] (POD 4) and a PICC was placed. Her bowel function resumed and she was advanced to a full diet on [2123-3-11] (POD 6). 2) Pulmonary: The pt was noted to have decreased oxygen saturations on [2123-3-9] (POD 4). A CTA could not be obtained as contrast could not be administered through the pt's PICC. A V/Q scan revealed high probability of pulmonary embolism. She was started on a heparin gtt per weight-based protocol. She was weaned off oxygen by POD 6. She received 10 mg [Date Range 197] on [3-11] and [2123-3-12]. Her INR was then noted to be increased to 3.4 on [2123-3-13]. Her heparin gtt was d/c'd and she was started on Lovenox 80 mg SQ [Hospital1 ]. Her [Hospital1 197] was held on [3-13]. Her INR was then 2.3 on [3-14] and she was given 2.5 mg [Month/Year (2) 197] that night. The [Month/Year (2) 197] was discontinued on [3-15] in preparation for port-a-cath placement. 3) Renal: The pt's urine output was adequate. Her foley catheter was maintained in place until POD 3. 4) CV: The pt's blood pressure was stable on her home regimen of Norvasc 5 mg qd. 5) FEN: The pt's electrolytes were checked and repleted daily as needed. 6) Access: The pt received a port-a-cath on [2123-3-17] without complications. Her PICC line was d/c'd on the day of discharge. 7) Psychiatry: The pt requested to be seen by psychiatry on the day of discharge. She was evaluated and no medication was recommended. She has outpatient psychiatric followup. On day of discharge she was ambulating, voiding and tolerating regular diet. Her pain was well controlled with oral medication. Medications on Admission: amlodipine, lipitor, effexor Discharge Medications: 1. 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 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. Disp:60 Capsule(s) Refills:0 3. Enoxaparin Sodium 80 mg/0.8 mL Syringe Sig: Eighty (80) mg Subcutaneous Q12H (every 12 hours). Disp:20 syringes Refills:2 4. [Date Range 197] 2.5 mg Tablet Sig: Four (4) Tablet PO at bedtime: Start Friday [2123-3-19]. Disp:50 Tablet(s) Refills:2 5) Amlodipine 5 mg po QD Discharge Disposition: Home Discharge Diagnosis: Ovarian cancer Postoperative ileus Pulmonary embolism Discharge Condition: good Discharge Instructions: no heavy lifting, nothing in vagina, no exercise 6 weeks no driving 2 weeks Followup Instructions: * Call ([Telephone/Fax (1) 1921] and say that you MUST be seen on Monday [2123-3-22] with Nurse Practitioner [First Name (Titles) ] [Last Name (Titles) ] followup * [Hospital 197] clinic will call you on [2123-4-8] Provider: [First Name11 (Name Pattern1) 1730] [Last Name (NamePattern4) 2301], M.D. Where: LM [Hospital Unit Name 22399] Phone:[Telephone/Fax (1) 1983] Date/Time:[2123-4-22] 8:30 Provider: [Name10 (NameIs) ],[First Name3 (LF) ] B. [Telephone/Fax (1) 5777] Call to schedule appointment Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], MD Where: [Hospital6 29] HEMATOLOGY/ONCOLOGY Phone:[Telephone/Fax (1) 22] Date/Time:[2123-3-25] 4:00 Provider: [Name10 (NameIs) ],HEM/ONC HEMATOLOGY/ONCOLOGY-CC9 Where: [Hospital 273] HEMATOLOGY/ONCOLOGY Phone:[Telephone/Fax (1) 22] Date/Time:[2123-3-25] 4:00 Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 7167], RD Where: [Hospital6 29] MEDICAL SPECIALTIES Phone:[Telephone/Fax (1) 3681] Date/Time:[2123-5-10] 4:00	[ "401.9", "197.5", "560.9", "997.4", "415.11", "196.6", "198.82", "530.81", "553.3", "197.6", "198.89", "183.0", "560.1", "E878.6" ]	icd9cm	[ [ [] ] ]	[ "38.93", "45.76", "86.07", "99.04", "54.4", "65.61" ]	icd9pcs	[ [ [] ] ]	6429, 6435	3180, 5780	371, 515	6532, 6538	2221, 3157	6662, 7788	1878, 1921		5859, 6406		6456, 6511		5806, 5836			6562, 6639									1936, 2202																									287, 333									543, 1497																	1519, 1771	1787, 1862
50,936	120,588	31643	Discharge summary	report	Admission Date: [2128-1-6] Discharge Date: [2128-1-13] Date of Birth: [2048-3-14] Sex: M Service: SURGERY Allergies: Tetanus / Amoxicillin / Morphine Attending:[First Name3 (LF) 3200] Chief Complaint: abdominal pain, nausea and vomitting Major Surgical or Invasive Procedure: [2128-1-6] Exlap, LOA, reduction of volvulus History of Present Illness: HPI: The patient is a 79-year-old male with a history of multiple abdominal operations who was transferred to the ED from an outside hospital for small bowel obstruction with possible volvulus. Last night he had 4 episodes of profuse vomiting following dinner and this morning was brought to an outside ED at 6:00. He was initially believed to be well and was almost sent home, but due to significant pain he received a CT scan which revealed a small bowel obstruction and was transferred to the [Hospital1 ] for further care. Past Medical History: Hypertension, coronary artery disease status post stenting in [2122] after an MI, hyperlipidemia, chronic obstructive pulmonary disease, asbestos exposure, and ulcer disease. Social History: He is married with two adult children. He is a retired contractor. He had a 60-pack/year smoking history, but quit approximately 18 months ago. He does not consume any alcohol at the present time. Family History: Father died in his 70s (possibly alcohol-related), and his mother who died of an MI in her 80s. He has no family history of colon cancer or any other bile duct cancers. Physical Exam: PHYSICAL EXAMINATION upon admission Temp:99.6 HR:114 BP:116/76 Resp:14 O(2)Sat:93 Normal Constitutional: Sleepy, NGT in place Chest: Normal Cardiovascular: Normal Abdominal: Soft, Nondistended, minimal bowel sounds, very well healed surgical scars Skin: Warm and dry Neuro: extremely poor historian ? delerium? Physical examination upon discharge: [1-13] Vital signs: bp=120/82, resp rate=19, t=98.8, hr=93, oxygen saturation 94% on 2 liters General: Alert and oriented, pleasant, conversant, breathing easily on 2 liters NC CV: Ns1, s2, -s3 -s4 LUNGS: Faint expiratory wheezes bases ABDOMEN: Soft, incision line clean, staples present, no drainage EXTEMITIES: Ext. warm, mild edema ankles Pertinent Results: [2128-1-10] 08:40AM BLOOD WBC-5.1 RBC-3.31* Hgb-10.0* Hct-30.2* MCV-91 MCH-30.2 MCHC-33.1 RDW-15.3 Plt Ct-177 [2128-1-9] 05:40AM BLOOD WBC-5.0 RBC-3.03* Hgb-9.1* Hct-27.7* MCV-91 MCH-30.0 MCHC-32.8 RDW-15.2 Plt Ct-140* [2128-1-6] 11:38PM BLOOD WBC-11.6* RBC-3.63* Hgb-11.0* Hct-33.7* MCV-93 MCH-30.2 MCHC-32.5 RDW-15.2 Plt Ct-196 [2128-1-6] 07:31AM BLOOD WBC-16.1* RBC-3.74* Hgb-11.2* Hct-34.6* MCV-93 MCH-29.9 MCHC-32.3 RDW-15.3 Plt Ct-192 [2128-1-6] 07:31AM BLOOD Neuts-93.4* Lymphs-4.3* Monos-1.9* Eos-0 Baso-0.3 [2128-1-10] 08:40AM BLOOD Plt Ct-177 [2128-1-9] 05:40AM BLOOD Plt Ct-140* [2128-1-7] 05:38AM BLOOD Plt Ct-162 [2128-1-6] 11:38PM BLOOD PT-17.1* PTT-40.4* INR(PT)-1.5* [2128-1-10] 08:40AM BLOOD Glucose-93 UreaN-19 Creat-0.6 Na-137 K-4.0 Cl-101 HCO3-31 AnGap-9 [2128-1-9] 05:40AM BLOOD Glucose-109* UreaN-21* Creat-0.7 Na-138 K-4.1 Cl-102 HCO3-31 AnGap-9 [2128-1-8] 06:02AM BLOOD Glucose-145* UreaN-20 Creat-0.6 Na-135 K-4.1 Cl-102 HCO3-29 AnGap-8 [2128-1-7] 01:29PM BLOOD CK(CPK)-579* [2128-1-7] 05:38AM BLOOD CK(CPK)-599* [2128-1-7] 01:29PM BLOOD CK-MB-11* MB Indx-1.9 cTropnT-0.03* [2128-1-7] 05:38AM BLOOD CK-MB-13* MB Indx-2.2 cTropnT-0.04* [2128-1-6] 11:38PM BLOOD cTropnT-0.04* [2128-1-10] 08:40AM BLOOD Calcium-8.1* Phos-2.7 Mg-1.7 [2128-1-9] 05:40AM BLOOD Calcium-7.7* Phos-2.8 Mg-1.8 [2128-1-7] 07:53AM BLOOD Type-ART pO2-68* pCO2-39 pH-7.40 calTCO2-25 Base XS-0 [2128-1-7] 12:10AM BLOOD Type-ART Temp-39 pO2-89 pCO2-47* pH-7.26* calTCO2-22 Base XS--5 Intubat-NOT INTUBA [2128-1-6] 11:03PM BLOOD Type-ART pO2-130* pCO2-67* pH-7.11* calTCO2-23 Base XS--9 [2128-1-6] 07:50AM BLOOD Type-ART Rates-14/ Tidal V-500 FiO2-50 pO2-164* pCO2-50* pH-7.22* calTCO2-22 Base XS--7 Intubat-INTUBATED Vent-CONTROLLED [2128-1-6] 11:03PM BLOOD freeCa-1.24 [2128-1-5]: EKG: Sinus tachycardia. Left anterior fascicular block. Low limb lead QRS voltage. Prior anterior wall myocardial infarction. Baseline artifact makes assessment difficult. Since the previous tracing of [2124-9-25] sinus tachycardia is now present [2128-1-5]: Chest x-ray: Opacification at the right middle/lower lung base consistent with infectious process such as pneumonia [2128-1-6]: EKG: Significant baseline artifact. Low voltage in the standard leads. Sinus tachycardia, rate 113. RSR' pattern in leads V1-V3 with a QRS duration of 86 milliseconds. QS deflections in lead V4 and possible Q waves in leads V1-V4. Compared to the previous tracing of [2128-1-6], when there was also significant baseline artifact, there are ST segment depressions in the lateral leads V5-V6 which may be more prominent. Otherwise, no diagnostic interval change. Consider prior anterior wall myocardial infarction of indeterminate age [2128-1-6]: Chest x-ray: FINDINGS: In comparison with the study of earlier in this date, the endotracheal tube tip appears to have been removed. Nasogastric tube and right IJ catheter are essentially unchanged. The change in the appearance of the right basilar and retrocardiac opacifications most likely reflects the more upright position of the patient [2128-1-8]: EKG: Normal sinus rhythm. There is now a stable baseline. Low voltage in the standard leads. Definite Q waves in leads V1-V5 with no R waves until V5. T wave inversion in leads V1-V3. Slight ST segment elevation in lead V4. Prior anterior wall myocardial infarction of indeterminate age. The rate has slowed compared to tracing #1 and the ST-T wave changes noted in leads V5-V6 are no longer present. This suggests a regression of myocardial ischemia in that territory [2128-1-8]: Chest x-ray: FINDINGS: In comparison with the study of [1-6], the central catheter and nasogastric tube have been removed. There is progression of the bibasilar opacification, worrisome for bilateral pneumonia with pleural effusion. Air bronchograms are now seen, especially at the left base. Mild fullness of pulmonary vessels suggests some increased pulmonary venous pressure [2128-1-6]: URINE CULTURE (Final [2128-1-7]): NO GROWTH [2128-1-9]: GRAM STAIN (Final [2128-1-9]): >25 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. PLEASE SUBMIT ANOTHER SPECIMEN. RESPIRATORY CULTURE (Final [2128-1-9]): TEST CANCELLED, PATIENT CREDITED Brief Hospital Course: 79 year old gentleman admitted to the Acute Care Service from an outside hospital with abdominal pain. Upon admission, he was noted to be somnolent after having received ativan prior to his arrival. He was given a reversal [Doctor Last Name 360] which improved his mental status. He was made NPO and given intravenous fluids. His cat scan showed a bowel obstruction. He was emergenly taken to the operating [**] where he underwent an exploratory laparotomy, lysis of adhesions and reduction of a volvulus. His operative course was stable with 100 cc blood loss. He did require a short course of neosynephrine during his procedure. He was extubated in the recovery room. He was transferred to the floor post-operatively where he had an episode of apnea and unresponsiveness. As a result of this, he was transferred to the Cardiac Care Intensive care unit where he was monitored and serial cardiac enzymes followed. His troponins have been normal. He has had no events and it was thought that the initial event was vaso-vagal in nature. His vital signs stabilized and on POD #2 he was transferred out of the intensive care unit. He has had isolated episodes of increased heart rate which have been controlled with metoprolol. His [Last Name (un) ]-gastric tube has been discontinued and he has started a regular diet. He is voiding without difficulty after the removal of his foley catheter. He has moved his bowels. He has been placed on levofloxacin for presumed pneumonia. This was started on [1-7] and will be complete after 10 days. His blood cultures are pending. He continues to have occasional episodes of oxygen desaturation accompanied by increased heart rate especially with walking. His oxygen saturation improves with rest, nebulizers and addition of oxygen via nasal cannula. He has been evaulated by Physical therapy and recommendations have been made for ambulating with assistance up to three times daily to increase tolerance. He is preparing for discharge to a extended care facility. He will follow up with the Acute Care Service in [3-12] weeks. Medications on Admission: ASA 81' , Combivent 4puffs', Lisinopril 10', Ativan 0.5 qhs prn, Metoprolol 25', Ezetemibe 10', Omeprazole 20' Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection TID (3 times a day). 2. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [2-8] Puffs Inhalation Q8H (every 8 hours) as needed for shortness of breath. 3. levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig: One (1) ML Inhalation q 4 hrs () as needed for wheezing. 4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. metoprolol succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 8. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): hold for diarrhea. 10. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for Constipation. 11. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 12. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) pack PO DAILY (Daily) as needed for constipation. 13. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain: as needed for pain. 14. Ultram 50 mg Tablet Sig: 0.5 Tablet PO every 4-6 hours: as needed for pain. 15. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day for 4 days: started [1-7]....10 day course, to complete on [1-16]. Discharge Disposition: Extended Care Facility: [Hospital1 ] [Location (un) 31384*] Discharge Diagnosis: Intestinal obstruction Acute abdomen Respiratory insufficiency Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: You are being discharged from the hospital after you were admitted for nausea, vomitting and abdominal pain. You were found to have an intestinal obstruction. You went to the operating room for an exploratory laparotomy. You are now being discharged to an extended care facility with the following instrucitons: 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. Please call your doctor or return to the emergency room if you have 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. * 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. Activity: No heavy lifting of items [11-21] 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: Please follow up with the Acute Care Service in [3-12] weeks. You can schedule this appointment by calling #[Telephone/Fax (1) 600] Completed by:[2128-1-13]	[ "V15.84", "V45.82", "414.01", "560.2", "401.9", "496", "780.2", "V45.3", "507.0", "272.4", "441.4", "560.81" ]	icd9cm	[ [ [] ] ]	[ "46.81", "33.24", "54.59" ]	icd9pcs	[ [ [] ] ]	10669, 10738	6828, 8932	328, 379	10845, 10845	2293, 6803	12884, 13056	1380, 1552		9093, 10646		10759, 10824		8958, 9070			10993, 12514									1567, 1903																									252, 290							12526, 12861	1920, 2274	407, 943										10860, 10969							965, 1146	1162, 1364
5,930	103,963	22107	Discharge summary	report	Admission Date: [2182-8-7] Discharge Date: [2182-8-14] Date of Birth: [2109-9-3] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: This is a 72-year-old patient, who has a [2-15] year history of chest discomfort with exertion, which resolves with rest. He had an abnormal EKG and was referred for stress testing. His stress test was positive for ST depression inferiorly and laterally, which improved with rest and he was referred for cardiac catheterization. PAST MEDICAL HISTORY: Hypercholesterolemia. He is a 50-pack-year smoker. Thalassemia trait with anemia. Claudication. ALLERGIES: No known drug allergies. PREOPERATIVE MEDICATIONS: 1. Aspirin 81 mg p.o. q.d. 2. Toprol XL 50 mg p.o. q.d. 3. Lipitor 10 mg p.o. q.d. 4. Plavix 75 mg p.o. q.d. 5. Imdur 30 mg p.o. q.d. PREOPERATIVE LABORATORY DATA: Significant for a creatinine of 1.5. HOSPITAL COURSE: Patient was admitted to [Hospital1 346] on [2182-8-7] and underwent cardiac catheterization. He was found to have an ejection fraction of 60 percent, LVEDP of 14, 80 percent heavily calcified left main coronary artery, 80 percent diffuse proximal LAD lesion with a distal LAD lesion at 70-80 percent. An 80 percent origin of left circumflex, 90 percent proximal left circumflex, and a totally occluded RCA with collaterals to RDL. Ba[Last Name (STitle) 57772] the results of the catheterization, it was determined that the patient would be admitted to the hospital and be taken for revascularization. Patient was placed on a Heparin drip. He had ultrasound evaluation of his carotid arteries, which showed a less than 40 percent lesion on the right and no stenosis on the left. He had lower arterial Doppler studies done, which showed normal flow to the left leg with significant aortoiliac disease on the right, and patient was taken to the operating room on [8-9] with Dr. [Last Name (Prefixes) ], where he underwent a CABG x4 LIMA to LAD, SVG to OM-1 and OM-2, and SVG to PDA. Total cardiopulmonary bypass time 133 minutes. Cross-clamp time 95 minutes. Patient was transported to the Intensive Care Unit in stable condition. Please see operative note for full details. Patient was weaned and extubated from mechanical ventilation on his first postoperative afternoon. On postoperative day one, the patient was started on Lasix for diuresis and beta blockers, and on postoperative day number one, the patient was transferred from the Intensive Care Unit to the regular part of the hospital. Patient began ambulating with Physical Therapy, had continued diuresis. By postoperative day number five, the patient had completed level 5 of Physical Therapy. Had appropriately diuresed and was cleared for discharge to home. CONDITION ON DISCHARGE: T max 99.4. Pulse 64 in sinus rhythm. Blood pressure 114/54. Respiratory rate is 18. On room air oxygen is 94 percent. Neurologically: He is awake, alert, and oriented times three and no obvious deficit. Heart: Regular rate and rhythm without rub or murmur. Respiratory: Breath sounds are clear bilaterally. GI: Positive bowel sounds, soft, nontender, nondistended, and tolerating a regular diet. Sternal incision is clean, dry, and intact. Sternum is stable. Steri-Strips open to air. Vein harvest site is clean, dry, and intact. There is no erythema and there is no drainage. Chest x-ray on [8-14] showed small bilateral pleural effusions without any evidence of CHF, no pneumothorax. LABORATORY DATA: Sodium 143, potassium 4.7, chloride 109, bicarb 25, BUN 24, creatinine 1.5, glucose 79. DISPOSITION: The patient is to be discharged to home in stable condition. DISCHARGE MEDICATIONS: 1. Percocet 5/325 mg 1-2 tablets p.o. q.4-6h prn. 2. Plavix 75 mg p.o. q.d. 3. Aspirin 325 mg p.o. q.d. 4. Lipitor 10 mg p.o. q.d. 5. Norvasc 5 mg p.o. q.d. 6. Lasix 20 mg p.o. q.d. x7 days. 7. Potassium chloride 20 mEq p.o. q.d. x7 days. 8. Toprol XL 50 mg p.o. q.d. DISCHARGE DIAGNOSES: Coronary artery disease. Status post coronary artery bypass graft. Right aortoiliac disease. FO[Last Name (STitle) 996]P: The patient should follow up with his primary care physician, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 57773] in [1-15] weeks. He should follow up with Dr. [Last Name (STitle) 1911], his cardiologist in [2-14] weeks, and he should follow up with Dr. [Last Name (Prefixes) ] in four weeks. [Doctor Last Name ] [Last Name (Prefixes) ], M.D. [MD Number(1) 1288] Dictated By:[Last Name (NamePattern4) 8524] MEDQUIST36 D: [2182-8-14] 13:01:36 T: [2182-8-15] 05:12:55 Job#: [Job Number 57774]	[ "414.01", "443.9", "272.0", "411.1", "282.49" ]	icd9cm	[ [ [] ] ]	[ "36.15", "88.55", "39.61", "36.13", "88.53", "37.22", "99.04" ]	icd9pcs	[ [ [] ] ]								3993, 4742	3701, 3971					909, 2763																						686, 891																							163, 499																	522, 660		2788, 3678
6,525	137,490	52809	Discharge summary	report	Admission Date: [2120-3-7] Discharge Date: [2120-3-12] Date of Birth: [2057-8-22] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1850] Chief Complaint: Fever Major Surgical or Invasive Procedure: none History of Present Illness: 62 yo male with MDS, pancytopenia who presented from clinic with fever in setting of platelet transfusion and hypotension. He only complained of productive cough, no dysuria, no headache, neck stiffness. In ED received 3 L NS, gvien cefepime, vanco, gentamicin and flagyl for febile neutropenia. Code sepsis called. Past Medical History: 1. Myelodysplastic anemia diagnosed eight years; treated with monthly blood transfusions. 2. Hypertension. 3. perinephric hematoma 4. h/o RLE cellulitis Social History: The patient lives his brother and son-in-[Name2 (NI) 108895] home and works in maintenance at [University/College 5130] [Location (un) ].The patient reports social alcohol use of one to two drinksper week. The patient denies tobacco use. Family History: NC Physical Exam: 101.1, 102, 85/44, 30, 97%RA GENL: NAD HEENT: pupils 1- 2 mm, reactive, anicteric, OP clear, dry MM, supple neck CV: tachy, 3/6 systolic murmur Lungs: dry crackles at bases Abd: soft, nt, nd, +bx Ext: 2+ pedal pulses Skin: numerous erythematous plaques with scale over torso Pertinent Results: [2120-3-12] 05:00AM BLOOD WBC-1.1# RBC-3.84 Hgb-11.0* Hct-30.0* MCV-78* MCH-28.6 MCHC-36.6* RDW-17.0* Plt Ct-14* [2120-3-7] 10:17AM BLOOD WBC-0.5* RBC-2.97* Hgb-8.3* Hct-24.9* MCV-84 MCH-28.1 MCHC-33.5 RDW-14.1 Plt Ct-14# [2120-3-7] 12:50PM BLOOD Neuts-50 Bands-14 Lymphs-22 Monos-4 Eos-0 Baso-0 Atyps-10* Metas-0 Myelos-0 [2120-3-12] 05:00AM BLOOD Plt Ct-14* [2120-3-9] 05:21AM BLOOD PT-16.2* PTT-43.7* INR(PT)-1.6 [2120-3-7] 10:17AM BLOOD Plt Ct-14# [2120-3-7] 02:19PM BLOOD PT-14.4 PTT-46.8* INR(PT)-1.3 [2120-3-8] 10:13PM BLOOD Fibrino-296 [2120-3-8] 10:31AM BLOOD Fibrino-332 D-Dimer->[Numeric Identifier 961]* [2120-3-8] 12:46AM BLOOD Fibrino-346 [2120-3-12] 05:00AM BLOOD Gran Ct-790* [2120-3-7] 10:17AM BLOOD Gran Ct-320* [2120-3-12] 05:00AM BLOOD Glucose-137* UreaN-113* Creat-3.1* Na-139 K-3.8 Cl-100 HCO3-22 AnGap-21* [2120-3-7] 12:50PM BLOOD Glucose-132* UreaN-28* Creat-1.3* Na-134 K-4.3 Cl-101 HCO3-25 AnGap-12 [2120-3-8] 09:19PM BLOOD ALT-58* AST-318* LD(LDH)-1708* AlkPhos-203* TotBili-0.5 [2120-3-7] 12:50PM BLOOD ALT-31 AST-128* LD(LDH)-1153* AlkPhos-203* Amylase-42 TotBili-0.2 [2120-3-7] 12:50PM BLOOD Lipase-13 [2120-3-8] 05:50AM BLOOD CK-MB-3 cTropnT-0.10* [2120-3-7] 07:24PM BLOOD CK-MB-NotDone cTropnT-0.07* [2120-3-12] 05:00AM BLOOD Calcium-8.9 Phos-7.4* Mg-2.2 [2120-3-7] 12:50PM BLOOD Albumin-2.1* Calcium-7.6* Phos-2.7 Mg-1.5* [2120-3-8] 12:46AM BLOOD Hapto-215* [2120-3-11] 04:01AM BLOOD Triglyc-111 [2120-3-7] 07:24PM BLOOD Cortsol-31.8* [2120-3-7] 07:23PM BLOOD Cortsol-31.5* [2120-3-7] 07:23PM BLOOD Cortsol-29.5* Brief Hospital Course: The patient was admitted to the [Hospital Unit Name 153] with sepsis of unclear etiology. 1. Sepsis: Placed on MUST protocol. He was given cefepime, vancomycin and flagyl and gentamicin. He was started on levophed for BP support and then switched to dopamine. Blood cultures grew MRSA. He was started on linezolid and vancomycin discontinued on [2120-3-9]. Cefepime, flagyl and azithromycin were discontinued on [3-10] after blood cultures return positive for MRSA. He has a port for transfusions that could have been the source which was removed by surgery. He was also given hydrocortisone and fludricort for adrenal insufficiency. 2. Heme/MDS: He was given DDAVP for uremic platelets. Transfused red cells and FFP and platelets given oozing from CVL site. Filagrastim was started for neutropenia. 3. ARF: His urine output fell. Dopamine was started to try to improve renal perfusion, with little success. He was tried on natrecor but had MAT on tele and it had to be decreased. UO did respond to the natrecor. 4. Resp status: He required BIPAP on HD 2 for respiratory support. he was DNR/DNI from admission. 5. Goals of care: His mental status began to deteriorate on HD 4. His prognosis remained poor given pnacytopenia, sepsis and acute renal failure. Discussions with the family were had and their goal was comfort care. Pt expired on [2120-3-12]. Medications on Admission: None Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: n/a Discharge Condition: n/a Discharge Instructions: n/a Followup Instructions: n/a [First Name8 (NamePattern2) 1176] [Name8 (MD) 1177] MD [MD Number(2) 1851]	[ "284.8", "785.52", "792.1", "482.41", "428.0", "995.92", "255.4", "518.81", "584.9", "696.1", "V09.0", "238.7", "038.11" ]	icd9cm	[ [ [] ] ]	[ "00.13", "00.17", "99.15", "93.90", "00.14", "99.05", "99.07", "99.04", "38.93" ]	icd9pcs	[ [ [] ] ]	4593, 4602	3134, 4510	320, 326	4649, 4654	1450, 3111	4706, 4828	1136, 1140		4565, 4570		4623, 4628		4536, 4542			4678, 4683									1155, 1431																									275, 282									354, 671																	693, 851	867, 1120
25,859	160,588	7615	Discharge summary	report	Admission Date: [2102-7-12] Discharge Date: [2102-7-18] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2387] Chief Complaint: Left-sided weakness Major Surgical or Invasive Procedure: Brain MRI/MRA Stenting of R carotid artery History of Present Illness: [Age over 90 ] year old Spanish-speaking male with PMH significant for CAD, T2DM and PVD, who presents with 9-day h/o brief periods of dysarthria, L-sided numbness and L-sided weakness. No amarouosis fugax. These episodes would last from a few minutes to an hour, and then resolve. This He saw his PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) 11679], in clinic on [7-10], who suspected TIAs, and ordered an outpatient MRI. On [7-11], he was admitted to NEBH with another episode of acute dysarthria, L-sided numbness and weakness. He denied CP, SOB, orthopnea, PND. Denies F/C/NS. No significant weight loss. No HA or visual changes. . At NEBH, he was placed on aspirin and heparin gtt. A carotid U/S was done, which confirmed tight right ICA stenosis with elevated peak systolic velocity of 260, and ICA/CCA ratio of 6. He had an MRI that reportedly demonstrated R corona radiata infarct with minimal edema. ECG was NSR. He was transferred to [Hospital1 18] CCU under Dr. [Last Name (STitle) ] for consultation with Dr. [Last Name (STitle) 27789] [Name (STitle) ] for possible carotid stent placement. On arrival, feeling somewhat nauseous, no other complaints. Past Medical History: 1) CAD: Two distant MIs, s/p angioplasty x 2, most recently 10 years ago. On baby aspirin at home. 2) PVD: With symptoms of intermittent claudication. 3) T2DM: Diagnosed 15 years ago. On NPH 32U qAM. 4) Hypothyroidism: Managed with levothyroxine 5) Glaucoma Social History: Married, lives at home, former office worker. Distant h/o very light smoking, distant h/o light EtOH use. Family History: NC Physical Exam: T: 98.7F BP: 158/75 HR: 91 RR: 16 SaO2: 96% RA Gen: Elderly Hispanic male, lying in bed, NAD HEENT: L eye s/p enucleation with prosthesis. R PERRL and EOMI. +periorbital swelling around L eye. MMM Neck: Supple, no carotid bruits. No LAD or thyromegaly CV: RRR, nl S1 and S2, +S4, no m/r/g Chest: Diminished BS bilaterally, no w/r/r Abd: Soft, NT/ND, +BS, no HSM Extr: No LE edema, trace DPs bilaterally. Good cap refill Neuro: A&O x 3. +L facial droop, otherwise CN II-XII intact, except for L eye. Strength 5-/5 RUE and RLE, 4+/5 LUE and LLE. Sensation intact to LT throughout. Toes equivocal bilaterally. Mild L pronator drift. No ataxia. DTRs 1+ at biceps, triceps, patella, and ankle jerk, and symmetric. Pertinent Results: [7-12] Carotid Stenting: PTA COMMENTS: We elected to treat the [Country ] with PTA/Stenting. The sheath was exchanged for a 6 French Shuttle sheath that was advanced to the RCCA over a supracore. A barewire was advanced into the [Country ] without difficulty, and a 5.0 mm Emboshield was delivered without difficulty. We predilated with a 2.5 x 20 mm Crossail at 10 atm, and deployed a [7-13] x 40 mm tapered Exact stent across the bifurcation. The stent was then post-dilated with a 4.5 x 20 mm Crossail at 10 atm. Final angiography demonstrated no dissection, a 10% residual stenosis, and normal flow. Intracerebral angiography demonstrated no significant change from the pre-intervention angiography with no significant filling of the ACA. The patient developed transient hypotension following stent placement, which was responsive to nesynephrine. 1. Access was retrograde via the RCFA with selective catheter placement to the RCCA and [Country ]. 2. Arch aortography demonstrated a Type I arch with bovine anatomy and calcified plaque at the aortic knob. 3. Angiography of the RCCA demonstrated a normal but slightly tortuous RCCA without lesions. The [Country ] had an ulcerated 80% lesion at the origin. The [Country ] filled the ipsilateral MCA without noted filling of the ACA. 4. Successful stenting of the RCCA/[Country ] bifurcation with a [7-13] x 40 mm Exact stent using distal embolic protection with the Emboshield filter. FINAL DIAGNOSIS: 1. Severe right internal carotid artery stenosis. 2. Successful stenting of the right internal carotid artery. . [7-12] Non-contrast head CT: FINDINGS: No intra- or extra-axial hemorrhage is identified. There is no mass effect or shift of normally midline structures. The ventricles are normal in size and symmetric, and the basal cisterns are well visualized. The outside hospital MRI is not available for review; however, the abnormality in the right corona radiata is not clearly identified on the current study. There are no parenchymal attenuation abnormalities. The paranasal sinuses and mastoid air cells are clear. The orbits demonstrate a band around the left globe. Surrounding soft tissue structures appear unremarkable. IMPRESSION: No evidence of intracranial hemorrhage or infarction. . [7-13] MRI/A: PRELIMINARY REPORT: Likely subacute infarct in right corona radiata with corresponding high T2 signal. Reportedly, there is an outside MR from two days prior (before stenting) that showed "right corona radiata infarct" but images not available for me to review. MRA is markedly abnormal, and unfortunately, evaluation of likely marked underlying disease is significantly limited by motion artifact. Discussed with [Doctor Last Name 19868]. [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ], 2 a.m., [7-14]. FINDINGS: There is a foci of abnormal slow diffusion noted in the right corona radiata with corresponding increased T2 signal seen on T2-weighted and FLAIR imaging, suggesting recent infarct. Possible area of increased anisotropy suggests an acute component to infarct. There is no evidence of hemorrhage. There is no shift of normally midline structures or evidence of hydrocephalus. Visualized portions of the paranasal sinuses appear normally aerated. IMPRESSION: Findings consistent with recent infarct in the right corona radiata, with possible acute component. Correlation with prior outside studies that reportedly demonstrate this finding is recommended. MRA: Study is limited by motion artifact. Flow is seen in the carotid and vertebral arteries, although not well assessed. Major branches of the circle of [Location (un) 431] appear patent, although it is impossible to evaluate for abnormal aneurysmal dilatation or stenosis. IMPRESSION: Study limited by motion artifacts. Carotid and vertebral ateries appear patent. . [2102-7-12] WBC-13.8* Hct-39.1* MCV-96 Plt Ct-212 Neuts-79.0* Lymphs-15.3* Monos-4.4 Eos-0.7 Baso-0.6 . [2102-7-18] WBC-10.6 Hct-32.0* MCV-95 Plt Ct-191 . [2102-7-12] PT-13.7* PTT-90.2* INR(PT)-1.2* . [2102-7-12] Glucose-77 UreaN-30* Creat-1.1 Na-139 K-4.0 Cl-104 HCO3-22 Calcium-10.1 Phos-3.2 Mg-2.2 . [2102-7-18] Glucose-179* UreaN-15 Creat-0.7 Na-138 K-3.8 Cl-104 HCO3-22 . [2102-7-12] %HbA1c-6.8* [2102-7-13] Triglyc-143 HDL-60 CHOL/HD-2.8 LDLcalc-80 LDLmeas-113 [2102-7-12] TSH-8.1* Free T4-1.4 . [2102-7-14] URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.017 URINE Blood-LG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-1 pH-5.0 Leuks-NEG RBC-21-50* WBC-[7-15]* Bacteri-FEW Yeast-NONE Epi-0-2 UCx negative Brief Hospital Course: 1) CVA: Mr. [Known lastname 27790] had an MRI that demonstrated subacute infarct in R corona radiata. Neurology was consulted, who agreed that the likely source of his recurrent TIAs was likely his tight R carotid, which, based on analysis of OSH carotid U/S, looked to be 90-95% stenotic. He was kept on a heparin gtt pending successful stenting of R carotid artery, occurred on [7-13]. The procedure was complicated by transient hypotension. Mr. [Known lastname 27790] was monitored in the CCU following this procedure, utilizing neosynephrine gtt to keep SBP between 140-170 for maximized cerebral perfusion pressure, per neurology recommendations. He was maintained on ASA and plavix. His blood sugars were closely monitored, and lipid profile was drawn, which was good. He was kep on lipitor 10mg PO qD. He was Mr. [Known lastname 27791] neurologic symptoms waxed and waned, with overall worsening of his L facial droop and LUE and LLE weakness. This was thought to reflect continuing progression of his stroke. After 3 days, his BP restrictions were eased, and he was allowed to autoregulate his BP, with occasional NS boluses to keep his SBP above 100s, which he tended to gravitate towards. He had a speech and swallow study that demonstrated no evidence of aspiration, despite slowed initiation of swallowing. He was started on ground solids and thickened liquids, which he tolerated well. He worked with PT, who agreed with need for acute stroke rehab placement. Prior to discharge, Mr. [Known lastname 27790] had a repeat MRI, which demonstrated 50% increase in size of R corona radiata CVA from 1.2cm to 2.1cm with brighter diffusion signal, suggesting natural evolution of stroke, with small area of edema adjacent to stroke, but no mass effect or hemorrhage. . 2) T2DM: A1C checked, which was 6.8%. q2h FSs were checked in the initial phases following his CVA, which were then extended to qid checks. He was maintained on SSI and diabetic diet. . 3) CAD: Stable, no evidence of ACS while in-house. ASA 325mg PO qD, plavix 75mg PO qD, and Lipitor 10mg PO qHS were continued in setting of acute TIA. Would likely beneft from addition of metoprolol as an outpatient, but deferred in inpatient setting due to goal of good cerebral perfusion pressure. . 4) Hypothyroidism: TSH 8.1, FT4 1.4. Continued levothyroxine at outpatient dose. Medications on Admission: Novolin NPH 32U qAM ASA 81mg PO qD Protonix 40mg PO qD Levothyroxine 50mcg PO qD Cosopt 1gtt OU [Hospital1 ] Xalatan 1gtt OU qHS Alphagan 1gtt OS qD prn Darvocet Discharge Medications: 1. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 2. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 3. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic QD (). 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 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. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 13. Insulin Humalog sliding scale: <50: [2-6] amp D50 51-150: Nothing 151-200: 2U 201-250: 4U 251-300: 6U 301-350: 8U >350: Call physician Discharge Disposition: Extended Care Facility: [Hospital6 979] - [Location (un) 246] Discharge Diagnosis: Stroke secondary to R subcortical infarct (corona radiata area) Discharge Condition: Stable. Discharge Instructions: You are being transferred to an acute stroke rehabilitation facility for further physical therapy. You should be returned to the hospital for new neurological symptoms, wide fluctuations in blood pressure, or for any other significant problems. Followup Instructions: Please follow up with Dr. [First Name4 (NamePattern1) 1104] [Last Name (NamePattern1) 4638] and [Doctor Last Name ] in one month after discharge. You can call [Telephone/Fax (1) 2574] to schedule an appointment. . You have a follow up appointment with Dr. [First Name (STitle) ] in Cardiology on [2102-9-8] at 9:30AM. You can call [Telephone/Fax (1) 4022] with questions. . You have a follow up appointment with Dr. [Last Name (STitle) ] in Cardiology on [8-16] at 2:30pm at [Location (un) 620]. You can call [Telephone/Fax (1) 2394] with questions.	[ "414.01", "365.9", "412", "244.9", "458.29", "V45.82", "342.90", "250.00", "440.21", "433.11" ]	icd9cm	[ [ [] ] ]	[ "00.61", "00.63", "00.40", "00.45" ]	icd9pcs	[ [ [] ] ]	11208, 11280	7442, 9808	282, 327	11388, 11398	2740, 4223	11691, 12291	1987, 1991		10025, 11185		11301, 11367		9834, 10002		4240, 4377	11422, 11668									2006, 2721																									223, 244									355, 1565				4386, 7419													1587, 1847	1863, 1971
24,968	120,350	21527	Discharge summary	report	Admission Date: [2190-7-31] Discharge Date: [2190-8-5] Date of Birth: [2135-7-24] Sex: F Service: MEDICINE Allergies: Iodine; Iodine Containing Attending:[First Name3 (LF) 2024] Chief Complaint: Confusion Major Surgical or Invasive Procedure: none History of Present Illness: 55 yo female s/p right mastectomy/xrt/chemo with diffusely metastatic CA presented w/ MS changes and dehydration. Patient became obtunded/agitated in ED, was noted to have a large JVD and right arm edema. She was given Ativan for agitation. CT scan of chest showed a large mediastinal mass that was impinging on her SVC. History limited to ED notes as patient did not have a family member with her upon arrival to ICU. Past Medical History: 1. Metastatic breast cancer: - noted RUE swelling in [9-28] - breast biopsy and the pathology showed infiltrating poorly differentiated carcinoma with invasion into skeletal muscles. - She was treated with 4 cycles of dose dense Adriamycin and cyclophosphamide, followed by Taxol and Taxotere. -She underwent a right mastectomy with left breast reduction by Dr. [Last Name (STitle) 56753] at [Hospital6 1708]. She was ER and PR negative and her Her2neu was negative as well. -history of carcinomatous meningitis -has undergone whole brain irradiation -[2190-7-14] Omaya resevoir placed Social History: She is married. She admits to use of tobacco and quit at the age of 33. She drinks one alcoholic drink per month. She does not use any illicit drugs. Family History: Mother was deceased at age 74 and she had diabetes and breast cancer (she had a mastectomy). Her father is alive at age 89 and he has peripheral vascular disease. She has one sister at age 57 and she has diabetes. Physical Exam: Vit: 97.7 111/57 104 26 98% RA Gen: middle aged woman, resting in bed, crying intermittently HEENT: PERRLA, EOMI CV: RRR, no MGR Pulm: rhonchi bilaterally anteriorly Abd: +BS, soft, NT, ND Ext: R UE erythematous and warm with pitting edema, no edema of other extremities. Skin: scar on right breast, multiple metastatic nodules on right breast Neuro: does not follow commands Pertinent Results: 2.4 > 10.0/30.5 < 67 MCV-88 N:94.3 Band:0 L:3.9 M:1.1 E:0.7 Bas:0.1 Anisocy: 1+ Macrocy: 1+ . 136 / 102 / 26 ------------< 112 4.6 / 21 / 0.5 . Ca: 9.5 Mg: 2.1 P: 3.0 . 7.39/34/74 HCO3 21 Lactate:2.5 PT: 13.2 PTT: 25.4 INR: 1.2 . CT HEAD: IMPRESSION: Markedly limited examination. No definite evidence of acute intracranial hemorrhage or mass effect. A questionable density within the left frontal lobe on one image is incompletely evaluated and may relate to artifact. . CHEST CT: Compression of SVC. 30% patent . CXR: IMPRESSION: 1. Moderate to large size right pleural effusion layering posteriorly. An underlying consolidation within the right lung cannot be excluded. 2. Right anterior mediastinal density, which may represent a mediastinal mass, is unchanged from [2190-6-25]. Right anterior mediastinal density is unchanged from the prior study and may represent a mediastinal mass. Brief Hospital Course: 55 yo female s/p right mastectomy/xrt/chemo with diffusely metastatic CA (including carcinomatous meningitis by MRI) presents w/ MS changes and dehydration. Pt's mental status and agitation initially improved with ativan. She was initially started on antibiotics in view of recent chemothearapy and declining cell counts, cultures were drawn. In addition, pt was found to have compression of her SVC, which she was started on IVF for. Initially there was discussion regarding possibly tapping her pleural effusion as well as doing a spinal tap. However, after discussion with family in view of her metastatic breast cancer resistant to treatment, it was decided that patient's care should focus on comfort and any further diagnostic test were discontinued. Pt was made comfortable with use a morphine drip. She continued to be able to interact slightly by opening her eyes and look around. Pt expired on [8-5] at 10:50. Medications on Admission: neurontin 300 TID oxycodone 5mg prn (usually needs two a day) Decadron 4 mg po bid (last dose 7/29) Pepcid 4 mg po bid Epo Iron Famotidine Levofloxacin Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: deceased Discharge Condition: deceased Completed by:[2190-8-5]	[ "198.5", "276.5", "284.8", "V10.3", "511.9", "459.2", "198.89", "197.1", "198.4" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	4282, 4291	3120, 4051	295, 301	4343, 4381	2197, 2432		1561, 1777		4253, 4259		4312, 4322		4077, 4230												1792, 2178																									246, 257									329, 751		2441, 3097															773, 1377	1393, 1545
43,165	151,165	7518	Discharge summary	report	Admission Date: [2199-8-15] Discharge Date: [2199-8-24] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2736] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: [Age over 90 ] yoF russian speaking only with history of HTN, HL, TIA who was in her USOH until 4 days ago when she started having subjective fever, non-prodcutive cough, headache, runny nose. She was seen by PCP on tuesday and prescribed Z-Pac for bronchitis. After being started on Z-pack patient had episodes of nausea, NB/NB vomting episodes. No appetite. No abdominal pain or diarrhea. VNA visited patient today noted to have O2 sats in mid 80s on RA and convinced patient to go to the ED. In the ED she was noted to be hypoxic to 80s also complained of chest pressure which was non-exertional. Vitals were T:98.4F, HR:74, BP:122/55, RR:16, O2:98% on 4L NC. CXR was notable for likely R sided PNA, and signs of volume overload with bilateral pleural effusions and vascular congestion. Labs were notable for a WBC of 16.8, stable renal dysfunction with a Cr of 1.3, a proBNP of 10K, and a Tn-T of 0.13. She continued to have low O2 sats therefore she was started on BIPAP but swiched back when her sats came back to normal. She was given aspirin, IV heparin, nitroglycerin for possible NSTAMI. She was also started on ceftirzone and azithromycin for PNA. She was seen by our cardiology service and found to have volume overloaded and pneumonia. She was determined not to have NSEMI based on her EKG. She was given 20mg IV lasix in the prior to being admitted to CCU for further monitoring. . Currently in the CCU patient complains fo headaches but denies any chest pain, shortness of breath, orthopnea, PND, chills, night sweats, abdominal pain, diarrhea. She does not use any nebs at home and denies any any prior history of CHF. No recent weight changes. Past Medical History: 1. CARDIAC RISK FACTORS: Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: None -PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: - Stable angina - Transient ischemic attack in [2197-3-23]. - Anemia - Osteoporosis - Ovarian Cyst - Pulmonary Nodule - Thyroid Nodule Social History: Retired construction engineer, married for 75 years. -Tobacco history: None -ETOH: None -Illicit drugs: None Family History: Non-contributory Physical Exam: Admission Physical: GENERAL: Appears fatigued and tachypnic. Oriented x3. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. NECK: Unable to asses JVP. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: Diffuse crackles int he lungs bilaterally along with decreased breath sounds. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ . Discharge Physical: GENERAL: Alert. Oriented x3. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. NECK: No JVD. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: CTAB. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: Admission/Relevant Labs: [2199-8-15] 01:10PM BLOOD WBC-16.8# RBC-3.40 Hgb-10.0* Hct-30.4* MCV-90 MCH-29.4 MCHC-32.9 RDW-13.2 Plt Ct-309 [2199-8-15] 01:10PM BLOOD PT-15.8* PTT-29.8 INR(PT)-1.5* [2199-8-15] 01:10PM BLOOD Glucose-120* UreaN-22* Creat-1.3* Na-139 K-4.8 Cl-102 HCO3-23 AnGap-19 [2199-8-15] 01:10PM BLOOD ALT-16 AST-27 LD(LDH)-248 CK(CPK)-159 AlkPhos-92 TotBili-0.4 [2199-8-15] 01:10PM BLOOD CK-MB-12* MB Indx-7.5* proBNP-[Numeric Identifier 27473]* [2199-8-15] 01:10PM BLOOD cTropnT-0.13* [2199-8-15] 08:50PM BLOOD CK-MB-20* MB Indx-8.8* cTropnT-0.24* [2199-8-16] 04:46AM BLOOD CK-MB-18* cTropnT-0.28* [2199-8-18] 04:57AM BLOOD CK-MB-3 [2199-8-16] 04:46AM BLOOD Calcium-8.9 Phos-4.1 Mg-2.2 [2199-8-15] 01:10PM BLOOD Albumin-3.4* . . CXR: [2199-8-15] FINDINGS: Frontal and lateral views of the chest were obtained. The heart size appears normal. Pulmonary vascular markings are indistinct and prominent in the upper lobes, compatible with mild pulmonary edema. Peripheral wedge shaped right upper lobe opacity is similar to prior. Right hilar and middle lobe patchy consolidative opacities are new. Small bilateral pleural effusions are present. No pneumothorax. No radiopaque foreign body. Osseous structures are unremarkable. . IMPRESSION: Pulmonary edema with small bilateral pleural effusions and new right hilar and middle lobe consolidative opacities, suggestive of pneumonia. Follow-up radiographs are recommended. . CXR: [2199-8-16] FINDINGS: Two frontal images of the chest demonstrate a decrease in the bilateral reticular interstitial markings of the lungs. There has also been interval increase in bilateral pleural effusions. These findings suggest a resolving pulmonary edema. There has also been interval increase in the density of the previously seen right hilar, right lower zone, and right upper zone opacities. Cardiomediastinal silhouette is unchanged. . IMPRESSION: Resolving pulmonary edema. Increasing density of right lung opacities suggest progressing pneumonia. . CXR: [2199-8-18] Mild-to-moderate cardiomegaly is stable. Right perihilar consolidation is less conspicuous than before. This is due to difference in positioning of the patient and re-distribution of the moderate right pleural effusion and adjacent atelectasis. Right middle lobe and right lower lobe pneumonic consolidations are unchanged. Right upper lobe wedge-shape opacity is more chronic. There is no pneumothorax. Small left pleural effusion is unchanged. Mild interstitial edema has improved. . TTE: [2199-8-16] The left atrium is elongated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed (LVEF= 45 %) secondary to hyokinesis of the inferior and posterior walls. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. Mild to moderate ([12-24]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. An eccentric, posteriorly directed jet of moderate (2+) mitral regurgitation is seen. Due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (Coanda effect). Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. DSCHRG LABS: [2199-8-24] 08:20AM BLOOD WBC-11.8* RBC-3.22* Hgb-9.3* Hct-29.4* MCV-91 MCH-28.8 MCHC-31.7 RDW-13.6 Plt Ct-458* [2199-8-24] 08:20AM BLOOD Glucose-97 UreaN-30* Creat-1.0 Na-146* K-4.8 Cl-106 HCO3-33* AnGap-12 [2199-8-21] 07:00AM BLOOD CK(CPK)-32 [2199-8-24] 08:20AM BLOOD Mg-2.3 Brief Hospital Course: [Age over 90 ]F, Russian-speaking, with history of HTN, HL, TIA, was in her USOH until 4 days prior to admission when she started having subjective fever, non-productive cough, headache, and chest pain with CXR showing pneumonia and mild pulmonary edema. Admission was complicated by Chest Pain with associated EKG ST depressions. . # Pneumonia: Patient presented with symptoms of subjective cough, headache, nausea, vomiting, and anorexia. WBC of 16.8 and CXR findings of opacities in the RML and RLL suggested pneumonia as the cause of the patient's symtoms. Urinary legionella antigen was negative. She had high oxygen requirement and was on 100% non-rebreather for the first two days of admission. She was started on azithromycin and ceftriaxone for CAP coverage. She continued to show clinical and radiologic improvement in her pneumonia. She was successfully weaned off of O2. Pt was afebrile > 72 hours on day of discharge. WBC was 11.8 from peak of 19.6 on day of discharge. Pt did have mild non productive cough on day of discharge, which she reported was decreasing in frequency. Patient completed a 7 day course of Ceftriaxone and Azithromycin. A [7-4] week follow up CXR is recommended. . # Chest Pain: UA. On presentation, patient complained of chest pain. EKG showed ST segment depression in V3, V4, V5, most likely demand ischemia in the setting of infection, pulmonary edema, and hypoxia. Patient's troponin rose to 0.28 and CK-MB to 20 with CK-MB normalizing back to 3 one day after admission. Repeat EKG did not show any changes concerning for ACS. Patient was contineud on aspirin and started on Imdur 60mg daily and on metoprolol (instead of her home atenolol). She continued to report mild chest pain, thought to be from pleural irritation. On [8-21], while at rest, the patient developed worsening chest pain with worsening diffuse ST depressions. These resolved with SL nitro x3. Diagnosis of UA. The patient was put on heparin drip for 48 hours. Metoprolol was increased, she was put on lisinopril, atorvastatin, and Plavix, and the Imdur was increased to 120mg daily. For the next two days the patient denied any chest pain, including while ambulating with physical therapy. After the heparin was stopped patient was observed for an additional 24 hours without chest pain. Close follow up is recommended. We did have a discussion with the patient about the potential for PCI if chest pain continues of worsens, but she was reluctant to undergo invasive procedures unless absolutely indicated. Pt was started on Atorva 80, Clopidogrel 75, Metoprolol Succ XL 300, and Imdur 120 mg daily (titrated up). She had no further episodes of chest discomfort on this regimen. . # Pulmonary Edema: Likely [1-24] acute decompensated systolic CHF. Patient does not have any documented history of CHF and denied any orthopnea and PND. An echo showed a mildly depressed EF of 45%. Her initial CXR showed mild pulmonany edema. After diuresis with IV Lasix, the patient's pulmonary congestion resolved. Pt was continued on furosemide po 40mg/day. . # Hypertension: Patient was started on Imdur 120mg daily and furosemide 40 mg daily. She was also started on metoprolol instead of her home atenolol. She was put back on her home amlodopine. Lisinopril was started as well. SBP 130s-140s during admission. . # Anemia: Patient has history of chronic anemia with HCT ranging in the 30-35. Currently HCT is 30.4. Has been noted to have guiaiac positive stools on admission. Patient will follow up with PCP for further management. . # UTI: UA consistent with UTI, and culture grew E. coli (pan-sensitive), which was covered with the antibiotics that were being used to treat PNA. Given lack of symptoms, patient was not continued beyond the 7 day abx regimen used for PNA. . ## Transitional Issues: - CXR for PNA resolution in [7-4] weeks - Discuss value of PCI if patient were to have similar symptoms in the future - Ensure adherence to new medication regimen - CODE: DNR/DNI - EMERGENCY CONTACT: [First Name4 (NamePattern1) 27474] [Last Name (NamePattern1) 27475] [Telephone/Fax (1) 27476]; [Telephone/Fax (1) 27477] Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientFamily/Caregiver. 1. Amlodipine 5 mg PO BID 2. Atenolol 100 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY RX aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 2. Multivitamins 1 TAB PO DAILY 3. Nitroglycerin SL 0.3 mg SL PRN chest pain RX nitroglycerin [Nitrostat] 0.3 mg 1 sublingually every 5 minutes Disp #30 Tablet Refills:0 4. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY RX isosorbide mononitrate [Imdur] 120 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 5. Amlodipine 5 mg PO BID RX amlodipine 5 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 6. Atorvastatin 80 mg PO DAILY RX atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 7. Clopidogrel 75 mg PO DAILY RX clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 8. Lisinopril 5 mg PO DAILY RX lisinopril 5 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 9. Metoprolol Succinate XL 300 mg PO DAILY RX metoprolol succinate 100 mg 3 tablet(s) by mouth daily Disp #90 Tablet Refills:0 10. Furosemide 40 mg PO DAILY hold for SBP <100 RX furosemide 40 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 Discharge Disposition: Home With Service Facility: ABP Best Homecare Discharge Diagnosis: 1. Community Acquired Pneumonia 2. Demand Ischemia / UA 3. Treated Acute Pulmonary Edema 4. Acute systolic CHF (EF 45%) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mrs. [Known lastname 27478], It was a pleasure taking care of you during your admission at [Hospital1 18]. You were admitted because you reported having shortness of breath and chest pain and found to have pneumonia on CXR. Your pneumonia was treated with antibiotics and you showed significant improvement. You had some chest pain that was likely due to blockages in the arteries around your heart. We increased your medicines and the chest pain has resolved. You were treated with antibiotics for an infection in your urine. On the day of discharge you were breathing well without any oxygen and your chest pain had resolved. You received medicine to remove extra fluid and you will need to watch closely for signs it is coming back. Weigh yourself every day before breakfast and call Dr. [Last Name (STitle) 3357] if weight increases more than 3 pounds in 1 day or 5 pounds in 3 days. Weight at discharge is 121 pounds. We will set up an appointment with Dr. [Last Name (STitle) 171], a cardiologist (Heart Doctor) who speaks Russian and would be happy to treat your heart condition. We will call you next week with an appointment time. Followup Instructions: Department: [Hospital ] HEALTHCARE [Location (un) ] When: THURSDAY [2199-8-29] at 12:00 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], MD [Telephone/Fax (1) 4606] Building: [State ] ([Location (un) 583], MA) [Location (un) ] Campus: OFF CAMPUS Best Parking: On Street Parking Completed by:[2199-8-24*]	[ "428.0", "799.02", "403.90", "486", "V49.86", "269.0", "272.4", "041.9", "585.9", "285.9", "733.00", "428.21", "V12.54", "599.0", "790.92", "411.89" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	13528, 13576	7908, 11727	271, 277	13740, 13740	3771, 7885	15081, 15451	2478, 2496		12368, 13505		13597, 13719		12118, 12345			13891, 15058									2511, 3752				2089, 2164																					212, 233									305, 1982										13755, 13867		2195, 2336	11750, 12092				2004, 2069	2352, 2462
19,458	174,727	27639	Discharge summary	report	Admission Date: [2179-7-26] Discharge Date: [2179-9-26] Date of Birth: [2113-6-25] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2534] Chief Complaint: fatigue, anemia, renal failure Major Surgical or Invasive Procedure: Renal biopsy, Exploratory laparotomy with removal of the left kidney and repair of an aortic puncture, plus renal vein laceration x2, abdominal closure with Kentuckypatch; plasmapheresis; abdominal wash-out, placement of gastrostomy tube, placement of jejunostomy tube, placement of right subclavian hemodialysis catheter; Insertion of right internal jugular Perma-Cath; arteriovenous fistula placement. Exploratory laparotomy (for: 1. Intra-abdominal abscess, 5 L. 2. Gangrene of the gallbladder. 3. Perforated proximal transverse colon. 4. Questionable perforated duodenal ulcer.) History of Present Illness: HPI: This is a 66 y/o M with h/o Churg [Doctor Last Name 3532] Sd who is transfered from outside hospital with hyperkalemia and acute renal failure. . Patient refers that over the last 3-4 days he was having increase of cough production with yellow sputum. No fevers or chills associated. He was also feeling very weak, lack of energy, malaise, fatigue and feeling short of breath with very small activities. He also reported abdominal distention, feeling bloated and very low po intake. + nausea and vomit. Low appetite. Decreased urine output. He went to PCP and labs were checked that showed high K and ARF. Apparently chest x ray also with fluid overload. He had Ct Scan with contrast done 2 weeks ago (see below) and reports taken Ibuprofen up to 1800/day for pain. No weight gain, no leg swelling. He was given kayexalate, insulin dextrose, calcium gluconate and he was transfered to [Hospital1 18] for further manatment. . Of note, Patient with dx of Churg [Doctor Last Name ] Sd about 2 years ago. He was taken prednisone and slowly tappering it off. He eventually stopped it on the first of [Month (only) ]. Few weeks at the end of this [Doctor Last Name 2949], when taking QOD he describes feeling worst the days that he did not take it. He also states that he has had episodes of small superficial "clots" about 3 in the last year, first in the behind the knee, another one in the right groin, and last one in the left armpit. He underwent per his hem onc doctor [Last Name (Titles) 67516] a CT Scan of the abdomen about 2 weeks ago which was normal and also chest x ray normal . Review of systems: + cough as above + mild headache, intermittent left sided. Constipation + No arthralgias or joint pain + difficulty getting out of bed in the mornings- thought to be associated to his steroids use . This patient was due to be transfered for a physical therapy institution. However, On the evening prior to transfer, the patient began to notice some mild abdominal distention. Physical examination revealed a mildly tympanitic abdomen and no change in his vital signs. The patient continued to tolerate oral feedings without difficulty. On the morning of the surgical procedure, which was [2179-9-21], the patient demonstrated further abdominal distention. Work-up included a KUB which revealed an 11 cm gas-filled structure in the midabdomen, and CT scan revealed this to be free of intraperitoneal air. The patient was therefore scheduled for urgent laparotomy. Findings included: Gangrene of the gallbladder with obscuration of structures in the right upper quadrant, question of perforation of a duodenal ulcer, 5 L intraperitoneal abscess, and a 2.5 cm perforation of the proximal transverse colon. . Past Medical History: PMH: Churg [Doctor Last Name 3532] dx 2 years ago Asthma for 35 years . PSH: Sinus surgeris x2 Hernia repair x 1 Social History: Lives with his wife. Lives 6 months in [State ] works as dentist, other six months in [Hospital1 6687]. He had 9 children. One son is general surgeon Negative tobacco use, Ocassional alcohol Family History: Father died of leukemia Mother died at [Age over 90 ] years old Two children with MS Physical Exam: On admission Vitals: T:98.6 145/85 P: 75 R: 20 BP: 145/85 SaO2: 96% General: Awake, alert in non apparent distress HEENT: Non-icteric, + JVD ~10cm, dry oral mucosa Pulmonary: Decrease breath sounds in the bases. Few cracles. Cardiac: RRR, nl s1-s2, no murmurs, no rubs Abdomen: soft, mild tenderness in the RUQ, slighly decrease bowel sounds. Extremities: mild ankle edema. distal pulses preserved Skin: no rashes or lesions noted. Neurologic: alert, oriented x3, no asterixis, reflexes preserved bilaterally. strength 5/5 Pertinent Results: OSH: WBC 8.3 Hb8.9 HCT 26, Plat 64 Diff N 62% L 25.6 Na 131 K 5.2 Chloride 105, HCO3 17 Gluc 97 BUN 110 Creat 6.4 Cal 8.0 Bil T 1.8 Alb 3.0 Alk phosph 78, AST 34, AlT 17 , U/A spec graity 1025, gluc neg, keton trace PH 5.0 urobili 0.2 Prot >300 RBC 50-75 WBC [1-26] . At [Hospital1 18]: On admission ([2179-7-26]): CBC: WBC-7.5 (Differential: Neuts-67 Bands-2 Lymphs-10* Monos-13* Eos-8* Baso-0 Atyps-0 Metas-0 Myelos-0) RBC-2.97* Hgb-8.5* Hct-24.3* MCV-82 MCH-28.5 MCHC-35.0 RDW-16.4* Plt Ct-47* . Blood Smear: Hypochr-NORMAL Anisocy-1+ Poiklo-1+ Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Schisto-1+ Bite-OCCASIONAL . Coagulation measurement: PT-13.1 PTT-25.6 INR(PT)-1.1; Plt Ct-47; Fibrinogen-452 . Chemistries: Glucose-93 UreaN-115* Creat-6.0* Na-136 K-5.1 Cl-105 HCO3-17* AnGap-19 . Liver function tests: ALT-13 AST-30 LD(LDH)-881* AlkPhos-68 TotBili-1.8* DirBili-0.4* IndBili-1.4 ALT-12 AST-28 LD(LDH)-942* AlkPhos-66 Amylase-45 TotBili-1.5; Lipase-31; TotProt-6.0* Calcium-8.3* Phos-9.0* Mg-2.8; Albumin-3.0 Iron-58 Hapto-<20* calTIBC-211 Ferritn-834* TRF-162* . Other: VitB12-359 Folate-13.3; CRP-123.5; PEP-NO SPECIFI b2micro-24.4 IgG-1441 IgA-145 IgM-79; Lactate-1.1; ESR-56* Parst S-NEGATIVE; Ret Aut-1.3 . ABG: ([2179-7-27]) Temp-37.1 pO2-79* pCO2-28* pH-7.35 calTCO2-16* Base XS--8 NOT INTUBATED . Hospital Course: Serum Free Calcium ranged from 0.37 ([2179-7-30]) to 1.36 ([2179-8-3]) and the most recent level at 0.95 ([2179-8-18]) Serum Hemoglobin/Hematocrit levels on admission were Hgb-8.5 Hct-24.3 on [2179-7-26] and ranged from Hgb-12.0 Hct-34.9 ([2179-7-30]) to Hgb-12.0 Hct-34.9 ([2179-7-30]) with the most recent levels Hgb-8.4 Hct-25.9 ([2179-9-18]). . WBC ranged from 4.7 ([2179-8-30]) to 42.8* ([2179-8-8]) with the most recent level 14.2 ([2179-9-18]) Platelets ranged from 32 ([2179-7-27]) to 243 ([2179-9-6]) with the most recent level 100 ([2179-9-18]) Na ranged from 129 ([2179-8-7]) to 148 ([2179-9-12]) with the most recent 141 ([2179-9-18]) K ranged from 3.4 ([2179-8-12]) to 5.7 ([2179-9-6]) with the most recent 4.4 ([2179-9-18]) Cl ranged from 93 ([2179-8-12]) to 115 ([2179-9-12]) with the most recent 110 ([2179-9-18]) Bicarbonate ranged: 11 ([2179-7-30]) to 31 ([2179-8-23]) with most recent 19 ([2179-9-18]) BUN ranged: 57 ([2179-8-3]) to 129 ([2179-8-8]) with most recent 79 ([2179-9-18]) Creatinine ranged: 1.3 ([2179-9-18]) to 8.4 ([2179-7-30]) Calcium ranged: 6.6 ([2179-8-18])to 9.1 ([2179-8-9]), most recent 7.7 ([2179-9-18]) Magnesium ranged: 1.7 ([2179-8-24]) to 2.9([2179-7-28]), most recent 2.0 ([2179-9-18]) Phosphate ranged:2.9 ([2179-9-15]) to 13.0 ([2179-7-30]), most recent 3.8 ([2179-9-18]) Glucose ranged: 78 ([2179-8-11]) to 308 ([2179-7-30]), most recent 142 ([2179-9-18]) INR ranged: 1.1 ([2179-7-26]) to 4.0 ([2179-8-15]), most recent 1.3 ([2179-9-18]) . Serum lactate level on admission was Lactate-1.1 ([2179-7-27]) and ranged from Lactate-1.5 ([2179-8-8]) to Lactate-7.1 ([2179-7-30]) with most recent level of Lactate-2.8 ([2179-9-18]) . . CULTURES: [2179-8-24] URINE CULTURE KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. This isolate is an extended-spectrum beta-lactamase (ESBL) producer and should be considered resistant to all penicillins, cephalosporins, and aztreonam. Sensitive only to Meropenem and Imipenem CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML . [2179-9-9] URINE CULTURE KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. This isolate is an extended-spectrum beta-lactamase (ESBL) - Sensitive only to Meropenem and Imipenem . [2179-9-15] URINE CULTURE: NO GROWTH. . PATHOLOGY: [2179-7-30]: Renal Biopsy, needle: 1. Immune complex glomerulonephritis, most consistent with lupus nephritis. 2. Thrombotic microangiopathy Light Microscopy: The specimen consists of renal cortex only containing approximately 13 glomeruli, of which 3 are globally sclerotic. The remainder show variable mild-moderate endocapillary proliferation with accompany neutrophils. One fresh cellular crescent is seen. Most also show congestion, thrombosis, and focal necrosis, with karyorrhectic debris. There is mild interstitial fibrosis and tubular atrophy. Mild chronic inflammation accompanies the scarring, but is also seen in preserved areas. No granulomatous interstitial inflammation is seen. Arterioles show mild intimal fibroplasia. Arteries show mild mural thickening, and hyaline change. No necrotizing vasculitis is seen. Immunofluorescence: The specimen consists of renal cortex only, containing approximately 7 glomeruli, of which none are globally sclerotic. There is granular mesangial, peripheral capillary loop, [Doctor Last Name ] capsule, vascular, and tubular basement membrane staining for IgG ([3-27]+), C1q (3+), IgA (trace-1+), IgM (trace-1+), Kappa ([2-26]+) and lambda ([2-26]+). Two glomeruli show [2-26]+ C3, others are negative. Vessels show trace C3. Albumin is non-contributory. Two glomeruli show fibrin thrombi, all others show segmented staining. Comment: The immunofluorescence findings, particularly the "full house" and Clq positivity together with the extensive vascular & tubular basement membrane positivity, strongly argue that this patient's immune complex glomerulonephritis is lupus nephritis. Of course, thrombotic microangiopathies may supervene on lupus nephritis, and often portend a bad prognosis. Although Churg [Doctor Last Name 3532] syndrome may involve the kidney, when it does, it typically demonstrates very different findings (pauci-immune crescentic glomerulonephritis) than the lesions in this sample. ELECTRON MICROSCOPY (C-4313): Fine structural studies of three glomeruli, which show occlusive endocapillary proliferation but no obvious thrombosis, reveal extensive foot process effacement. Occasional subepithelial and intramembranous electron dense deposits are seen. The capillary lumens are occluded by hypercellularity, some of which are likely leukocytes. Endocapillary, mesangial, and subendothelial electron dense deposits are seen, together with cytoplasmic swelling. No electron lucent widening of the subendothelial space is noted. Focal mesangial interposition is identified. Tubuloreticular structures are not seen. Electron dense deposits are also seen along [Doctor Last Name ] capsule and tubular basement membranes. These findings confirm an immune complex glomerulonephritis, and exhibit the multi-site deposition that is typical of lupus nephritis. While classic findings of a thrombotic microangiopathy are not seen in these particular [Hospital1 ], this may be due to the morphology being altered by the extensive immune complex related changes, as well as to sampling (no thrombi seen in these glomeruli). . . [2179-7-30]: LEFT KIDNEY (Left Nephrectomy): Thrombotic microangiopathy, see note. Endocapillary proliferative glomerulonephritis with cellular crescents seen in less than 10% of the glomeruli. Probable biopsy site with no associated inflammation or hemorrhage. Significant hemorrhage seen in renal hilum only. Major arteries and veins with chronic injury (intimal fibroplasia) and no active vasculitis. Note: No hemorrhage or inflammation is seen in the presumed area of biopsy. By report, only one needle biopsy core of renal parenchyma was obtained, approximately 3 hours prior to the nephrectomy, and the kidney was found, at operation, to be poorly perfused. Please see renal biopsy report (S06-[Numeric Identifier 67517]) for details on this patients renal disease. PAS, MT, and [Doctor Last Name ] special stains reviewed. [2179-8-4] PORTION OF OMENTUM: Focal fat necrosis and recent hemorrhage. . IMAGING: RENAL U.S. [2179-7-27] REASON FOR THIS EXAMINATION: Rule out hydronephrosis The right kidney measures 11.7 cm and the left kidney 11.4cm. Both kidneys are unremarkable without evidence of hydronephrosis, stones or mass. The urinary bladder is decompressed. Incidental note is made of gallbladder sludge but no wall thickening or pericholecystic fluid. IMPRESSION: No evidence of hydronephrosis. . ABDOMEN U.S. (COMPLETE) [2179-7-29] REASON FOR THIS EXAMINATION: size and texture of spleen INDICATION: 66-year-old man with left upper quadrant pain and flank pain. Evaluate size and texture of spleen. Comparison is made to prior study of [2179-7-27]. The liver is normal in size and without focal lesions. The common bile duct is unremarkable measuring 6 mm. The gallbladder is filled with sludge, but has no wall thickening or pericholecystic fluid. The right kidney measures 11.2cm. The parenchyma of the right kidney is unremarkable. The left kidney measures 12.8 cm. There is no hydronephrosis or stones. The spleen is normal in size measuring 11.5 cm and is of homogeneous echogenicity. IMPRESSION: 1. Normal appearance of both kidneys. No evidence of hydronephrosis. 2. Normal-sized spleen. 3. Gallbladder filled with sludge. No evidence of cholecystitis. . CHEST (PA & LAT) [2179-7-27] REASON FOR THIS EXAMINATION: r/o volume overload INDICATION: Acute renal failure and shortness of breath. The heart is mildly enlarged. There is upper zone vascular redistribution, and there are diffuse bilateral interstitial opacities with numerous septal lines. Small bilateral pleural effusions are present, right greater than left. Additionally, there is evidence of previous granulomatous infection with calcified lymph nodes in the left hilum, aorticopulmonary window, and a small calcified left upper lobe granuloma. An asymmetrical area of opacity in the right perihilar region is likely due to asymmetrical edema, and less likely a superimposed process such as aspiration or infection. IMPRESSION: Diffuse interstitial edema, associated small bilateral pleural effusions. . ABDOMEN (SUPINE ONLY) [2179-7-27] REASON FOR THIS EXAMINATION: r/o obstruction INDICATION: Abdominal distention. Supine radiographs of the abdomen demonstrate a nonobstructive bowel gas pattern. If there is clinical suspicion for free intraperitoneal air, either an upright or lateral radiograph would be recommended. Within the imaged portions of the lung bases, there are interstitial abnormalities likely due to diffuse interstitial edema as revealed on recent chest radiograph of earlier the same date. . CT CHEST W/O CONTRAST [2179-7-29] REASON FOR THIS EXAMINATION: characterize lung parenchyma and pleural space, infiltrates, edema, effusions, masses CONTRAINDICATIONS for IV CONTRAST: creatinine elevated INDICATION: Churg-[Doctor Last Name 3532] syndrome. Cough. Multidetector CT of the chest was performed without intravenous or oral contrast administration. Images are presented for display in the axial plane at 5-mm and 1.25-mm collimation. There are multifocal lung abnormalities including smoothly thickened septal lines, as well as multifocal areas of ground-glass attenuation. Some of the ground-glass opacities are spherical (for example right upper lobe) (image 21, series 3), and others are more confluent. The confluent ground-glass opacities are most prominent in the central, perihilar regions coursing along bronchovascular bundles. There are also two broad band-like areas of linear opacification in both perihilar regions with some associated mild volume loss. The central airways are patent. Areas of multifocal bronchial wall thickening. There is mediastinal lymphadenopathy. The largest node is in the subcarinal region measuring 3 cm x 1.6 cm in diameter. Additional enlarged nodes are present throughout the paratracheal portions of the mediastinum. There is also one hyperdense calcified node in the left prevascular space in conjunction with a small calcified left upper lobe granuloma and additional calcified hilar and AP window nodes. Heart is upper limits of normal in size. There is a small pericardial effusion and there are also small dependent bilateral pleural effusions. Within the imaged upper abdomen, the adrenal glands are normal. There is nonspecific stranding of the mesentery. Numerous small abdominal and retroperitoneal lymph nodes are present. There are no suspicious lytic or blastic skeletal lesions. Additional note is made of bilateral retrocrural lymphadenopathy as well as numerous small nodes in the posterior mediastinum just above the diaphragm level and adjacent to the GE junction. Additional small nodes are present in the pericardial region. IMPRESSION: 1. Multifocal septal thickening, ground-glass opacities and bronchial wall thickening, likely due to provided history of Churg- [Doctor Last Name 3532] syndrome. 2. Bilateral dependent small pleural effusions, with small anterior loculated component of the left effusion. Small pericardial effusion. 3. Multiple lymph nodes throughout the mediastinum (largest in subcarinal area), hila, and imaged portion of the abdomen. This could be due to mediastinal eosinophilic lymphadenopathy from Churg-[Doctor Last Name 3532] syndrome, but it is difficult to fully exclude lymphoma. Followup scans after treatment for Churg-[Doctor Last Name 3532] would be helpful to assess for resolution. 4. Evidence of previous granulomatous exposure. . [2179-7-30] NEEDLE BIOPSY OF LEFT KIDNEY BY NEPHROLOGIST Reason: ATN vs HUS vs Churgg [Doctor Last Name 3532] exacerbaction BIOPSY GUIDANCE: Ultrasound guidance was provided to the nephrology service during performance of biopsy of the right native kidney. Five passes were made under ultrasound guidance. The patient experienced pain following the procedure and was transferred to the CT Suite for further evaluation. The CT scan has demonstrated perirenal hematoma. This was not imaged during the biopsies or immediately following the biopsies using ultrasound. IMPRESSION: Son[Name (NI) 493] guidance provided to nephrology service for obtaining core biopsies of the left native kidney. . CT PELVIS W/O CONTRAST [2179-7-30] Reason: s/p kidney biopsy with sever pain INDICATION: Status post renal biopsy, with severe left-sided pain. Evaluate for hematoma. CONTRAINDICATIONS for IV CONTRAST: Cr 7.9 COMPARISON: None. TECHNIQUE: MDCT acquired contiguous axial images were obtained from the lung bases to the pubic symphysis. Multiplanar reconstructions were performed. CT OF THE ABDOMEN WITHOUT CONTRAST: Bilateral small pleural effusions are seen at the lung bases. There is a small pericardial effusion also noted. Within the left lung base, there are areas of ill-defined patchy opacity, which likely reflect changes from the patient's known Churg-[Doctor Last Name 3532] disease. On this non-contrast enhanced study, the liver, gallbladder, right kidney, and right adrenal gland are normal. There is a large area of fat stranding and soft tissue density material surrounding the left kidney, and within the posterior pararenal space and extending along Gerota's fascia anteriorly, consistent with a perinephric hematoma. The left kidney is markedly displaced anteriorly. The hematoma extends from the level of the diaphragm within the retroperitoneum inferiorly to the level of the superior portion of the bladder, and the left pelvic side wall. The spleen and pancreas are also displaced anteriorly. No free intraperitoneal air is seen. . CT OF THE PELVIS WITH IV CONTRAST: There is extensive retroperitoneal hematoma surrounding the left kidney, as described above. BONE WINDOWS: No suspicious lytic or sclerotic lesions are identified. CT RECONSTRUCTIONS: Multiplanar reconstructions were essential in delineating the anatomy and pathology. IMPRESSION: 1. Extensive retroperitoneal and perinephric hematoma, displacing the left kidney anteriorly. 2. Small bilateral pleural effusions and pericardial effusion. 3. There are patchy opacities within the left lower lobe, which are likely related to patient's known Churg-[Doctor Last Name 3532] disease. . CHEST XRAY: LINE PLACEMENT [2179-7-30] INDICATION: Check position of CVL. COMPARISON: [2179-7-27]. Compared to the prior study, there is a right CVL with the tip in the SVC and there is a left entering Swan-Ganz with tip in the right pulmonary outflow tract. Bilateral patchy densities are seen, left greater than right, the left being newer and suspicious for. Upper lungs also shows increased density compared to the prior study and a followup film is recommended. There is no PTX. The patient has been intubated since the prior study, with the tip of The ETT 3.6 cm above the carina. The heart size is within normal limits. IMPRESSION: No PTX with two CVLs placed as described above. New patchy density in the left mid lung field, which would be consistent with pneumonia in the appropriate clinical setting. Increased density in the upper lung fields bilaterally. Followup is recommended to see if this process evolves further. . CHEST (PORTABLE AP) [2179-8-1] Reason: Acute increased 02 requirement SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Acute increased O2 requirement. Patient with hemoperitoneum with nephrectomy and history of Churgh-[Doctor Last Name 3532] syndrome. Comparison is made with prior study dated [2179-7-30]. FINDINGS: There has been improvement in the moderate pulmonary edema. The endotracheal tube tip is located 7.6 cm above the carina (3cm above the standard position). Swan-Ganz catheter tip is in the right pulmonary outflow tract. Unchanged position of the right SCV Line in the lower third of the SVC. The feeding tube is folded in the stomach, its tip facing the GE junction. The heart size is normal. Unchanged small left pleural effusion IMPRESSION: Interval improvement in the moderate pulmonary edema Folded feeding tube in the stomach. Unchanged small left pleural effusion. . CHEST (PORTABLE AP) [2179-8-2] REASON FOR THIS EXAMINATION: new decrease in oxygen saturations CHEST, SINGLE AP FILM IMPRESSION: Increase in size of left pleural effusion and, even allowing for rotation of the chest to the left, likely increased collapse of left lower and left upper lobes. Small ill-defined focal opacity, right midzone for which re-evaluation on followup is suggested. . BILATERAL LOWER EXTREMITY VENOUS DOPPLER, [2179-8-3] COMPARISON: None. INDICATION: Rule out DVT. History of left common femoral line. FINDINGS: The common femoral, superficial femoral, and popliteal veins are patent bilaterally demonstrating normal color flow, compressibility, and augmentation. There is no evidence of intraluminal venous thrombus. A central line is seen in the left common femoral vein. IMPRESSION: No evidence of deep venous thrombosis of the lower extremities bilaterally. . CHEST (PORTABLE AP) [2179-8-6] INDICATION: Hemoperitoneum status post ex lap and nephrectomy with desats. COMPARISON: [2179-8-4]. FINDINGS: An endotracheal tube is in place with tip terminating 6.6 cm from the carina. Left subclavian venous access catheter with tip in upper SVC, and right subclavian venous access catheter with tip in mid SVC, are in unchanged position. Since the previous examination, the left mid lung consolidation has improved and there is continued left lower lobe atelectasis and pleural effusion. The right lung is clear and there is no pneumothorax. IMPRESSION: 1. Improved left mid lung consolidation. Stable left pleural effusion and left lower lobe atelectasis. 2. Lines and tubes in satisfactory position. . FLUOROSCOPIC GUIDED EXCHANGE OF NEW DIALYSIS CATHETER [2179-8-8] INDICATION FOR EXAM: The patient with left subclavian hemodialysis catheter that is not working. PROCEDURE AND FINDINGS: The procedure was performed by Dr. [Last Name (STitle) 15785] and Dr. [Last Name (STitle) 4686], the attending radiologist, who was present and supervising throughout the procedure. Initially, both ports were aspirated with a 4 mL syringe. Since the lateral port could not be aspirated, a fluoroscopic image of the thorax was performed demonstrating the tip of the catheter in the left brachiocephalic vein. An Amplatz guidewire was advanced through the patent port into the superior vena cava. The catheter then was pulled out through the guidewire with compression of the right subclavian vein. A new 14.5 French dual-lumen tunneled dialysis catheter was then advanced into the right internal jugular vein and the tip placed into the distal superior vena cava under flouroscopic guidance. The catheter was secured to the skin with 0 Prolene sutures. There were no immediate complications during the procedure. IMPRESSION: Successful exchange of a hemodialysis catheter with a new 14.5 French 23 cm dual-lumen tunneled dialysis catheter placed through right internal jugular vein approach. The line is ready for use. . BILATERAL LOWER EXTREMITY ULTRASOUND: [2179-8-9] INDICATION: History of left common femoral line. Evaluate for DVT. COMPARISON: [2179-8-3]. Grayscale and Doppler ultrasound of the right and left common femoral, superficial femoral, and popliteal veins were performed. Normal flow, augmentation, compressibility, and waveforms are demonstrated. No intraluminal thrombus is identified. Please note that the left common femoral vein was examined distally and was not examined proximally due to the presence of a left groin bandage. IMPRESSION: No evidence of DVT in the right or left lower extremity vessels examined. Note that the left common femoral vein at the level of the bandage was not examined. . ABDOMEN (SUPINE ONLY) [2179-8-13] INDICATION: 66-year-old man with renal failure and abdominal distension. Comparison is made with abdominal radiograph dated [2179-7-30]. Note is made of dilated small bowel gas in the left lower quadrant, measuring up to 5 cm. Colon gas is seen distally, without marked dilatation. No evidence of free air is identified on this abdominal radiograph. IMPRESSION: Dilated small bowel gas up to 4 cm in left lower quadrant; however, distal colon gas is seen without dilatation. This may represent partial obstruction or ileus. If there is a high clinical concern, CT of the abdomen can be performed. . RIGHT UPPER EXTREMITY ULTRASOUND: [2179-8-17] INDICATION: Increasing upper extremity swelling. Evaluate for DVT in the right arm. Grayscale and Doppler examination of the right internal jugular, subclavian, axillary, brachial, basilic and cephalic veins were performed. Normal flow, augmentation, compressibility where appropriate and waveforms are demonstrated. No intraluminal thrombus is identified. There is a catheter in place within the right subclavian vein. IMPRESSION: No evidence of DVT in the right upper extremity. . BILATERAL LOWER EXTREMITY ULTRASOUND: [2179-8-20] INDICATION: [Hospital 24084] hospital stay and immobility. Patient with GI bleed. Evaluate for DVT. COMPARISON: [2179-8-9]. Grayscale and Doppler son[Name (NI) 867] of the right and left common femoral, superficial femoral, and popliteal veins were performed. Normal flow, augmentation, compressibility and waveforms are demonstrated. No intraluminal thrombus is identified. IMPRESSION: No evidence of DVT in either lower extremity. . Portable AP chest radiograph [2179-8-25] REASON FOR EXAMINATION: Postoperative evaluation of the patient after nephrectomy. Compared to [2179-8-8]. The patient was extubated in the meantime interval. The right subclavian double lumen catheter terminates 1 cm below the cavoatrial junction. There is left pleural effusion which seems to be slightly decreased in comparison to the previous film with adjacent left lower lobe atelectasis. The consolidation due to infectious process cannot be excluded. There is some worsening of the right lower lobe discoid atelectasis. IMPRESSION: Left pleural effusion with adjacent left lower lobe atelectasis. Worsening of the right lower lobe atelectasis. . RENAL U.S. [2179-8-28] INDICATION: 66-year-old man with lupus-like kidney disease worsening renal function. Evaluate for hydronephrosis, bladder obstruction, or other renal pathology. COMPARISON: [2179-7-27]. The right kidney measures 13.0 cm. The left kidney has been removed. There is no evidence of hydronephrosis or stones within the right kidney. Within the urinary bladder is a small linear echogenic structure measuring approximately 4 to 5 cm in length that likely represents a bladder fold. Incidentally noted is a gallbladder partially filled with sludge. IMPRESSION: 1. No evidence of hydronephrosis or stones. 2. Status post left kidney removal. . SPLEEN ULTRASOUND [2179-8-28] INDICATION: 66-year-old male with acutely drop in platelet count. Evaluate for splenic congestion/splenomegaly. The spleen is at the upper end of normal size limits measuring 12 cm. Normal echotexture is demonstrated throughout the spleen with no focal abnormalities. No perisplenic fluid is demonstrated. IMPRESSION: Normal sized spleen at the upper limits of normal with no focal abnormalities identified. . SHOULDER [2-26] VIEWS NON TRAUMA [2179-8-28] HISTORY: Right shoulder pain. Rule out fracture. IMPRESSION: Three views of the right shoulder show no fracture, dislocation, or abnormality of the adjacent ribs or pleura. There is mild degenerative spurring at the acromioclavicular joint. . CHEST (PORTABLE AP) [2179-9-4] INDICATION: Placement of a tunneled catheter. A single AP view of the chest is obtained on [2179-9-4] at 16:18 hours and is compared with the prior radiograph performed on [2179-8-26]. A right-sided internal jugular hemodialysis catheter is seen with its tip projecting over the expected location of the mid SVC. No pneumothorax is seen. A small left pleural effusion is present. There is also increased density in the left retrocardiac area consistent with airspace disease/atelectasis, which appears to have improved slightly since the prior examination. Linear atelectasis in the right lower lobe is essentially unchanged. There is no evidence of failure. IMPRESSION: 1. Hemodialysis catheter with the tip projecting over the mid SVC. 2. Persistent asbestos disease and/or atelectasis on the left side, improving slightly. 3. Small left pleural effusion, unchanged. 4. Right lower lobe linear atelectasis, unchanged. . . . . Brief Hospital Course: Patient passed away on [2179-9-26] at [2098]. . A/P: 66 year old man with history of Churg-[Doctor Last Name 3532] presents with cough, malaise found to be in acute renal failure, hyperkalemia, and hemolytic anemia/thrombocytopenia. On [2179-7-30], the patient underwent a left kidney biopsy, developed flank pain immediately post biopsy, with CT demonstrating a retroperitoneal hematoma. The patient was transferred to the medical intensive care unit, at which time he developed hypotension, requiring resuscitation with blood products. His belly became distended and he was taken emergently to the operating room. Emergent exploratory laparotomy was performed, with removal of the left kidney, repair of an aortic puncture and renal vein lacerations, and abdominal closure via [State 19827] patch. Pt returned to the OR on [2179-8-4] for abdominal wash-out, placement of gastrostomy tube, placement of jejunostomy tube, placement of right subclavian hemodialysis catheter. He then returned to the OR for an urgenet laparatomy on [2179-9-21]. The remainder of his hospital course is described by system below. Patient passed away on [9-26] at [2098]. . . Neuro Pt has remained neurologically intact throughout the course. Pain management has been the most significant neurologic issue, with control obtained by Oxycodone-Acetaminophen and Hydromorphone PRN. Overall, the patient was alert and orientated to time, person and place throughout his stay at [Hospital1 18]. He was calm and cooperative during his stay, and with no obvious neurological deficit (generalized weakness present on lower extremities bilaterally present during the majority of his stay). . . Pulmonary Pt had acute on chronic exacerbations of his asthma as an inpatient, which were treated directly by albuterol prn and secondarily by the prednisone for his renal condition. After his exploratory laparotomy on [2179-7-30], his abdomen was closed using the [State 19827]-patch technique and he was kept intubated and transferred to the ICU. After he returned to the OR for definitive abdominal closure, patient was gradually weaned off the ventilator. He was extubated on [2179-8-12]. . . Cardiac Although the patient developed a post-operative atrial fibrillation and Atrial flutter (from [8-6] - [8-14]), he was rate-controlled without further issues, although he did experience coumadin sensitivity (subsequently discontinued); from [8-14] to the present, pt remained in normal sinus rhythm on Metoprolol 25 mg PO. . . GI Beyond post-operative bowel rest per routine, pt has not experienced significant GI difficulties. He tolerated full diets thoughout the bulk of his inpatient stay, including at discharge. Of note, pt's LFTs and amylase has been elevated since the emergent surgery, with unclear etiology (possibly due to intraoperative manipulation)and clinical significance, certainly requiring continued monitoring an evaluation. The patient was also seen by the nutrition service during his stay at [Hospital1 18]. During the time period during which he had a G-tube in place, they reccomended supplemental tube feeds promoted with fibre, a regular diet with boost, and a calorie count. The patient did have a poor appetite when he was first admitted to the hospital and was encouraged to increase his oral intake, which he did so gradually. On [9-15], the patient's G-tube was removed by Dr. [Last Name (STitle) ]. . . Renal Pt presented with acute renal failure of new onset, unknown origin, and with unknown baseline Cr. Pt exhibited a pre-op BUN in the 80s and Cr in the 4-5 range. Initial laboratory testing also revealed heavy proteinuria with heavy intact RBC load, suggestive of active nephritis, also with urine eos and a hemolytic anemia. Although renal failure can occur with Churg [Doctor Last Name 3532], it is unusual to have it occur so rapidly; and while hemolytic anemia has also been seen with Churg [Doctor Last Name 3532], it is a rare complication (more commonly, one sees anemia of chronic disease). This constellation of findings c/w nephritis but inconsistent with Churg [Doctor Last Name 3532] prompted further evaluation by renal biopsy. Pt underwent renal bx on [2179-7-30], which was complicated as stated above. The pathology report noted that immunofluorescence findings, particularly the "full house" and Clq positivity together with the extensive vascular & tubular basement membrane positivity, strongly argue that this patient's immune complex glomerulonephritis is lupus nephritis. It also noted that, although Churg [Doctor Last Name 3532] syndrome may involve the kidney, when it does, it typically demonstrates very different findings (pauci-immune crescentic glomerulonephritis) than the lesions in this sample. Electron microscopy analysis of three glomeruli showed occlusive endocapillary proliferation but no obvious thrombosis, and revealed extensive foot process effacement. Occasional subepithelial and intramembranous electron dense deposits were seen. The capillary lumens were occluded by hypercellularity, some of which were likely leukocytes. Endocapillary, mesangial, and subendothelial electron dense deposits were seen, together with cytoplasmic swelling. No electron lucent widening of the subendothelial space was noted. Focal mesangial interposition was identified. Tubuloreticular structures were not seen. Electron dense deposits are also seen along [Doctor Last Name ] capsule and tubular basement membranes. These findings confirmed an immune complex glomerulonephritis, and exhibited the multi-site deposition that is typical of lupus nephritis. While classic findings of a thrombotic microangiopathy were not seen in these particular [Hospital1 ], this may be due to the morphology being altered by the extensive immune complex related changes, as well as to sampling (no thrombi seen in these glomeruli). Following his nephrectomy and Pt received several courses of HD for his RF and associated electrolyte abnormalities, but as his renal function improved, he was weaned from HD and was not HD-dependent at D/C, Prednisone, a prominent aspect of his pre-admit Churg-[Doctor Last Name 3532] regimen, was utilized throughout his stay for the purpose of controlling his SLE-like nephritis. . . Heme Pt was admitted with Hct 24, and throughout his course, displayed a waxing and [Doctor Last Name 688] normocytic anemia, with elevated LDH, elevated total bilirubin (although >4 and combined with elevated direct bili and haptoglobin) and smears revealing schistocytes suggestive of a microangiopathic process, possibly secondary to his preexisting Churg-[Doctor Last Name 3532]. Although the exact etiology of his anemia remains unclear, he was treated with Epoetin Alfa (10,000 UNIT SC given M,W,F) and folate. Pt also displayed waxing and [Doctor Last Name 688] thrombocytopenia (40,000 to 240,000 throughout stay), a finding of unclear etiology but likely secondary to Churg-[Doctor Last Name 3532]. Pt was negative for anti-heparin antibodies making HIT unlikely, but because plt count increased after d/c'ing heparin, anticoagulation was peformed using fondaparinux. Because HUS was considered as a possible cause of this hemolytic, uremic, thrombocytopenic process, pt received plasmapharesis until discontinued due to pathology report indicating SLE-like nephritis. Although stable, his Hct remains in the mid-20s at D/C. At D/C, he was given 2 units of pRBC. On [9-3], the patient underwent a fistula placement. His Perma-cath was removed by Dr.[Name (NI) 670] transplant team. . . ID Pt had one urine culture on [2179-8-24] (white count = 6.1), which grew Klebsiella pneumoniae sensitive only to imipenem and meropenem. He began antibiotic treatment with meropenem. A second urine culture on [2179-9-3] (white count = 14.9) showed no growth. The third urine culture on [2179-9-9] (white count = 18.5) grew out Klebsiella pneumoniae, again sensitive to meropenem and imipenem. At this point, it was reccomended by the Renal service to re-start antibiotic treatment, with possible failure of prior antibiotic treatment. Dr [Known lastname 67518] was started on meropenem for a total of 10 days. No growth was shown on a fourth urine culture done on [2179-9-15] (white count = 17.7) (to confirm no further bacterial growth after antibiotic treatment). . . Rheum The Rheumatology service consulted this patient on [2179-7-27] to find out if the patient??????s renal failure and hemolytic anemia was related to his Churg-[Doctor Last Name 3532] diagnosis. At this point, symptoms included wheezing, DOE, cough, pleuritic chest pain, myalgias, headache, constipation, Raynaud??????s phenomenon, rhinitis, but the patient denied arthritis, and rashes. At this point, it was felt by rheumatology that the patient was likely having a Churg-[Doctor Last Name 3532] flare and reccomended to treat with prednisone 1 mg/kg per day. They suggested a renal biopsy, which was then obtained. The following tests were performed during this hospital stay: - [2179-8-11] Hepatitis C Virus Antibody - Negative; - [2179-8-17] HIV antibody - negative; - [2179-7-28] Complement levels C3 5* mg/dL, C4 1* mg/dL; - [2179-7-27] Beta-2 Microglobulin - 24.9 mg/L; - [2179-8-6] Double Stranded DNA - negative; - [2179-7-28] Anti-Neutrophil Cytoplasmic Antibody - Negative; - [2179-8-30] Parathyroid Hormone - 29 pg/mL; - [2179-8-2] Thyroid Stimulating Hormone - 1.1 uIU/mL; - [2179-8-6] Anticardiolipin Antibody IgG 5.4 GPL - [2179-8-6] Anticardiolipin Antibody IgM - 8.6 MPL; - [2179-7-27] IGE - 497 H; [2179-7-27] FREE KAPPA; - [2179-7-27] SERUM - 169.0 MG/L, FREE LAMBDA; - [2179-7-27] SERUM 128.0 MG/L, FREE KAPPA/LAMBDA RATIO 1.32. A renal biopsy was consistent with immune-complex disease, per the rheumatology service (though atypical given age, sex and labs). The patient then underwent immunosuppresion via high dose steroids, tapered to 80mg IV qday. On [2179-8-30], the patient continued to receive Cellcept, the dosage changed to 1000mg [Hospital1 ] PO as well as continued prednisone of 100 mg daily. His prednisone dosing was planned for 80mg PO qd for 14 days starting on [2179-9-5], and then switching to 60mg PO qd for 14 days, followed by a re-evaluation on furthur dosing requirements. On [9-15], this regimen was changed to 140mg qd for 3 days, followed by 120mg qd, along with Cellcept at 1g [Hospital1 ]. . . Endocrine This patient's prednisone regimen was changed and adjusted as necessary throughout his hospital course. Initially, he was started at prednisone 1 mg/kg per day. This was followed by 100 mg daily; this was then changed to 80mg PO qd for 14 days starting on [2179-9-5], and then switching to 60mg PO qd for 14 days, followed by a re-evaluation on furthur dosing requirements. On [9-15], this regimen was changed to 140mg qd for 3 days, followed by 120mg qd, along with Cellcept at 1g [Hospital1 ]. The final reccomendations are as follows per the renal service: 120mg prednisone [9-21], [9-24], [9-26], then 100mg prednisone [9-28], [9-30], [10-2], and then 80mg qd [10-4], [10-6], [10-8], and finally, 60mg qd for a while until seen by Dr [First Name (STitle) 10083]; throughout this regimen, Cellcept is to be continued at 1g [Hospital1 ]. The patient was on a sliding insulin scale during the initial time period of his hospital stay. Medications on Admission: - Prilosec - Ibuprofen up to 1800/day - Was on prednisone until [6-24] Discharge Medications: 1. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed) as needed for dry eyes. 2. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [1-25] Drops Ophthalmic PRN (as needed) as needed for dry eyes. 3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 4. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 6. Zolpidem 5 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Please HOLD for HR<60; SBP<100. 11. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection Injection QMOWEFR (Monday -Wednesday-Friday). 12. Calcium Carbonate 1,250 mg (500 mg) Tablet Sig: One (1) Tablet PO TID (3 times a day): Please give between meals. 13. Prednisone 20 mg Tablet Sig: Six (6) Tablet PO Q48H (every 48 hours): Take on [2179-9-21]; [2179-9-24]; [2179-9-26]. 14. Prednisone 20 mg Tablet Sig: Five (5) Tablet PO Q48H (every 48 hours): Take on [2179-9-28]; [2179-9-30]; [2179-10-2]. 15. Prednisone 20 mg Tablet Sig: Four (4) Tablet PO Q48H (every 48 hours): Take on [2179-10-4]; [2179-10-6]; [2179-10-8]. 16. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO Q48H (every 48 hours): Start on [2179-10-10]. 17. Hydromorphone 2 mg/mL Syringe Sig: 0.5-2 mg Injection Q4-6H (every 4 to 6 hours) as needed for breakthrough severe pain. 18. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane TID (3 times a day) as needed. 19. Fondaparinux 2.5 mg/0.5 mL Syringe Sig: 2.5 milligrams Subcutaneous DAILY (Daily). 20. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: Sliding Scale As Directed Subcutaneous Sliding Scale As Directed. 21. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed. Discharge Disposition: Extended Care Facility: [Hospital6 18346] Discharge Diagnosis: Acute renal failure, hyperkalemia, hemolytic anemia, thrombocytopenia with renal biopsy that was complicated by aortic and left renal vein injury. Discharge Condition: Patient passed away on [9-26] at [2098]. Discharge Instructions: N/A. Patient passed away on [9-26] at [2098]. Followup Instructions: N/A. Patient passed away on [9-26] at [2098]. Completed by:[2179-9-27]	[ "995.92", "719.41", "569.83", "998.2", "567.29", "599.0", "790.4", "V58.65", "575.0", "584.5", "284.8", "790.5", "998.83", "710.0", "518.5", "E932.0", "428.0", "580.81", "427.31", "446.4", "493.92", "998.11", "038.9", "E879.8", "567.22", "251.8" ]	icd9cm	[ [ [] ] ]	[ "99.15", "00.14", "55.51", "55.23", "96.72", "99.71", "43.19", "39.95", "99.06", "99.07", "45.74", "38.95", "97.51", "39.27", "99.04", "99.05", "96.6", "46.39", "46.11" ]	icd9pcs	[ [ [] ] ]	45425, 45473	31364, 42994	345, 934	45664, 45714	4739, 6100	45816, 45901	4086, 4176		43119, 45402		45494, 45643		43020, 43096	6117, 12741		45738, 45793									4191, 4720																					2599, 3712				275, 307	22873, 31341								962, 2580																	3734, 3853	3869, 4070
83,120	164,262	44956	Discharge summary	report	Admission Date: [2172-9-18] Discharge Date: [2172-10-9] Date of Birth: [2092-5-30] Sex: M Service: NEUROSURGERY Allergies: Iodine-Iodine Containing Attending:[First Name3 (LF) 1271] Chief Complaint: seizure Major Surgical or Invasive Procedure: [2172-9-18] Right craniotomy resection of right temporal mass History of Present Illness: Mr. [Known lastname 96140] is a 80 y.o. RH male had a generalized convulsion at home witnessed by his wife. EMS took him to [Hospital3 417] Hospital. He had an MRI showing a right temporal tumor enlarged when compared to MRI done in [6-/2170] when he had a CVA. He has not had follow up for this. He was given one dose of Keppra. EEG showed no seizures at the time of recording. He also had an ECHO and carotid US. He was admitted to Neurosurgery at [Hospital1 18] and was discharged home for scheduled surgery. Past Medical History: 1. Coronary disease as noted above. Currently, free of any typical anginal symptoms. A recent Persantine myocardial perfusion study negative for any fixed or reversible defects. 2. Peripheral vascular disease status post bilateral lower extremity revascularization procedure. 3. Carotid disease status post right carotid endarterectomy at [Hospital3 417] Hospital in the fall of [2169]. That particular a surgical procedure was complicated by limited CVA. He is being followed by Dr. [Last Name (STitle) ] locally for asymptomatic moderate left system disease, which is being treated conservatively. 5. History of mild mitral regurgitation by remote echocardiography, but most recent study did not reveal any significant valvular abnormalities. 6. History of spinal stenosis status post surgical intervention. 7. Hypertension, on pharmacologic therapy. 8. Hyperlipidemia, on pharmacologic therapy. 9. Insulin-dependent diabetes. 10. History of small abdominal aortic aneurysm, which is followed locally with annual ultrasounds. 11. stenting of the RCA in the [2150]. He was last intervened upon in [2164-5-22], at which time a drug-eluting stent was placed in the RCA for a high-grade in-stent restenosis Social History: He stopped smoking many years ago. He does not drink alcohol or use drugs. He is right handed Family History: unknown Physical Exam: O: T: afebrile BP: 112/64 HR: 75 R 12 O2Sats 98% RA Gen: WD/WN, comfortable, NAD. HEENT: normocephalic, atraumatic Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Slight left ptosis, Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric except slight left ptosis. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [Doctor First Name 81]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. Bilat tremors. Strength full power [3-26] throughout except left grip is 4+. No pronator drift Sensation: Intact to light touch bilaterally. Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin Bilateral tremor Discharge exam: AOx3. Follows commands. Left facial droop. L ptosis. Moves all extremities R>L. Pertinent Results: MRI Head [9-18] Surgical planning study showing an extra-axial mass, which homogeneously enhances in the area of the right temporal lobe. This mass is consistent with a meningioma. CT Head [9-18] Post op Status post resection of right frontal meningioma with postoperative pneumocephalus and small amount of hemorrhage. There is resulting edema with effacement of the right suprasellar cistern, which could indicate an impending uncal herniation CXR [2172-9-19] The NG tube tip is in the stomach. Lung volumes are low with crowding at the bases. There is mild pulmonary vascular redistribution. There is probable small left pleural effusion that is new compared to the prior study. EEG [2172-9-20] This is an abnormal continuous ICU monitoring study because of continuous focal slowing, attenuation of faster frequencies, frequent epileptiform discharges in the right centroparietal region, and frequent electrographic seizures over the right frontotemporal region. These findings are indicative of an epileptogenic focal structural lesion in the right hemisphere, giving rise to frequent (58) right frontotemporal electrographic seizures. In addition, there is diffuse background slowing and slow alpha rhythm, indicative of mild diffuse cerebral dysfunction, which is etiologically non-specific. Compared to the prior day's recording, electrographic seizures have increased in frequency, but the background activity is unchanged. CT HEAD W/O CONTRAST [2172-9-24] New hypodensity in the right MCA territory. This change is most likely ischemic, less likely post-surgical. BILAT LOWER EXT VEINS [2172-9-24] No evidence of deep vein thrombosis in either leg. CT HEAD W/O CONTRAST [2172-9-25] : IMPRESSION: 1. Unchanged right MCA territory infarct with mild internal hemorrhage. 2. Unchanged bilateral occipital [Doctor Last Name 534] intraventricular hemorrhages. MRI Head [2172-9-25]: IMPRESSION: 1. Large subacute infarct in the right frontal and temporal lobes. 2. Postoperative changes of the right frontal and temporal skull and scalp. 3. Stable small amount of intraventricular blood in the posterior horns of the lateral ventricles. 4. No evidence of herniation or obstructive hydrocephalus. 5. Small 1- to 2-mm outpouchings along the distal aspect of the M1 segment of the right MCA, possible infundibular dilatation of normal branch vessles or true aneurysms. Findings are similar compared to prior outside hospital MRA. Further characterization with CTA is recommended or possibly direct angiography if clinically indicated. CXR: [2172-9-27] IMPRESSION: 1. Right internal jugular central line with its tip in the superior vena cava unchanged. Endotracheal tube now has its tip approximately 3 cm above the carina. Nasogastric tube is seen coursing below the diaphragm with the tip not identified. 2. Persistent relatively low lung volumes with patchy bibasilar opacities most likely reflecting patchy atelectasis though an infectious process cannot be entirely excluded. No pleural effusions or pulmonary edema. No large pneumothorax although evaluation is limited as the patient is likely supine on the current examination. Cardiac and mediastinal contours are stable with calcification of the aorta consistent with atherosclerosis. CXR portable [9-28] 1. Mild improvement in the degree of pulmonary vascular distention. 2. No evidence of ventilator-associated pneumonia. 3. Stable bibasilar atelectasis. CXR portable [9-28] for line placement: Repositioned right PICC terminating at the superior cavoatrial junction. CXR portalbe [9-29]: improved left basilar atelectasis, stable rightsided atelectasis CXR portable [9-30]: stable appearance of lungs compared with prior xray CXR Portable [10-1]:SEMI-ERECT PORTABLE CHEST: A nasogastric tube again passes into the stomach and off the inferior margin of the film. Right PICC extends to the cavoatrial junction, possibly into the upper right atrium. The lungs are unchanged in appearance with persistent low lung volumes and bibasilar atelectasis. No new opacity to suggest pneumonia. No pneumothorax or large effusion. There is bronchovascular crowding and mild vascular congestion without convincing evidence of pulmonary edema. IMPRESSION: No significant change from one day prior. CT HEAD W/O CONTRAST Study Date of [2172-10-1] 1:37 PM FINDINGS: There is persistent hypodensity in the right operculum, consistent with evolution of infarct in the right MCA territory. There is less conspicuous involvement of the right temporal lobe. There is no shift of midline structures. A small amount of dependent layering blood in the occipital horns of the lateral ventricle is unchanged from NECT of the head on [2172-9-25]. There is no evidence of intracranial hemorrhage. The ventricles and sulci are prominent consistent with age-related atrophy. Postsurgical changes from right frontoparietal craniotomy are again noted. Pneumocephalus noted on prior NECT of the head is resolved. The left sphenoid sinus is almost completely opacified. The mastoid air cells and middle ear cavities are clear. IMPRESSION: 1. Evolving right MCA infarct. No evidence of mass effect. 2. No evidence of intracranial hemorrhage. CXR [10-3] The tip of the nasogastric tube and side port are below the gastroesophageal junction appropriately sited. There is again seen cardiomegaly. There is some atelectasis at the left lung base. There is a right-sided PICC line with distal lead tip at the upper right atrium. There are no pneumothoraces or pleural effusions. LENIs [10-5] - negative for DVT CXR [2172-10-7] 1. There is no pneumothorax. 2. Left lower lung atelectasis has worsened since [2172-10-3]. 3. Pneumoperitoneum, most likely related to recent PEG, as suggested from the clinical history. 11/17 L foot x ray 1. No evidence of fracture or dislocation Brief Hospital Course: Mr. [Known lastname 96140] was admitted to Neurosurgery on [2172-9-18] and underwent a right frontal craniotomy for tumor resection. Please review dictated operative report for details. Patient was extubated without incident and remained in the ICU for close monitoring. He apeared to be a bit lethargic on exam on post operative day one and per nursing report he was intermitantly not moving his left arm which could be consistant with subclinical seizures. An EEG was ordered along with a keppra 750mg bolus and his daily dose was increased to 1000mg [Hospital1 ]. Over the weekend of [2091-9-19] he continued to have focal seizures and his daily dose was again increased to 1250mg [Hospital1 ]. He had a speech and swallow exam on [9-21] and he was not cleared for a PO diet. His DHT remained in and he was kept on tube feeds. He was transferred to the floor with 24 hour EEG monitoring. His diet [Last Name (un) 19692] advance to puree/nectar thick after Swallow exam on [9-23]. EEG was negative for seizure activity for 24 hours and the leads were discontinuued. He was seen by PT/OT and required rehab. Overnight 11/2-3 he was agitated and needed restraints. He was lethargic in the am but was oriented to all but month. In late afternoon he was only arousable to sternal rub. CT head showed a right sided stroke and he was transfered to the ICU. Stroke Neurology was consulted. A carotid US was ordered. ASA and Plavix was restarted. Overnight, patient was intubated for airway protection and lethargy. On [9-25], on examination, patient had no EO, followed simple commands and MAE R>L. MRI head and stroke workup pending. Repeat head CT performed overnight for increased lethargy showed stable stoke. EEG was negative for seizure activity. On [9-26] the patient's neurological exam was improving. neurology felt the the stroke was post operative in nature and not do to an embolic source. Echo was negative and carotid u/s revealed 60-65% stenosis in Right ICA. He was given 2 units or PRBC's for a dropping Hct. He failed trial of extubation. He was extubated and became stridorous and required reintubation. He was bradycardic to the 40's so his beta blockade was discontinued. His decadron was weaned on [9-28]. Patient's keppra was decreased from 1250 to 1000mg [Hospital1 ] and EEG over the weekend were negative for seizure activity. On [9-29], patient was placed on CPAP and subsequently weaned to extubate. His exam was stable with EO to noxious stimuli and following commands in all 4 extremities. On [9-30] a speech and swallow exam was attempted however the patient was too lethargic to fully cooperate and so it was defered. On [10-1] he was lethargic and CT showed evolving CVA .He remained in the unit. PT and OT were consulted for assistance with discharge planning.A chest xray was performed which was consistent no new relevant changes in the lungs. Lung volumes are low. Minimal bibasal atelectasis is unchanged. There are no new lung opacities of concern. Top normal heart size, mediastinal and hilar contours are similar. On [10-1], A Head CT was performed due to lethargy which was consistent with evolving right MCA infarct, no evidence of mass effect or intracranial hemorrhage. The patient stayed in the Intensive Care Unit for lethragy and inability to clear respiratory secretions. A chest Xray was performed which was stable. On [10-2], the patient failed his Speech and Swallow. He was unable to transfer out of the ICU today due to increase respiratory secretions. On [10-3] he was transferred to Stepdown Unit in stable condition. He remained stable throughout his floor course. LENIs was obtained on [10-5] which demonstrated no DVT. He was reevaluated by Speech/Swallow and they recommended considering a PEG placement. ACS/Surgery were consulted and they agreed with PEG placement. On [10-4], On exam, the patient was intermittently lethargic. He was oriented to self and hospital.The patient opens eyes intermittently. The patient followed commands in all 4 extremities, he moves the left side less. The left leg was spastic. The craniotomy incision staples were closed. On [10-5], Bilateral Lower Extremity ultrasound was Negative. The patient failed her Speech Swallow test. The ACS service was consulted for placement of a Gastric Tube. On [10-6] he was taken to the OR with Dr. [Last Name (STitle) ]. ASA/Plavix were not held due to his recent CVA. The the risks and benfits of this were discussed with his wife. [Name (NI) ] had this done on [10-7]. He tolerated the procedure well and returned to the [Hospital Ward Name 121] 11 floor. At 4pm he had 55 cc of bright red blood and lcot suctioned from his mouth but there was no sign of acute bleeding. ACS was called and a STAT HCt was sent, this was 31.3 then 30.8. The next day he was without further bleeding from the mouth. He was more awake and communicative and did well with PT on [10-8]. CXR ruled out pneumothroax with some mild pneumoperitoneum from his procedure. His tube feeds continued. Heparin was restarted. Rehab screening was in place. He had some left foot pain and X-ray showed no fracture or dislocation. He was tolerating his tube feeds per GT without difficulty.He was transferred to rehab in stable condition. Medications on Admission: 1. tamsulosin 0.4 mg Capsule, Ext Release 24 hr [Month/Year (2) ]: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 2. levetiracetam 500 mg Tablet [Month/Year (2) ]: One (1) Tablet PO BID (2 times a day). 3. hydrochlorothiazide 12.5 mg Capsule [Month/Year (2) ]: Two (2) Capsule PO DAILY (Daily). 4. oxybutynin chloride 5 mg Tablet [Month/Year (2) ]: One (1) Tablet PO DAILY (Daily). 5. finasteride 5 mg Tablet [Month/Year (2) ]: One (1) Tablet PO DAILY (Daily). 6. acetaminophen 325 mg Tablet [Month/Year (2) ]: Two (2) Tablet PO Q6H (every 6 hours) as needed for Pain: max 4g/day. 7. lisinopril 20 mg Tablet [Month/Year (2) ]: One (1) Tablet PO DAILY (Daily). 8. aspirin 325 mg Tablet [Month/Year (2) ]: One (1) Tablet PO DAILY (Daily). 9. metoprolol tartrate 50 mg Tablet [Month/Year (2) ]: One (1) Tablet PO BID (2 times a day). 10. simvastatin 10 mg Tablet [Month/Year (2) ]: Two (2) Tablet PO DAILY (Daily). 11. amlodipine 5 mg Tablet [Month/Year (2) ]: Two Discharge Medications: 1. acetaminophen 325 mg Tablet [Month/Year (2) ]: 1-2 Tablets PO Q4H (every 4 hours) as needed for HA, pain, fever. 2. docusate sodium 50 mg/5 mL Liquid [Month/Year (2) ]: Ten (10) ml PO BID (2 times a day). 3. hydrochlorothiazide 12.5 mg Capsule [Month/Year (2) ]: Two (2) Capsule PO DAILY (Daily). 4. atorvastatin 40 mg Tablet [Month/Year (2) ]: One (1) Tablet PO DAILY (Daily). 5. amlodipine 5 mg Tablet [Month/Year (2) ]: Two (2) Tablet PO DAILY (Daily). 6. lisinopril 20 mg Tablet [Month/Year (2) ]: One (1) Tablet PO DAILY (Daily). 7. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette [Month/Year (2) ]: [11-24] Drops Ophthalmic PRN (as needed) as needed for dry eyes. 8. guaifenesin 100 mg/5 mL Syrup [Month/Day (2) ]: 5-10 MLs PO Q6H (every 6 hours) as needed for secretions. 9. clopidogrel 75 mg Tablet [Month/Day (2) ]: One (1) Tablet PO DAILY (Daily). 10. aspirin 325 mg Tablet [Month/Day (2) ]: One (1) Tablet PO DAILY (Daily). 11. heparin (porcine) 5,000 unit/mL Solution [Month/Day (2) ]: One (1) ml Injection TID (3 times a day). 12. phenol 1.4 % Aerosol, Spray [Month/Day (2) ]: One (1) Spray Mucous membrane Q4H (every 4 hours) as needed for throat pain/irritation. 13. oxybutynin chloride 5 mg Tablet [Month/Day (2) ]: One (1) Tablet PO DAILY (Daily). 14. levetiracetam 100 mg/mL Solution [Month/Day (2) ]: Ten (10) ml PO BID (2 times a day). 15. heparin, porcine (PF) 10 unit/mL Syringe [Month/Day (2) ]: One (1) ML Intravenous PRN (as needed) as needed for line flush. 16. heparin, porcine (PF) 10 unit/mL Syringe [Month/Day (2) ]: One (1) ML Intravenous PRN (as needed) as needed for line flush. 17. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Meningioma Seizures post operative anemia requiring transfusion right frontal infarct right temporal infarct respiratory failure ventilator required pneumonia Ventricular tachycardia Bradycardia dysphagia Malnutrition Confusion Hemoptysis Discharge Condition: AOx3. Activity as tolerated. Discharge Instructions: ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Your may wash your hair. Your staples have been removed on [2172-10-4]. ?????? You now can shower. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? You may use Aspirin and Plavix ???????????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([Telephone/Fax (1) 88] to schedule an appointment with Dr. [Last Name (STitle) 739], to be seen in 4 weeks. ??????You have follow-up at the Brain [Hospital 341] Clinic on [10-19] at 4 pm. [Location (un) 858] [Hospital Ward Name 23] Building. Phone: Phone: [Telephone/Fax (1) 1844]. You will need an MRI of the brain with and without gadolinium contrast. [Name6 (MD) 742] [Name8 (MD) ] MD [MD Number(2) 1273] Completed by:[2172-10-9*]	[ "780.39", "272.4", "348.39", "427.1", "250.00", "433.10", "285.9", "434.91", "997.02", "414.01", "263.9", "V58.67", "997.31", "225.2", "401.9", "V49.87", "V45.82", "427.89", "441.4", "518.51", "348.4", "787.20", "431" ]	icd9cm	[ [ [] ] ]	[ "01.51", "96.04", "43.11", "33.24", "96.72", "33.22", "96.6" ]	icd9pcs	[ [ [] ] ]	17892, 17962	9611, 14979	297, 364	18245, 18276	3684, 9588	19521, 20085	2313, 2322		16046, 17869		17983, 18224		15005, 16023			18300, 19498									2337, 2497								3583, 3665																	250, 259									392, 921	2749, 3567									2512, 2733							943, 2185	2201, 2297
70,623	184,722	39750	Discharge summary	report	Admission Date: [2141-9-18] Discharge Date: [2141-9-25] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2758] Chief Complaint: Altered mental status, UTI Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [Known lastname 52584] is an 86 year-old gentleman with a history of PNA resulting respiratory failure and eventual trach and PEG who was admitted on [2141-9-18] with altered mental status. Per report, patient was alert and oriented on morning of admission, then became more confused and sleepy and later unresponsive. EMS was called and patient was brought to ED. In the ED patient was afebrile with HR 66 BP 128/62 with O2 sats 99 % on trach mask. A UA was grossly positive and foley was changed in the ED. He was given ceftriaxone 1 g IV. A head CT showed full mastoids bilaterally. On [9-21] the patient was transferred to the ICU with bradycardia (HR 20s-30s). He was given atropine x 1 and HR eventually came up into 50-60s with questionable of abnormal conduction on multiple EKGs. Both metoprolol and Digoxin were held and cardiology was consulted; they felt the current rhythm was complete heart block with junctional escape rhythm with rate in high 50s with occasional atrial beats being conducted. Also thought that hypothyroidism contributing to bradycardia and potentially potentiating digoxin effect. (TSH was 75 at the time). The cardiology service recommended holding nodal agents, continuing levothyroxine, and said that as long as rates in high 40s-60s and pt asymptomatic that no further intervention would be needed. At the time of transfer back to the floor, the patient was feeling well and without complaints. He denied chest pain or shortness of breath. He felt more clearheaded. Past Medical History: 1. Hypertension 2. Hyperlipidemia 3. Hypothyroidism 4. Recurrent pneumonias 5. Osteoarthritis 6. Sleep apnea 7. Paranoid schizophrenia 8. Bipolar 9. Gynecomastia 10. BPH 11. History of upper GI Bleed 12. Chronic back pain 13. Oropharygneal carcinoma 14. Spinal stenosis Social History: Lives in [Hospital ] nursing home ([Hospital 87550] nursing home; [Telephone/Fax (1) 87551]). Has a sister [Name (NI) 2155] [Name (NI) 26173] who is HCP and lives in [Name (NI) 3908] per his report. Family History: Not relevent in this patient for this admission. Physical Exam: Physical exam on arrival to the floor: Vitals: Afebrile; SBPs ranging 120-130s; HRs 40s-60s; 99% on trach mask General: Lying in bed, eyes closed, but easily opens them when asked to Eyes: No pallor or icterus HEENT: Trach in place with clear secretions noted; no mastoid tenderness CV: Regular and bradycardic; distant sounds; no obvious murmurs Pulm: Clear anteriorly Abd: Soft; PEG in place; non-tender Ext: Warm; thin; 1+ edema Neuro: Alert and oriented x3; able to lift arms and legs off bed equally Skin: Warm with no rashes Pertinent Results: Labs: BLOOD WBC-6.6 RBC-4.04* Hgb-12.6* Hct-37.5* MCV-93 MCH-31.2 MCHC-33.6 RDW-14.7 Plt Ct-351 PT-12.3 PTT-23.5 INR(PT)-1.0 Glucose-111* UreaN-35* Creat-1.1 Na-136 K-4.9 Cl-98 HCO3-28 AnGap-15 TSH-75* T4-2.7* T3-61* calcTBG-1.15 TUptake-0.87 T4Index-2.3* WBC-4.9 RBC-3.39* Hgb-10.7* Hct-31.2* MCV-92 MCH-31.4 MCHC-34.2 RDW-15.0 Plt Ct-333 [2141-9-21] 6:30 am URINE Source: CVS. FINAL REPORT [2141-9-23] URINE CULTURE (Final [2141-9-23]): Culture workup discontinued. Further incubation showed contamination with mixed skin/genital flora. Clinical significance of isolate(s) uncertain. Interpret with caution. PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA \| CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S Imaging: ECG ([2141-9-18]): Sinus rhythm. Left atrial abnormlaity. Left axis deviation may be due to left anterior fascicular block and/or possible prior inferior myocardial infarction, although it is non-diagnostic. Consider anterior myocardial infarction of indeterminate age. Anterolateral lead ST-T wave abnormalities are non-specific but cannot exclude ischemia. Clinical correlation is suggested. No previous tracing available for comparison. ECG ([2141-9-22] at 7:22AM): Sinus bradycardia rate 44 with single APC Atropine given: [2141-9-22] at 7:43-7:47: Sinus rate approximately 60 with high grade AV block. Accelerated Junctional rhythm, rate of 75bpm Telemetry from [2141-9-22] at 9:11AM competing sinus and junctional rhythm rates 58 and 60 repectively. ECG ([2141-9-23]): NSR in 40s-50s. CXR ([2141-9-18]): Within limitations of the study, elevated right hemidiaphragm and no definite evidence of acute cardiopulmonary process. CT HEAD ([2141-9-18]): 1. No acute intracranial process 2. Opacified bilateral mastoids and middle ears suggests otomastoiditis. 3. Mild sinus disease. ECHO ([2141-9-22]): Very limited study. Grossly preserved biventricular systolic function. Dilated aortic root. CT ORBITS ([2141-9-22]): Nonspecific opacification of the mastoid air cells and middle ear cavities bilaterally without bony destruction. Otomastoiditis is a clinical diagnosis and correlation with the patient's presentation should be made to determine if concern exists for otomastoiditis. Brief Hospital Course: Brief summary of hospital course: Mr. [Known lastname 52584] is an 86 yo man with multiple medical problems including history of atrial fibrillation with rapid ventricular response, recurrent pneumonia s/p trach 7 months ago w/ chronic PEG, and indwelling Foley catheter who lives in a skilled nursing facility. He was originally admitted on [2141-9-18] with delirium that was felt to be attributed to a complicated UTI related to his indwelling Foley catheter. In addition, he was felt to be hypothyroid with a TSH of 75. His hospital course was complicated by bradycardia with symptomatic HRs in the 20-30 range. He received atropine for this and was briefly transferred to the ICU for close monitoring. We stopped his lopressor and digoxin. In addition, we increased his Synthroid dose. His heart rates improved, he did not develop atrial fibrilation, and his delirium resolved. Active problems: 1. Bradycardia: thought to be secondary to hypothyroidism, lopressor use, and digoxin use. These were held and his heart rates improved. If he develops atrial fibrillation he may start on low-dose lopressor with monitoring of his heart rate. Regardless, he should follow-up with VA cardiology as follows: Dr. [Last Name (STitle) 87552] [Name (STitle) ] Location: 1400 [Location (un) 87553], [Numeric Identifier 26374] Department: Cardiology Phone: [Telephone/Fax (1) 19336] Appointment: Tuesday [2141-10-10] 3:30pm 2. Hypothyroidism: On admission the patient's TSH was elevated to 75. He was started on levothyroxine 50. His hypothyroidism may be contributing factor to his delirium and bradycardia. Please ensure that his levothyroxine is administered in the morning on an empty stomach, at least 30 minutes before any food is administered to ensure proper absorption. He should have a repeat TSH checked [2141-10-20] and his levothyroxine adjusted accordingly. 3. Recurrent urinary tract infections: He was found to have a UTI on admission, culture positive for pseudomonas. During the pre-ICU course, the patient was treated with ceftriaxone, however on transfer to the ICU, a UA demonstrated persistant pyuria. The patient was swithed to Cipro based on culture sensitivities (the pseudomonas had not been tested for ceftriaxone sensitivity). At the time of his transfer out of the ICU, it was recommended that he have an outpatient follow-up appt in the VA system given he has now had 3 UTIs and may benefit from suppressive antibiotics and or suprapubic catheter. He should continue on ciprofloxacin with last dose on [2141-9-25] and follow-up as follows: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 656] Location: [Location (un) 87554] [Location (un) 538], [Numeric Identifier 7023] Department: Urology Phone: [Telephone/Fax (1) 41354] Appointment: Monday [2141-10-2] 10:40am 4. Otitis media with effusion: Mr. [Known lastname 52584] has a long history of left-sided conductive hearing loss. During this admission a head CT demonstrated fluid in his mastoid, although the patient was asymptomatic. ENT was consulted and a dedicated ear exam revealed otitis media with effusion but no evidence of infection. He is recommended to follow-up with ENT as follows: Dr. [First Name (STitle) ] Gooey Location: [Location (un) 87554] [Location (un) 538], [Numeric Identifier 7023] Department: Otolaryngology Phone: [Telephone/Fax (1) 41354] Appointment: Thursday [2141-9-28] 10:20am 5. Code status: despite this patient's multiple medical problems, he requested to remain full code during this admission. Medications on Admission: ophthalmic lubricant to both eyes at bedtime Polyvinyl alcohol solution 1 gtt to both eyes daily Tylenol Albuterol nebs Q 6H PRN Levothyroxine 0.025 mg 1 tab Qday Metoprolol 12.5 mg NG [Hospital1 ] Simvastatin 80 mg NG at bedtime Trazadone 25 mg NG QHS Chlorhexidine Flunisonide inhal nasal 2 sprays each nostril daily MVI PEG daily Omeprazole 20 mg Po QDAY ASA 325 mg PEG tube Q day Digoxin 0.125 mg via PEG qday Docusate liquid via PEG [Hospital1 ] Finasteride 5 mg via PEG daily Heparin 5000 units SC Q8H Discharge Medications: 1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [Hospital1 ]: [1-7] Inhalation Q6H (every 6 hours) as needed for wheezing. 2. Simvastatin 40 mg Tablet [Month/Day (2) ]: Two (2) Tablet PO DAILY (Daily). 3. Chlorhexidine Gluconate 0.12 % Mouthwash [Month/Day (2) ]: 1-2 MLs Mucous membrane [Hospital1 ] (2 times a day). 4. Aspirin 325 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 5. Docusate Sodium 50 mg/5 mL Liquid [Hospital1 ]: One (1) PO BID (2 times a day). 6. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [Hospital1 ]: [1-7] Drops Ophthalmic QHS (once a day (at bedtime)). 7. Levothyroxine 50 mcg Tablet [Month/Day (2) ]: One (1) Tablet PO DAILY (Daily). 8. Ciprofloxacin 250 mg Tablet [Month/Day (2) ]: Two (2) Tablet PO Q12H (every 12 hours): last dose [2141-10-5]. 9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 10. Therapeutic Multivitamin Liquid [Last Name (STitle) ]: Five (5) ML PO DAILY (Daily). 11. Acetaminophen 650 mg/20.3 mL Solution [Last Name (STitle) ]: One (1) PO TID (3 times a day) as needed for pain. 12. Tramadol 50 mg Tablet [Last Name (STitle) ]: 0.5 Tablet PO Q6H (every 6 hours) as needed for pain. 13. Trazodone 50 mg Tablet [Last Name (STitle) ]: 0.25 Tablet PO HS (at bedtime) as needed for insomnia. 14. Finasteride 5 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 15. Omeprazole 20 mg Capsule, Delayed Release(E.C.) [Last Name (STitle) ]: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital ] Healthcare Center - [Location (un) 86] Discharge Diagnosis: Delirium Discharge Condition: Alert, oriented x 2. Conversant. Cranial nerves normal. Does not ambulate. He is able to describe current symptoms and recent hospital course. He remembers the name of his doctors and previous medical treatments but does not know medications or doses from memory. Discharge Instructions: Dear Mr. [Known lastname 52584], You were admitted with confusion and were found to have a urinary tract infection, which is related to your Foley. This improved with antibiotics and you should continue on ciprofloxacin with your last dose on [2141-10-5]. You also developed bradycardia which we think is related to your lopressor and digoxin use. It was probably also related to the fact that you were not receiving enough thyroid replacement and we increased this. We have a number of follow-up appointments for you outlined below. We made the following medication changes: - stop lopressor - stop digoxin - increase levothyroxine to 50mcg daily Followup Instructions: With: Dr. [First Name (STitle) ] Gooey Location: [Location (un) 87554] [Location (un) 538], [Numeric Identifier 7023] Department: Otolaryngology Phone: [Telephone/Fax (1) 41354] Appointment: Thursday [2141-9-28] 10:20am With: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 656] Location: [Location (un) 87554] [Location (un) 538], [Numeric Identifier 7023] Department: Urology Phone: [Telephone/Fax (1) 41354] Appointment: Monday [2141-10-2] 10:40am With: Dr. [Last Name (STitle) 87552] [Name (STitle) ] Location: 1400 [Location (un) 87553], [Numeric Identifier 26374] Department: Cardiology Phone: [Telephone/Fax (1) 19336] Appointment: Tuesday [2141-10-10] 3:30pm	[ "272.4", "E849.9", "V44.1", "V44.0", "599.0", "584.9", "401.9", "276.52", "244.9", "382.9", "293.0", "427.89", "996.64", "389.05", "600.00", "E879.6", "295.30" ]	icd9cm	[ [ [] ] ]	[ "96.6" ]	icd9pcs	[ [ [] ] ]	11642, 11727	5756, 5762	289, 295	11780, 12046	3022, 5733	12754, 13514	2406, 2456		9949, 11619		11748, 11759		9409, 9926			12070, 12635									2471, 3003													5790, 9383										12656, 12731		223, 251									323, 1856																	1878, 2149	2165, 2390
2,729	132,777	29651+57650	Discharge summary	report+addendum	Admission Date: [2179-12-18] Discharge Date: [2179-12-24] Date of Birth: [2128-11-6] Sex: M Service: SURGERY Allergies: Penicillins Attending:[First Name3 (LF) 5880] Chief Complaint: s/p Motor vehicle crash Major Surgical or Invasive Procedure: Bilateral chest tube thoracostomies History of Present Illness: 51 yo male unrestrained driver s/p motor vehicle crash vs oil tanker. He was taken to an area hospital and intubated. Head imaging revealed intracranial hemorrhage; he was then transferred to [Hospital1 18] for furthe care. Upon arrival he was pulseless, once chest decompressed his pulse returned. Past Medical History: ?Psychiatric history Family History: Noncontributory Pertinent Results: [2179-12-18] 06:58PM GLUCOSE-102 UREA N-13 CREAT-0.7 SODIUM-143 POTASSIUM-4.2 CHLORIDE-107 TOTAL CO2-25 ANION GAP-15 [2179-12-18] 06:58PM WBC-11.3* RBC-3.97* HGB-13.7* HCT-39.9* MCV-100* MCH-34.4* MCHC-34.3 RDW-12.6 [2179-12-18] 06:58PM PLT COUNT-115* [2179-12-18] 06:58PM PT-12.8 PTT-27.6 INR(PT)-1.1 CHEST (PORTABLE AP) Reason: Eval for recurrent ptx [Hospital 93] MEDICAL CONDITION: 40 year old man with B PTX, B chest tubes. L Chest tube pulled yesterday AM, R Chest tube pulled this AM REASON FOR THIS EXAMINATION: Eval for recurrent ptx INDICATION: Removal of right chest tube. COMPARISON: [2179-12-21]. AP UPRIGHT CHEST: The heart size, mediastinal and hilar contours are normal. There has been interval removal of the right-sided chest tube. There is no pneumothorax. Subcutaneous emphysema is again visualized along the right lateral thoracic wall. The lungs are grossly clear. No pleural effusions are identified. IMPRESSION: No pneumothorax. Interval removal of right chest tube. CT HEAD W/O CONTRAST Reason: eval for bleeding [Hospital 93] MEDICAL CONDITION: 40 year old man s/p MVA REASON FOR THIS EXAMINATION: eval for bleeding CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: MVA. NON-CONTRAST HEAD CT: No hydrocephalus, shift of normally midline structures, or acute major vascular territorial infarct is identified. Several foci of intraparenchymal hemorrhage are identified in the frontal lobes. For example, in the left frontal lobe, there is an 8-mm focus of blood. In the right frontal lobe near the vertex, there is a 6-mm focus, a 4-mm focus, and a 5-mm focus. No other foci of intraparenchymal hemorrhage are seen. High density material in the occipital [Doctor Last Name 534] of the right lateral ventricle is not likely to be blood. There is opacification of the dependent portion of the nasal cavity. Air is seen dissecting along the soft tissues overlying the right posterior fossa, though no soft tissue defect is seen in the imaged portion. No fractures are seen. Other imaged sinuses including the mastoid air cells, maxillary sinuses, and ethmoid and sphenoid sinuses appear clear. High density indicating blood is seen in right occipital [Doctor Last Name 534]. IMPRESSION: Bifrontal traumatic small intraparenchymal hemorrhages. Air in subcutaneous tissues of right occipital region originates from right chest tube. Intraventricular blood in the occipital [Doctor Last Name 534] of right lateral ventricle. Findings discussed with trauma surgery team at time of interpretation. CT C-SPINE W/O CONTRAST Reason: r/o fracture, dislocation [Hospital 93] MEDICAL CONDITION: 40 year old man s/p MVA REASON FOR THIS EXAMINATION: r/o fracture, dislocation CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: MVA. CT CERVICAL SPINE: No prior for comparison. Slight kyphosis of the C-spine centered at C5, probably degenerative in nature; there is loss of disc height at C4-5 through C6-7. There is grade I anterolisthesis of C4 on C5. A large amount of retropharyngeal and paravertebral subcutaneous emphysema is seen dissecting along the retropharyngeal space and posterior to both sternocleidomastoid muscles into the mediastinum. Endotracheal tube is noted, as is a nasogastric tube. The tube cuff is slightly over-distended. Some dependent opacity in the left lung apex is seen, and there is a small left pneumothorax. Incidentally noted is surgical fusion of the right facet joints of C4-5, with a cerclage wire encircling the spinous processes of C4-5. IMPRESSION: 1. Degenerative changes of the spine. No acute fractures seen. 2. Slight overdistention of the ETT cuff. For details regarding the traumatic injuries to the chest, please see CT torso of the same day. Brief Hospital Course: He was admitted to the trauma Service under the care of Dr. [Last Name (STitle) ]. Neurosurgery was immediately consulted. An ICP bolt was placed, he was loaded with Dilantin and remained on a stable dose for 7 days. He underwent serial head imaging which revealed stable ICH. This injury was nonoperative. Psychiatry was consulted because of behavioral issues; he initially required Ativan for extreme agitation and required sitters for safety. The Ativan appeared to have contributed to a delirium and so this was stopped; he was placed on Haldol which he did require for subsequent agitated episodes. Over the next several days his behavior improved considerably, he was less agitated and more cooperative with his care. The Haldol was eventually stopped. Behavioral Neurology was consulted because of his traumatic brain injury and made several recommendations; Ambien was initiated to help regulate his sleep/wake cycle. He will need to follow up with Dr. [Last Name (STitle) 8012] in [1-8] weeks. Physical and Occupational therapy were consulted and have recommended home with outpatient Occupational therapy for ongoing cognitive rehab. Medications on Admission: Seroquel Discharge Medications: 1. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:45 Tablet(s) Refills:0 3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 4. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML's PO once a day as needed for constipation. 5. Phenytoin 50 mg Tablet, Chewable Sig: Three (3) Tablet, Chewable PO TID (3 times a day) for 2 days. Disp:18 Tablet, Chewable(s) Refills:0 6. Outpatient Occupational Therapy DX: Traumatic Brain Injury - Subdural hematoma Discharge Disposition: Home Discharge Diagnosis: s/p Motor vehicle crash Intraparenchymal hemorrhage (bifrontal) Bilateral pneumothorax Pneumomediastinum Discharge Condition: Stable Discharge Instructions: Return to the Emergency room if you develop any fevers, chills, severe headaches, dizziness, visual distubances, chest pai, shortness of breath, nausea, vomiting, diarrhea and/or any other symptoms that are concerning to you. Followup Instructions: Follow up as needed in the Trauma Clinic, call [Telephone/Fax (1) 6429] for an appointment. Follow up in [1-8] weeks with Dr. [Last Name (STitle) 71066], Behavioral Neurology, call [Telephone/Fax (1) 1690] for an appointment. Folow up in 4 weeks with Neurosurgery, call [Telephone/Fax (1) 1669] for an appointment. Inform the office that you will need a repeat head CT scan for this appointment. Follow up in [2-6] weeks in Trauma Clinic, call [Telephone/Fax (1) 6429] for an appointment. Completed by:[2179-12-24] Name: [Known lastname 3992],[Known firstname ] Unit No: [Numeric Identifier 11975] Admission Date: [2179-12-18] Discharge Date: [2179-12-24] Date of Birth: [2128-11-6] Sex: M Service: SURGERY Allergies: Penicillins Attending:[First Name3 (LF) 813] Addendum: Pt. was offered substance-abuse counseling/tx and declined. He is tied in with AA and says he will resume with that program. Discharge Disposition: Home [First Name11 (Name Pattern1) 801] [Last Name (NamePattern4) 815] MD [MD Number(2) 816] Completed by:[2179-12-24]	[ "E812.0", "E939.4", "292.81", "853.06", "860.0", "303.90", "958.7" ]	icd9cm	[ [ [] ] ]	[ "96.71", "01.18", "34.04" ]	icd9pcs	[ [ [] ] ]	7907, 8072	4565, 5731	297, 335	6578, 6587	763, 1143	6862, 7884	727, 744		5790, 6400	3440, 3464	6450, 6557		5757, 5767			6611, 6839																																		234, 259	3493, 4542								363, 667				2032, 3403													689, 711
43,584	139,756	45932	Discharge summary	report	Admission Date: [2141-12-30] Discharge Date: [2142-1-13] Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 7651] Chief Complaint: Fatigue Major Surgical or Invasive Procedure: DC cardioversion EGD History of Present Illness: This is an 87 y/o female with significant medical history of paroxysmal atrial fibrillation s/p cardioversion in [2138], tricuspid regurgitation and right sided heart failure p/w lightheadness with movement, nausea and fatigue in setting of INR of 9.7 and ARF. Patient has had these symptoms for the past 3-4 days and noted to be dyspneic after walking [12-27] steps. The patient was recently admitted to [Hospital1 18] on [2141-12-7] with initial presentation with lightheadedness, dizziness, and nausea and was found to be in atrial fibrillation with rapid ventricular response. Initial plans for TEE and cardioversion could not be done as she was unable to swallow the TEE probe. Plan was to rate control, maintain INR > 2 for a month and cardiovert. Diltiazem was added 120 mg daily and metoprolol was increased from 75 [Hospital1 ] to 100 [Hospital1 ]. The night of her discharge she was noted to feel more tired per her daughter. She progressively became more tired with decreased PO in setting of nausea through the course of the week, worse in the past 3-4 days. Noted to have decreased uop at home. She denies cp/palpitations/orthopnea/PND/fevers/chills. Came to the ED for further evaluation. In the ED, initial vitals were T 97.3 HR 74 BP 96/62 RR 18 O2: 80% RA (per report this was a poor pleth and patient without any respiratory distress). She was found to have an elevated INR of 9.7 and was given 5mg PO vitamin K. Found to have BNP of 2508. As well as ASA 325mg. CXR showed no pulmonary edema and no evidence of inflitrate. Bedside echo showed no evidence of pericardial effusion. Vitals prior to discharge were 97.5 HR 71, BP 109/80 RR 12 98% on 4L . On the floor, patient triggered for hypoxia O2sats in low 80s on RA and bp 84/61. Patient appeared quite volume down. She was given IVF boluses that apparently showed some degree of fluid responsiveness to sbp 91. However, after 2 liters bp continued to drift back down to sbp in the low 80s. She was given a total of 4 liters NS with minimal UOP. Her bp ultimately increased to sbp of 104. Past Medical History: HTN Paroxysmal atrial fibrillation initially diagnosed in [2138] s/p CV; been in NSR since previous admission [12-3], pending CV [1-1] Tricuspid regurgitation Right sided heart failure (thought to be [12-26] TR) Mild mitral valve prolapse Arthritis Hysterectomy Dyslipidemia Osteopenia s/p abdominal hysterectomy Peripheral arterial disease Social History: She is a widow. She lives with her daughter who accompanied her to hospital today. She is independent in her activities of daily living. She does not smoke and rarely drinks alcohol Family History: No family history of sudden cardiac death or early coronary artery disease. One brother had rheumatic heart disease and another required a pacemaker for unknown reason. Physical Exam: VS - 97/54 67 18 94-95% RA (on ambulation 82% RA) -> 99% 10 L Mask, then normalized to 94% RA. Wt. 52.4 kg, ht: 5;3" Gen: Elderly black female. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Dry MM Neck: Supple with JVP pulsatile to 17 cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, 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. Skin: No stasis dermatitis, ulcers, scars, or xanthomas Pertinent Results: Pertinent Results: Brief Hospital Course: This is an 87 year old female with history of Afib w/RVR awaiting DC cardioversion as outpatient, right heart failure in setting of severe tricuspid regurgitation presented with malaise, nausea/anorexia, hypotension (sbp's in the 80s), bradycardia to the 50s on multiple nodal agents, and intermittent hypoxia. HYPOXIA: Patient initially presented intermittently hypoxic that did not correct with oxygen. Her hypoxia was exacerbated by her initial presentation with hypotension with systolic blood pressures in the 80s in setting of recent addition of multiple nodal agents. Patient had a recent increase in her home metoprolol from 75 [Hospital1 ] to 100 [Hospital1 ] and new addition of diltiazem (120 mg daily) all in the setting of new afib with RVR. With history of severe right heart failure and addition of IV fluids to help correct her hypotension, the overall increase in right heart pressures with low systemic blood pressures caused an ideal setting for a significant right to left shunt. An echocardiogram was performed with bubble study that showed a patent foramen ovale causing this right to left shunt that ultimately was thought to be the cause of her intermittent hypoxia. Her hypoxia was corrected with positional changes and maneuvers, such as valsalva, to decrease venous return and minimize the shunt. She was slowly and gently diuresed to decrease her right sided pressures and midodrine was added to increase her left sided pressures. Her hemodynamics improved considerably and she was no longer hypoxic. PFO closure was planned. Patient was admitted with an elevated INR of 10.8, thought secondary to poor nutrition. Coumadin was held during admission and her INR slowly drifted down to 5.0. Since it was not drifting down as quickly as was desired to perform this procedure, she was given 5 mg of Vitamin K. Her INR normalized to 1.5. She was started on Heparin drip in setting of recent cardioversion approximately five days prior until her PFO closure. In the setting of supratherapeutic PTTs the patient developed several melanotic stools. Her hematocrit dropped from 41.1 to 31.6 in 24 hours. Her heparin drip was stopped and GI was consulted. Her hematocrit stabilized in the low 30s and she did not need a blood transfusion. Since she will need anti-coagulation in the future, it was felt that an EGD should be performed during this admission. Her EGD showed erosive gastritis, two cratered 10-15 mm ulcers in the duodenal bulb. Both ulcers had evidence of a visible vessel which were not actively bleeding. These ulcers were cauterized with no further signs of active bleeding. She was continued on pantoprazole 40 mg [Hospital1 ] and she was empirically started on H.pylori treatment. Given her high risk of stroke post-cardioversion she was re-started on coumadin 24 hours post EGD. She was closely monitored and had no signs of bleeding. She was discharged with close INR and Hematocrit follow up with her PCP. HYPOTENSION: Felt to be secondary to anorexia and nausea for several days prior to admission in setting of increasing metoprolol and adding diltiazem. Most likely the loss of the right atrial "kick" and known RV dysfunction meant that she was not able to move fluids through the pulmonary system and back to the right atrium. She was maintained on midodrine prn sbp <130. She remained normotensive through remainder of admission. ACUTE ON CHRONIC RENAL FAILURE: Peaked to 2.6 on admission. It was felt it was secondary to pre-renal etiology given prolonged hypotension prior to admission. Once hemodynamics improved, renal function improved as well. Creatinine on discharge was 1.4. Further follow up should be performed in the outpatient with her PCP next week. PAROXYSMAL ATRIAL FIBRILLATION: History of PAF with DCCV in [2138]. Reportedly has been in sinus until [12-3] where she was admitted for afib with RVR. Patient was planned to have an outpatient DC cardioversion after 3 weeks of anticoagulation, but subsequently was admitted. After her blood pressure and hypoxia was corrected the patient had a DC cardioversion during this admission. She was subsequently started on Dronedarone. It was felt amiodarone should be avoided given her elevated LFTs. Patient stayed in sinus with frequent ecotpy during the remainder of her admission. It is likely that at least part of the patient's hypotension was supratherapeutic nodal [Doctor Last Name 360] levels in renal dysfunction. In the future, we must try to keep Ms. [Known lastname 933] in sinus rhythm as it is clear that she does not tolerate atrial fibrillation well. Should she develop atrial fibrillation as an out-patient we will promptly arrange cardioversion. CORONARY ARTERY DISEASE: No known coronary artery disease. No chest pain or EKG changes during admission. CHRONIC SYSTOLIC RIGHT HEART FAILURE: Initially patient appeared volume down in setting of poor po intake. Diuretics were held initially and in setting of UGIB, and once patient was stable, diuretics were adjusted further. Her regimen upon discharge included torsemide 20 mg daily. Upon discharge patient did not appear volume overloaded. CODE STATIS: DNR/DNI Medications on Admission: DILTIAZEM HCL ER 120 mg daily FUROSEMIDE 20 mg Tablet daily METOPROLOL TARTRATE 100 mg [Hospital1 ] SPIRONOLACTONE 25 mg daily WARFARIN 3 mg daily Calcium Carbonate Cholecaciferol Discharge Medications: 1. Dronedarone 400 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 33 doses. Disp:33 Tablet(s) Refills:0 3. Bismuth Subsalicylate 262 mg/15 mL Suspension Sig: Thirty (30) ML PO QID (4 times a day) for 11 days. Disp:1320 ML(s) Refills:0 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 5. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. Disp:30 Tablet(s) Refills:2 6. Tetracycline 250 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours) for 11 days. Disp:88 Capsule(s) Refills:0 7. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:30 Tablet Sustained Release 24 hr(s) Refills:2 8. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea for 15 doses. Disp:15 Tablet, Rapid Dissolve(s) Refills:0 9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day: Please take at least two hours apart from Tetracycline. 10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO once a day. 11. Outpatient Lab Work Please draw INR, Hematocrit, Creatinine Monday, [2142-1-15] and send results to Dr.[Name (NI) 35583] office and Dr.[Name (NI) 2935] office. 12. Torsemide 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 13. 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 Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Primary: Right to left shunt (PFO) Right Heart Failure Upper GI bleed s/p EGD Secondary: Hypertension Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: You were admitted because you had low blood pressure and the oxygen level in your blood was low. You were found to have a right to left shunt. You were found to have a small hole in the wall that seperates the upper [Doctor Last Name 1754] of your heart, called a patent foramen ovale. Your blood was moving through this small hole instead of your lungs which caused your oxygen level to be low. We felt this occured because you had low blood pressure in combination with your right heart failure. As your blood pressure improved and we removed fluid with lasix and spironolactone, your oxygen level improved. You had no further episodes of low oxygen levels. Because you were also in atrial fibrillation, you underwent a procedure called a DC cardioversion. This procedure sent an electric shock to your heart that got you out of this abnormal heart rhythm. You were also started on a medication to help prevent this from recurring, called Dronederone. You should continue to take this medication and follow up with Dr. [Name (NI) 11723] for further management. We also planned for you to have a closure of the small hole in your heart (PFO). We started heparin to thin your blood and you started having blood in your bowel movements. The gastroenterologists were consulted and proceded with a procedure called an EGD. This procedure passes a tube with a camera on the end to look at your esophagus, stomach, and first part of the small intestine. You were found to have inflammation in your stomach and two ulcers in your small intestine. These ulcers had blood vessels exposed, but were not actively bleeding. These blood vessels were likely the source of your bleeding. These were destroyed to significantly reduce the liklihood of a re-bleed. You tolerated this procedure well. You will need to continue to take medications for this and follow up with your primary care doctor for further evaluation. Given your risk of stroke with atrial fibrillation, you were re-started on coumadin. You will again follow up with your primary care doctor and cardiologist for further management. You should weigh yourself every morning, and call your doctor if your weight goes up more than 3 lbs. Your new medications include: Pantoprazole 40 mg twice a day (this is to reduce the acid in your stomach) Warfarin 2 mg daily (You will have this dose adjusted by your PCP based on your INR levels) Tetracycline HCl 500 mg pills every 6 hours, four times per day. STOP: Wednesday, [1-24]. (Total Duration: 14 Days) MetRONIDAZOLE (FLagyl) 500 mg PO/NG Q8H Duration: STOP: Wednesday, [1-24] (Total Duration: 14 days) Bismuth Subsalicylate 30 mL PO QID STOP: Wednesday, [1-24] (Total Duration: 14 days) DECREASE: Metoprolol Succinate to 25 mg daily HOLD: Spironolactone 25 mg daily and follow up with Dr. [Doctor Last Name 11723] at your appointment for further management of this. You were a little dizzy after this medication with blood pressures in the 90s. You should continue to eat and drink the best you can and stop this medication for now. STOP: furosemide (Lasix) 20mg once a day. Start: torsemide (Demadex) 20mg once a day, which is a more powerful diuretic. Start: Potassium Chloride Sustained Release 10meq daily to prevent your potassium from going low. You should call your primary care doctor or go to the emergency room if you experience significant lightheadedness, chest pain, palpitations, shortness of breath or ANY symptom that is concerning to you. Followup Instructions: You have the following appointments scheduled: DR. [First Name (STitle) ] [Last Name (NamePattern4) 6559], MD Phone:[Telephone/Fax (1) 62] Date/Time:[2142-1-16] 1:00 PM Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2204] Date: His office will call you for an appointment on Monday. If they do not call you, please call the office for an appointment Monday. Phone: [Telephone/Fax (1) 2205]	[ "424.2", "584.9", "733.90", "427.31", "443.9", "535.40", "428.0", "V58.61", "424.0", "458.8", "403.90", "585.9", "272.4", "532.40", "790.92", "428.22", "745.5" ]	icd9cm	[ [ [] ] ]	[ "99.61", "44.43" ]	icd9pcs	[ [ [] ] ]	11217, 11274	3996, 9177	228, 251	11420, 11420	3973, 3973	15077, 15513	2964, 3135		9412, 11194		11295, 11399		9203, 9389			11565, 15054									3150, 3933																									181, 190									279, 2368										11434, 11541							2390, 2749	2765, 2948
17,440	169,094	12523+56379	Discharge summary	report+addendum	Admission Date: [2144-4-8] Discharge Date: [2144-4-16] Date of Birth: [2086-7-21] Sex: M Service: CHIEF COMPLAINT: Found unresponsive status post ventricular fibrillation arrest. HISTORY OF PRESENT ILLNESS: The patient is a 57 year old gentleman with a history of non-insulin dependent diabetes mellitus, hypertension, high cholesterol, who was found down in front [Hospital1 38823] this evening. Friends state that the patient was walking and collapsed face down onto the ground. No preceding chest pain, shortness of breath, lightheadedness or note. EMS arrived at the scene; a police officer performing CPR. It was estimated that CPR was initiated four minutes after found unresponsive. The patient was unconscious, pulseless; blood was oozing from his mouth and nares after the fall. The patient was shocked at 200 joules with an AED rhythm of ventricular fibrillation and was converted into AIVR without pulse. Airway was suctioned with return of a piece of gum from the top of his vocal cords. The patient was given 1 mg of Epinephrine and 1 mg of Atropine. The patient's rhythm converted into complete heart block at a rate of 70 and back into sinus tachycardia at 150, at which point a 12-lead EKG was performed which showed ST elevations in leads II, III and AVF. Lidocaine 100 mg intravenous bolus was given on arrival to the Emergency Room. In the Emergency Room, the patient was placed on a Lidocaine drip at 2 mg a minute, was given p.r.n. Versed and Ativan sedation while he was intubated. The patient vomited large amount of brownish fluid with food particles. OG tube was placed with return of 200 to 300 cc of brownish liquid smelling of alcohol. Saturations were 88 to 90% on 100% FIO2 on a vent with a PEEP of 5. PEEP was increased to 10. The patient had a head CT scan from the Emergency Room which was negative for a bleed and a CT scan angiogram which was negative for a pulmonary embolism which showed total left lower lobe lung collapse and the patient was taken emergently to the Catheterization Laboratory. PAST MEDICAL HISTORY: 1. Diabetes mellitus type 2. 2. Hypertension. 3. Hypercholesterolemia. MEDICATIONS ON ARRIVAL: 1. Aspirin 325. 2. Zestril 40. 3. Pravachol 40. 4. Metformin 1000 twice a day. 5. Avandia 4. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient is married, no history of tobacco. PHYSICAL EXAMINATION: The patient was afebrile with a rate of 110. Blood pressure 120/80; saturation of 88% while intubated on FIO2 of 100%, PEEP of 5. PIPs in the 28 to 30 range. On general examination, the patient is a middle-aged white male smelling of alcohol, intubated, lying on the Emergency Room stretcher with light sedation. HEENT and Neck examination: Pupils equally round and reactive to light. Oropharynx is clear. There was crusted blood among the nares, swollen upper lip with an abrasion. Mucous membranes were moist. Chest: There were coarse breath sounds at the bases bilaterally. The patient was in a C-spine collar. Cardiovascular: Regular rate, faint S1, S2, no murmurs. Abdomen was distended. Bowel sounds were positive, nontender, no rebound or guarding. Extremities with no edema. Good distal pulses. Skin examination: The patient had warm extremities; he had a lipoma in the right flank. Neurologic examination: He was intubated, lightly sedated, moving all four extremities. LABORATORY: On admission, white blood cell count 12.5, hematocrit 43.2, platelets 355. SMA-7 significant for a potassium of 3.1, bicarbonate 18, with a gap of 21. Creatinine 1.3, lactate was 8. INR 1.2. Initial arterial blood gases 7.28, 37, 88, which was on 60% oxygen, which improved to 7.30, 44, 83, on 100% oxygen. The patient had a urinalysis which was negative for leukocyte esterase and nitrites. Serum alcohol level was 42. Urines were positive for benzodiazepines, barbiturates, opiates, and amphetamines. Cocaine was negative. Initial CK 328, MB 3, troponin less than 0.3. HOSPITAL COURSE: 1. Cardiac: The patient is status post ventricular fibrillation arrest, likely secondary to ischemia given the EKG changes, with ST elevations in the inferior leads. The patient was taken for an emergent catheterization. Pressures in the catheterization laboratory revealed right ventricle 42/17, PA 42/19, wedge of 20, cardiac output 8.2, cardiac index 3.7, SVR 1112. The patient's catheterization revealed an right coronary artery with a proximal 70% diffuse, mid-90% diffuse; left main was normal. Left anterior descending showed a 40% D2 lesion. Mid-LAD had a 90% lesion. Distal circumflex had a 30% lesion. The mid-LAD 90% lesion was successfully percutaneous transluminal coronary angioplasty and stented. The patient transferred to the Cardiac Care Unit. In the Cardiac Care Unit the patient was continued on aspirin, Plavix, Integrilin for 18 hours, started on Lipitor. The patient's enzymes were cycled with a maximum CK of 1300, ruling positive troponin. However, CK's trended down to normal by the time of discharge. The patient also had an echocardiogram which showed an ejection fraction of 35 to 40% with multiple regional wall motion abnormalities. The patient was diuresed aggressively throughout his stay. The patient with a ventricular fibrillation arrest, was continued on Lidocaine drip until the following morning, however, at which point Lidocaine was discontinued. The patient remained on Telemetry without any evidence of ventricular tachycardia or ventricular fibrillation after his stent was placed, due to a Staphylococcus aureus blood infection. The patient will be overturned for a defibrillator placement after his antibiotic course is finished. The patient's Captopril and Lopressor were titrated up as tolerated; see final Medicine List. 2. Pulmonary: The patient initially intubated with left lower lobe collapse, question of aspiration. The patient was started on Levaquin and Flagyl for aspiration pneumonia with aggressive deep suctioning and chest Physical Therapy. The patient was able to extubated successfully on hospital day three. The patient maintained excellent saturations for the rest of his stay off the ventilation. While intubated, the patient had a bronchoscopy which showed evidence of left lower lobe secretions consistent with aspiration pneumonia. 3. Infectious Disease: The patient with likely aspiration event. He was started on intravenous Levaquin and Flagyl which was switched over to p.o. when tolerating. The patient to finish a ten day course of p.o. Levaquin and Flagyl. Methicillin resistant Staphylococcus aureus: The patient with four out of four positive blood cultures with Staphylococcus aureus. Final sensitivities showed that Staphylococcus aureus was resistant to Oxacillin but sensitive to Vancomycin. Given Methicillin resistant Staphylococcus aureus the patient was placed on contact precautions and will be discharged to complete a 14 day course of Vancomycin. The patient had a PICC placed prior to discharge. The patient is starting Vancomycin on [4-14], to continue until [4-28]. 4. Endocrine: The patient with history of diabetes mellitus. Was put on an insulin drip initially and switched over to NPH and insulin sliding scale; to restart his oral medications, Avandia 4 mg with an insulin sliding scale for tight control. Avandia can be increased as tolerated. 5. Renal: The patient with initial creatinine of 1.3, which improved with fluid resuscitation and remained in the normal limits with diuresis. 6. Fluids, Electrolytes and Nutrition: The patient was initially NPO and was receiving tube feeds. However, after the patient was extubated, he was able to tolerate clears and advancing diet as tolerated. The patient will be discharged with a mechanical soft diet to be increased to a full diet as tolerated. 7. Orthopedics: The patient initially in a cervical spine collar status post fall. The patient had an x-ray which revealed no evidence of cervical spine fractures. Cervical spine was cleared, the collar was removed and the patient to resume full activities as tolerated. 8. Gastrointestinal: The patient continued on Protonix for GI prophylaxis. 9. Neurologic: The patient with a question of mental status changes given his four minutes of hypoxia. Initial CT scan showed questionable white matter changes consistent with possible early anoxic encephalopathy. However, after sedation was weaned and the patient was extubated, the patient's neurologically mental status was returned to [Location 213] per wife; however, the patient will need aggressive physical therapy to improve his strength and coordination prior to resuming full activities. DISCHARGE DIAGNOSES: 1. Status post ventricular fibrillation arrest. 2. Coronary artery disease status post left anterior descending stent. 3. Methicillin resistant Staphylococcus aureus bacteremia. 4. Aspiration pneumonia. FINAL DISCHARGE MEDICATIONS: 1. Aspirin 325 mg p.o. q. day. 2. Plavix 75 mg p.o. q. day times 30 days. 3. Lipitor 20 mg p.o. q. day. 4. Atenolol 100 mg p.o. q. day. 5. Zestril 40 mg p.o. q. day to be increased to 80 as blood pressure tolerates. 6. Protonix 40 p.o. q. day. 7. Levaquin 500 mg p.o. q. day times ten days to complete [4-19]. 8. Flagyl 500 mg p.o. three times a day times ten days to be completed [4-19]. 9. Vancomycin one gram intravenous q. 12 hours times 14 days to be continued until [4-27]. 10. Haldol 1 to 2 mg p.o. q. 12 p.r.n. 11. Tylenol p.r.n. 12. Regular insulin sliding scale. DISCHARGE INSTRUCTIONS: 1. The patient will be discharged to Acute Rehabilitation for Physical Therapy, be in a monitored setting with at least daily electrocardiograms if not Telemetry. 2. The patient to have intravenous antibiotics through his PICC line. 3. The patient will return for an Internal Cardiac Defibrillator placement as early as [4-27], after his intravenous antibiotics course is completed. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 2057] Dictated By:[Name8 (MD) 2439] MEDQUIST36 D: [2144-4-16] 13:04 T: [2144-4-16] 14:19 JOB#: [Job Number 38824] Name: [Known lastname 7037], [Known firstname 133] Unit No: [Numeric Identifier 7038] Admission Date: [2144-4-8] Discharge Date: [2144-4-20] Date of Birth: [2086-7-21] Sex: M Service: ADDENDUM: Since the last dictation summary, the patient has been awaiting placement secondary to patient admitted with a V fib arrest status post LAD stent and has subsequently developed a [4-9] MRSA staph aureus bacteremia. Patient on IV Vancomycin, likely site is a right antecubital fossa superficial thrombophlebitis. Given increasing pain in the right arm the patient had a right upper extremity ultrasound which revealed evidence of a superficial main thrombosis but no evidence of abscess or fluid collection. Given persistent fevers, the patient was given a one time dose of IV Gentamycin 100 mg times one. The patient will continue his course of IV Vancomycin times 14 days prior to returning for an ICD placement. The patient also started on Glyburide 3 mg po q d for further diabetic control. DISCHARGE MEDICATIONS: Same as on the initial discharge summary, in addition to Glyburide 3 mg q d. Patient to be discharged to acute rehab, likely [2144-4-20]. [First Name8 (NamePattern2) 77] [Last Name (NamePattern1) ], M.D. [MD Number(1) 715] Dictated By:[Name8 (MD) 7039] MEDQUIST36 D: [2144-4-20] 12:12 T: [2144-4-20] 12:19 JOB#: [Job Number 7040]	[ "933.1", "414.01", "427.41", "348.3", "518.0", "250.00", "E912", "507.0", "038.11" ]	icd9cm	[ [ [] ] ]	[ "88.56", "36.01", "88.53", "96.71", "96.04", "33.23", "37.23", "36.06" ]	icd9pcs	[ [ [] ] ]								8779, 8993	11373, 11775					4042, 8758		9635, 11349																								2436, 3343										149, 214									243, 2089														3368, 4025			2111, 2348	2365, 2413
17,024	164,366	1089	Discharge summary	report	Admission Date: [2104-10-17] Discharge Date: [2104-10-20] Date of Birth: [2053-11-23] Sex: M Service: MEDICINE Allergies: Bactrim Ds / Dapsone / Delavirdine / Abacavir Sulfate / Amoxicillin Attending:[First Name3 (LF) 2159] Chief Complaint: Nausea, vomiting, fever, fatigue. Major Surgical or Invasive Procedure: Right Subclavian Line Placement History of Present Illness: Mr. [Known lastname 7086] is a 50 year old man with HIV on HAART (CD4 count of 589 [2104-9-24]) and CAD who presented to the ED with nausea, vomiting, diarrhea, weakness, fevers, chills, pruritis and abdominal pain. Patient had a dental visit today and took antibiotic prophylaxis (amoxicillin). Shortly after, he developed symptoms of nausea, vomiting, diarrhea, fever, chills. In the ED his initial temperature was 98.7 with HR of 102, BP 91/61, O2 sat 97% RA. Abdominal CT showed no diverticulitis or appendicitis. While in the ED he developed a temperature of 102.2 with HR of 110, BP 84/47, O2 sat 100%. Lactate was 4.9. Patient received ceftriaxone 2 gm, vancomycin and flagyl. After 4 liters of normal saline his BP was 86/63, temp 100.4, HR 107. He had several episodes of watery diarrhea. LP was performed which showed no signs of infection. He was started on the sepsis protocol and received a total of 6L of NS with 1000 cc of urine output. Patient was started on levophed and it was titrated to 0.05 mcg/kg/min for a bp of 90/42 with a MAP 59. CVP was 9, SVO2 83%. In the ICU, he initially required pressors to maintain his blood pressure but his hemodynamics quickly stabilized so that he did not require pressors or IV fluids. On [10-19] he was afebrile with stable vitals on po levofloxacin and he was transferred to the medical floor. On transfer he endorsed continued fatigue and nausea but felt subjectively much better and specifically denied fevers, chills, sweats, chest pain, dyspnea, abdominal pain, or dysuria. Past Medical History: 1. HIV (CD4 count of 589 [2104-9-24]) 2. Coronary artery disease status post ST elevation MI in [2102-1-7], with stenting of the LAD. 3. Dyslipidemia. 4. Peptic ulcer disease. 5. Low back pain. 6. Gastritis. 7. History of abnormal LFTs with repeat normal LFTs. 8. Depression. Pertinent cardiac studies: [9-8]- cardiac cath FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Normal ventricular function. 3. Patent LAD stent. focal 80% stenosis is the mid PDA that upon review, did not appear significantly worse than on his previous catheterization of 1/[2101]. ECHO [1-10]: EF 50% , E:A 1.2 The left atrium is normal in size. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with focal hypokinesis of the distal inferior wall and distal half of the anterior septum and apex. The remaining segments contract well. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated. The aortic valve leaflets (3) are mildly thickened but not stenotic. There is no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Social History: previously from [Male First Name (un) ], moved to the states after high school; lives in [Location ] and works as a social worker with the homeless denies tobacco or IVDU drinks ETOH occasionally Family History: maternal uncle w/ MI at age 28 father w/ MI in his 70s and another uncle with a recent myocardial infarction Physical Exam: VS: T 98.4 HR 84 BP 76/44 RR 10 O2 sat 97% RA Gen: Ill appearing, comfortable, lying in bed in NAD. HEENT: PERRL, EOMI, sclera anicteric, MMM. Neck: No LAD, JVD or thyromegly. CV: RRR with 2/6 SEM at LUSB Lungs: Crackles at the left base. Abd: soft, distended, non tender, active BS, no hepatosplenomegly. Rectal: guaic negative per ED. ext: No clubbing, cyanosis or edema. No rash. Pertinent Results: Labs: wbc 5.3 hct 37.7 plt 137 Na 137, K 3.6, Cl 105, HCO3 23, BUN 10, Cr 1.0, glucose 88, Ca 9.0, Mg 2.0, Ph 2.5 Lactate trend: 4.9 -> 1.8 CSF: 2 WBC (10 poly, 85 lymph, 5 mono) 1 RBC TP 43, glucose 76 Microbiology: [10-17] Blood clx: NGTD. [10-17] Urine Clx: No growth. [10-18] CSF: No micro-organisms, no PMNs, negative culture. [10-18] Stool: C.difficile negative, salmonella, shigella, campylobacter, O&P negative. [10-17] ABD/PELVIC CT: 1. No evidence of appendicitis, bowel obstruction or free air. 2. Diverticulosis of the sigmoid and descending colon without evidence of diverticulitis. [10-19] CXR: Opacity at the left lung base. Brief Hospital Course: Mr. [Known lastname 7086] is a 50 year old man with HIV, CAD, and HTN who presented with nausea, vomting, diarrhea, weakness, fevers, chills, pruritis and abdominal pain. He initially required pressors and IV fluids to support his blood pressure. 1) SIRS: His presentation with fever, tachycardia, hypotension and an elevated lactate was thought to be consistent with SIRS. The etiology of his SIRS was unclear as his infectious workup was largely negative with the exception of a potential LLL pneumonia. It was thought that this was most likely due to an anaphylactic reaction to amoxicillin as on further questioning he endorsed pruritis, facial erythema/edema, and that these symptoms felt quite similar to an anaphylactic exposure to bactrim he had several years ago. Regardless of the etiology he quickly improved in terms of hemodynamics and lactate level. He was continued on levofloxacin and given a prescription to complete a seven day course to finish on [2104-10-23]. 2) Abdominal pain/diarrhea/vomiting: This was thought to be part of his SIRS process and generally improved during his hospitalization. A CT scan was negative for an infectious or inflammatory process. He still complained of slight nausea at discharge and was given a prescription for compazine to use as needed. 3) HIV: He was continued on his HAART regimena and will follow up with Dr. [First Name (STitle) ]. 4) CAD/HTN: His anti-hypertensives were initially held due to his hypotension. At discharge his blood pressure was stable in the 110-150/50-80 range. At discharge he was restarted on atenolol at 25 mg daily. He has a follow-up appointment in [Company 191] on [2104-9-22] and at this time he should have his blood pressure checked and medications adjusted if needed (he was previously taking metoprolol 50 mg and lisinopril 5 mg). He was continued on his aspirin. 5) Hyperlipidemia: He was restarted on his pravastatin at discharge. Medications on Admission: ANDROGEL 1%(50MG)--Apply to shoulders every day as instructed ASPIRIN 325 mg--one tablet(s) by mouth daily FOLIC ACID 1MG--One mg every day FOSAMPRENAVIR 700MG--Take two pills twice a day with food KALETRA 33.3-133.3--4 capsules twice a day with food LISINOPRIL 5MG--5 mg every day LORATADINE 10 mg--1 tablet(s) by mouth once a day LORAZEPAM 1MG--Take [12-9] pill as needed for insomnia METOPROLOL TARTRATE 50MG--50 mg every day PATANOL 0.1 %--1-2 drops to each eye twice a day PRAVASTATIN SODIUM 20MG--Take one pill at night RHINOCORT AQUA 32 --[12-9] sprays to each nostril once a day TENOFOVIR 300 MG--Take one pill a day with food TRICOR 145MG--One tablet by mouth every day ZANTAC 300MG--One tablet at bedtime Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s)* Refills:2 2. Fosamprenavir 700 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours). Disp:120 Tablet(s) Refills:2 3. Lopinavir-Ritonavir 133.3-33.3 mg Capsule Sig: Four (4) Cap PO BID (2 times a day). Disp:240 Cap(s) Refills:2 4. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 days. Disp:3 Tablet(s) Refills:0 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for headache for 3 days. Disp:15 Tablet(s) Refills:0 7. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 8. Patanol 0.1 % Drops Sig: 1-2 drops Ophthalmic twice a day: 1-2 drops in each eye [Hospital1 ]. Disp:1 bottle Refills:2 9. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 10. AndroGel 1 % (50 mg) Gel in Packet Sig: One (1) packet Transdermal once a day. Disp:30 packets Refills:2 11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 12. Loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 13. Tricor 145 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 14. Compazine 10 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea for 1 weeks. Disp:20 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: 1. SIRS 2. ? amoxicillin anaphylaxis Secondary Diagnoses: 1. HIV 2. Coronary Artery Disease 3. Hypertension 4. Hypercholesterolemia Discharge Condition: Stable Discharge Instructions: Please take all medications as perscribed. Please refrain from using amoxicillin, as you may have an allergy. Please keep all follow up appointments. Keep yourself well hydrated to prevent your headache from becoming worse. Please come to the emergency room with any fevers, chills, nausea, vomiting, shortness of breath, palpitations, throat swelling. Followup Instructions: Provider: [First Name11 (Name Pattern1) 7087] [Last Name (NamePattern4) 7088], M.D. Date/Time:[2104-12-24] 8:30 Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 7089] [Hospital 7090]-[Telephone/Fax (1) 250]-[2110-10-23] AM. *PLEASE HAVE YOUR BP CHECKED AT THIS VISIT AND HAVE YOUR BLOOD PRESSURE MEDICATIONS ADJUSTED as Necessary. Until this visit please only take atenolol for your blood pressure. Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], [Telephone/Fax (1) 250]-[2103-12-20], 10AM Completed by:[2104-10-20*]	[ "V45.82", "V08", "272.4", "414.01", "995.91", "038.9", "E930.0", "412", "486" ]	icd9cm	[ [ [] ] ]	[ "03.31", "38.93" ]	icd9pcs	[ [ [] ] ]	9120, 9126	4798, 6758	365, 399	9321, 9330	4101, 4775	9733, 10349	3572, 3682		7531, 9097		9147, 9147		6784, 7508		2356, 3334	9354, 9710									3697, 4082			9224, 9300																						292, 327									427, 1981							9166, 9203										2003, 2339	3350, 3556
4,063	121,386	9594+9595+56047	Discharge summary	report+report+addendum	Admission Date: [2150-7-14] Discharge Date: [2150-8-9] Date of Birth: [2078-7-19] Sex: M Service: HISTORY OF PRESENT ILLNESS: This is a 71-year-old man with history of coronary artery disease, status post a large anterior myocardial infraction in [1-8], as well as a stent of his RCA for severe systolic and diastolic dysfunction, hypertension, and hyperlipidemia. He presented on [2150-7-14] with intermittent chest pressure since that morning. The patient awoke feeling pressure across his chest "like a weight on my chest" with associated shortness of breath. The shortness of breath lasted 1 hour, at which time chest pressure diminished in intensity. The patient denies orthopnea, PND, or decreased exercise tolerance. He states that his lower extremity edema is normal for him. He denies fevers or chills, nausea or vomiting, urinary symptoms, cough, weight loss, change in appetite, arthritis, rash, abdominal pain, or history of trauma. PAST MEDICAL HISTORY: Coronary artery disease. Congestive heart failure. Hypertension. Hyperlipidemia. ALLERGIES: No known drug allergies. MEDICATIONS AT HOME: 1. Lipitor 10 mg p.o. q.d. 2. Lasix 40 mg p.o. b.i.d. 3. Atenolol 50 mg q.d. 4. Imdur 120 mg p.o. q.d. 5. Lisinopril 40 mg p.o. q.d. 6. Atrovent 2 puffs b.i.d. PHYSICAL EXAMINATION: Vital Signs: Temperature 98.1, heart rate 70, blood pressure is 135/92, respirations 16, and O2 saturation 98 percent on room air. General: A well- appearing, disheveled man in no acute distress. HEENT: Pupils are equal, round, and reactive to light and accommodation. Extraocular eye movements are intact. Neck: Supple. No lymphadenopathy. Jugular venous distention to approximately 10 cm. Lungs: Bibasilar crackles, left more than right. Cardiovascular: Regular rate and rhythm with S1 and S2, positive S4, and a loud rub. Abdomen: Obese, normoactive bowel sounds, soft, nontender, and nondistended. Liver edge is palpable at 2 cm below right costal margin. Extremities: A 3 plus pitting edema bilaterally with hyperpigmentation consistent with chronic venous insufficiency, right worse than left. LABORATORY DATA ON ADMISSION: CBC, white blood cell count 11.4, hematocrit 32.2, platelets 323. Differential is, neutrophils 81 percent, lymphocytes 11 percent. Chem-7, sodium 130, potassium 4.1, chloride 93, bicarbonate 25, BUN 29, creatinine 1.4, and glucose 94. Cardiac markers, CK 212, MB 6, and troponin 0.14. RADIOLOGY DATA: Chest x-ray reveals interval development of polychamber cardiomegaly versus pericardial effusion, no pulmonary edema. EKG, normal sinus rhythm at 74 beats per minute, normal axis, LAE, no electrical alterans. AVL unchanged, ST elevations to V1 to V3, which are unchanged. Echocardiogram, large fibrinous pericardial effusion, thickened pericardium 2 to 2.5 cm in diameter, lateral/apical with 1 cm. Left ventricular ejection fraction less than 20 percent. No right ventricle collapse in diastole and no diastolic right atrial collapse, right atrial invagination present, mild respiratory variation in transmitral valve, transtricuspid valve inflow, no tamponade, 2 plus mitral regurgitation. CT scan with nonionic contrast revealed a left-sided anterior mediastinal mass, contiguous and inseparable from the pericardial effusion. It also revealed bilateral pulmonary nodules. There was also a possible left cavitary lung mass or possibly a loculated pleural effusion. Also discovered on CT scan was an abdominal aortic aneurysm, infrarenal in position and extended into the common iliac arteries. It measures approximately 5.6 cm in maximum diameter. HOSPITAL COURSE: The patient was seen by Thoracic Surgery service who elected to perform a pericardial window to relieve his effusion. The patient was taken to the operating room on [2150-7-15] for this procedure, which he tolerated well with minimal blood loss. Two chest tubes were placed. One in pleural space and other in pericardium. Pericardial biopsy was sent to pathology and a caseating mediastinal mass was noted in the findings of this procedure. The patient was seen by the Vascular Surgery service to follow up on his abdominal aortic aneurysm. They suggested that he may be a candidate for an endovascular AAA repair, but would need a CT angiogram protocol to study and assess the position/size of the AAA. The patient remained in the CCU until [2150-7-19] when his condition was stable enough to be transferred to floor. PATHOLOGY RESULTS: The patient had 2 specimens sent to pathology from his procedure on [2150-7-15]. One included mediastinal cyst walls as well as pericardium. Mediastinal cyst wall was interpreted as fragments of detached highly atypical keratinizing squamous epithelium and also a foreign body giant cell reaction. Pericardium fibroadipose tissue with local fibrin deposition and reactive mesothelial reaction. Mediastinal cyst wall contents, superficial squamous epithelium and keratinous debris. A note on this pathology result, invasion of tumor cells into the surrounding stroma is not seen. Immunohisto chemistry shows that the tumor cells are focally positive for CD5 and are negative for TTF1. Differential diagnoses include a thymic cyst with carcinoma in situ, thymic carcinoma with a squamous differentiation, and a metastatic process. Focal CD5 expression tends to favor a primary thymic lesion. However, a metastasis cannot be excluded. Flow cytometry immunophenotyping was interpreted as a non- diagnostic study due to the paucity of specimen. A cytology report for the pericardial fluid was negative for malignant cells. Because of the caseating mass found during the surgery, tuberculosis was suspected, although all of the cultures were negative. FURTHER WORKUP: Because the pathologic specimens were nondiagnostic and the bilateral pulmonary nodules were not biopsied at that time, a decision was made in cooperation with Medical service as well as the consulting Oncology service to perform a video-assisted wedge resection of at least 1 of the nodules for definitive diagnosis. The patient was taken to the operative room on [2150-7-23] for a left video-assisted wedge resection, a biopsy and lysis of adhesions as well as an insertion of a chest tube and bronchoscopy. The patient tolerated the procedure well with 50 cc of blood loss. He was extubated in the PACU and returned to the floor. Once back on the floor, the patient was noted to have a persistent air leak and as his medical, oncological, and vascular issues stabilized and the only remaining problem remained his chest tube, he was transferred to the Thoracic service where we followed him almost exclusively for the management of his persistent air leak. He was transferred to the Thoracic Surgery service on [2150-7-31], and continued to be followed daily by chest x-ray and manipulation of the Pleur-evac to and from wall suction and water seal. The patient continued to have a small pneumothorax on the left, which only resolved slightly when put to suction from water seal. His air leak remained until he was discharged. During this period, the discharge from his chest tube diminished such that on [2150-8-4], his chest tube put a 120 cc of fluid. The following day, [2150-8-5], it put out 35 cc and the following day, [2150-8-6], it put out nothing. On [2150-8-7], the patient's chest tube was converted to a Heimlich valve and was placed to a Foley bag. As his other issues have resolved for now, the thought was the patient could go to a rehabilitation facility with this Heimlich valve in place and be seen for his other issues as an outpatient. Physical Therapy evaluation was that the patient continue physical therapy 2 to 4 times a week and that he ambulate 3 to 4 times a day with assistance. With this in mind, he was discharged on [2150-8-9] to an extended care facility. He was also scheduled for multidisciplinary outpatient clinic the following Thursday, [2150-8-13], with Dr. [Last Name (STitle) ], Dr. [Last Name (STitle) 952], and Dr. [Last Name (STitle) ]. He will also be scheduled for a PET scan in the interim between his discharge and his outpatient appointments. DISCHARGE DIAGNOSES: Mediastinal mass. Lung nodules. Pericardial effusion. Coronary artery disease. Hypertension. Congestive heart failure. Hyperlipidemia. DISCHARGE MEDICATIONS: 1. Ipratropium bromide 18 mcg/actuation aerosol 2 puffs q.i.d. 2. Metoprolol tartrate 25 mg 3 tablets p.o. t.i.d. 3. Amiodarone HCL 200 mg tablet 2 tablets p.o. q.d. 4. Oxycodone and acetaminophen 5/325 mg tablet 1 to 2 tablets p.o. q.4-6h. p.r.n. pain. 5. Vitamin C 500 mg tablet p.o. b.i.d. 6. Calcium carbonate 500 mg tablet 1 tablet p.o. q.i.d. 7. Lisinopril 20 mg tablet p.o. q.d. 8. Atorvastatin calcium 10 mg tablet p.o. q.d. 9. Aspirin 325 mg p.o. q.d. FOLLOWUP PLANS: As mentioned above. The patient has appointments with [Hospital 32535] Clinic on Thursday, [2150-8-13]. [First Name11 (Name Pattern1) 951] [Last Name (NamePattern4) ], [MD Number(1) 15911] Dictated By:[Last Name (NamePattern1) 32536] MEDQUIST36 D: [2150-8-7] 21:04:56 T: [2150-8-8] 04:19:16 Job#: [Job Number 32537] Admission Date: [2150-7-14] Discharge Date: [2150-8-11] Date of Birth: [2078-7-19] Sex: M Service: [Hospital Unit Name 196] Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 425] Chief Complaint: Chest pressure w/ associated shortness of breath Major Surgical or Invasive Procedure: Pericardial window VATS with wedge resection History of Present Illness: 71 yo M w/ h/o HTN, CAD, s/p anterior MI [2147] (RCA stent, unsuccessful LAD intervention); severe systolic and diastolic dysfunction (EF 35 % [3-9]), hyperlipidemia; he had vague CP w/ assoc SOB x days prior to admission. In ed, CXR w/ globular heart prompted echo that showed large pericardial effusion w/o echocardiographic tamponade however clinically impending as he went into rapid AF. Amiodarone initiated. Serial echo later revealed 5cm mediastinal mass, collaborated by CT, and ultimately biopsied in OR (Dr. [Last Name (STitle) 952], thoracics) and pericardial effusion drained. Past Medical History: CONGESTIVE HEART FAILURE (systolic dysfunction) CORONARY ARTERY DISEASE anterior MI in [1-/2147], cath old TO of the LAD and an acute thrombus in the RCA. Stent to RCA HYPERLIPIDEMIA ANTICOAGULATION HYPERTENSION Social History: Lives in a room at the [Company 3596] Pt has 40 pack year smoking history, patient has quit smoking 4 years ago Pt socially drinks 1 beer per day Pt has no illicit drug history Family History: Pt has no history of cancer in the family Physical Exam: Tm 98.1 BP 135/92 P 70 R 16 O2 98% Gen: well appearing, NAD HEENT: Perrla, EOMI Neck: supple, from, no LAD, JVP = 10cm Lungs: bibasilar crackles (l>r) CV: RRR, S1 < S2 +S4 loud rub Abd: obese, NABS, soft NTND, liver edge palpable 2cm below RCM Ext: 3+ pitting edema B/L with hyperpigmentation, c/w chronic venous insuff. Pertinent Results: [2150-7-28] 06:00AM BLOOD WBC-9.9 RBC-3.02* Hgb-9.2* Hct-28.3* MCV-94 MCH-30.4 MCHC-32.4 RDW-13.3 Plt Ct-362 [2150-7-27] 06:19AM BLOOD WBC-10.2 RBC-2.93* Hgb-8.7* Hct-27.5* MCV-94 MCH-29.7 MCHC-31.7 RDW-13.1 Plt Ct-386 [2150-7-15] 07:11AM BLOOD WBC-12.8* RBC-3.80* Hgb-11.6* Hct-35.8* MCV-94 MCH-30.6 MCHC-32.5 RDW-13.0 Plt Ct-379 [2150-7-14] 07:50PM BLOOD WBC-11.4* RBC-3.55* Hgb-11.0* Hct-32.2* MCV-91 MCH-30.9 MCHC-34.1 RDW-13.2 Plt Ct-323 [2150-7-18] 06:22AM BLOOD Neuts-80.6* Lymphs-9.5* Monos-7.3 Eos-2.4 Baso-0.3 [2150-7-28] 06:00AM BLOOD Plt Ct-362 [2150-7-14] 07:50PM BLOOD PT-14.3* PTT-27.2 INR(PT)-1.4 [2150-7-28] 06:00AM BLOOD Glucose-82 UreaN-23* Creat-1.0 Na-134 K-4.2 Cl-99 HCO3-27 AnGap-12 [2150-7-14] 07:50PM BLOOD Glucose-94 UreaN-29* Creat-1.4* Na-130* K-4.1 Cl-93* HCO3-25 AnGap-16 [2150-7-26] 06:16AM BLOOD ALT-29 AST-46* AlkPhos-126* [2150-7-14] 07:50PM BLOOD ALT-40 AST-36 CK(CPK)-212* AlkPhos-187* TotBili-0.7 [2150-7-25] 11:42PM BLOOD CK-MB-10 MB Indx-2.0 cTropnT-0.03* [2150-7-25] 04:05PM BLOOD CK-MB-14* MB Indx-2.4 cTropnT-0.05* [2150-7-25] 05:45AM BLOOD CK-MB-13* MB Indx-2.3 cTropnT-0.04* [2150-7-28] 06:00AM BLOOD Calcium-8.3* Phos-3.2 Mg-2.0 [2150-7-15] 07:11AM BLOOD Calcium-8.9 Phos-3.4 Mg-2.3 [2150-7-14] 07:50PM BLOOD calTIBC-273 Ferritn-452* TRF-210 [2150-7-14] 07:50PM BLOOD TSH-2.9 [2150-7-15] 07:11AM BLOOD Free T4-1.4 [2150-7-17] 03:15PM BLOOD HIV Ab-NEGATIVE [2150-7-15] 07:11AM BLOOD RheuFac-14 [2150-7-15] 01:51AM BLOOD [Doctor First Name ]-POSITIVE Titer-1:40 Echo Results [2150-7-14]: Conclusions: Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is severely depressed with near akinesis of the distal 2/3rds of the ventricle. The remaining segements are markedly hypokinetic. Right ventricular chamber size and free wall motion are normal. Moderate (2+) mitral regurgitation is seen. There is a large circumferential pericardial effusion measuring 2.7cm lateral to the left ventricle, 1.5cm inferior to the left ventricle and anterior to the right atrium with relative sparing of anterior to the right ventricle (<1cm). The effusion is echo dense, consistent with blood, inflammation or other cellular elements. There is mild intermittent RA invagination. There is no evidence of RV diastolic collapse. An unusual "mass" is visualized anterior to the right ventricle. The echo texture is atypical for hepatic tissue.. [2150-7-27]: Conclusions The left atrium is moderately dilated. The left atrium is elongated. The right atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is mild global left ventricular hypokinesis. Overall left ventricular systolic function is mildly depressed. Right ventricular chamber size is normal. Right ventricular systolic function is normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the findings of the prior study (tape reviewed) of [2150-7-15], the LV function has improved and the pericardial effusion is no longer present. The mediastinal mass is no longer apparent., Brief Hospital Course: 71 yo M w/ h/o HTN, CAD, s/p anterior MI [2147] (RCA stent, unsuccessful LAD intervention); severe systolic and diastolic dysfunction (EF 35 % [3-9]), hyperlipidemia; he had vague CP w/ assoc SOB x days prior to admission. In ed, CXR w/ globular heart prompted echo that showed large pericardial effusion w/o echocardiographic tamponade however clinically impending as he went into rapid AF. Amiodarone initiated. Serial echo later revealed 5cm mediastinal mass, collaborated by CT, and ultimately biopsied in OR (Dr. [Last Name (STitle) 952], thoracics) and pericardial effusion drained. sugeons described lesion as caseating/cheesy hence TB concern and precautions. extubated, post op w/o complications and diuresed in CCU for mild decomp HF. effusion w/u labs included a negative [Doctor First Name ], RF. HIV negative. Preliminary pathology results reported on [2150-7-17] (Dr. [Last Name (STitle) ] revealed highly atypical squamous epithelial cells w/o invasion w/ a differential most suggestive for Thymic cyst (w/ CIS) vs Thymic CA (w/ sqaumous differentiation) vs primary lung CA (w/ Mets). Staining for TTF (lung CA) and CD5 (thymic CA) were non-diagnostic and the decision to biopsy upper lung nodules that were noted on CT as staging for possible mets. Respiratory precautions d/c'd as pathology not c/w infection (AFB stain and flow cytometry negative additionally). Incidental 5.6cm AAA is evaluated by vasc [Doctor First Name ] consult who felt no acute surgical repair necessary. Pt had VATS and wedge resection on [7-23] and lung nodules were sent to pathology. Two lung lesions were biopsied and third lesion was too deep to be removed. Pt while recovering from surgery had an episode of hypotension with blood pressure drop to 75/30s. Pt was thought to be dry and was given aggresive fluids. Pt's BP returned to [Location 213] and kidney function improved. PT fluids stopped and pt started on lasix for net 1L fluid output. Pt s/p VATS remianed with a chest tube until pneumothorax from surgery resolved. Pt will follow up outpt in terms of results of biopsy and treatment decisions. UTI - Pt urine culture came back positive for psuedomonas while in hospital and pt was started and finished 7 day course of cipro while in the hospital. Pt repeat urine cx came back negative. Medications on Admission: Lipitor 10mg qd Lisinopril 40mg qd Lasix 40mg [Hospital1 ] Atrovent 2p [Hospital1 ] Atenolol 50mg qd Imdur 100mg qd Discharge Medications: 1. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). Disp:1 IH Refills:2 2. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO QD (once a day). Disp:60 Tablet(s) Refills:2 3. 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 4. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 6. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO once a day. 7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. 8. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) as needed for lung effusion for 4 days. Disp:4 Tablet(s) Refills:0 9. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO QD (once a day). Disp:30 Tablet Sustained Release 24HR(s) Refills:2 10. Lopressor 100 mg Tablet Sig: One (1) Tablet PO twice a day. 11. Miconazole Nitrate Powder Sig: One (1) Appl Miscell. [Hospital1 ] (2 times a day) as needed. 12. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day) as needed. Discharge Disposition: Extended Care Facility: [Hospital3 2558] - [Location (un) ] Discharge Diagnosis: Medistinal Mass; Thymic CA vs. metastasis Lung nodules Pericardial Effusion CAD HTN CHF Hyperlipidemia Discharge Condition: stable Discharge Instructions: Please return if you have any chest pain, shortness of breath, loss of conciousness. Please follow up as an outpatient at [Hospital 32538] clinic. Followup Instructions: [Hospital ] clinic appointments: Dr. [Last Name (STitle) 32539] at 1030 Dr. [Last Name (STitle) 952] at 1100 Dr. [Last Name (STitle) ] at 1530 Follow up at vascular clinic w/ Dr. [Last Name (STitle) ]; call the office for an appointment. Name: [Known lastname 5648], [Known firstname ] Unit No: [Numeric Identifier 5649] Admission Date: [2150-7-14] Discharge Date: [2150-8-11] Date of Birth: [2078-7-19] Sex: M Service: CME HISTORY OF PRESENT ILLNESS: The patient is a 71-year-old man who had a pericardial window biopsy for pericardial effusion and mass on [2150-7-15]. He had video-assisted thoracic surgery on [2150-7-27] and a chest tube placed. His pleural pathology was negative. This addendum is to update his current disposition, which is to rehabilitation and his medications. Since the last Discharge Summary, the patient had three chest x-rays after his chest tube on the left had fallen out. The chest x-rays were stable and showed no change in the status of his left lung. The patient had no untoward complications since his chest tube was out and has done well for the four days since his last Discharge Summary had been dictated. His medications that he will go to rehabilitation with are. DISCHARGE MEDICATIONS: 1. Amiodarone 400 mg p.o. q d. 2. Isosorbide mononitrate 60 mg p.o. q d. Please hold for systolic blood pressure of less than 100. 3. Metoprolol 75 mg p.o. q.i.d. Hold for heart rate less than 55 and systolic blood pressure of less than 95. 4. Levofloxacin 250 mg p.o. q d. The patient will have a seven day course. He is currently on day three. 5. Simethicone 5-30 cc p.o. q.i.d. p.r.n. 6. Calcium carbonate 500 mg p.o. q.i.d. p.r.n. 7. Ascorbic acid 500 mg p.o. b.i.d. 8. Polysaccharide-iron complex 150 mg p.o. q d. 9. Docusate sodium 200 mg p.o. b.i.d. p.r.n. 10. Percocet 5/325 mg, 1-2 tablets p.o. q 4-6 hours p.r.n. 11. Ipratropium bromide metered dose inhaler, two puffs q.i.d. 12. Miconazole powder two percent, one application b.i.d. p.r.n. 13. Pantoprazole 40 mg p.o. q 24 hours. 14. Acetaminophen 325-650 mg p.o. q 4-6 hours p.r.n. DIET: Ad lib as tolerated. ACTIVITY: Physical Therapy to continue to walk with him to improve his gait and strength. FOLLOW UP: The patient is to follow-up as previously described in the previous Discharge Summary. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], [MD Number(1) 4295] Dictated By:[Last Name (NamePattern1) 3126] MEDQUIST36 D: [2150-8-11] 10:21:47 T: [2150-8-11] 10:57:20 Job#: [Job Number 5652]	[ "518.89", "428.0", "512.1", "423.9", "584.9", "786.6", "599.0", "427.31", "276.7" ]	icd9cm	[ [ [] ] ]	[ "38.93", "34.26", "33.23", "34.21", "32.29", "37.12", "33.39" ]	icd9pcs	[ [ [] ] ]	18489, 18559	14681, 17029	9705, 9751	18706, 18714	11237, 14658	18914, 19421	10838, 10881	8286, 8428	20236, 21246		18580, 18685		17055, 17180	3675, 8264		18738, 18891					1157, 1319				10896, 11218										21258, 21612					1342, 2174										9617, 9667									19450, 20213								2189, 3657									10405, 10624	10640, 10822
24,559	137,520	17461	Discharge summary	report	Admission Date: [2118-3-29] Discharge Date: [2118-4-4] Service: HISTORY OF PRESENT ILLNESS: The patient is an 83-year-old female who is complaining of shortness of breath with exertion and increasing dizziness with exertion. On [2-20], the patient was treated for a pneumonia and congestive heart failure. She has had an ejection fraction of 30% on echocardiogram with left ventricular hypertrophy. CT scan shows interstitial fibrosis and BOOP. In [8-23], the patient had a cerebrovascular accident. Cardiac catheterization was done on [2-21] showing 100% right femoral profunda, ejection fraction 70%, LVEDP 12, left axis deviation 40% diagonal, 40% right coronary artery, 50% severe AS with [Location (un) 109]. Cardiac echocardiogram shows severe AS, MAC, mild MR, moderate TR. PAST MEDICAL HISTORY: 1. Osteoarthritis. 2. Pneumonia in [2-20]. 3. Congestive heart failure. 4. Interstitial lung fibrosis. 5. Blind in the right eye secondary to embolus. 6. Cerebrovascular accident in [8-23]. 7. Near syncope. 8. Hypertension. 9. Fractures of both wrists and pelvis. 10. Postoperative .................... status post total abdominal hysterectomy. PAST SURGICAL HISTORY: 1. Bladder SURP. 2. Total abdominal hysterectomy. HOME MEDICATIONS: 1. Plavix 75 mg q day. 2. Spironolactone 25 mg [Hospital1 ]. 3. Aspirin 81 mg q day. 4. Metoprolol 50 mg [Hospital1 ]. 5. Zocor 20 mg q day. 6. Lasix 40 mg q day. 7. Prednisone 1 mg [Hospital1 ]. 8. Detrol 40 mg q day. ALLERGIES: Codeine causes nausea and vomiting. SOCIAL HISTORY: Patient quit smoking 30 years ago. REVIEW OF SYSTEMS: In general, weight is stable this year, lost about 15 pounds last year. Appetite okay. HEENT: The patient wears glasses, no sinuses, or throat polyps. Positive retinal embolus in the right eye. Respiratory: Positive pneumonia, no emphysema or asthma. Cardiac: Positive near syncope, positive palpitations, no PND. Gastrointestinal: No nausea, vomiting, diarrhea, constipation, liver disease, or gallbladder disease. Genitourinary: No calculi, no renal disease. Musculoskeletal: Old fracture of both wrists, old fracture of both knee, old pelvic fracture, osteoarthritis left hip and hand. Peripheral vascular: No claudication, no varicosities. Neurologic: Positive cerebrovascular accident, no transient ischemic attacks, positive coma 30 years ago, result in after which the patient continued to have an unusual speech pattern. Heme/Endocrine/other: No bleeding disorders, no diabetes, no thyroid disease, and no psychiatric issues. PHYSICAL EXAMINATION: Heart rate 76, blood pressure 139/63. In general, the patient is frail, but well-nourished. Skin: Multiple small ecchymosis, no rash, good skin tone. HEENT: Pupils are equal, round, and reactive to light. Extraocular movements are intact. Sclerae are anicteric. Normal buccal mucosa. Neck: No jugular venous distention. Murmur radiated to both sides of her neck. Chest: Bibasilar crackles, otherwise clear, slightly kyphotic. Heart: Regular, rate, and rhythm, 3/6 systolic ejection murmur radiates throughout the precordium and neck. Abdomen is soft, nontender, nondistended, no hepatosplenomegaly, well-healed suprapubic scar. Extremities are warm and well perfused. No clubbing, cyanosis, or edema. Varicosities, small spider veins, bilateral lower extremities, no varicosities. Neurologic is grossly nonfocal. Cranial nerves II through XII are grossly intact. Excellent strength in all four extremities. Pulses: Bilateral femoral 2+, bilateral DP and PT pulses 1+, radial bilateral 2+. HOSPITAL COURSE: The patient was admitted on [2118-3-29] and taken to the operating room where an aortic valve replacement was performed for symptomatic aortic stenosis. Postoperatively, the patient left operating room on a propofol and Neo-Synephrine drip. She had chest tubes and pacing wires in place. Patient received perioperative Vancomycin treatment. Patient did well postoperatively. Was immediately tried on regular food. She was extubated in a timely fashion. Her drips were stopped on a timely fashion. The patient was noted to have a left bundle branch block, prolonged P-R intervals. She was seen by the Electrophysiology Department, who believed that her conduction recovery would likely be predictably low, and therefore recommended a permanent DDD pacemaker which was placed on postoperative day one. Patient was started on an ACE inhibitor and beta blocker, Plavix as her carotid disease and history of cerebrovascular accident was restarted at the appropriate time. The patient was seen by Physical Therapy worked with her extensively, and believes the patient will do well with some kind of rehabilitation facility. The patient was stable. The patient was transferred to the regular surgical floor, where she did well. She did have bilateral crackles, and interval chest x-rays confirmed improvement of her lung status. Lasix was given to increase the patient's urinary output and decrease her volume overload. Patient failed her voiding trial, had to be recatheterized for 24 hours. Patient is being seen by Cardiology to readjust her pacemaker to a lower heart rate. On [2118-4-4], the patient was doing well and will be discharged today to a rehabilitation facility in good condition. The patient should not drive while on pain medication. She may take showers, but she may not take bathes. She should avoid strenuous activity. FO[Last Name (STitle) ]P INSTRUCTIONS: She is to followup with Dr. [Last Name (Prefixes) 411] in four weeks. She should followup with Dr. [First Name4 (NamePattern1) 38329] [Last Name (NamePattern1) 48765] in [12-23] weeks, and with Electrophysiology in approximately one week. MEDICATIONS AT REHABILITATION: 1. Lopressor 50 mg po bid. 2. Cepacol lozenge po prn. 3. Guaifenesin 5 mL q6 prn. 4. Ibuprofen 400-600 q6 prn. 5. Simvastatin 20 mg po q day. 6. Tolterodine 4 mg po q hs. 7. Clopidogrel 75 mg po q day. 8. Prednisone 1 mg po bid. 9. Milk of magnesia 30 mL po q hs prn. 10. Percocet 1-2 tablets po q4-6h prn. 11. Lasix 20 mEq po q12 x10 days. 12. Lasix 40 mg po bid x10 days. 13. Tylenol 650 mg po q4 prn. 14. Enteric coated aspirin 325 mg po q day. 15. Ranitidine 150 mg po bid. 16. Colace 100 mg po bid. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Last Name (NamePattern4) 8358] MEDQUIST36 D: [2118-4-4] 11:43 T: [2118-4-4] 11:49 JOB#: [Job Number 48766]	[ "424.1", "515", "397.0", "401.9", "426.0", "428.0" ]	icd9cm	[ [ [] ] ]	[ "37.83", "35.22", "39.61", "37.72" ]	icd9pcs	[ [ [] ] ]														3647, 6607										1224, 1275						1293, 1574										2619, 3629						1647, 2596													112, 825																	847, 1201	1591, 1627

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