Split (1)

train · 26.9k rows

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30,608	175,403	9640	Discharge summary	report	Admission Date: [2134-6-7] Discharge Date: [2134-6-12] Date of Birth: [2064-6-23] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2181] Chief Complaint: Shortness of breath, hypoxia Major Surgical or Invasive Procedure: None History of Present Illness: 69 year old man with COPD (on 2L NC at home; FEV1 1.12 at baseline), central hypoventilation, sleep disordered breathing on home BiPAP, obesity, CAD s/p MI and LAD stent, h/o recurrent Vfib/Vtach s/p AICD placement, presents from pulmonary clinic with dyspnea and hypoxia. He reports that since a hospitalization in [State 108] in late [Month (only) 547] for COPD exacerbation, although improved, his breating has never subjectively felt back to his previous baseline although his oxygen sats were at his baseline low 90s% on 2-3L NC. Over the past few weeks however, he has noted worsening LE edema and increasing DOE so that even walking across the room from the bathroom made him feel SOB. He reports discomfort in B/L LEs with the edema, but not marked pain nor asymmetry. He reports he drove from [State 108] to Mass. in 10 hour stretches approximately 2 weeks ago. He reported his worsening LE edema and SOB to his cardiologist who increased his lasix dose from 40mg PO daily to 80mg PO daily for the 4 days prior to his admission. He reports he has been making "good" urine to this and his LE edema has improved, however his SOB has not. He denies increased sputum production nor fevers/chills. so held on seeking medical attention until this previously scheduled appointment. At pulmonary clinic, he was noted to be hypoxic to 82% on 2-3L NC. A CT chest was performed which showed bilateral ground glass opacities. Following imaging and in the setting of his worsened hypoxia, he was referred to the medical floor for direct admission. . With respect to his late [Month (only) 547] admission for hypoxia. He reports he developed worsening hypoxia at home and presented to a local hospital in [State 108]. He endorses worsening in his sputum production at that time. He was treated for COPD exacerbation with 10 day course of levofloxacin and 30 day slow taper of prednisone. Although he reports improvement from that hospitalization, he never returned to baseline and over the past 2 weeks has further decompensated as outlined above. . Upon direct admission to the floor, initial O2 sats were noted to be in the 70s, he was placed on additional supplemental O2 (unclear exact amount via NC) and initial ABG revealed 7.28/75/72. He was then placed on bipap after which repeat gas was 7.28/76/51. From there he was changed to cpap although ABG on cpap was not obtained. He received 100mg IV lasix x1 to which he put out 450ccs urine. Upon transfer to the ICU, he was on 4L NC with O2 sats high 80s to low 90s. Repeat ABG at that time was 7.30/77/57. He has made an additional 220 ccs urine for a total of 670cc out since lasix dosing. . ROS: No changes in vision, no headache. No numbness/tingling/weakness. No chest pain/palpitations. No abdominal pain, no frank blood in stool (but endorses guaiac positive at recent PCP [Name Initial (PRE) ]), no dark tarry stools. No dysuria/hematuria. No rashes. +joint pain specifically low back. Past Medical History: 1. COPD (on 2L nc at home, last PFTs [7-/2133]: FVC 1.82 (44% predicted), FEV1 1.12 (39% predicted), FEV1/FVC 61 (90% predicted)); DLCO 34% predicted. 2. Complex sleep disordered breathing on home BiPAP. 3. Obesity, kyphosis, and restrictive pulmonary dysfunction. 4. CAD s/p anteroseptal MI in [2125], s/p prox LAD stenting. 5. History of recurrent Vfib/Vtach and cardiac arrest, s/p AICD. 6. Hypercholesterolemia. 7. History of bladder cancer. 8. Diabetes mellitus. 9. Status post multiple laminectomies for disc disease. 10. CRI; baseline creatinine unclear ? 1.4-1.6 11. Anemia Social History: Lives with wife. Spends winter and early spring in [State 108], summers in [State 350]. Quit tobacco in [2124], smoked 2ppd x 30years prior to that. No EtOH since [2124] prior to which he reports "heavy" drinking although does not elaborate. Denies other illicits. Previously worked in construction as welder. Family History: non-contributory Physical Exam: T 96.9 BP 104/57 HR 87 RR 30 O2sat 95% on 4L NC GEN: Speaking in full sentences however appears mildly tachypneic HEENT: PERRL, EOMI, no conjuctival injection, anicteric, OP clear although dry from recent cpap mask, neck supple, no carotid bruits, unable to assess jvd given body habitus CV: RRR, distant heart sounds however no m/r/g appreciated PULM: Bibasilar rales [12-24] way up, no wheezes nor rhonchi ABD: obese, soft, NT, ND, + BS EXT: warm, dry, palpable DP/PT pulses b/l, 2+ pitting edema to mid shins b/l NEURO: alert & oriented x3, CN II-XII grossly intact, strength intact throughout grossly. No sensory deficits to light touch appreciated. Mild asterixis. PSYCH: appropriate affect Pertinent Results: [2134-6-7] CT chest: Newly occurred diffuse, inhomogeneous, and slightly apical predominant pattern of parenchymal opacities that suggests either RB-ILD or DIP. Early NSIP is less likely given the distribution of the changes. . [2134-6-7] TTE: The left atrium and right atrium are normal in cavity size. The estimated right atrial pressure is 0-5 mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (area 1.2-1.9cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is an anterior space which most likely represents a fat pad. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Mild aortic valve stenosis. Pulmonary artery systolic hypertension (50 mmHg). . [2134-6-9] Bubble study: Right to left intracardiac shunting is present at rest. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. Tricuspid regurgitation is present but cannot be quantified. Compared with the prior study (images reviewed) of [2134-6-7], right to left intra-cardiac shunting is present at rest. If clinically indicated, a TEE may clarify the degree of intracardiac shunting and to clarify PFO versus ASD. Brief Hospital Course: 69yo M with h/o COPD (2-3L home O2 requirement), CAD, CHF, v. fib/v. tach arrest s/p AICD presents with subacute worsening of dyspnea and hypoxemia and hypercarbia. . # Hypoxemia/Hypercarbia: Multifactorial in the setting of known COPD with mixed obstructive/restrictive pattern on PFTs. He was not, however, markedly bronchospastic on exam and denies increased sputum production to suggest overt COPD exacerbation. Also without focal infiltrate, leukocytosis and fever to suggest underlying lobar pneumonia although atypical infection was possible, but less likely. Further review of ground glass opacities on chest CT suggested that this was actually the result of poor inspiratory effort more than fluid buildup or atypical pneumonia. His BNP was 838 (although may be somewhat lower than expected given obesity) and thus not overwhelming for CHF. On TTE he had pulmonary htn (50 mmHg) when compared to prior which may also be contributing. In terms of risk for PE, he had long drives from [State 108] and thus perhaps a significant risk, but a lung scan was done and suggested low probability for PE. Additionally TTE without decline in EF (actually better than previously) to suggest acute ischemic event causing drop in EF; CEs negative x2 and EKG without ischemic changes. . Additionally, it appears that he had a right-to-left shunt seen on TTE, which likely contributed to hypoxia; additionally with increased right heart pressure, left ventricular function may have worsened and contributed to pulmonary hypertension. This would help to explain his right heart failure symptoms like increasing peripheral edema while his hypoxia was really most response to steroids. He was started on 125mg IV solumedrol followed by 80mg q8h for one day, 60 mg q6h for one day, and then a conversion to PO prednisone with a taper described in the outpatient medication list below. Azithromycin for four days was given for bronchitis and effects on inflammation. Supplemental oxygen and home BiPAP was continued. . # COPD/central hypoventilation: Patient was hypercarbic however by history had no increase in cough nor sputum production and on exam is not bronchospastic. We gave albuterol/atrovent nebs, his home advair, and steroids as described above. . # Metabolic alkalosis: Was started on diamox nearly a year ago per old OMR pulmonary note twice weekly. Appears compensatory in the setting of CO2 retention however worsened in the setting of contraction with diuresis. Diamox was held but was restarted for his outpatient regimen as detailed below. . # CAD: H/o CAD s/p LAD stent in [2125]. CEs negative and EKG without new ischemic changes. Had multiple VF/VT events and in fact his wife informs us that he was the topic of an academic medical article; of note, this was in the same room of the same MICU that he was admitted to this time, which he and his wife took to be a good sign. Less suspiciously, we continued aspirin, statin, and beta blocker. . # CHF: Repeat chemistries show hypernatremia and climbing bicarb (contraction alkalosis). Given BNP of 838 and echo with evidence of LVH, however with improved LVEF from prior, suspect CHF not contributing markedly to the above picture despite ground glass opacities on CT chest. He put out nearly 700ccs to 100mg IV lasix. He got diamox x1 but this was then held as above. BB and [Last Name (un) ] were continued. . # CRI: In review of labs, appears baseline creatinine runs 1.4-1.6 however we have few measurement points since [2125] admission. He has been stable at 1.6 thus far. We continued his [Last Name (un) ] and monitored closely. At discharge his creatinine was 1.3. . # Diabetes mellitus: We used an insulin SS for much of the admission pending possible further imaging modalities in the setting of CRI, but then switched to his oral medications and an insulin sliding scale. His glucose was poorly controlled prior to the switch, and after the switch his glucose was improved; serum glucose was 87 on the morning of discharge after being elevated in all prior labs. . # Anemia: Hct 34 on this admission (no priors since [2126] and prior to that [2125] at which time he was hospitalized for prolonged period). Elevated MCV and RDW. Guaiac positive stools however without gross blood nor black stools. His Hct did not drop precipitously. This merits GI followup. Heparin gtt was stopped and pneumoboots were used for PPX. . # Hyperlipidemia: Continued atorvastatin 40mg PO daily. . #FEN: DM, cardiac diet. Replete lytes PRN . #ACCESS: PIV . #PPx: - pneumoboots - continued omeprazole as on as outpatient - bowel meds . #CODE: FULL . #COMMUNICATION: patient and wife [Name (NI) ] [Name (NI) 1683] [Telephone/Fax (1) 32629] . #DISPO: Home Medications on Admission: Acetazolamide 125mg PO qTuesday and Thursday Advair Diskus 500-50mcg 1 puff [Hospital1 ] Allopurinol 100mg PO daily ASA 81mg PO daily Benzonatate 100mg q6h prn Calcium 500mg PO daily Centrum silver MVI Clobetasol 0.05% apply to skin [Hospital1 ] Coreg 25mg PO bid Cozaar 50mg PO bid Erythromycin ointment to affected areas as needed for skin irritation from CPAP Glyburide-metformin 5-500mg; 1.5 tabs PO bid K-Dur 10mEq [Hospital1 ] Lasix 80mg daily, recently increased from 40mg daily Lipitor 40mg PO daily Magnesium oxide 400mg once daily Meloxicam 15mg PO daily NTG 0.4mg SL prn Oxygen 2-3L Prilosec 40mg PO daily Uniphyl 600mg SR daily Vitamin E Xopenex neb q4h prn Discharge Disposition: Home Discharge Diagnosis: COPD Diabetes Right-to-left intracardiac shunt Hypertension Chronic renal insufficiency Discharge Condition: Stable Discharge Instructions: You were admitted for shortness of breath and lack of oxygen in your blood. There are several things that might have contributed to this, but things that did contribute were: 1)a flare of your COPD and 2)heart failure, complicated by the shunt in your heart that causes blood without oxygen to mix with blood that has oxygen. . Additionally, probably mostly because we used high-dose steroids to help treat you, you had very high sugar levels while you were here. While you are still on steroids, you will need to watch your sugar levels closely. We are starting you on insulin, and you should stop taking the diabetes pills you take for the time being. If you are consistently having sugar levels about 250 or you are having low blood sugars (below 70) please call your doctor as soon as possible to consider redosing your insulin. If your sugar levels are below 60, you should drink a glass of juice. You will probably need less insulin as you take lower doses of steroids. You should write down each sugar level and bring them to your PCP's office. You will need to see your PCP early next week, and regularly after that for continued manegment. . Follow the prescription for your steroid taper closely. You'll be changing doses after two days, and then every five days after that. If you develop worsened shortness of breath, fever, chest pain, palpitations, lightheadedness, or other concerning symptoms, call your PCP or go to the emergency room. Followup Instructions: You should call your PCP [Name9 (PRE) ],[Name9 (PRE) ] [Name Initial (PRE) ]. [Telephone/Fax (1) 5424] on monday morning to schedule an appointment early next week. Dr[Name (NI) 4025] office is trying to find you a time within the next 1-2 weeks to see Dr [Last Name (STitle) 575]. If you do not hear from Dr [Name (NI) 20186] office, you should call to make an appointment at the first available time; call ([Telephone/Fax (1) 513]. . Already-made appointments: Provider: [Last Name (NamePattern4) ]. [First Name (STitle) ] & DR. [First Name (STitle) ] Phone:[Telephone/Fax (1) 612] Date/Time:[2134-6-18] 9:20 Provider: [Name10 (NameIs) 676] CLINIC Phone:[Telephone/Fax (1) 59] Date/Time:[2134-8-30] 8:30	[ "280.9", "272.4", "584.9", "428.0", "276.3", "428.32", "V10.51", "V45.01", "518.84", "V45.82", "250.02", "585.3", "745.5", "412", "491.21", "416.8", "414.01", "278.00", "327.26", "327.23" ]	icd9cm	[ [ [] ] ]	[ "93.90" ]	icd9pcs	[ [ [] ] ]	12474, 12480	6976, 11741	343, 349	12612, 12621	5109, 6953	14127, 14902	4353, 4371			12501, 12591		11767, 12451			12645, 14104							4386, 5090																275, 305								377, 3374													3396, 3989	4005, 4337
2,482	126,245	4887	Discharge summary	report	Admission Date: [2148-1-8] Discharge Date: [2148-1-11] Date of Birth: [2084-11-24] Sex: M Service: Surgery HISTORY OF PRESENT ILLNESS: The patient is a 61 year old gentleman who, shortly prior to admission, had been in previously good health but developed left scapular discomfort and left arm paresthesias as well as mild weakness in his fingers. A chest x-ray showed a questionable nodule. CT scan confirmed the presence of multiple lung metastases as well as a left thyroid mass abutting an obstructive lesion in the T2 vertebra. A fine needle aspiration of the left thyroid mass was consistent with "microfollicular neoplasm suspicious for carcinoma". The patient is scheduled for a thyroidectomy so that he can receive iodine-131. He is being referred to Dr. [Last Name (STitle) ] for this procedure. PAST MEDICAL HISTORY: Hypertension. PAST SURGICAL HISTORY: Status post laparoscopic cholecystectomy. MEDICATIONS ON ADMISSION: Norvasc. PHYSICAL EXAMINATION: On physical examination, the patient appeared healthy. He had a barely palpable left thyroid mass. HOSPITAL COURSE: On [2148-1-8], the patient was admitted to [First Name4 (NamePattern1) 3867] [Last Name (NamePattern1) ] [First Name (Titles) ] [Last Name (Titles) ] for a partial left thyroidectomy. Dr. [Last Name (STitle) ] performed the procedure. Intraoperatively, there was extensive extra-glandular disease. It was deemed unresectable. During the operation, there was an increased amount of bleeding and extensive electrocautery was used to achieve hemostasis. Please see the previously dictated operative note for further details. The patient tolerated the procedure well. Due to the increased risk of bleeding postoperatively, the patient was transferred to the Intensive Care Unit and left paralyzed and intubated for his first night following surgery. On postoperative day number two, the patient was reversed and extubated. The remainder of his hospital course was uncomplicated. By hospital day number three, the patient was able to tolerate a regular diet, his pain was well controlled, and he was able to ambulate and void without problems. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: The patient was discharged to home. DISCHARGE MEDICATIONS: Norvasc 5 mg p.o.q.o.d. Lorcet [6-30] p.o.q.d. Percocet one to two tablets p.o.q.4-6h.p.r.n. pain. Colace 100 mg p.o.b.i.d. while taking Percocet. Keflex 500 mg p.o.q.i.d. times five days. FOLLOW-UP: The patient was instructed to follow up with Dr. [Last Name (STitle) ] in one week, at which point he will have his staples removed. The patient should see his endocrinologist, Dr. [Last Name (STitle) 20393], within the next week or so. DISCHARGE DIAGNOSIS: Thyroid cancer, status post partial resection of thyroid gland. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 11126] Dictated By:[Last Name (NamePattern1) 6355] MEDQUIST36 D: [2148-1-11] 09:14 T: [2148-1-16] 12:15 JOB#: [Job Number 20394]	[ "E878.8", "401.9", "193", "198.5", "197.0", "998.11" ]	icd9cm	[ [ [] ] ]	[ "06.39", "06.09" ]	icd9pcs	[ [ [] ] ]									2317, 2770	2791, 3132		979, 989	1131, 2204								909, 952									1012, 1113																165, 847													870, 885		2229, 2294
2,049	115,372	14661	Discharge summary	report	Admission Date: [2185-1-4] Discharge Date: [2185-1-24] Date of Birth: [2116-8-2] Sex: F Service: SURGERY Allergies: Dilaudid / Morphine Attending:[First Name3 (LF) 4111] Chief Complaint: Bright red blood per rectum. Major Surgical or Invasive Procedure: 1) [2185-1-5] Proctosigmoidoscopy, fulguration of rectal bleeding point at 13 cm, injection of epinephrine and irrigation with epinephrine. 2) [2185-1-5]: Right IJ central venous line placement 3) [2185-1-12] Flexible sigmoidoscopy to 50 cm (no bleeding seen) 4) [2185-1-15] Flexible sigmoidoscopy with [Hospital1 ]-CAP Electrocautery applied for hemostasis successfully at 10cm History of Present Illness: 68 year-old female known to Dr. [Last Name (STitle) 957] presented to [Hospital1 5109] today with bright red blood per rectum. This morning she experienced lower abdominal pain and had copious blood per rectum in the toilet. She no longer has pain. She has had two subsequent bloody bowel movements today. She was well until this morning. She denies nausea and/or vomiting. She has no fever, chills, no weight loss or change in appetite. Past Medical History: CHF (ECHO [9-3]: EF 55%) Hypertension Mild carotid stenosis Hyperlipidemia Sigmoid diverticulitis Enterocutaneous fistula Thyroid nodules Peripheral vascular disease (lower extremities) followed by Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] . PSH: [9-4] s/p Left renal stent [7-4] s/p L fem-AK [Doctor Last Name ], left profunda- patch angioplasty [9-2] s/p cholecycectomy [5-1] incisional hernia repair, s/p Chole, s/p appendectomy, s/p sigmoid colectomy, Resection of a pilonidal cyst, T&A [4-29] Aortobifemoral bypass graft c/b a splenic laceration requiring splenectomy, ischemic proctitis, an infarcted left colon, s/p left colectomy and transverse colostomy (since reversed), Enterocutaneous fistula, subphrenic abscess Social History: She is a widow and lives alone. She admits to occasional ETOH and tobacco use. Family History: Non-contributory Physical Exam: PE: Afebrile, HR 70, BP 160/80 GEN: no acute distress, alert and oriented x 3, appears comfortable HEENT: no scleral icterus or jaundice, neck supple CARDIAC: regular rate and rhythm LUNG: clear to ausculation bilaterally ABD: soft, non tender, non distended, guaiac positive Rectal: no hemorrhoids, no obvious source of bleeding, no masses Ext: symmetrical pulses bilaterally Pertinent Results: Admission Labs:[2185-1-4] 06:55PM --------------- GLUCOSE-101 UREA N-11 CREAT-0.7 SODIUM-141 POTASSIUM-4.3 CHLORIDE-106 TOTAL CO2-24 ANION GAP-15 CALCIUM-8.8 PHOSPHATE-3.3 MAGNESIUM-2.0 WBC-10.1 RBC-4.33 HGB-13.3 HCT-38.3 MCV-88 MCH-30.8 MCHC-34.9 RDW-17.1* NEUTS-58.2 LYMPHS-33.2 MONOS-6.9 EOS-1.6 BASOS-0.2 PLT COUNT-289 PT-12.8 PTT-21.0* INR(PT)-1.1 . Serial hematocrits: [1-19]: 29.8 [1-20]: 29.8 [1-21]: 28.0 [1-22]: 28.2 [1-23]: 29.1 [1-24]: 28.4 . Nutrition Labs: --------------- Date---Fe---TIBC---TRF---[Last Name (un) ]---Alb---TG [1-5]----109--333----256---31-----3.9---.. [1-11]---31---289----222---43-----3.4---137 [1-16]---22---283----218---28-----3.3---338 . Radiology --------- [2185-1-4] ~ GI BLEEDING STUDY(Tag RBC Scan) IMPRESSION: Increase blood flow in the region of the descending colon. No evidence of active GI bleed during the time of the study. . [2185-1-5] ~ GI BLEEDING STUDY (Tag RBC Scan) Bleeding was first noticed at 6-8 minutes. IMPRESSION: Evidence of bleeding in the pelvic bowel loops notable within first 10 minutes. Further angiographic/surgical correlation to determine the vscular site of origing is recommended. . Cultures: [Date range (1) 43171] C.diff: Negative [1-9] C.diff toxin B (send out): Negative [1-20] C.diff: Negative Brief Hospital Course: Ms. [Known lastname ] is known to Dr.[Name (NI) 6275] [Name (STitle) 4869] and presented with bright red blood per rectum. GI: She was admitted to the ICU for recusitation. She was kept NPO, central venous access was obtained, and a PPI was started prophylactically. 3 units of PRBCs were transfused after her HCT dropped from 42-> 38-> 33. She was started on Cipro and Flagyl empirically and a Pitressin drip. A tagged RBC scan on [2185-1-4] did not indicate an active bleed. A CT scan revealed no extravasation of contrast, but there was new wall thickening of the 7-8cm segment of distal colon just proximal to the distal surgical anastomosis. GI Service was consulted for further evaluation of her bleed. Patient continued to pass large amounts of fresh bloody stool. A gastric lavage was bilious without evidence of blood. A second ([2185-1-5]) tagged RBC scan revealed bleeding in the rectosigmoid area, probably right around the sacral and coccygeal hollow. This was the area where the right colon was connected to the rectum. She was taken to the operating room for a proctosigmoidoscopy and had fulguration of a rectal bleeding point at 13 cm, injection of epinephrine and irrigation with epinephrine. She was monitored in the ICU and passed maroon to green stool with presence of clots. C. Diff cultures x3 were all negative and C. Diff toxin B negative. Her HCTs were stable and she remained on a vasopressin drip that was titrated down daily. On Hospital Day 8 she experienced maroon stool with clots, her HCT dropped to 24 from 28 so she was transfused 2units of PRBCs. She had a flexible sigmoidoscopy to 50cm that showed no bleeding. She remained in the ICU for monitoring. She continued to have maroon stools on Hospital Day 11. The GI service performed another flexible sigmoidoscopy that revealed 2 bleeding ulcers at 20cm, the distal ulcer was injected with epinephrine. Her hematocrits subsequently remained stable at 29-30. She was transferred out of the ICU and had no more melenic stools. She did have a high amount of liquid diarrhea and was empirically started on PO Vanc. A repeat C.diff was negative, but it was decided to finsih a 7 day course of the Vancomycin. Her diet was slowly advanced from sips to a regular house diet. At the time of discharge she was having regular formed bowel movements and had no melena for 4 days. . GU (Urinary tract Infection): A urine culture from the ED grew Klebsiella pneumoniae. She was treated with a course of Ciprofloxacin. . Anemia (Blood Loss and Iron Deficiency): On arrival to the hospital she her Fe was 109 and her HCT was 38. Her iron levels dropped to 31 ([1-11]) and 22 ([1-16]). She received a total of 5 units PRBC while in the ICU for the GI bleed. She was started on Iron 325mg orally. At the time of discharge, she was advised to continue with the iron supplements. Her hematocrit was stable at 29-30. . Nutritional: Due to her prolonged NPO status, on HD9 TPN was started to deliver 25kcal/kg and 1.5g protein/kg for an IBW of 64kg. TPN was cycled for 12hours overnight on HD15 and discontinued on HD17. Once stablized on the floor, she was started on a clear liquid diet and slowly advanced to a low residue diet. . Hypertension: Patient was managed with Lopressor 5mg every 6hours to maintain SBP <140 and HR 60-80. She has had no acute cardiovascular events during this admission and was resumed on her home regimen. Medications on Admission: Aspirin 325mg daily Atenolol 25mg daily Fish oil Zocor 10mg daily MVI HCTZ 12.5mg daily Discharge Medications: 1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:90 Tablet(s) Refills:2 3. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO every six (6) hours for 3 days. Disp:12 Capsule(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Lower GI Bleed - requiring 5 units of PRBCs Acute blood loss/Iron Deficiency Anemia Urinary Tract Infection - treated with Bactrim DS H/O CHF (EF 55% on ECHO in [2182]) Discharge Condition: Stable Discharge Instructions: Please call Dr. [Last Name (STitle) 957] for any of the following: -Fever >101.5 -Chills -Nausea -Vomiting -Abdominal pain and/or tenderness -Rectal Bleeding -Changes in bowel habits ?????? such as constipation or diarrhea -Changes in urinary habits ?????? frequency, difficulty or pain while urinating -Any serious change in your symptoms, or any new symptoms that concern you. . Please resume your home medications except for the aspirin. Please continue taking the antibiotic, Vancomycin, until it is gone. Dr. [Last Name (STitle) 957] will instruct you when it is safe to resume the aspirin. Followup Instructions: Please follow-up with Dr. [Last Name (STitle) 957] in [12-29] weeks. Please call [Telephone/Fax (1) 2359] to schedule your appointment.	[ "V43.3", "285.1", "443.9", "401.9", "433.10", "599.0", "428.0", "272.4", "V12.79", "557.9", "569.3", "V45.3", "534.40" ]	icd9cm	[ [ [] ] ]	[ "96.34", "99.04", "38.93", "48.24", "99.15", "45.43" ]	icd9pcs	[ [ [] ] ]	7893, 7899	3895, 7367	306, 706	8116, 8125	2535, 2535	8778, 8930	2104, 2122		7505, 7870	7920, 8095		7393, 7482			8149, 8755							2137, 2516																238, 268								734, 1187					2550, 3872								1209, 1990	2006, 2088
10,582	185,094	30226	Discharge summary	report	Admission Date: [2196-3-15] Discharge Date: [2196-3-19] Date of Birth: [2196-3-15] Sex: M Service: NB HISTORY OF PRESENT ILLNESS: Baby [Name (NI) ] [Known lastname ] is a 3190 gram, 40 and 2/7 weeks male infant newborn who was admitted to the NICU for continuing management of severe neonatal depression, status post resuscitation in the delivery room. Infant was born to a 37 year-old, Gravida I, Para 0 now I mother. Prenatal screens included blood type A negative, antibody negative, hepatitis B surface antigen, RPR nonreactive, Rubella immune and Group B strep negative. The pregnancy had been uncomplicated with normal second trimester screening and normal fetal surveys. No significant maternal family past medical history. On [3-13], mother presented to [Hospital1 18] with decreased fetal movement and possible trickle of clear fluid. Fetal assessment was reassuring with reactive NST and biophysical profile with 8 out of 8 with an amniotic fluid index of 9. Ruptured membranes could not be confirmed at that time and the mother was discharged to home. On the evening of [3-14], mother represented in spontaneous labor after rupture of membranes at home. Retrospectively, the father noted that meconium was present at the time of initial rupture. Meconium was noted at [Hospital3 ] when mother began to push. On admission, she did have a nonreactive nonstress test. At the perineum, a nuchal cord was noted. It was cut and the infant was delivered. The infant presented floppy, apneic and was transferred to the radiant warmer. The infant was intubated. There was meconium noted in nasopharynx as well as below the vocal cords. After suctioning, the endotracheal tube was removed and positive pressure ventilation with 100% oxygen was provided. The infant did not have an adequate response to the positive pressure ventilation and was intubated around 2 minutes of life and given continued positive pressure ventilation by ET tube with 100% oxygen. Due to low heart rate, chest compressions were also started. The infant received 2 doses of epinephrine down the endotracheal tube followed by normal saline and subsequent to that, an umbilical venous catheter was placed with 10 ml per kg of normal saline given and 2 doses of epinephrine given with a heart rate rising to around 60 to 80 beats per minute until after the second dose of epinephrine when the heart rate increased to over 100 with pink color. Apgar scores were 0 at 1 minute, 0 at 5 minutes, 0 at 10 minutes and 4 at 15 minutes. PHYSICAL EXAMINATION: On admission weight was 3190 grams; head circumference 33.5 cm. In general, flaccid, hypotonic, pale, pink infant who would intermittently gasp on an ventilator, non dysmorphic. Anterior fontanel was soft and flat. Red reflex bilaterally. Intact palate, clavicles intact. Regular rate and rhythm, no murmur, 2+ femoral pulses. Lungs were clear to auscultation bilaterally with good aeration. Abdomen soft with bowel sounds. Genitourinary: Normal male, testes descended bilaterally, patent anus. Hips stable and no sacral anomalies. Extremities: Pink with improving perfusion. Neuro: Flaccid, no reflexes, absent suck, grasp and plantar reflex. Pupils not reactive or very minimally reactive to light. Some fasciculations noted in the extremities, chest and tongue. Stimulus induced and suppressible. Skin: Deep yellow staining of umbilical cord and nails; large circumferential nevus versus [Last Name (un) 71999] stain on scalp. Of note, the cord gases, the umbilical artery pH was 6.86, PC02 of 83, PA02 17, base deficit -24. The umbilical vein, pH 7.04, PC02 41, PA02 of 47, base deficit -20. HOSPITAL COURSE: RESPIRATORY: Initially on ventilator settings of 22/5, rate of 30 with initial ABG with pH of 6.78, C02 52; PA02 85, base excess -30. He received a total of 3 doses of sodium bicarbonate for his metabolic acidosis. He eventually weaned to very low settings on the ventilator, 16/5, rate of 8 in room air with pH at that time running 7.62 with C02 of 22. The decision was made on day of life two to extubate. After several hours, he was reintubated after apnea and remained on low vent settings with a most recent blood gas pH of 7.41, PC02 of 42, base deficit of -1. Cardiovascular: Maintained normal blood pressure and heart rate, no murmurs. Fluids, electrolytes and nutrition: Remained N.P.O., initially on D-10-W at 60 ml with total fluids of 60 ml per kg a day but due to poor urine output, total fluids were decreased to 40 ml per kg per day. His electrolytes were followed closely and his potassium rose to a high of 7.2, treated with sodium bicarbonate. His BUN and creatinine steadily rose with a final BUN of 70, creatinine of 3.6. His urine output was always less than 1 ml/kg per hour, reflecting kidney failure. Gastrointestinal: LFTs were followed and were abnormal, with maximal values of AST 493, ALT 644. His bilirubin remained low with a high total of 2.3. Hematology: His hematocrit on admission was 48%. His blood type was AB negative, direct Coombs negative. He received 10 ml/kg dose of cryoprecipitate on [2196-3-18] due to bleeding from his urinary catheter. Infectious disease: A CBC and blood culture were drawn on admission. He received ampicillin and Cefotaxime. He had additionally received 3 doses of Oxacillin due to the UVC placement during resuscitation. His blood culture remained negative. His CBC was benign. Neurology: Initially obtunded with pinpoint pupils and flaccid tone that changed to rigid tone on day of life one. An EEG done on day of life one showed no seizures and burst suppression pattern. Subsequent to that, he developed clinical seizure activity and was loaded with phenobarbital with a high level of 38. He was seen by neurology. A second EEG on [2196-3-18] showed severe encephalopathy and multifocal electrographic seizures without clinical correlation. A MRI done on [2192-3-18] showed global hypoxic ischemic encephalopathy affecting all areas of the cortex and subcortex. Clinical exam remained severely concerning throughout hospital course, with no responsiveness, dilated and minimally responsive pupils, and increased tone throughout. Psychosocial: The baby was baptized. The family had frequent meetings with staff and social service due to his severe injury to his brain and other organs. With no chance seen for meaningful recovery, the decision was made to redirect care to comfort measures which was done on [2196-3-19]. [Known lastname 518] expired at 17:44 on [2196-3-19]. Autospy was declined. Medical examiner and organ bank were notified, both of whom declined participation. DISCHARGE DISPOSITION: [First Name9 (NamePattern2) 72000] [Last Name (un) 72001] Funeral Home in [Location (un) ]. DISCHARGE DIAGNOSES: 1. Appropriate for gestational age term male. 2. Severe hypoxic ischemic encephalopathy. 3. Severe neonatal depression. 4. Rule out sepsis. 5. Multi-organ failure. [First Name8 (NamePattern2) ] [Name8 (MD) ], MD [MD Number(2) 56682] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2196-3-19] 18:58:28 T: [2196-3-20] 17:07:15 Job#: [Job Number 72002]	[ "585.9", "V30.00", "742.9", "779.89", "311", "770.82", "V29.0" ]	icd9cm	[ [ [] ] ]	[ "99.11", "38.93", "96.04", "38.92", "96.71" ]	icd9pcs	[ [ [] ] ]	6745, 6850							6871, 7300					3720, 6721																	2590, 3702																164, 2567
48,025	146,151	35742	Discharge summary	report	Admission Date: [2129-7-26] Discharge Date: [2129-7-31] Date of Birth: [2059-10-28] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) / Bee Pollens / Codeine / Epinephrine / Tetanus Attending:[First Name3 (LF) 922] Chief Complaint: Completion of decending Aortic repair Major Surgical or Invasive Procedure: [2129-7-26] Repair of descending thoracic aortic aneurysm with completion elephant trunk procedure via left thoracotomy and partial right heart bypass using the existing 28 mm Vascutek Dacron graft used for the original elephant trunk procedure History of Present Illness: This is a 69-year-old female who underwent an aortic valve replacement, ascending aorta replacement, total arch replacement with the implantation of the arch vessels, and elephant trunk graft on [2129-5-18]. She recently underwent a CT scan which revealed similar results of her dilated distal arch and descending thoracic aorta measurement as previously recorded. Therefore, she will be undergoing the 2nd part of her planned operation. Past Medical History: ascending aortic aneurysm/ aortic insufficiency s/p aortic valve replacement (25mm [Company 1543] Mosaic), ascending aorta-arch replacement (elephant trunk) [2129-5-18] recurrent syncope right lower lobe nodule right upper lobe subpleural plaques hypercholesterolemia s/p partial oophorectomy s/p ligal ligation s/p removal of sebaceous cyst on neck Social History: Ms. [Known lastname 6160] is a retired human resources manager. Lives with Husband [Name (NI) 1139]: quit tobacco in [2105] ETOH: occasional wine Family History: Her family history is non-contributory. Physical Exam: Admission: Pulse: 75 Resp: 16 O2 sat: 98% RA B/P Right: 152/87 Left: Height: 63" Weight: 54 kg General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] well-healed mediansterotomy incision, stable sternum Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [] Neuro: Grossly intact Pulses: Femoral Right: 2+ Left: 2+ DP Right: 1+ Left: 1+ PT [Name (NI) 167]: 1+ Left: 1+ Radial Right: 1+ Left: 1+ Carotid Bruit Right: no Left: no Pertinent Results: [2129-7-28] 02:24AM BLOOD WBC-7.4 RBC-2.71* Hgb-8.2* Hct-23.6* MCV-87 MCH-30.1 MCHC-34.6 RDW-14.7 Plt Ct-140* [2129-7-28] 02:24AM BLOOD Glucose-108* UreaN-15 Creat-0.7 Na-133 K-4.2 Cl-101 HCO3-27 AnGap-9 Brief Hospital Course: Mrs. [Known lastname 6160] was a same day admit after undergoing all pre-operative work-up as an outpatient. On the day of admission she was brought to the Operating Room where she underwent repair of the descending thoracic aortic aneurysm with completion elephant trunk procedure via left thoracotomy. There was a noticeable right gri=oin hematoma at the end of the case and the groin wa explored. Please see operative report for surgical details. Following surgery she was transferred to the CVICU for invasive monitoring in stable condition on Propofol and phenylephrine. Within 24 hours she was weaned from sedation, awoke neurologically intact and extubated. She was transferred to the floor on POD 2. Her CTs were removed on POD 2 and the JP drain on POD 3. CXR demonstrated no pneumothorax afterward. Physical therapy worked with her for mobilization and she progressed nicely. She was ready for discharge on POD 4. Medications, followup and limitations were discussed with her prior to discharge. wounds were clean and healing well and a regular diet was being tolerated. Medications on Admission: Toprol XL 50 mg PO daily Aspirin 325 mg PO daily Discharge Medications: 1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 weeks. Disp:28 Tablet(s) Refills:0 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 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: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 4 weeks. Disp:50 Tablet(s) Refills:0 6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO DAILY (Daily) as needed for constipation. 7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 8. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. Disp:10 Tablet(s) Refills:2 9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 10 days. Disp:10 Tab Sust.Rel. Particle/Crystal(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital3 3765] Homecare Discharge Diagnosis: Ascending and descending Aortic Aneurysms s/p Repair of descending thoracic aortic aneurysm with completion elephant trunk procedure via left thoracotomy, exploration of right groin Recurrent syncope Right lower lobe nodule Right upper lobe subpleural plaques hypercholesterolemia s/p Aortic valve replacement (25mm [Company 1543] Mosaic), ascending aorta-arch replacement (elephant trunk) [2129-5-18] s/p partial oophorectomy s/p ligal ligation s/p removal of sebaceous cyst on neck Discharge Condition: Good Discharge Instructions: shower daily, no baths or swimming no lotions, creams or powders to incisions no driving for 4 weeks and off all narcotics no lifting more than 10 pounds for 10 weeks report any redness of, or drainage from incisions report any fever greater than 100.5 report any weight gain greater than 2 pounds a day or 5 pounds a week take all medications as directed Followup Instructions: Dr. [Last Name (STitle) 914] in 4 weeks ([Telephone/Fax (1) 170]) Dr. [Last Name (STitle) ] in [3-8] weeks Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 18920] in [2-4] weeks ([Telephone/Fax (1) 81289]) [Hospital Ward Name 121] 6 for wound check in 2 weeks Please call for appointments Completed by:[2129-7-30]	[ "426.11", "998.12", "E878.2", "441.2", "E849.7", "V42.2" ]	icd9cm	[ [ [] ] ]	[ "38.45", "38.93", "39.61" ]	icd9pcs	[ [ [] ] ]	4992, 5052	2684, 3777	398, 648	5588, 5594	2448, 2661	5998, 6365	1692, 1733		3878, 4969	5073, 5567		3803, 3853			5618, 5975							1748, 2429																321, 360								676, 1120													1142, 1501	1517, 1676
23,656	178,526	9445	Discharge summary	report	Admission Date: [2118-1-19] Discharge Date: [2118-1-29] Date of Birth: [2043-7-18] Sex: M Service: CARDIOTHORACIC Allergies: Heparin Agents Attending:[First Name3 (LF) 165] Chief Complaint: increased SOB Major Surgical or Invasive Procedure: [2118-1-21] redo sternotomy AVR ( [Street Address(2) 17009]. [Male First Name (un) 923] mechanical) cardiac cath [2118-1-19] History of Present Illness: 74 year old man with history of CAD status post CABG in [2111] (LIMA to Diagonal, SVG to OM2, SVG to RCA), with a cardiac catheterization in [2115] that revealed three vessel disease, but all grafts were patent. Mild aortic stenosis was noted in [2115] (mean gradient 32 mmHg and valve area 1.1 cm2). Drug eluting stents were placed into the lower pole of OM2 and the proximal LAD. In addition, patient has a history of atrial fibrillation and COPD. On [2118-1-14], he presented to [Hospital1 ] [Location (un) 620] with chest tightness and shortness of breath, with rapid ventricular rate of 126, following several day course of antibiotics prescribed by his PCP. [Name10 (NameIs) ] was converted to normal sinus rate with IV diltiazem and he received IV lasix for diuresis. A TEE was performed on [2118-1-18] that revealed an EF of 65%, worsened AS (0.7cm2), 1+AR, 1-2MR. Patient was transferred for cardiac catheterization on [1-19]. Results demonstrated severe 3 vessel disease, with patent stents to proximal LAD and OM2 and patent graft of SVG to RCA and OM2, and the LIMA to D1 was patent. Severe AS was noted. Patient awaiting AVR. Past Medical History: PMH: 1. CAD, s/p cath and CABG as above, recent TTE showing EF=60-65% 2. AS, AV area 1.1 cm2 3. Carotid stenois, occlusive [Country ], <40% [Doctor First Name 3098] [2111] 4. Gout x 40 yrs 5. Hyperlipidemia 6. HTN 7. COPD, recent flare [10-20] 8. ILD 9. Prostate ca 8 yrs ago, s/p prostatectomy Social History: Lives with wife, quit smoking 25 yrs ago (smoked 1.5 ppd), no Etoh, retired roofer Family History: Mother died age 72 CAD Father died age 63 CAD Physical Exam: T:98.4 BP:150/68 HR:60 RR:18 O2saturation:94% on room air Gen: Pleasant, well appearing. Elderly man laying in bed. HEENT: Slight conjunctival pallor. No icterus. Slightly dry mucous membranes. Oropharynx clear. NECK: Supple. No cervical or supraclavicular lymphadenopathy. No JVD. No thyromegaly. Did not appreciate any carotid bruits. CV: Irregularly irregular rate. Normal S1 and S2. Systolic [4-22] ejection murmur in upper right sternal border. No rubs or [Last Name (un) 549] appreciated. LUNGS: On anterior examination, diffuse inspiratory wheezes noted. Did not auscultate posterior chest. ABD: Infrapubic surgical scar. Distended abdomen. Normal active bowel sounds in all four quadrants. Soft. Nontender and nondistended. No guarding or rebound. Liver edge not palpated. No splenomegaly appreciated. No abdominal aortic bruit. EXT: Warm and well perfused in upper extremities, but feet cool. No clubbing or cyanosis. No lower extremity edema, bilaterally. 2+ radial pulses, bilaterally, but DP 1+ bilaterally. SKIN: No rashes, ulcers, petechiae, or pigmented lesions. No ecchymoses. No xerosis. NEURO: Alert and oriented to person, place, date. Affect appropriate. Cranial nerves II-XII grossly intact. Pertinent Results: [2118-1-29] 05:25AM BLOOD WBC-10.8 RBC-2.72* Hgb-8.6* Hct-25.2* MCV-92 MCH-31.8 MCHC-34.4 RDW-15.3 Plt Ct-186 [2118-1-29] 05:25AM BLOOD PT-21.4* PTT-35.4* INR(PT)-2.1* [2118-1-29] 05:25AM BLOOD Glucose-91 UreaN-36* Creat-1.6* Na-138 K-4.3 Cl-105 HCO3-25 AnGap-12 [2118-1-19] 04:50PM BLOOD %HbA1c-6.3* [Hgb]-DONE [A1c]-DONE [2118-1-19] 04:50PM BLOOD Triglyc-153* HDL-72 CHOL/HD-2.5 LDLcalc-79 [2118-1-19] 04:50PM BLOOD Glucose-144* UreaN-46* Creat-1.6* Na-139 K-5.6* Cl-103 HCO3-28 AnGap-14 [2118-1-19] 04:50PM BLOOD WBC-15.7# RBC-3.90 Hgb-12.2* Hct-36.1* MCV-93# MCH-31.4 MCHC-33.9 RDW-15.0 Plt Ct-177 [2118-1-19] Cardiac Cath: Selective coronary angiography of this right dominant system revealed mult-vessel native disease. The LMCA had no flow limiting lesions. The LAD had a patent stent with competitive flow from the D1. The LCX had a patent stent in the lower pole of OM2. The RCA was distally occluded. Graft angiography revealed patent SVG-OM, SVG-PDA, and SVG-LIMA. The aortic valve had a mean gradient of 55mmHg and a calculated [Location (un) 109] of 0.64 cm2. Mean PCPW was elevated at 20mmHg and cardiac index was low normal at 2.4 l/min/m2. Brief Hospital Course: Preoperatively Mr. [Known lastname ] was seen by pulmonary medicine for his COPD, with recommendations to start standing Atrovent, and continue Prednisone therapy. Preoperative chest CT scan showed severe cystic bronchiectasis involving all lobes of both lungs, with associated air-fluid levels, scattered areas of bronchial mucoid impaction, and minimal peribronchiolar inflammation. There were however no contraindications to surgery. He was taken to the operating room on [2118-1-21] where Dr. [First Name (STitle) ] performed a redo sternotomy, and a mechanical aortic valve replacement. For surgical details, please see seperate dictated operative note. He was transferred to the CSRU in critical but stable condition. Within 24 hours, he awoke neurologiclly intact and was extubated on POD #1 without incident. He was seen by nephrology for oliguria and acute renal insufficiency with likely diagnosis ATN(acute tubular necrosis)secondary to hypotension and bypass, with recomendations for volume and avoiding diuresis. A decrease in platelet count prompted a HIT screen which was positive. He was subsequently started on Argatroban, and eventually Warfarin once his platelet count was > 100. While in the CSRU, he also experienced episodes of paroxsymal atrial fibrillation which was initially treated with Amiodarone and beta blockade. Given his severe COPD, Amiodarone was discontinued while beta blockade was continued for rate control. Despite advancement in beta blockade, he continued to experience PAF. He otherwise remained stable from a cardiac and pulmonary standpoint and transferred to the SDU for further care and recovery. He gradually became therapeutic on Warfarin and Argatroban was eventually discontinued. His renal function continued to improve and returned to baseline prior to discharge. He worked daily with physical therapy and continued to make clinical improvements with gentle diuresis. He was eventually cleared for discharge on POD 8. Prior to discharge, arrangements were made to follow up with primary care physician/cardiologist regarding outpatient Warfarin monitoring. Given his PAF and mechanical AVR, his goal INR should be between 2.5 - 3.0. Medications on Admission: Norvasc 5 Singulair 10 Lasix 20 Crestor 30 Bisoprolol 5 ASA Advair Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). Disp:QS Disk with Device(s) Refills:0 5. Rosuvastatin 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 8. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 9. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:50 Tablet(s) Refills:0 11. Combivent 103-18 mcg/Actuation Aerosol Sig: One (1) Inhalation PRN. Disp:QS 1 month Refills:0 12. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3 times a day). Disp:225 Tablet(s) Refills:0 13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 weeks: 40 [Hospital1 ] x 1 week, then 20 daily as prior to surgery. Disp:60 Tablet(s) Refills:0 14. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a day) for 1 weeks. Disp:14 Tab Sust.Rel. Particle/Crystal(s) Refills:0 15. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: s/p redo sternotomy/ AVR [2118-1-21] Heparin induced thrombocytopenia Post op AFib Postop renal insufficiency COPD/interstitial lung dz. HTN prostate CA/[Doctor First Name ]. elev. lipids gout CRI AS s/p cabg [2111] CAD with PCI/DE stent OM2 [11-20] DE stent LAD [2115] Discharge Condition: Good. Discharge Instructions: may shower over incisions and pat dry no lotions, creams or powders on any incision no driving for one month no lifting greater than 10 pounds for 10 weeks call for fever greater than 101, redness or drainage Followup Instructions: see Dr. [Last Name (STitle) 32208] in [1-18] weeks see Dr. [Last Name (STitle) 121] in [2-19] weeks see Dr. [First Name (STitle) ] in 4 weeks [Telephone/Fax (1) 170] Provider: [Name10 (NameIs) ],[Name11 (NameIs) 7721] [Name11 (NameIs) ] LMOB (NHB) Date/Time:[2118-11-21] 2:00 Provider: [Name10 (NameIs) 1111],[First Name7 (NamePattern1) 1112] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] SURGERY (NHB) Date/Time:[2118-11-21] 2:30 [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2118-2-9]	[ "403.90", "E934.2", "584.5", "V58.61", "494.0", "V10.46", "428.0", "458.29", "V45.82", "414.01", "424.1", "V45.81", "515", "287.4", "V58.65", "427.31", "274.9" ]	icd9cm	[ [ [] ] ]	[ "35.22", "37.23", "88.56", "39.61", "99.04", "88.57", "88.72" ]	icd9pcs	[ [ [] ] ]	8928, 8977	4630, 6829	294, 439	9312, 9320	3408, 4607	9578, 10199	2104, 2151		6946, 8905	8998, 9291		6855, 6923			9344, 9555							2166, 3389																241, 256								467, 1644													1666, 1987	2003, 2088
31,994	112,228	33156	Discharge summary	report	Admission Date: [2151-3-26] Discharge Date: [2151-4-13] Date of Birth: [2082-11-30] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Sulfa (Sulfonamides) / Keflex / Diovan / Ciprofloxacin / Ace Inhibitors / Quinine / Levaquin / Novocain / Lidocaine Attending:[First Name3 (LF) 1505] Chief Complaint: Dsypnea and fatigue Major Surgical or Invasive Procedure: [2151-4-2] - 1. Redo sternotomy with aortic valve replacement with a 19-mm St. [Hospital 923] Medical Biocor Epic Supra tissue heart valve. 2. Mitral valve replacement, 27-mm St. [Hospital 923] Medical Biocor Epic tissue valve. [2151-3-26] - Cardiac catheterization History of Present Illness: 68F w/CAD s/p CABG '[39](LIMA/LAD, SVG/OM1, SVG/RCA) c/b occlusion of LIMA/LAD graft s/p DES to LAD '[46], NSTEMI due to LAD in-stent stenosis [2-22] s/p repeat DES, recurrrent NSTEMI during HD run [2-23] in context of LGIB & cath demonstrating patent vein grafts & LAD stent and an echo indicating moderate to severe aortic stenosis ([Location (un) 109] 0.8-1.0) at that time who is seen today as an inpatient consultation to evaluate her appropriateness for AVR/MVR. Had recent episode of sub-sternal chest pain after HD; responsive to SLNTG. Sent to ED for eval and subsequently to cath lab. Past Medical History: IDDM CAD, s/p CABG CHF ESRD on hemodialysis Tues, Thurs and Sat Anemia PVD, s/p right BKA Irritable bowel syndrome Diverticulitis Social History: Patient lives iwth her daughter and son-in-law as well as granddaughter. She does not work. She reports recent significant stressors as 2 family members have died in the last month and a great-grandaughter was born. Tobacco: smoked as a teenager EtOH: rare glass of wine Drugs: denies Family History: Mother died of colon ca; she also had diabetes. Father died of heart disease. Physical Exam: Pulse: 68 BP: 100/46 Resp: 16 O2 sat: 97/2L Height: Weight: General: NAD Skin: Dry [x] intact [x] HEENT: PERRLA [] EOMI [x] Neck: Supple [] Full ROM [x] Chest: Lungs clear bilaterally [ ] bibasilar crackles Heart: RRR [] Irregular [] Murmur [x] III/VI at base > neck Abdomen: Soft [x] non-distended [x] non-tender [x] Extremities: Warm [x], well-perfused [] R BKA Neuro: Grossly intact Pulses: Femoral Right: nd Left: palp DP Right: na Left: - PT [Name (NI) 167]: na Left: - Radial Right: na Left: palp Carotid Bruit obscured by murmur Pertinent Results: [2151-3-26] Cardiac Catheterization 1. Two vessel coronary artery disease. 2. Patent native LAD, SVG-OM, and SVG-RCA unchanged from prior. 3. Severe aortic stenosis. 4. Severe mitral regurgitation. 5. Mild systolic ventricular dysfunction. 6. Elevated biventricular filling pressures. 7. Severe pulmonary hypertension. [2151-4-2] ECHO PRE-BYPASS: The left atrium is moderately dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. The left ventricular cavity size is normal. There is mild global left ventricular hypokinesis (LVEF = 45 %). The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. There are simple atheroma in the ascending aorta. There are complex (>4mm) atheroma in the descending thoracic aorta. 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 moderately thickened. There is severe mitral annular calcification. There is severe thickening of the mitral valve chordae. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is no pericardial effusion. [2151-3-30] Carotid duplex ultrasound Impression: Right ICA stenosis <40%. Left ICA stenosis <40%. Pre-op: [2151-3-26] 09:49PM GLUCOSE-196* UREA N-55* CREAT-5.7# SODIUM-135 POTASSIUM-5.0 CHLORIDE-95 TOTAL CO2-22 ANION GAP-23* [2151-3-26] 09:49PM CK(CPK)-28* [2151-3-27] 06:50AM BLOOD WBC-9.0 RBC-3.25* Hgb-11.0* Hct-33.0* MCV-102* MCH-33.9* MCHC-33.4 RDW-14.5 Plt Ct-213 [2151-3-27] 06:50AM BLOOD Plt Ct-213 [2151-3-26] 09:49PM BLOOD Glucose-196* UreaN-55* Creat-5.7# Na-135 K-5.0 Cl-95 HCO3-22 AnGap-23* [2151-3-27] 06:50AM BLOOD ALT-5 AST-15 CK(CPK)-22* AlkPhos-99 [2151-3-27] 06:50AM BLOOD CK-MB-NotDone cTropnT-0.28* [2151-3-27] 06:50AM BLOOD %HbA1c-6.0* eAG-126* [2151-3-29] 06:25AM BLOOD PTH-559* Post-op: [2151-4-13] 03:51AM BLOOD WBC-11.8* RBC-2.91* Hgb-9.7* Hct-31.0* MCV-107* MCH-33.2* MCHC-31.1 RDW-21.8* Plt Ct-335 [2151-4-13] 03:51AM BLOOD Plt Ct-335 [2151-4-13] 03:51AM BLOOD Glucose-181* UreaN-43* Creat-5.0* Na-132* K-4.7 Cl-90* HCO3-30 AnGap-17 Radiology Report CHEST (PORTABLE AP) Study Date of [2151-4-7] 5:22 PM Final Report CHEST RADIOGRAPH INDICATION: Triple lumen change over wire, evaluation of line placement. COMPARISON: [2151-4-5]. FINDINGS: As compared to the previous examination, the right central venous introduction sheath has been removed and exchanged against a central venous access line. The tip of this access line projects over the leads of the pacemaker and is difficult to visualize but appears to be positioned at the inflow tract of the right atrium. No evidence of complications, notably no pneumothorax. Subtle increase of bilateral basal opacities. Unchanged size of the cardiac silhouette. The study and the report were reviewed by the staff radiologist. DR. [First Name (STitle) ] [Doctor Last Name 3900] DR. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 4130] OROPHARYNGEAL VIDEOFLUOROSCOPIC SWALLOWING EVALUATION EVALUATION: An oral and pharyngeal swallowing videofluoroscopy was performed today in collaboration with Radiology. Thin liquid, Nectar-thick liquid, and pureed consistency barium were administered. Results follow: RECOMMENDATIONS: 1. PO diet: soft solids, thin liquids 2. PO meds whole with thin liquids as tolerated 3. TID oral care 4. Strict aspiration precautions including: a) sit fully upright for all PO intake b) alternate between bites and sips to clear oropharynx c) swallow twice per bite as needed to clear oropharynx d) swallow-cough-swallow with ALL liquids including when taking meds 5. ENT eval in if vocal quality does not continue to improve 6. Swallow follow up in rehab setting to ensure tolerating diet, re-assess need for swallow-cough-swallow maneuver. These recommendations were shared with the patient, the nurse and the medical team. [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 77062] M.S., CCC-SLP Brief Hospital Course: Ms. [Known lastname ] was admitted to the [Hospital1 18] on [2151-3-26] for work up of her chest pain during hemodialysis. She underwent a cardiac catheterization which revealed two vessel coronary artery disease with patent grafts froom her previous bypass syrgery. Severe aortic stenosis and mitral regurgitation were also noted. Given the severity of her valvular disease, the cardiac surgical service was consulted for evaluation for redo surgery. She was accepted for AVR/MVR and on [4-2] she was brought to the operating room for aortic and mitral valve replacement. Please see OR report for details, in summmary she had: 1. Redo sternotomy with aortic valve replacement with a 19-mm St. [Hospital 923] Medical Biocor Epic Supra tissue heart valve. 2. Mitral valve replacement, 27-mm St. [Hospital 923] Medical Biocor Epic tissue valve. She tolerated the operation well and was transferred from the operating room to the cardiac surgery ICU in stable condition. She was sedated through the night on the surgical day, the following day see awoke and followed commands but remained intubated as she was somewhat lethargic and she needed to have hemodialysis prior to extubation to support her pulmonary status. She was dialyzed on a daily basis and was ultimately extubated on POD3. She remained hemodynamically stable throughout this period. On POD4 she was transferred from the ICU to the stepdown floor for further recovery. She made slow progress in her physical activity and was transferred to rehabilitation at [Hospital1 2670] Care and Rehab in [Location (un) 5871],MA on POD 11 Medications on Admission: Plavix 375mg today, aspirin 324mg today lopressor 25mg, TUMS, NTP (held), Insulin sliding scale, celexa, Lantus at hs, prilosec, renagel, vitamin C, Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/fever. 4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 9. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Insulin Lispro 100 unit/mL Solution Sig: sliding scale Subcutaneous QAC&HS. 11. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: SunbridgeCare and Rehab for [Location (un) 5871] Discharge Diagnosis: Aortic valve stenosis s/p AVR Mitral valve regurgitation s/p MVR s/p CABG '[39](LIMA/LAD, SVG/OM1, SVG/RCA) c/b occlusion of LIMA/LAD graft s/p DES to LAD '[46], NSTEMI due to LAD in-stent stenosis [2-22] s/p repeat DES, CHF(EF50% 2/09) HTN hyperlipidemia, IDDM2 ESRD on HD(Tu-Th-Sa) Anemia Irritable bowel syndrome Diverticulitis PAD s/p R BKA Discharge Condition: Alert and oriented x3 nonfocal s/p BKA: prostetic device not yet fitting stump, unable to ambulate Sternal pain managed with percocet prn Sternal wound healing well, no erythema or drainage Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: Surgeon Dr. [Last Name (STitle) ] [2151-5-13] @ 1PM [Telephone/Fax (1) 170] Wound check appointment - [Hospital Ward Name 121] 6 ([Telephone/Fax (1) 3071]) - your nurse will schedule Please call to schedule appointments: Primary Care Dr. [Last Name (STitle) 77063]([Telephone/Fax (1) 8539]) in [1-16] weeks OUTPATIENT CARDIOLOGIST: [Location (un) 24344] [Telephone/Fax (1) 77064] in [2-17] weeks Completed by:[2151-4-13]	[ "433.30", "585.6", "428.0", "403.91", "V58.67", "396.2", "V45.81", "443.9", "564.1", "272.4", "998.0", "459.81", "V49.75", "707.15", "285.21", "414.01", "428.42", "410.71", "416.8", "250.00", "276.2" ]	icd9cm	[ [ [] ] ]	[ "35.23", "35.21", "88.56", "88.53", "38.93", "39.95", "37.23", "39.61" ]	icd9pcs	[ [ [] ] ]	9856, 9935	6943, 8567	417, 701	10337, 10529	2525, 6920	11154, 11625	1819, 1898		8767, 9833	9956, 10316		8593, 8744			10553, 11131							1913, 2506																358, 379								729, 1346													1368, 1500	1516, 1803
27,894	136,871	30905	Discharge summary	report	Admission Date: [2107-9-12] Discharge Date: [2107-9-15] Date of Birth: [2036-4-3] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Last Name (NamePattern4) 290] Chief Complaint: hemoptysis Major Surgical or Invasive Procedure: fiberoptic laryngoscopy bronchoscopy History of Present Illness: 71 year old man w/ multiple medical problems including locally invasive laryngopharyngeal cancer developed approx. 75cc hemoptysis while at XRT today. He has been spitting and coughing up several tsps of blood daily or sometimes multiple times daily for about one month leading up to this. Daily cough, which does not seem associated with hemoptysis. . He was seen by ENT in the ED, who performed fiberoptic exam through trach and did not see any active bleeding or friable tissue. CTA of neck was performed to rule out invasion of carotid sheath. Of note, he was seen in the ED on [2107-8-30] for similar hemoptysis, at which point the bleeding was thought to be coming from his tumor and pt was discharged home. Past Medical History: Diabetes Hypertension Coronary Artery Disease, s/p CABG x 5 Permanent Pacemaker for sick sinus Peripheral Vascular Disease (AAA s/p repair) COPD Spontaneous Pneumothorax s/p chest tube Colon Cancer s/p resection and chemo (pt does not know details of therapy) in approximately [2102] Social History: Patient is single. He does not have any children. He reports he has been an alcoholic for the past 45 years and had been drinking 2 glasses wine per day up to hospitalization in [Month (only) ]. He has a 59 pack year smoking history. Family History: Aunt with breast cancer and uncle with throat cancer. Physical Exam: VITALS: 98.2 194/72 78 20 97% on 35% trach collar GEN: cachectic male lying comfortably in bed HEENT: NC/AT, + temporal wasting, OP clear NECK: trach with button CARDIAC: heart sounds obscured by lung sounds LUNG: rhonchorous throughout ABDOMEN: scaphoid, PEG site clean, dry, healing EXT: decreased bulk and tone, no c/c/e NEURO: grossly intact SKIN: no rashes Pertinent Results: [2107-9-12] 03:30PM WBC-5.8 RBC-3.06* HGB-9.0* HCT-27.4* MCV-90 MCH-29.5 MCHC-32.9 RDW-14.6 [2107-9-12] 03:30PM NEUTS-82.0* LYMPHS-14.1* MONOS-2.1 EOS-1.8 BASOS-0.2 [2107-9-12] 03:30PM PLT COUNT-174 [2107-9-12] 03:30PM PT-13.2* PTT-24.6 INR(PT)-1.1 [2107-9-12] 03:30PM GLUCOSE-93 UREA N-25* CREAT-0.9 SODIUM-140 POTASSIUM-3.6 CHLORIDE-98 TOTAL CO2-38* ANION GAP-8 CXR: Single bedside AP examination labeled "upright at 5:00 p.m." is compared with study dated [2107-8-30]. The patient is status post tracheostomy, median sternotomy with CABG with left-sided dual-chamber cardiac pacemaker with intact RA and RV leads, unchanged. There is evidence of underlying hyperinflation and probable edema. There is persistent moderately large, posteriorly-layering right pleural effusion with associated basilar atelectasis. There is a small left pleural effusion with left basilar atelectasis, as before. The remainder of the lungs is grossly clear; specifically, there is no new focal airspace process to specifically suggest pulmonary hemorrhage. Again demonstrated are numerous surgical clips and gastrostomy tube in the left upper central abdomen. IMPRESSION: Findings suggestive of CHF with bilateral pleural effusions, superimposed on underlying emphysema. However, there is no distinct new airspace process to suggest pulmonary hemorrhage. The appearance of the cervicothoracic trachea and tracheostomy site are grossly unchanged since the [2107-8-30] examination. CTA Neck: 1. There is redemonstration of an ill-defined, heterogeneous mass that is filling the left piriform sinus, with obliteration of the airway. Compared to prior study, this lesion appears to be more extensive. 2. There is no evidence of active extravasation of contrast. 3. There is a right pulmonary parenchymal consolidation that is partially imaged. CT Chest: 1. Large right and mild/moderate left pleural effusion, slightly smaller compared to the previous exam. 2. No lesion seen in the trachea and lobar bronchi. 3. Extensive vascular disease. 4. Please refer to the report from the CTA Neck from one day prior for description of the known laryngeal mass. Brief Hospital Course: 71M with head and neck cancer undergoing chemo and XRT with worsened hemoptysis # hemoptysis--likely related to necrosis of either primary mass induced by XRT. - bronchoscopic exam of lower airways limited by mass, but no active bleeding seen - Hct down to 24.9, transfused one unit PRBCs [9-14] - bleeding likely to continue until large enough total dose of radiation has been delivered to substantially debulk the mass . # SCCa--will contact [Name (NI) ] team in am to let them know patient is here; undergoing XRT, which we are attempting to coordinate while patient is in-house. Oncology fellow saw patient and explained to him that his performance status and bleeding prevents him from safely receiving more chemo. - morphine and tylenol prn for pain . # HTN--poorly controlled on admission, increased lisinopril. Continue metoprolol, lasix, and clonidine. . # COPD--nebs . # CAD--h/o CABG but no active issues. Holding ASA since bleeding. . # Diabetes--lantus 10 qhs + SSI. . # FEN--TF through PEG. . # Ppx--heparin sub-q, ppi . # Full Code Medications on Admission: # Albuterol Sulfate 0.083 % neb Q6H and Q2H prn # ipratropium neb # Lisinopril 10 mg DAILY # Metoprolol Tartrate 25 mg [Hospital1 ] # Clonidine 0.2 mg/24 hr Patch QTHUR # HydrALAzine 20 mg IV Q6H:PRN SBP > 160 # Insulin Glargine 10 units QHS # Insulin sliding scale # lasix 20mg daily # Nitroglycerin 0.3 mg SL prn # esomeprazole 20 mg daily # reglan # ativan 0.5mg prn # morphine prn Discharge Medications: 1. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [Hospital1 ]: One (1) neb Inhalation Q4H (every 4 hours) as needed. 2. Ipratropium Bromide 0.02 % Solution [Hospital1 ]: One (1) neb Inhalation Q6H (every 6 hours) as needed. 3. Clonidine 0.2 mg/24 hr Patch Weekly [Hospital1 ]: One (1) Patch Weekly Transdermal QTHUR (every Thursday). 4. Lisinopril 20 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 5. Metoprolol Tartrate 25 mg Tablet [Hospital1 ]: One (1) Tablet PO BID (2 times a day). 6. Insulin Glargine 100 unit/mL Solution [Hospital1 ]: Ten (10) units Subcutaneous at bedtime. 7. Insulin Lispro 100 unit/mL Solution [Hospital1 ]: ASDIR units Subcutaneous four times a day: 2 units for FS 151-200, 4 units for FS 201-250, 6 units for FS 251-300, 8 units for FS 301-350, 10 units for FS 351-400. 8. Lorazepam 0.5 mg Tablet [Hospital1 ]: One (1) Tablet PO Q8H (every 8 hours) as needed. 9. Metoclopramide 10 mg Tablet [Hospital1 ]: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 10. Heparin (Porcine) 5,000 unit/mL Solution [Hospital1 ]: One (1) syringe Injection TID (3 times a day). 11. Docusate Sodium 50 mg/5 mL Liquid [Hospital1 ]: Ten (10) mL PO BID (2 times a day). 12. Acetaminophen 160 mg/5 mL Solution [Hospital1 ]: Twenty (20) mL PO Q6H (every 6 hours) as needed. 13. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 14. Furosemide 40 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 15. Morphine 10 mg/5 mL Solution [Last Name (STitle) ]: Five (5) mL PO every four (4) hours as needed for pain. Discharge Disposition: Extended Care Facility: [Hospital1 700] - [Location (un) 701] Discharge Diagnosis: Necrotic Left Piriform Sinus Squamous Cell Carcinoma Diabetes Hypertension Coronary Artery Disease, s/p CABG x 5 Permanent Pacemaker for ?sick sinus/tachy brady Peripheral Vascular Disease (AAA s/p repair) COPD Spontaneous Pneumothorax s/p chest tube Colon Cancer s/p resection in approximately [2102] Esophageal stricture s/p open gastrostomy [7-14] s/p tracheostomy [7-14] Discharge Condition: fair Discharge Instructions: You were admitted for evaluation of your hemoptysis. The source of bleeding was from your known throat cancer, which is undergoing radiation treatment. You may need blood transfusions while undergoing treatment to make up for blood loss. Please have your blood counts checked regularly. Followup Instructions: You will be undergoing daily radiation therapy at [Hospital3 ] for your cancer. . Provider: [First Name8 (NamePattern2) 2191] [Last Name (NamePattern1) ], RN Phone:[Telephone/Fax (1) 22] Date/Time:[2107-9-22] 8:00 [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292]	[ "148.1", "414.00", "305.00", "V15.82", "V45.01", "786.3", "496", "285.22", "V45.81", "E879.2", "401.9", "V44.0", "443.9", "V10.05", "V12.71", "250.00" ]	icd9cm	[ [ [] ] ]	[ "33.23", "99.04" ]	icd9pcs	[ [ [] ] ]	7592, 7664	4351, 5408	332, 370	8095, 8101	2155, 4328	8436, 8809	1702, 1757		5848, 7569	7685, 8074		5434, 5825			8125, 8413							1772, 2136																282, 294								398, 1118													1140, 1430	1446, 1686
72,978	192,823	5949	Discharge summary	report	Admission Date: [2189-8-31] Discharge Date: [2189-9-4] Date of Birth: [2114-5-12] Sex: F Service: MEDICINE Allergies: Magnesium Sulfate Attending:[Last Name (NamePattern4) 290] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Bilateral chest tubes placed [2189-8-31] Right sided pleurex chest tube [2189-9-3] History of Present Illness: Pt is a 75yo woman with critical AS, CHF (EF 30%), complete heart block s/p pacemaker, HCV, hypothyroidism, recently diagnosed aggressive B cell lymphoma c/b SVC syndrome s/p Y stent and subsequent removal, C3D+11 reduced R-CHOP. Recently admitted for hypotension and anemia/thrombocytopenia requiring transfusions in the setting of her critical AS. She was given 500cc IVF for SBP in the 80s, with good response to her baseline SBP of 90s-100s. She was then transfused 1unit PRBCs and 1 bag of platelets, and given a dose of Neupogen. Since discharge, she has been feeling more dyspneic, with symptoms increasing over the last 3-4 days while at home. She also describes occasional cough and clear phlegm production. She denies fevers or chills, but noted a "rising temp" and generalized weakness. She also describes increasing difficulty swallowing and odynophagia. She denies any chest pain, abd pain, nausea, vomiting, change in bowel habits, or dysuria. Her home health nurse has also noted increasing accessory muscle use and adventitious lung sounds. In the ED, initial VS: Temp 98.4 F, HR 88, BP 96/56, RR 18, SaO2 100% 2L NC. She was 93% on RA, which improved to 97% on 2L O2 NC. Exam was notable for decreased BS on the right. She otherwise appeared comfortable and not tachypneic. She was speaking in full sentences and A&Ox3. Labs included WBC 10.2 (86% PMNs), stable H&H, Plts, and normal INR. Chemistries notable for Na 133, K 3.2, Cl 90, HCO3 34. Other labs included BNP [Numeric Identifier 23459], normal trop and lactate. Blood culture was sent and is pending. ECG was V-paced at 88 bpm with lateral ST depressions, unchanged on repeat. CXR with increasing pleural effusion from previous. Interventional pulmonology fellow was alerted. She was given PO K 40 mEq but she vomited the pills. No IV fluids or Abx were given. She is admitted for further care. VS prior to transfer: Temp 97.6 F, HR 91, BP 99/76, RR 20, SaO2 96% 2L NC. ROS: As listed above in the HPI. All other systems are negative. Past Medical History: ONCOLOGY HISTORY: Aggressive B cell lymphoma [3-/2189]: Presented to PCP with neck and facial swelling. Referred to allergy and ENT with neck CT revealing SVC syndrome from extensive mediastinal lymphadenopathy. Chest CT showed right supraclavicular mass displacing trachea and massive mediastinal lymphadenopathy. [Date range (3) 23460]: Admitted to [Hospital1 18] with c/o 2 months of facial swelling, poor appetite and 10 lbs weight loss. [2189-5-11]: Bronchoscopy with diagnostic EBUS-TBNA revealed B cell lymphoma although minimal specimen was obtained. LDH was 314. Silicone Y stent placed for extrinsic compression in light of [Year (4 digits) 9140] respiratory symptoms. TREATMENT HISTORY: * Received two doses of emergency radiation therapy on [2189-5-15], a dose of Cytoxan on [2189-5-16] and three-fifth dose of [Hospital1 ] chemotherapy starting on [2189-5-20] that had to be aborted secondary to failure of her vascular access. Repeat CT chest showed a widely patent Y stent and she was discharged to home [2189-5-26]. * Admitted on [2189-6-1] with hypotension (SBP 80s) with increasing dyspnea for further evaluation. Mediastinal biopsy on [2189-6-3] was nondiagnostic and the Y stent was removed. * 2nd cycle of [Hospital1 ] (dose level 1) given on [2189-6-8], requiring increasing doses of Lasix to maintain her volume status. * [2189-6-11], developed non-occlusive PICC associated thrombus in the brachial vein extending into the axillary vein. Given her difficult access, it was decided to leave PICC in place and she continued on Lovenox twice per day. Discharged on [2189-6-16]. * Required an admission on [2189-6-19] with pancytopenia, [Year (4 digits) 9140] dyspnea, and increased creatinine. Diureses and underwent right thoracentesis. Noted for C difficile infection and treated with Flagyl which has been switched to Vancomycin. * Discharged on [2189-7-2] and saw Dr. [Last Name (STitle) 23461] [Name (STitle) 3315] from [Company 2860] in consultation who recommended a dose adjusted CHOP regimen given her age and other medical issues with usual dose of Rituxan. * Required admission again on [2189-7-9] with weakness and increased dyspnea requiring oxygen support. Transferred to Cardiology for [Year (4 digits) 9140] peripheral edema and dyspnea. Started on a lasix drip and underwent aggressive electrolyte and fluid management. Switched to Torsemide. After her fluid status was optimized, transferred back to the Hematologic Malignancy service for her chemotherapy. * Received dose adjusted CHOP on [2189-7-18](Cytoxan given at a dose of 400 mg per meter squared, Adriamycin 25 milligrams per meter squared, vincristine 2 mg(no dose reduction) and prednisone 60 milligrams daily for 5 days). Discharged on [2189-7-20] with close follow up with the Heart failure clinic. * [2189-7-24], attempts were made to give Rituxan as outpatient. Developed shortness of breath given large fluid volume. Dose divided and she received 150 mg on [2189-7-29] and [2189-7-31]. * [2189-8-3], admitted with acute dyspnea with a drop in her oxygen saturation. Chest CTA without pulmonary embolus. Noted for large pleural effusions, right greater than left. Transferred again to Cardiology service for closer management of her fluid status. Cardiac catheterization done which revealed full occlusion of her RCA stent and 70-80% stenosis of her LMCA that had developed since the most recent angiogram. No surgical intervention was performed given her high risk; continued on her aspirin. Metoprolol has been held with low blood pressure but restarted along with aspirin. Right pleural effusion was again tapped. * Third consultation with Dr. [Last Name (STitle) 23462] @ [Hospital1 2025] on [2189-8-7] who agreed with the current plan. Maintained on Oxygen and was discharged on [2189-8-8]. * [2189-7-23], admitted for her 2nd cycle of the dose adjusted RCHOP. Chemotherapy given on [2189-8-19] and Rituxan on [2189-8-20] after her pleural effusion was again tapped and her fluid status maximized with aggressive diuresis. Repeat echocardiogram on [2189-8-14] which showed an EF of ~ 30%. Repeat upper extremity ultrasound showed resolution of upper extremity thrombus and Lovenox discontinued. Discharged on [2189-8-22] and has been receiving Neupogen daily. Past Medical History: - Left breast cancer s/p lumpectomy and radiation in [2153], at [State 792]Hospital - Critical aortic stenosis with plans for possible percutaneous aortic valve replacement, aortic valve area of 0.87 cm2 - Coronary artery disease s/p drug-eluting stent to the RCA in [2188-5-21] - moderate aortic regurgitation - Complete heart block status post pacemaker [2185-6-21] - CHF, EF 35-40% ([2189-7-15]) - History of Pericarditis- prior to [2184] - Chronic Hepatitis C: stage II fibrosis per biopsy [Month (only) ] [2185] - Osteopenia - Hypothyroidism - Basal cell carcinoma s/p resection of right clavicular lesion [2187] - Hyperlipidemia - Hypertension - Endometriosis - Superior vena cava syndrome resulting from primary mediastinal lymphoma, s/p Y bronchial stent placement, Y stent has been removed. XRT for SVC syndrome - s/p [Company 1543] PPM [2184] (Model # ADDRL1) - s/p Bilateral Cataracts - s/p Left Breast Lumpectomy - s/p Laparoscopy for Endometriosis - s/p Squamous Cell Removal Social History: Lives alone, works as an artist(abstract art). Used to be very active, but activities have been curtailed by symptomatic shortness of breath. Divorced, no children. Currently with 24 hour nursing care. - Tobacco: former use, quit age 60 - 30 yr <1 PPD history - Occassional ETOH use - Denies IVDA Family History: Mother colon ca [56]'s. Grandmother, sister with breast ca in 40s and 60s respectively. Father died in car accident. Several relatives on maternal side have had valvular problems. [Name (NI) ] history of lymphomas. Physical Exam: Admission physical exam VS: Temp 98.6F, HR 86, BP 105/49, RR 20, SaO2 98% 3L General: chronically-ill elderly woman in resp distress, comfortable, appropriate [Name (NI) 4459]: NC/AT, pupils equal, EOMI, sclerae anicteric, dry MM, OP clear Neck: supple, no LAD or thyromegaly Lungs: decreased BS in RML/RLL, crackles at left base; labored breathing, using accessory muscles Heart: RRR, nl S1-S2, +3/6 SEM throughout precordium Abdomen: +BS, soft/NT/ND, no masses or HSM Extrem: WWP, no c/c/e Skin: multiple ecchymoses on BUE and BLE Neuro: A&Ox3, grossly intact Discharge physical exam Vs: T 97.5, BP 80/46, HR 109, RR 18, 100% on 4L General aaox3 in nad, chronically ill appearing [Name (NI) ]: [Name (NI) ], peerla, no facial flushing when recumbent, no stridor Card: rrr, coarse holosystolic murmur at lusb that extends throughout Lungs: diffuse crackles, decreased breath sounds on the right base compared to the left base Ab: thin, soft, non tender, nondistended, normative bowel sounds Extremities: no peripheral edema, 1+dp pulses bilaterally Skin: petichiae on extremities and multiple ecchymotic areas on the extremities Pertinent Results: Admission Labs: [2189-8-30] 10:55PM WBC-10.2# RBC-2.85* HGB-10.2* HCT-30.1* MCV-105* MCH-35.7* MCHC-33.9 RDW-19.4* [2189-8-30] 10:55PM NEUTS-85.8* LYMPHS-7.1* MONOS-6.7 EOS-0.2 BASOS-0.2 [2189-8-30] 10:55PM PLT COUNT-52* [2189-8-30] 10:55PM PT-11.4 PTT-30.1 INR(PT)-1.1 [2189-8-30] 10:55PM GLUCOSE-108* UREA N-18 CREAT-0.8 SODIUM-133 POTASSIUM-3.2* CHLORIDE-90* TOTAL CO2-34* ANION GAP-12 [2189-8-30] 10:55PM CALCIUM-10.0 PHOSPHATE-3.5 MAGNESIUM-1.7 [2189-8-30] 10:55PM cTropnT-<0.01 proBNP-[Numeric Identifier 23459]* [2189-8-30] 11:04PM LACTATE-1.8 Discharge labs: [2189-9-3] 03:09AM BLOOD WBC-7.4 RBC-2.86* Hgb-10.1* Hct-30.1* MCV-105* MCH-35.4* MCHC-33.7 RDW-18.5* Plt Ct-82* [2189-9-2] 02:34AM BLOOD Neuts-86.1* Lymphs-5.5* Monos-8.1 Eos-0.1 Baso-0.2 [2189-9-3] 03:09AM BLOOD PT-10.7 PTT-30.2 INR(PT)-1.0 [2189-9-3] 03:09AM BLOOD Glucose-90 UreaN-21* Creat-0.6 Na-134 K-3.9 Cl-97 HCO3-29 AnGap-12 [2189-9-3] 03:09AM BLOOD ALT-23 AST-22 AlkPhos-74 TotBili-0.8 [2189-9-3] 03:09AM BLOOD Calcium-8.3* Phos-1.7# Mg-1.7 Microbiology: Blood cultures 9/9: SPHINGOMONAS SPECIES \| CEFEPIME-------------- 16 I CEFTAZIDIME----------- 4 S CEFTRIAXONE----------- <=4 S CIPROFLOXACIN--------- 1 S GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S LEVOFLOXACIN---------- <=1 S MEROPENEM------------- 1 S PIPERACILLIN/TAZO----- <=8 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=2 S Pleural fluid cultures 9/10: negative Blood cultures 9/10: pending, no growth at time of discharge Urine culture [8-31]: PROBABLE ENTEROCOCCUS. ~3000/ML. Blood cultures 9/12: pending, no growth at time of discharge Urine culture [9-2]: negative Blood culture [9-3]: pending, no growth at time of discharge Pleural fluid cytology [8-31]: negative for malignant cells Imaging: CXR [8-30]: There is a large right and moderate left pleural effusion, increased since [2189-8-26]. Superimposed PNA cannot be excluded, but seems unlikely given lateral radiograph demonstrates no definite opacity. The cardiomediastinal shilhouette and hila are normal. No pneumothorax. Echo [9-1]: The left atrium is normal in size. Overall left ventricular systolic function is moderately depressed (LVEF ?35%) with septal hypokinesis (the anterior wall and apex are not fully visualized). Right ventricular chamber size is normal. with normal free wall contractility. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (valve area 0.8-1.0cm2). Moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Moderate to severe (3+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [2189-8-14], findings are similar. Left ventricular cavity size is now smaller and left ventricular systolic function appears slightly more vigorous. CXR [9-4]: The pacemaker leads terminate in right atrium and right ventricle. Right chest tube has been inserted replacing a pigtail catheter. Bilateral effusions are unchanged, small to moderate on the right and moderate to large on the left. There is slight interval improvement of pulmonary edema. Brief Hospital Course: Ms. [Known lastname ] is a 75yo F with PMH of critical AS, systolic heart failure (EF 30%), complete heart block s/p pacemaker, hypothyroidism, aggressive B cell lymphoma s/p multiple rounds of reduced CHOP and many admissions over the past few months for dyspnea and decompensated heart failure in the setting of fluid resuscitation for chemotherapy and transfusions, who presented with [Known lastname 9140] dyspnea on exertion. Patient was found to be in heart failure with an elevated BNP and signs of pulmonary edema and [Known lastname 9140] pleural effusions on CXR. She had bilateral chest tubes placed and developed [Known lastname 9140] hypoxia following this, likely due to reexpansion pulmonary edema and required transfer to the ICU. Her hemodynamic status was tenuous, as small fluid boluses to increase her blood pressure and improve her renal perfusion (to treat her actue renal failure) would lead to [Known lastname 9140] respiratory status. She was diuresing well out of her chest tubes prior to them becoming kinked and they were pulled on [9-2]. Her blood pressures ranged sbp 70-100 and she had waxing and [Doctor Last Name 688] confusion, consistent with delirium. Given her tenous balance between renal perfusion and her respiratory status, and difficulty diruesing her and her known preload dependence from her critical AS, discussion was had with her heme-onc providers about whether she was tolerating the chemotherapy. It was clear that she was not tolerating her chemotherapy sessions, as they required large volumes of fluids to prevent renal toxicity and other complications, and it was unclear if there was significant improvement in her disease. Discussions with the patient and her family were held, and it was decided to switch her goals to management of her symptoms. She was seen by the palliative care team, and decision was made for discharge to home with hospice. Prior to discharge she had a right sided pleurex chest tube placed for palliative diuresis of her reaccumulating pleural effusion. Medications on Admission: 1. Acyclovir 400 mg PO Q8H 2. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB or wheeze 3. Cyanocobalamin 50 mcg PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Filgrastim 300 mcg SC Q24H 6. FoLIC Acid 1 mg PO DAILY 7. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 8. Levothyroxine Sodium 125 mcg PO DAILY 9. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN back pain To mid-back 10. Lorazepam 0.25 mg PO HS:PRN insomnia 11. Metoprolol Succinate XL 25 mg PO DAILY 12. Mucinex NF* (guaiFENesin) 1,200 mg Oral q12h 13. Multivitamins 1 TAB PO DAILY 14. Nystatin Oral Suspension 10 mL PO Q8H 15. Omeprazole 20 mg PO DAILY 16. Ondansetron 4-8 mg PO Q8H:PRN nausea 17. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain 18. Senna 1 TAB PO BID:PRN constipation 19. Sodium Chloride Nasal [12-22] SPRY NU TID:PRN SOB or wheeze 20. Sucralfate 1 gm PO TID 21. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 22. Torsemide 10 mg PO DAILY 23. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain 24. traZODONE 12.5 mg PO HS:PRN sleep 25. Vancomycin Oral Liquid 125 mg PO DAILY 26. Vitamin D 400 UNIT PO DAILY 27. Albuterol Inhaler [12-22] PUFF IH Q4H:PRN shortness of breath 28. Aspirin 81 mg PO DAILY 29. PredniSONE 60 mg PO ONCE Duration: 1 Doses Please take 1 more prednisone on [8-23] to complete treatment 30. Sodium Chloride 0.9% Flush 10 mL IV DAILY PICC - Inspect site every shift Discharge Medications: 1. Morphine Sulfate (Concentrated Oral Soln) 2-20 mg PO Q1H:PRN pain or shortness of breath 20 mg/mL solution, please dispense 30 mL RX morphine concentrate 20 mg/mL 2-20 mg by mouth Q1H Disp #30 Milliliter Refills:2 2. Docusate Sodium 100 mg PO BID 3. Nystatin Oral Suspension 10 mL PO TID 4. Torsemide 10 mg PO DAILY 5. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN shortness of breath or wheezing 6. Albuterol Inhaler [12-22] PUFF IH Q4H:PRN shortness of breath or wheezing 7. Levothyroxine Sodium 125 mcg PO DAILY 8. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN pain 9. Ondansetron 4-8 mg PO Q8H:PRN nausea 10. Senna 1 TAB PO BID:PRN constipation 11. Sodium Chloride Nasal [12-22] SPRY NU TID:PRN shortness of breath Discharge Disposition: Home With Service Facility: CIRCLE OF CARING AT HOSPICE OF THE GOOD [Doctor Last Name ] Discharge Diagnosis: B Cell lymphoma Critical Aortic stenosis Acute on chronic systolic heart failure Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. [Known lastname ], It was a pleasure taking care of you while you were here at [Hospital1 18]. You were admitted with shortness of breath, which was likely caused by increased fluid in your lungs. The fluid built up due to your aortic stenosis and congestive heart failure. You had chest tubes placed, and after developing more difficluty breathing you were monitored in the ICU. We treated you with medications to help remove the fluid, and your breathing improved. You also received morphine, which helped treat your shortness of breath. After discussion with Dr. [First Name (STitle) ], it was felt that you were not tolerating the chemotherapy. We also spoke with your cardiologist, and your aortic stenosis cannot be fixed surgically. Therefore, we switched our focus of our treatment on managing your symptoms. You were seen by our palliative care team, and will be discharged to home with hospice services. They will help you manage your shortness of breath. Before your discharge, the interventional pulmonary doctors placed a [Name5 (PTitle) 19843] on your right side to help [Name5 (PTitle) 19843] more fluid. Below are the orders for taking care of the [Name5 (PTitle) 19843], and your home nurses will be able to assist you with this. Standard Pleurx orders: Right side 1. Please [Name5 (PTitle) 19843] Pleurx every other day. Keep a log of amount & color, have the patient bring it with him to his appointment. 2. Do not [Name5 (PTitle) 19843] more than 1000 ml per drainage. 3. Stop draining for pain, chest tightness, or cough. 4. Do not manipulate catheter in any way. 5. Keep a daily log of Drainage amount and color. 6. You may shower with an occlusive dressing 7. If the drainage is less than 50cc for three consecutive drainages please call the office for further instructions. 8. Please call office with any questions or concerns at [Telephone/Fax (1) ]. Pleurex catheter sutures to be removed when seen in clinic [10-4] days post PleurX placement. Please call [Telephone/Fax (1) 7769] if there are any questions. Followup Instructions: Please follow up with Dr [Last Name (STitle) ] in [Hospital 23463] clinic on Wednesday for suture removal in 2 weeks. [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292] Completed by:[2189-9-6*]	[ "V45.82", "414.01", "518.81", "V45.02", "285.22", "401.9", "458.9", "287.5", "396.8", "428.23", "V49.86", "428.0", "070.54", "V10.3", "584.9", "272.4", "511.9", "244.9", "459.2", "733.90", "790.7", "202.88", "787.20" ]	icd9cm	[ [ [] ] ]	[ "34.04", "38.93", "38.91" ]	icd9pcs	[ [ [] ] ]	17522, 17616	13181, 15252	293, 386	17741, 17741	9706, 9706	20044, 20336	8301, 8526		16774, 17499	17637, 17720		15278, 16751			17919, 20021		10326, 13158					8541, 9687																245, 255								414, 2433					9722, 10310			17756, 17895					6935, 7970	7986, 8285
16,642	188,241	43430	Discharge summary	report	Admission Date: [2157-10-2] Discharge Date: [2157-10-5] Date of Birth: [2099-12-3] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 11495] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Cardiac catheterization with 2 Cypher stents placed in LAD History of Present Illness: Mr. [Known lastname 21136] is a 57 yo male with PMH significant for DM and HTN who presents with an STEMI, now s/p cardiac catheterization. Pt presented to [Hospital1 18] ED at 4:30 pm with chest pain. He describes having 2 episodes earlier this afternoon. The first occurred at 3pm and lasted for approximately 15-20 minutes associated with significant diaphoresis. Patient describes the pain as a discomfort in his chest with a sense of relief when it went away. He admits to doing some light yardwork prior to the 1st episode but denies any pain at the time. The second episode occurred at 3:30pm and lasted until his presentation to the ED. Denies any associated SOB, PND, orthopnea, vomiting, or lightheadedness. In the ED his inital vitals were: T 97.9 BP 170/109 AR 82 RR 16 O2 sat 95% RA. EKG showed ST elevations I, aVL, V1-V4 and reciprocal ST depressions in II, III, & aVF. He was given Heparin 5000 units SQ, Metoprolol 5mg IV (3 doses), Nitroglycerin IV, Plavix 75mg, and Integrillin gtt and was taken immediately to the cath lab. In the cath lab he was found to have 60% proximal stenosis and 99% stenosis before D1 of the LAD. Two Cypher stents were placed and patient had immediate relief of his chest pain. Patient also admits to claudication symptoms in his L leg for the past 1.5 months. He describes it as crampiness at the bottom of his calf and is unable to walk more than [Age over 90 ] yards before he develops these symptoms. He was hoping to see Dr. [Last Name (STitle) 172] in the next few weeks. Past Medical History: 1)Type 2 DM, diagnosed 2-3 years ago 2)Hypertension 3)Peripheral [Last Name (STitle) 1106] disease s/p femoral-tibial bypass 3)Hyperlipidemia 4)Recurrent bilateral renolithiasis: -Lithotripsy with stenting in [2147-1-27], a -Cystoscopy with angioplasty of the urethral orifice and lithotripsy with J stent in [2152-1-27] - L renal calculus with cystoscopy, a right ureteroscopy with lithotripsy and stenting in [2153-6-28]. 5)Gout Social History: He is retired from the [State 350] Port Authority. He is married and lives with his spouse. [Name (NI) 1139] history of greater than 40 pack years, [11-29] ppd. No significant alcohol use. Family History: Hx of CAD in maternal uncles and aunts Physical Exam: vitals: T 98.3 BP 154/89 AR 93 RR 16 O2 sat 97% RA Gen: Pleasant male, NAD HEENT: MMM Neck: no JVD or lymphadenopathy Heart: nl s1/s2, no s3, s4, no m,r,g Lungs: CTAB, +crackles at the bases Abdomen: obese, soft, NT/ND, no hepatomegaly, +BS Extremities: no edema, 2+ DP/PT pulses in RLE, pulses not palpable in LLE and cool to touch. Neuro: awake and alert Pertinent Results: Laboratory Results: [2157-10-2] 04:30PM BLOOD WBC-13.6# RBC-5.21 Hgb-17.0 Hct-49.4 MCV-95 MCH-32.5 MCHC-34.4 RDW-13.1 Plt Ct-231 [2157-10-2] 04:30PM BLOOD Neuts-71.8* Lymphs-21.8 Monos-4.8 Eos-0.8 Baso-0.9 [2157-10-2] 04:30PM BLOOD PT-11.4 PTT-22.0 INR(PT)-1.0 [2157-10-2] 04:30PM BLOOD Glucose-214* UreaN-18 Creat-1.1 Na-138 K-4.0 Cl-97 HCO3-31 AnGap-14 [2157-10-2] 04:30PM BLOOD CK(CPK)-113 [2157-10-2] 04:30PM BLOOD CK-MB-4 [2157-10-3] 03:56AM BLOOD Mg-1.7 Cholest-150 [2157-10-3] 03:56AM BLOOD CK(CPK)-3652* [2157-10-3] 03:56AM BLOOD CK-MB-190* MB Indx-5.2 cTropnT-9.86* [2157-10-4] 04:00AM BLOOD CK(CPK)-842* [2157-10-4] 04:00AM BLOOD CK-MB-23* MB Indx-2.7 [2157-10-5] 06:35AM BLOOD WBC-10.0 RBC-4.86 Hgb-15.2 Hct-45.8 MCV-94 MCH-31.2 MCHC-33.1 RDW-13.1 Plt Ct-238 [2157-10-5] 06:35AM BLOOD PT-13.0 PTT-54.6* INR(PT)-1.1 [2157-10-5] 06:35AM BLOOD Glucose-152* UreaN-15 Creat-0.9 Na-136 K-4.2 Cl-102 HCO3-24 AnGap-14 Relevant Imaging: 1)Cardiac catheterization ([10-2]): 1. Selective coronary angiography of this left dominant system revealed 2 vessel disease. The LMCA has mild disease. The ostial LAD had a 60% lesion, followed by 99% lesion immediately before D1 take-off with TIMI 2 flow. The mid-distal LAD as well as D1 has diffuse disease- up to 40% stenosis. The ramus intermedius is a small caliber vessel and has 50% stenosis. The LCx is a large vessel and gives off 3 OMs as well as the L-PDA. OM2, which is a moderate caliber vessel, has 60% stenosis in its mid-portion. The L-PDA has 80% stenosis at its origin as well as a 60% stenosis in its mid-portion. The RCA is a small, non-dominant vessel with diffuse disease. 2. Limited resting hemodynamic measurement reveals elevated left sided filling pressure with an LVEDP of 30mmHg. 3. Left ventriculography revealed an ejection fraction of 40% with anterior lateral and apical akinesis. 2)Cxray ([10-2]): Limited study. Low lung volumes. Faint opacity in left lower lobe. 3)ECHO ([10-3]): The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is top normal/borderline dilated. There is severe regional left ventricular systolic dysfunction with near akinesis of the distal 2/3rds of the anterior septum and anterior walls, distal inferior wall and apex. The remaining segments contract well. The apex is heavily trabeculated, but no intraventricular thrombus is seen. Right ventricular chamber size and free wall motion are normal. The aortic root, ascending aorta, and aortic arch are mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be quantified. There is no pericardial effusion. Brief Hospital Course: A/P: Patient is a 57 yo male with DM and HTN who presented with chest pain and is now s/p cardiac catheterization with 2 stents placed in the LAD. 1)STEMI: Patient presented to the ED with EKG changes consistent with an anteroseptal infarction. He underwent urgent cardiac catheterization with two Cypher stents placed in the LAD and is currently chest pain free. Also has significant stenosis in the PDA but no further intervention was done. Currently in sinus rhythm and euvolemic. He was continued on Integrilin and then transitioned to Heparin gtt & Coumadin given the increased risk of a clot given the significant apical akinesis. He was also started on Plavix 75mg and high dose ASA 325mg, which he should take for 12 months. Medical management was optimized with b-blocker, Ace inhibitor, and statin. An ECHO 2 days after the cath suggested significant anteroseptal akinesis with a depressed EF. He is being discharged with Lovenox and Coumadin. I have scheduled him for a repeat ECHO in 4 weeks and have also scheduled him to see Dr. [Last Name (STitle) ]/Dr. [Last Name (STitle) ] to determine course of anticoagulation. 2)HTN: Blood pressure was elevated in the ED and remained high in the CCU. He is on Bisoprolol/HCTZ as an outpatient. This was changed to Toprol XL 50mg. He was also maintained on his home dose of Lisinopril 10 mg. He was started on a Nitro gtt in the ED but was d/c'ed after cath. 3)Peripheral [Last Name (STitle) ] Disease: Patient is s/p R femoral-tibial bypass in [4-1]. He presents on this admission with claudication symptoms in his L leg for the past few months. He states that he is not able to walk more than [Age over 90 ] yards before developing cramps in his legs. On exam his left leg was initally cool and the DP pulse was not dopplerable. We contact[Name (NI) ] Dr. [Last Name (STitle) 1391] to come by and see Mr. [Known lastname 21136] during his stay in the hospital. He suggested further work-up with ABI's, U/S of R graft, and angiogram all of which are scheduled for as an outpatient. 4)Hyperlipidemia: He was continued on outpatient regimen of Lipitor but dose was increased from 20mg to 80mg daily. 5)Type 2 DM: Patient on Metformin 500mg [Hospital1 ] at home. Last Hgb A1C was 8.7 in [2155], which decreased to 8.3 this admission. Metformin was held for 48 hours post cath. He was started on an insulin sliding scale and sugars were monitored closely. Discharged on home regimen of Metformin. 6)Elevated WBC: Patient presented with a leukocytosis of 13.6. Likely secondary to myocardial ischemia. Cxray suggested possible left lower lobe infiltrate but he was asymptomatic. He was initally started on a Azithromycin but this was stopped given that that there were no clear signs of infection. Medications on Admission: Lisinopril 10mg PO daily Bisoprolol/HCTZ 10/6.25 Lipitor 20mg PO daily Folgard Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. 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 7. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:30 Tablet Sustained Release 24HR(s) Refills:2 8. Lovenox 100 mg/mL Syringe Sig: One (1) syringe Subcutaneous twice a day. Disp:7 syringes Refills:2 9. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Primary diagnosis: 1)STEMI, s/p cardiac catheterization Secondary diagnosis: 1)Type 2 DM, diagnosed 2-3 years ago 2)Hypertension 3)Peripheral [Location (un) 1106] disease s/p femoral-tibial bypass 3)Hyperlipidemia Discharge Condition: Stable Discharge Instructions: 1) Please start medications, as listed in the discharge summary 2) You are being discharged on 2 new medications: Lovenox and Coumadin. You will be taught how to inject Lovenox before you leave the hospital. To make sure that you are getting the correct doses, you will need to get labs drawn on Friday ([10-8]) and Monday ([10-11]) and then weekly. 3) Please follow up with your primary care physician in the next 2 weeks. You are also scheduled for additional tests and appointments as listed in the discharge instructions. 4)If you experience any chest pain, pressure, shortness of breath, or any other concerning symptoms please return to the ED. Followup Instructions: 1)Provider: [Name10 (NameIs) ] STUDY Phone:[Telephone/Fax (1) 327] Date/Time:[2157-11-7] 9:00 2)Provider: [Name10 (NameIs) ] Phone:[Telephone/Fax (1) 128] Date/Time:[2157-11-7] 11:00 3)Provider: [Name10 (NameIs) 251] [Last Name (NamePattern4) 677], M.D. Phone:[Telephone/Fax (1) 2934] Date/Time:[2157-11-23] 1:00	[ "414.01", "V17.3", "305.1", "486", "428.40", "V43.4", "V58.67", "V13.01", "428.0", "401.9", "272.4", "440.21", "410.11", "250.00" ]	icd9cm	[ [ [] ] ]	[ "37.22", "88.53", "36.07", "00.46", "99.20", "88.56", "00.40", "00.66" ]	icd9pcs	[ [ [] ] ]	10034, 10091	6038, 8833	327, 388	10354, 10363	3107, 4087	11073, 11429	2674, 2714		8962, 10011	10112, 10112		8859, 8939			10387, 11050							2729, 3088																277, 289	4105, 6015							416, 1960			10190, 10333			10131, 10169							1982, 2439	2455, 2658
52,228	155,354	11705	Discharge summary	report	Admission Date: [2172-3-31] Discharge Date: [2172-4-4] Date of Birth: [2127-2-22] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2145] Chief Complaint: Epistaxis and Menorrhagia in Setting of Thrombocytopenia Major Surgical or Invasive Procedure: None History of Present Illness: Pt is a 45 y/o F with hx of SLE who presented with 3 days of nose bleeds, heavy vaginal bleeding and blood blisters in her mouth. She states she noted oozing epistaxis over the past 3 days from her bilateral nares. She has been having heavier periods, needing to change her pads q2 hrs (nl 3x/day). She has felt generally weak and tired (but no focal symptoms). The morning of presentation she noted some "blood blisters" in her mouth which prompted her to go to the ED. Denies other bleeding eg hematemesis, hematuria, or GI bleed, bruising, headache, chest discomfort, dyspnea, lightheadedness. Also, no fevers, chills, sweats, weight loss, adenopathy, abd or back pain. No recent illness. She did use some 400mg of ibuprofen the day prior to presentation for bilateral knee aches. She reports HIV negative 6 years ago. Past Medical History: -Sarcoid-variant lupus with prior lung and kidney involvement (per patient) followed by Dr. [Last Name (STitle) ] in [Hospital1 ]. Has received Steroids in past for SLE but not for past 10-15 years. No hx of rash. Currently no lung or renal manifestations. -Arthritis [1-21] SLE. Chronic. Not treated with medications. -s/p Tonsillectomy Social History: Married, works as manager. Occ. marijuana and EtoH, no smoking or IVDA. Family History: Patient believes that her mother has arthritis, thrombocytopenia, and cancer (unsure of type). Father died in hospital (unsure of cause). 2 sisters and brother are healthy. Daughter was hospitalized for meningitis in the past, developed blood clots, received anticoagulation, and suffered a stroke. Physical Exam: (Per Admitting Resident) Vitals T 98.3, BP 124/78, HR 58, RR 100% on RA General: well appearing. Appropriately interactive. NAD HEENT anicteric, MMM. nares with some dry crusted blood. oropharynx non-erythematous. No oral lesions noted. Neck: supple, no LAD Heme: no cervical, supraclavicular adenopathy Pulm: lungs clear to auscultation bilaterally, no wheezing. CV: RRR. nl S1, S2. No MRG. Abd. soft nontender +bowel sounds. no mass Extrem: warm no edema 2+ palpable distal pulses. Neuro alert, appropriately interactive, A&Ox2. CN grossly intact., moving all extremities. Motor grossly in tact. Skin: Mild scattered petechia on LE bilaterally. Pertinent Results: Admission Labs [2172-3-31] 02:10PM BLOOD WBC-4.8 RBC-3.88* Hgb-11.1* Hct-33.4* MCV-86 MCH-28.6 MCHC-33.2 RDW-15.1 Plt Ct-6# [2172-3-31] 02:10PM BLOOD Neuts-57.5 Lymphs-34.4 Monos-5.7 Eos-1.5 Baso-0.8 [2172-3-31] 02:10PM BLOOD PT-12.0 PTT-24.7 INR(PT)-1.0 [2172-3-31] 02:10PM BLOOD Ret Aut-2.0 [2172-3-31] 02:10PM BLOOD Glucose-88 UreaN-11 Creat-0.8 Na-136 K-3.9 Cl-101 HCO3-25 AnGap-14 [2172-3-31] 02:10PM BLOOD LD(LDH)-244 TotBili-0.3 [2172-3-31] 02:10PM BLOOD Iron-39 [2172-3-31] 02:10PM BLOOD calTIBC-377 VitB12-546 Folate-9.8 Hapto-107 Ferritn-13 TRF-290 [2172-3-31] 02:10PM BLOOD IgA-277 [2172-3-31] 02:10PM BLOOD C3-162 C4-27 Discharge Labs [2172-4-4] 06:55AM BLOOD WBC-10.8 RBC-2.82 Hgb-8.6* Hct-24.9* MCV-88 MCH-30.3 MCHC-34.4 RDW-17.3* Plt Ct-11# [2172-4-4] 06:55AM BLOOD PT-11.4 PTT-23.4 INR(PT)-1.0 [2172-4-4] 06:55AM BLOOD Glucose-84 UreaN-12 Creat-0.9 Na-140 K-3.5 Cl-106 HCO3-27 AnGap-11 [2172-4-4] 06:55AM BLOOD Calcium-8.2 Phos-2.9 Mg-1.9 Other Labs [2172-3-31] 02:10PM BLOOD Ret Aut-2.0 [2172-4-2] 10:32PM BLOOD Lupus-NEG [2172-3-31] 02:10PM BLOOD IgA-277 [2172-4-1] 02:32PM BLOOD C3-110 C4-22 [2172-3-31] 02:10PM BLOOD C3-162 C4-27 [2172-4-1] 02:32PM BLOOD HIV Ab-NEGATIVE [2172-3-31] 08:32PM BLOOD Lactate-3.8* [2172-3-31] 06:51PM BLOOD Lactate-5.4* [2172-3-31] 08:04PM BLOOD TRYPTASE (BETA-SUBUNIT AND ALPHA/BETA FRACTIONS)- PENDING AT THE TIME OF DISCHARGE Urine Studies [2172-4-1] 01:16AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.012 [2172-4-1] 01:16AM URINE Blood-MOD Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [2172-4-1] 01:16AM URINE RBC-0 WBC-1 Bacteri-NONE Yeast-NONE Epi-1 [2172-4-1] 01:16AM URINE Mucous-RARE [2172-4-1] 01:16AM URINE Hours-RANDOM [2172-4-1] 01:16AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG Brief Hospital Course: Patient is 45 y/o F c hx of Lupus who presented to the hospital with 3 days of epistaxis, menorrhagia and blood blisters in her mouth. When she arrived in the ED, she had a HCT of 33 and platelet count of 6. Once on the floor she was transfused with one dose of platelets. # Thrombocytopenia: When patient presented to the hospital she had a platelet count of 6. Heme was consulted and feels that thrombocytopenia is most likely [1-21] SLE / ITP. Patient was tested and found to be HIV negative. She was treated with 2 transfusions of platelets and had an anaphylactic reaction to the first transfusion (see below). Second dose tolerated well. Patient was started on 1mg / kg of PO prednisone. One dose of amicar was also given in the MICU. All antiplatelt medications were held as an inpatient. Neuro evaluations were performed TID as an inpatient by nursing staff to evaluate for intracranial bleed, but neuro exam was consistently WNL. Patient should continue taking 1mg/kg of prednisone daily as an outpatient. Patient should follow up with Heme/Onc this week to evaluate her CBC and signs of bleeding. Heme/Onc will also direct her course of PO prednisone. She should also follow up with her PCP and rheumatology within 2 weeks. Of note, on [2172-4-4] (the day after she had been called out to the floor, the patient's platelet count had improved to 11). She was informed by the primary team that she should remain in-house for one more night to monitor her platelet count; however, she decided to leave AMA. She was given a prescription for prednisone as well as instructions to return on [2172-4-7] to the lab to have her platelet count drawn. She was also instructed to call the [Hospital 478] clinic to arrange a follow-up appointment within 1 week of discharge. # Anaphylaxis: Pt developed pruritis, facial swelling, and emesis while being treated with first dose of platelets. She was transiently unresponsive and BP nadired at 75/43. She was given epipen with good effect, along with famotidine, 100mg methylprednisolone, and 1L of normal saline. Anesthesia evaluated her there, felt that she did not require intubation or endoscopy. She was then transferred to the MICU and monitored closely. Pt recovered well with prednisone and H2 blocker. Pt. was given a second dose of platelets (washed products) while in the unit on [4-2]. Patient had no reaction to the second transfusion. At the time of callout from the MICU, the patient had been stable for the last several days and was still being treated with 1mg / kg prednisone. Patiet will continue on this dose of steroids as an outpatient (for her ITP), but no longer needs an H2 blocker or antiemetics. # Anemia: Patient HCT dropped slightly after she received fluids and transfusion with platelets. However HCT remained stable for the last several days as an inpatient. No transfusion of PRBC was needed. Patient received iron supplements while an inpatient. We continued to follow her CBC [Hospital1 ] while an inpatient. Patient should follow up with Heme/Onc within one week of discharge to evaluate her CBC. She should also follow up with her PCP [Name Initial (PRE) 176] 2 weeks. She should contine taking iron supplements as an outpatient. #SLE: Patient is not currently on any treatment for SLE. She had no other signs or symptoms of SLE other than thrombocytopenia and arthritis as an inpatient. Arthritis is controlled at home, and was maintained in the hospital with PRN acetominophen. Patient should continue taking 1mg/kg of PO prednisone as an outpatient. She should follow up with rheumatology after discharge to follow her for SLE. Medications on Admission: Occasional motrin/ibuprofen for knee pain. Discharge Medications: 1. Prednisone 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:0 2. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO three times a day. Disp:90 Tablet(s) Refills:0 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 4. Outpatient Lab Work Patient needs to have her platelets checked on Tuesday [2172-4-7]. Results should be faxed to her PCP's office [Telephone/Fax (1) 37043]. Results should also be given to her to be brought to her heme/onc follow-up appointment. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis - Idiopathic Thrombocytopenic Purpura Secondary Diagnosis - Systemic Lupus Erythematosus Discharge Condition: *Pt left AMA* Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: *Pt left AMA* You were admitted to the hospital with bleeding from your nose and excessive menstual bleeding. You were found to have very low platelets. You were given a platelet transfusion but developed an allergic reaction. As a result, you spent some time in the ICU. Your low platelets were thought to be related to a condition called ITP, and you were started on steroids to treat this. You are being discharged on steroids with plans for you to follow up with heme/onc. We advised you to stay an extra day for monitoring of your platelets; however, you decided to leave against medical advice. You need to come to the hospital on Tuesday [2172-4-8] to have your platelet count drawn. CHANGES TO YOUR MEDICATIONS: - START Prednisone 80 mg daily. You should continue this regimen until your heme/onc follow-up appointment. At that time, you can discuss your prednisone regimen with your doctor. - START Iron 325 mg three times a day - START Pantoprazole 40 mg daily. You should continue to take this to protect your stomach while you are on steroids. It was a pleasure taking part in your medical care. Followup Instructions: You need to follow-up with heme/onc within 1 week of your discharge. You can call [Telephone/Fax (1) 22] to arrange this appointment. You also should follow-up with your PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) 37044], within [12-21] weeks of discharge. You can contact Dr.[Name (NI) 37045] office at [Telephone/Fax (1) 16658] to schedule an appointment. [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 2158]	[ "287.31", "626.2", "285.1", "710.0", "E849.7", "E879.8", "784.7", "999.89" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	9128, 9134	4682, 8355	371, 378	9286, 9305	2699, 4659	10601, 11090	1711, 2011		8448, 9105	9155, 9265		8381, 8425			9456, 10159							2026, 2680													10188, 10578			275, 333								406, 1229								9320, 9432					1251, 1606	1622, 1695
29,688	138,413	18568	Discharge summary	report	Admission Date: [2143-12-11] Discharge Date: [2143-12-18] Date of Birth: [2074-2-5] Sex: M Service: SURGERY Allergies: Lopid / Lipitor / Zocor / Pravastatin Attending:[Last Name (NamePattern1) 4659] Chief Complaint: 69 Male with Factor V Leiden and status post Pulmonary Emboli x 2(4/07,[10-2])admitted for anticoagulation before laparoscopic sigmoidectomy on Friday([2143-12-13]) for adenocarcinoma. Major Surgical or Invasive Procedure: Status Post Laparoscopic Sigmoidectomy for adenocarcinoma History of Present Illness: Patient had left-sided, nonradiating, & nonpleuritic chest pain (sharp,[3-5]) yesterday while sitting down watching television that resolved on its own in a few hours. This was his first episode of chest pain since his last [Hospital1 18] admission([2143-9-30]). He also stated that 2 weeks ago he had some blood streaks on his toilet paper after bowel movements, but his [Month/Day/Year 3390] told him it was secondary to hemorrhoids. He denies recent history of palpitations,SOB, cough, wheezing, abdominal pain, N/V, headache, visual changes, hematochezia, black/tarry stools, diaphoresis,palpitations, change in bowel habits, or unintended weight loss. Past Medical History: Factor V Leiden (heterozygous) status Post Pulmonary Embolism x2(4/07,[10-2]) HTN, Hyperlipidemia, Diabetes Mellitus, Chronic LBP(L4 arthritis), Fe def. anemia, CRF (baseline Cr=1.4-2.0), R knee arthritis (ambulates w/cane @ baseline), s/p cardiac catheterization ([2143-10-2]->LAD 50% stenosis, elevated left & right filling pressures, & PA HTN), EGD suggestive of Barrett's Esophagus ([2143-10-12]), History of EtOH abuse. Social History: Social history is significant for the absence of current tobacco use though he smoked 4 PPD for 35 years, but quit 12 years ago. There is a history of alcohol abuse, but currently drinks 2 drinks/ week. There is no family history of premature coronary artery disease or sudden death. Family History: No history of hematological malignancies/PE/DVT. No family history of premature coronary artery disease or sudden death. Physical Exam: Physical Exam: Tc:96.5 HR:74 BP:138/80 RR:18 98%RA General: No Acute Distress,Awake,Alert,& Oriented x 3 HEENT: neck supple, no masses,no cervical lymphadenopathy, no JVD Heart: regular rate and rhythm, without murmurs, rubs, or gallops Lungs: Clear to Auscultation Right Lung & Left Base, decreased breath sounds LML & LUL Abdomen: + bowel sounds,obese, nontender Extremities: 1+ pitting edema (LLE) & trace pitting edema (RLE),no clubbing/cyanosis, 1+ dorsalis pedis/1+ posterior tibial/2+ radial,capillary refill<2 seconds,decreased sensation to light touch on left foot (from midfoot distally to toes),[3-30] muscle strength, + healed incision scar left anterior knee Neuro: CNII-XII grossly intact Pertinent Results: [2143-12-11] 03:45PM BLOOD WBC-4.9 RBC-4.04* Hgb-11.1* Hct-32.8* MCV-81* MCH-27.4 MCHC-33.7 RDW-18.3* Plt Ct-267 [2143-12-14] 01:56AM BLOOD WBC-10.4# RBC-3.91* Hgb-10.6* Hct-32.4* MCV-83 MCH-27.2 MCHC-32.8 RDW-16.7* Plt Ct-222 [2143-12-17] 05:46AM BLOOD WBC-5.3 RBC-3.35* Hgb-9.1* Hct-27.8* MCV-83 MCH-27.2 MCHC-32.8 RDW-16.3* Plt Ct-228 [2143-12-11] 03:45PM BLOOD PT-18.8* PTT-27.3 INR(PT)-1.7* [2143-12-18] 04:27AM BLOOD PTT-60.6* [2143-12-11] 03:45PM BLOOD Glucose-243* UreaN-34* Creat-1.4* Na-137 K-4.7 Cl-105 HCO3-25 AnGap-12 [2143-12-17] 05:46AM BLOOD Glucose-127* UreaN-17 Creat-1.8* Na-137 K-3.8 Cl-101 HCO3-29 AnGap-11 [2143-12-11] 03:45PM BLOOD Calcium-9.0 Phos-3.5 Mg-1.8 [2143-12-17] 05:46AM BLOOD Calcium-6.0* Phos-3.4 Mg-1.8 [2143-12-13] 02:01PM BLOOD Type-ART pO2-233* pCO2-48* pH-7.39 calTCO2-30 Base XS-3 [2143-12-13] 02:01PM BLOOD freeCa-1.15 Brief Hospital Course: 69 year old male admitted on [2143-12-11] two days before elective sigmoidectomy for anticoagulation as has history of two pulmonary embolisms in past. Patient stopped his coumadin on [2143-12-8]. Patient started on a heparin drip on [2143-12-11] and ptt levels maintained 60-80. Heparin drip discontinued 4 hours before surgery on [2143-12-13]. Underwent a laparoscopic sigmoidectomy without complications. Postoperative Day 1 - Patient admitted to the intensive care unit postoperatively. Patient had a stable night and was sent out to the regular floor. Heparin drip restarted and PTT maintained between 60-80. Postoperative Day 2 - Coumadin resumed. Diet advanced from clears to full liquids. Postoperative Day 3 - Abdominal distention noted though patient passing gas. Diet changed to sips. Foley discontinued. Patient voiding without problems. Postopertive Day 4 - Blood sugars alittle high, 258, 282. Sliding scale adjusted and placed back on [11-27] dose of previous nph level. Mild erythema/pinkness noted inferior to umbilical incision. Kefzol 1 gm every 8 hours intravenous started. Postoperative Day 5 - Good bowel function. Had BM and flatus on regular diet. Afebrile, vital signs stable. No wound or abdominal wall erythema. Out of bed and ambulating independently. "feels good" today. Chronic issues 1. Anticoagulation - INR 2.5 today. Heparin drip discontinued. Talked to primary care Dr. [Last Name (STitle) 1576] ([Telephone/Fax (1) 51008] hospital course. He will follow up with him this Friday or Monday and check his INR. 2. Diabetes mellitus - Blood sugars have been fairly stable except on postoperative day 4 with several readings in the high 200's. His NPH insulin was restarted. He will continue his preoperative diabetic regimen upon discharge. 3. Chronic renal insufficiency - baseline creatinine 1.4 - 2.0, this was maintained with last creatinine on [2143-12-17] of 1.8. Urine output has been good throughout hospital course. He was able to diuresis without help. 4. Erthemic area on abdomen - has resolved. No longer needs antibiotics. Medications on Admission: Metoprolol 50 mg PO TID, Lisinopril 10 mg daily, Isosorbide Mononitrate 30 mg PO DAILY, A.M. 73 units NPH, P.M. 35 units NPH, Gabapentin 400mg TID, FoLIC Acid 1 mg PO DAILY, Ferrous Sulfate 325 mg PO DAILY, Docusate Sodium 100 mg PO BID, (Coumadin HELD SINCE [12-8]) Discharge Medications: 1. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 4. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily). 7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Warfarin 7.5 mg Tablet Sig: One (1) Tablet PO every night for 1 doses: Please monitor INR with Primary care. 9. insulin please resume your preoperative doses of insulin including your NPH. Please follow your blood sugars closely and report abnormals to your primary care physician. 10. Gabapentin 400 mg Tablet Sig: One (1) Tablet PO tid. 11. FerrouSul 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Status Post Laparoscopic Sigmoidectomy for adenocarcinoma Discharge Condition: Stable Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or becoming progressively worse, or inadequately controlled with the prescribed pain medication. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. Followup Instructions: Please call Dr.[Name (NI) 6218] office to confirm your return appointment at [Telephone/Fax (1) 51009] Provider: [Name Initial (NameIs) 3390]: [Name10 (NameIs) 357] call Dr. [Last Name (STitle) 1576] at [Telephone/Fax (1) 1144] to see you on [2143-12-20] or [2143-12-23] to follow up on his INR. Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1523], MD Phone:[Telephone/Fax (1) 4022] Date/Time:[2143-12-30] 4:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 10486], MD Phone:[Telephone/Fax (1) 1228] Date/Time:[2144-4-3] 9:05 [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [Name8 (MD) ] MD, [MD Number(3) 4661] Completed by:[2143-12-18]	[ "250.00", "724.2", "153.3", "272.4", "280.9", "V12.51", "289.81", "403.90", "716.96", "585.9" ]	icd9cm	[ [ [] ] ]	[ "45.76" ]	icd9pcs	[ [ [] ] ]	7307, 7313	3835, 5945	499, 559	7415, 7424	2906, 3812	8247, 9056	2040, 2163		6266, 7284	7334, 7394		5971, 6243			7448, 8224							2193, 2887																267, 461								588, 1262													1284, 1722	1738, 2024
31,928	109,459	52465	Discharge summary	report	Admission Date: [2125-5-28] Discharge Date: [2125-6-1] Date of Birth: [2045-6-5] Sex: F Service: MEDICINE Allergies: Keflex / Heparin Agents Attending:[First Name3 (LF) 1973] Chief Complaint: Femur Fracture, Fall Major Surgical or Invasive Procedure: Femur repair Midline placement History of Present Illness: 79 year old Female who presents with femoral trochanteric fracture after sustaining a fall in the bathroom. She states she was cleaning her bathroom when she is unsure exactly what happened, but she fell after getting her walker. Her husband found her, and believes she fell over a cleaning bottle with her walker. The patient denies fainting or loss of consciousness. Her husband called EMS where plain film [Name (NI) 108380] revealed left intertrochanteric femur fracture. Ortho-Trauma was consulted and recommended operative repair. In addition, cervical spine films were concerning for cervical vertebral subluxation, so the patient was placed in a Cervical Hard-Collar pending orthospine clearance. Of note the patient was recently admitted here at [Hospital1 18] for workup of cryptogenic cirrhosis with a significant variceal bleed, requiring ICU admission with Dr. [Last Name (STitle) ]. Past Medical History: Lower GIB [2123-12-13] - colonoscopy with diverticulosis and angioectasias Diabetes Type 2 - on insulin (last A1C unknown) Atrial fibrillation CAD s/p stent to RCA in [2104] and 2 bare metal stents to the LCx on [2123-11-23] Acute and Chronic Diastolic CHF (EF per records preserved but no records in our system) Benign Hypertension Pulmonary Hypertension Dyslipidemia Hypothyroidism (s/p thyroidectomy) Breast CA s/p b/l mastectomies and tamoxifen (Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 2036]) s/p breast reconstruction COPD Thrombocytopenia Recent ICU admission [10/2123] at OSH with staph aureus bacteremia Infected 3rd left toe [10/2123] . Cardiologist Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [Telephone/Fax (1) 108377] PCP: [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) 4768] [Last Name (NamePattern1) 5456] Social History: Social history is significant for the absence of current tobacco use; she quit smoking in [2106]. There is no history of alcohol abuse. Patient lives with her husband; she used to work in a candy factory. She currently uses a walker and has home PT and [Year (4 digits) 269]. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: ROS: GEN: - fevers, - Chills, - Weight Loss EYES: - Photophobia, - Visual Changes HEENT: - Oral/Gum bleeding CARDIAC: - Chest Pain, - Palpitations, - Edema GI: - Nausea, - Vomitting, - Diarhea, - Abdominal Pain, - Constipation, - Hematochezia PULM: - Dyspnea, - Cough, - Hemoptysis HEME: - Bleeding, - Lymphadenopathy GU: - Dysuria, - hematuria, - Incontinence SKIN: - Rash ENDO: - Heat/Cold Intolerance MSK: + Myalgia, + Arthralgia (hip), - Back Pain NEURO: - Numbness, - Weakness, - Vertigo, - Headache PHYSICAL EXAM: VSS: 97.1, 90/40, 77, 18, 94% GEN: NAD Pain: 0/10 HEENT: EOMI, MMM, - OP Lesions PUL: CTA B/L COR: RRR, S1/S2, - MRG ABD: NT/ND, +BS, - CVAT EXT: Trace LE Edema, Externally rotated Left leg, moderate echymosis Left knee DERM: CVS changes NEURO: CAOx1, Non-Focal ,CN II-XII intact, - Asterixis VASC: DP Pulses 1+ B/L Pertinent Results: [2125-5-29] 06:20AM BLOOD WBC-6.7 RBC-3.15* Hgb-10.1* Hct-30.3* MCV-96 MCH-32.1* MCHC-33.5 RDW-17.3* Plt Ct-76* [2125-5-28] 01:50PM BLOOD WBC-9.2# RBC-3.49* Hgb-10.7* Hct-32.3* MCV-93 MCH-30.7 MCHC-33.1 RDW-16.8* Plt Ct-98* [2125-5-29] 06:20AM BLOOD PT-13.5* PTT-29.2 INR(PT)-1.2* [2125-5-29] 06:20AM BLOOD Glucose-89 UreaN-37* Creat-2.2* Na-134 K-4.5 Cl-97 HCO3-24 AnGap-18 [2125-5-29] 06:20AM BLOOD CK(CPK)-33 [2125-5-28] 01:50PM BLOOD CK(CPK)-57 [2125-5-29] 06:20AM BLOOD CK-MB-NotDone cTropnT-0.04* [2125-5-28] 01:50PM BLOOD cTropnT-0.04* [2125-5-29] 06:20AM BLOOD Calcium-9.0 Phos-3.7 Mg-1.8 [2125-5-28] 03:30PM URINE Color-Yellow Appear-Hazy Sp [Last Name (un) ]-1.017 [2125-5-28] 03:30PM URINE Blood-SM Nitrite-NEG Protein-NEG Glucose-NEG Ketone-TR Bilirub-SM Urobiln-1 pH-6.5 Leuks-MOD [2125-5-28] 03:30PM URINE RBC-[3-22]* WBC->50 Bacteri-MANY Yeast-MANY Epi-0-2 TransE-0-2 CT C-SPINE W/O CONTRAST Study Date of [2125-5-28] 1:37 PM IMPRESSION: 1. No acute fracture or prevertebral soft tissue swelling. 2. Anterolisthesis at C6-C7 is of unknown chronicity in the lack of prior comparisons, though likely degenerative given presence of additional extensive degenerative change. If there is high concern for ligamentous injury, an MRI may be performed for further characterization. 3. Extensive cervical spondylosis, as described above, causing multilevel neural foraminal narrowing and moderate canal stenosis from C3 through C5, which predisposes the patient to cord injury. MRI should be considered for further evaluation of cord injury if clinically indicated. 4. Right pleural effusion. CT HEAD W/O CONTRAST Study Date of [2125-5-28] 1:37 PM IMPRESSION: No acute intracranial process. Final Attending Comment: There is a small hyperdense focus( 2:13) in the right frontal lobe which could represent a small acute bleed versus calcification.There is no significant edema. Findings conveyed to the clinical team. KNEE (AP, LAT & OBLIQUE) LEFT Study Date of [2125-5-28] 2:12 PM Intertrochanteric fracture of left proximal femur. Findings conveyed to the referring physician via [Name9 (PRE) ]. HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW) Study Date of [2125-5-28] 2:12 PM IMPRESSION: Intertrochanteric fracture of left proximal femur. Findings conveyed to the referring physician via [Name9 (PRE) ]. CHEST (PRE-OP AP ONLY) Study Date of [2125-5-28] 2:12 PM IMPRESSION: 1. Significant interval decrease in right-sided pleural effusion which is now small. No left pleural effusion. 2. Lucency at the right lung base may be related to loculated fluid, however, basilar pneumothorax cannot be excluded. Recommend followup radiograph for further evaluation. 3. Stable cardiomegaly and prominent main pulmonary artery suggestive of pulmonary hypertension. CHEST (SINGLE VIEW) Study Date of [2125-5-28] 6:42 PM FINDINGS: In comparison with the earlier study of this date, the degree of blunting of the right costophrenic angle consistent with a small right effusion is unchanged. Lucency at the right lung base again is suggestive of basilar pneumothorax. Progressive followup of this area is again suggested. Stable cardiomegaly with prominence of the central pulmonary arteries consistent with pulmonary arterial hypertension. Central catheter position is unchanged. Brief Hospital Course: 1. Intratrochanteric Femoral Fracture due to Fall in Bathroom Patient was evaluated by orthopedics in the ED and was scheduled for femur repair in OR. She was dialyzed first then sent to the OR. She underwent successful repair of her femur and post-op had a short stay in the ICU for hypotension but then was transferred to the floor without further complications. Patient required DVT prophylaxis after surgery however she was unable to receive heparin products given her history of HIT and could not be on fondaparinux given her renal disease so was started on argatroban gtt and bridged to coumadin. she should continued coumadin for ONLY ONE MONTH and then it should be discontinued. Given her increased risk of GIB and fall risk coumadin is not a good long term drug for her. 2. PREOPERATIVE CARDIAC ASSESSMENT : Patient was deemed to be at moderate risk by ESRD, CHF (Diastolic) which is compensated, Diabetes, Atrial Fibrillation for a intermediate risk procedure (ORIF). Patient was already beta-blocked with Nadolol. Patient is a type 2 diabetic, so could be off insulin during operation, however good glucose control post-operative was important for wound healing. Patient has a history of COPD, so used a prolonged I:E ratio to prevent air trapping. 3. Chronic Diastolic CHF - Chronic. Remained euvolemic throughout hospital course. 4. Bacterial UTI. Patient had positive UA on admission and h/o Klebsiella UTI in past that was sensitive to Cipro. She was started on ciprofloxacin [2125-5-28] and completed a 5-day course. 5. Pre-Existing Diabetic Heel Ulcer. Wound care consult obtained. Wound dressed appropriately. Should continue dressing per wound care recommendations. 6. Dementia, Acute Delerium. Patient appeared demented without diagnosis in the past, and as such there was the concern of an acute delerium as the precipitant of the fall. The UTI could be a preciptant as well. Geriatric consultation obtained. MSSE performed and scored 17. Geriatrics suggested outpatient initiation of donepezil for alzheimers/vascular dementia and this will be initiated by her PCP. 7. Cryptogenic Liver Cirrhosis, Esophageal Varices: Medications were hepatically dosed. 8. ESRD: Medications were renally dosed. Patient continued on HD Tues/Thurs/Sat. 9. Type 2 Diabetes Uncontrolled with Complications. Controlled with RISS 10. Benign Hypertension - Patient has a history of benign hypertension, but for the last 2 months has been intermittantly hypotensive, likely due to liver disease. BP was monitored carefully. Nadolol was held when necessary. No longer on any other anti-hypertensives. Patient is Full Code, confirmed with husband Medications on Admission: Prilosec 20mg daily Nadolol 20mg daily if BP>100 and not on dialysis days Synthroid 75mg daily Lipitor 20mg daily Acidophilus am and pm Folic Acid 800mg QAM Novolin sliding scale Discharge Medications: 1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Insulin Lispro 100 unit/mL Solution Sig: AS DIR Subcutaneous ASDIR (AS DIRECTED). 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours). 7. Oxycodone 5 mg/5 mL Solution Sig: Five (5) mg PO Q6H (every 6 hours) as needed for pain. 8. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM for 30 days. 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 11. Outpatient Lab Work Please draw INR 2 days after discharge and fax to physician at the facility and have him dose the coumadin appropriately. Goal is INR [2-20]. Discharge Disposition: Extended Care Facility: [First Name4 (NamePattern1) 533] [Last Name (NamePattern1) ] for Extended Care - [Location 1268] Discharge Diagnosis: Femur Fracture UTI ESRD on HD Discharge Condition: The patient was afebrile and hemodynamically stable. Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet You were admitted to the hospital with a broken hip. You had surgery to fix this. You also had a urinary tract infection. You were treated with antibiotics for this. Medication Changes: START: Coumadin 3mg daily for THIRTY DAYS Please come back to the hospital or call your doctor if you have fevers, chills, shortness of breath, palpitations, chest pain, abdominal pain, nausea, vomiting, pain with urinating, pain in your leg, dizziness, or any other concerning symptoms. Followup Instructions: Provider: [First Name11 (Name Pattern1) 1521] [Last Name (NamePattern1) 1522], [MD Number(3) 1240]:[Telephone/Fax (1) 2422] Date/Time:[2125-7-9] 11:50 Please follow up with your primary care doctor in [2-21] weeks. Completed by:[2125-6-1]	[ "585.6", "403.91", "244.0", "V58.67", "416.0", "427.31", "571.5", "V45.11", "414.01", "250.82", "496", "V45.82", "287.4", "E885.9", "272.4", "293.0", "428.0", "820.21", "599.0", "428.32", "707.14" ]	icd9cm	[ [ [] ] ]	[ "79.35", "39.95" ]	icd9pcs	[ [ [] ] ]	10861, 10996	6884, 9545	303, 336	11070, 11125	3494, 6861	11750, 12020	2540, 2622		9774, 10838	11017, 11049		9571, 9751			11149, 11417							3158, 3475															11437, 11727	243, 265								364, 1276													1298, 2222	2238, 2524
67,858	168,695	9497	Discharge summary	report	Admission Date: [2123-8-12] Discharge Date: [2123-8-21] Date of Birth: [2048-9-20] Sex: M Service: SURGERY Allergies: morphine Attending:[First Name3 (LF) 6088] Chief Complaint: wet gangrene of left foot Major Surgical or Invasive Procedure: Left first and second toe amputation, heel debridement Completion left TMA with closure History of Present Illness: 74M s/p R CFA/profunda endartarectomy and R CF-AKpop bypass graft with PTFE [4-/2122], L [Name (NI) 1793] PTA/stent [7-19], admitted with left first and second toe gangrene for IV antibiotics and debridement, likely amputation. Patient also has known left heel ulcer that is nonhealing. Past Medical History: -CAD s/p MI x2, PMHx: -paroxysmal afib -ESRD on HD (Tu/Th/Sa) since [10-17] -NSCLC s/p RUL lobectomy -Multiple bacteremia's and septicemia's over past 6mo per OMR. -DM -HTN -HL -PVD -hypothyroidism -GERD Vascular Hx: 1. [2122-4-9], right common femoral and profunda endarterectomy with vein patch. Right common femoral to above- knee popliteal bypass graft with 8-mm PTFE. 2. History of large right posterior heel ulcer, healed. 3. End-stage renal failure, on dialysis. Social History: Smoked heavily when he was younger, quit 25-30 years ago. Also admits to heavy drinking when he was young and in the service, but now only has an occasional beer or glass of wine. Denies illicit/recreational drugs. Family History: NC. Physical Exam: Admission: Vital Signs: Temp: 100 HR 68: BP: 128/72 RR: 12 Pulse Exam (P=Palpation, D=Dopplerable, N=None) RUE Radial: P. Ulnar: P. Brachial: P. LUE Radial: P. Ulnar: P. Brachial: P. RLE Femoral: P. DP: P. PT: P. LLE Femoral: P. DP: N. PT: P. DESCRIPTION OF WOUND: He has woody induration of the lower extremity. There are multiple areas of gangrene on the great toe and 2nd toe. foul odor to foot. cellulitis is noted, there is wetness between toes. There is a superficial blood blister on the plantar surface of the foot with a relatively large posterior heel ulcer. The heel ulcer has a mostly dry eschar without evidence of deep infection. The foot is ischemic. Discharge: Vital Signs: Temp:99.1 HR: 82 BP: 128/59 RR: 20 96% on 3L Pulses: RLE: Femoral P DP D PT D LLE: Femoral P DP D PT D L TMA site - closed with suture and intact, some periincisional edema and bruising, no purulent drainage, no erythema L heel ulcer - dry, no surrounding erythema or fluctuance, no warmth, VAC in place Pertinent Results: [2123-8-12] 09:05PM BLOOD WBC-5.3 RBC-4.07* Hgb-12.0* Hct-38.6* MCV-95 MCH-29.5 MCHC-31.1 RDW-18.6* Plt Ct-159 [2123-8-13] 11:07AM BLOOD WBC-7.4 RBC-4.10* Hgb-12.0* Hct-37.7* MCV-92 MCH-29.4 MCHC-31.9 RDW-18.2* Plt Ct-159 [2123-8-14] 07:55AM BLOOD WBC-5.8 RBC-3.88* Hgb-11.3* Hct-36.4* MCV-94 MCH-29.0 MCHC-31.0 RDW-18.0* Plt Ct-161 [2123-8-15] 06:47AM BLOOD WBC-5.7 RBC-3.74* Hgb-11.2* Hct-34.9* MCV-93 MCH-29.9 MCHC-32.1 RDW-17.8* Plt Ct-148* [2123-8-16] 11:51AM BLOOD WBC-5.5 RBC-3.67* Hgb-10.8* Hct-33.4* MCV-91 MCH-29.3 MCHC-32.2 RDW-17.8* Plt Ct-165 [2123-8-17] 06:45AM BLOOD WBC-5.3 RBC-3.70* Hgb-10.3* Hct-33.9* MCV-91 MCH-27.8 MCHC-30.4* RDW-17.5* Plt Ct-170 [2123-8-18] 07:05AM BLOOD WBC-5.8 RBC-3.53* Hgb-10.3* Hct-32.3* MCV-91 MCH-29.1 MCHC-31.8 RDW-17.4* Plt Ct-164 [2123-8-18] 01:29PM BLOOD WBC-4.5 RBC-3.50* Hgb-10.6* Hct-33.7* MCV-96 MCH-30.4 MCHC-31.6 RDW-17.8* Plt Ct-189 [2123-8-18] 04:22PM BLOOD WBC-4.5 RBC-3.16* Hgb-9.6* Hct-29.7* MCV-94 MCH-30.4 MCHC-32.4 RDW-17.9* Plt Ct-166 [2123-8-19] 02:14AM BLOOD WBC-4.9 RBC-3.04* Hgb-9.1* Hct-28.6* MCV-94 MCH-30.0 MCHC-31.9 RDW-17.8* Plt Ct-142* [2123-8-20] 07:20AM BLOOD WBC-6.1 RBC-3.25* Hgb-9.7* Hct-30.8* MCV-95 MCH-30.0 MCHC-31.6 RDW-17.5* Plt Ct-160 [2123-8-21] 07:40AM BLOOD WBC-5.3 RBC-3.04* Hgb-9.0* Hct-29.0* MCV-95 MCH-29.5 MCHC-31.0 RDW-17.3* Plt Ct-144* [2123-8-12] 09:05PM BLOOD Glucose-99 UreaN-35* Creat-4.5# Na-144 K-4.3 Cl-97 HCO3-35 AnGap-16 [2123-8-21] 07:40AM BLOOD Glucose-135* UreaN-32* Creat-4.1# Na-139 K-5.1 Cl-99 HCO3-32 AnGap-13 [2123-8-12] 09:05PM BLOOD Calcium-8.7 Phos-4.3# Mg-2.1 [2123-8-21] 07:40AM BLOOD Calcium-8.4 Phos-3.7 Mg-2.0 [2123-8-13] 8:12 pm SWAB 1ST AND 2ND TOES LEFT. FINAL REPORT [2123-8-22]* GRAM STAIN (Final [2123-8-13]): THIS IS A CORRECTED REPORT ([2123-8-14]). 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S). 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. . PREVIOUSLY REPORTED AS. 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S). 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS ([2123-8-13]). Reported to and read back by DR [Last Name (STitle) ] ([Numeric Identifier 32309]) [2123-8-14] AT 12:55PM. WOUND CULTURE (Final [2123-8-22]): 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.. WORKUP REQUESTED [2123-8-16] BY DR. [Last Name (STitle) ] 3-8862. PROTEUS VULGARIS. MODERATE GROWTH. Piperacillin/tazobactam sensitivity testing available on request. ENTEROCOCCUS SP.. SPARSE GROWTH. NON-FERMENTER, NOT PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. sensitivity testing performed by Microscan. RESISTANT TO Cefepime MIC >= 32 MCG/ML. SENSITIVE TO MEROPENEM MIC <= 1 MCG/ML. ENTEROCOCCUS SP.. QUANTITATION NOT AVAILABLE. SECOND MORPHOLOGY. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PROTEUS VULGARIS \| ENTEROCOCCUS SP. \| \| NON-FERMENTER, NOT PSEUDOMO \| \| \| ENTEROCOCCUS SP. \| \| \| \| AMIKACIN-------------- 16 S AMPICILLIN------------ <=2 S <=2 S CEFEPIME-------------- <=1 S R CEFTAZIDIME----------- <=1 S =>32 R CEFTRIAXONE----------- <=1 S =>64 R CIPROFLOXACIN---------<=0.25 S =>4 R GENTAMICIN------------ <=1 S 8 I IMIPENEM-------------- <=1 S LEVOFLOXACIN---------- 1 S <=1 S MEROPENEM-------------<=0.25 S S PENICILLIN G---------- 4 S 0.5 S PIPERACILLIN---------- =>128 R PIPERACILLIN/TAZO----- =>128 R TOBRAMYCIN------------ <=1 S 4 S TRIMETHOPRIM/SULFA---- <=1 S <=2 S VANCOMYCIN------------ 1 S 2 S Preop CXR [2123-8-17] HISTORY: Preoperative evaluation prior to toe amputation. FINDINGS: Upright frontal and lateral views of the chest show a moderately sized right pleural effusion. Given the unilaterally it is unlikely to be cardiac in origin despite the bilateral vascular congestion. Cardiac silhouette not enlarged. There are postoperative changes within the right hemithorax suggestive of prior right upper lobe resection. IMPRESSION: Moderate right pleural effusion as above. Postop CXR [2123-8-18] INDICATION: Assessment for fluid overload. COMPARISON: [2123-8-17]. FINDINGS: As compared to the previous radiograph, the pre-existing right pleural effusion has substantially increased. Effusion now occupies most of the right hemithorax and leads to substantial atelectasis as well as to mediastinal displacement towards the left. Unchanged appearance of the left lung. No focal parenchymal opacities in the ventilated lung areas. Repeat [2123-8-18] SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Followup right lung collapse. Comparison is made with prior study performed 3 hours earlier. There has been interval improvement of aeration in the right lung. The right lower lobe is still collapsed. There is new interstitial edema. There is no evident pneumothorax. There are no other interval changes. Cardiomediastinum is midline. Brief Hospital Course: 74M with significant medical history including DM, ESRD on HD, NSCLC s/p multiple radiation treatments, PVD s/p R CFA-AKpop bypass [2122], L [Name (NI) 1793] PTA/stent [7-19] presented with gangrene of the left first and second toes and chronic nonhealing left heel ulcer with a new foul odor. The patient was admitted from clinic and placed on vancomycin, cipro, and flagyl. Forefoot PVRs were performed showing that the metatarsal waveforms on the right are dampened but slightly improved compared to left. Moderate flow deficit to both forefeet, more severe on the left than on the right. He was continued on his regular hemodialysis schedule while an inpatient and nephrology followed his care daily. The patient underwent left first and second toe amputation and left heel debridement in the OR on [2123-8-13]. Initially wet to dry dressings were placed to the open amputation site as well as the heel. We transitioned the heel wound to VAC dressing on [2123-8-15] and placed multipodus boots bilaterally. The patient needed ongoing encouragement to keep lower extremities elevated and saturated his dressings from the open amputation site on multiple occurrenes, requiring reinforcement. Throughout the early hospital stay he had multiple low fingersticks requiring amps of glucose. [Last Name (un) ] evaluated the patient and recommended decreasing his lantus dose from 40 units to 20 units nightly and adding in a sliding scale. Podiatry was consulted on [2123-8-16] to follow the patient and help care for his heel wound. On [2123-8-18], the patient underwent completion of left TMA and closure of amputation site. The case required general anesthesia secondary to patient not tolerating MAC/LMA. Postoperatively he was extubated without difficulty although anesthesia noted an intraoperative episode of transient desaturation and hypotension which did not persist. The patient did have a wet cough immediately in the PACU and was agitated. A CXR was obtained to evaluate for fluid overload since the patient had received 900 cc of fluid intraoperatively in addition to missing his morning dialysis session. The CXR showed white out of the right lung consistent with R lung collapse. The patient has a known history of lung CA s/p radiation but this CXR was significantly different from his preoperative exam. Initially he did require increasing amounts of oxygen support and a 100% nonrebreather. He was transferred from the PACU to the ICU for bedside HD and consideration of intubation and bronchoscopy with suspicion for a mucous plugging event being the culprit for these findings. He was placed on BIPAP and monitored and aggressive chest PT was performed. He was never intubated or bronched. Serial CXRs were obtained and improved over the next 24-48 hours. He was transferred out of the ICU on [2123-8-19]. We continued to place a VAC to the left heel with dry dressings to the L TMA site after POD 1. The patient was seen by physical therapy who recommended rehab or home with PT. The patient and his family wanted to go home with services. The patient did struggle with intermittent, unpredictable anxiety and stress, at times improved with family presence, other times exacerbated by family presence. He did respond to bedside support by various members of the care team. We transitioned his antibiotics to IV vancomycin with HD and PO cipro/flagyl which he will continue until at least his follow up with Dr. [Last Name (STitle) ]. His respiratory status gradually improved and he was weaned down to 2-3 L NC which is his baseline at home. He was discharged to home on [2123-8-21] with plans for close follow up with Dr. [Last Name (STitle) ] and podiatry. Medications on Admission: allopurinol amlodipine calcium acetate clopidogrel [Plavix] hydralazine insulin glargine [Lantus Solostar] insulin lispro [Humalog] levothyroxine metoprolol succinate ranitidine HCl aspirin omega-3 fatty acids-vitamin E [Fish Oil] vitamin B comp & C no.3 [B Complex Plus Vitamin C] Discharge Medications: 1. [Hospital 485] hospital bed Dx: status post left transmetatarsal amputation with right lung collapse postoperatively, requiring oxygen 2. Lightweight wheelchair Dx: status post left transmetatarsal amputation, needs to be nonweightbearing on the left side 3. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain : no alcohol or driving when taking this medication. no more than 4000mg of tyenol in a day. Disp:40 Tablet(s) Refills:0 4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 weeks. Disp:14 Tablet(s) Refills:0 6. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 2 weeks. Disp:42 Tablet(s) Refills:0 7. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 8. amlodipine 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 9. calcium acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 10. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. hydralazine 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 15. omega-3 fatty acids Capsule Sig: One (1) Capsule PO BID (2 times a day). 16. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 17. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 18. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:60 Tablet(s) Refills:0 19. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. Disp:500 ML(s) Refills:0 20. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: One (1) Inhalation every six (6) hours as needed for shortness of breath or wheezing. Disp:qs qs Refills:0 21. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) per HD protocol Intravenous HD PROTOCOL (HD Protochol): For 2 weeks, during dialysis, per protocol. Disp:qs per HD protocol Refills:2 22. Lantus 100 unit/mL Solution Sig: One (1) 20 units Subcutaneous at bedtime. 23. Humalog Subcutaneous Discharge Disposition: Home With Service Facility: VNA East inc Discharge Diagnosis: peripheral vascular disease, status post left TMA Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Full weight-bearing on right leg only. Discharge Instructions: This information is designed as a guideline to assist you in a speedy recovery from your surgery. Please follow these guidelines unless your physician has specifically instructed you otherwise. Please call our office nurse if you have any questions. Dial 911 if you have any medical emergency. . ACTIVITY: . There are restrictions on activity. On the side of your amputation you are non weight bearing until cleared by your Surgeon. You should keep this amputation site elevated when ever possible. . You may use the other leg to assist in transferring and pivots. But try not to exert to much pressure on the amputation site when transferring and or pivoting. Please keep knee immobilizer on at all times to help keep the amputation site straight. . No driving until cleared by your Surgeon. . Exercise: . Limit strenuous activity for 6 weeks. . Do not drive a car unless cleared by your Surgeon. . Try to keep leg elevated when able. . BATHING/SHOWERING: . You may shower immediately upon coming home. No bathing. A dressing may cover you??????re amputation site and this should be left in place for three (3) days. Remove it after this time and wash your incision(s) gently with soap and water. You will have sutures, which are usually removed in 4 weeks. This will be done by the Surgeon on your follow-up appointment. . WOUND CARE: . Sutures / Staples may be removed before discharge. If they are not, an appointment will be made for you to return for staple removal. . When the sutures are removed the doctor may or may not place pieces of tape called steri-strips over the incision. These will stay on about a week and you may shower with them on. If these do not fall off after 10 days, you may peel them off with warm water and soap in the shower. . Avoid taking a tub bath, swimming, or soaking in a hot tub for four weeks after surgery. . MEDICATIONS: . Unless told otherwise you should resume taking all of the medications you were taking before surgery. You will be given a new prescription for pain medication, which can be taken every three (3) to four (4) hours only if necessary. . Remember that narcotic pain meds can be constipating and you should increase the fluid and bulk foods in your diet. (Check with your physician if you have fluid restrictions.) If you feel that you are constipated, do not strain at the toilet. You may use over the counter Metamucil or Milk of Magnesia. Appetite suppression may occur; this will improve with time. Eat small balanced meals throughout the day. . CAUTIONS: . NO SMOKING! We know you've heard this before, but it really is an important step to your recovery. Smoking causes narrowing of your blood vessels which in turn decreases circulation. If you smoke you will need to stop as soon as possible. Ask your nurse or doctor for information on smoking cessation. . Avoid pressure to your amputation site. . No strenuous activity for 6 weeks after surgery. . DIET : . There are no special restrictions on your diet postoperatively. Poor appetite is expected for several weeks and small, frequent meals may be preferred. . For people with vascular problems we would recommend a cholesterol lowering diet: Follow a diet low in total fat and low in saturated fat and in cholesterol to improve lipid profile in your blood. Additionally, some people see a reduction in serum cholesterol by reducing dietary cholesterol. Since a reduction in dietary cholesterol is not harmful, we suggest that most people reduce dietary fat, saturated fat and cholesterol to decrease total cholesterol and LDL (Low Density Lipoprotein-the bad cholesterol). Exercise will increase your HDL (High Density Lipoprotein-the good cholesterol) and with your doctor's permission, is typically recommended. You may be self-referred or get a referral from your doctor. . If you are overweight, you need to think about starting a weight management program. Your health and its improvement depend on it. We know that making changes in your lifestyle will not be easy, and it will require a whole new set of habits and a new attitude. If interested you can may be self-referred or can get a referral from your doctor. . If you have diabetes and would like additional guidance, you may request a referral from your doctor. . FOLLOW-UP APPOINTMENT: . Be sure to keep your medical appointments. The key to your improving health will be to keep a tight reign on any of the chronic medical conditions that you have. Things like high blood pressure, diabetes, and high cholesterol are major villains to the blood vessels. Don't let them go untreated! . Please call the office on the first working day after your discharge from the hospital to schedule a follow-up visit. This should be scheduled on the calendar for seven to fourteen days after discharge. Normal office hours are 8:30-5:30 Monday through Friday. . PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR QUESTIONS THAT MIGHT ARISE VAC Instructions: * Please keep an accurate recording of the consistency and quantity of the vacuum-assisted device output and bring this log to your follow-up appointment for your surgeon to review. * If you notice any leaking of the vacuum dressing, apply tegaderm dressings as needed for reinforcement to promote further suction and prevent air leak. * Change VAC dressing every 3 days and monitor wound for granulation, fibrinous exudate or purulence. Apply new VAC sponge dressing every 3 days following wound evaluation. * Please leave VAC suction setting at -125 mmHg, continuous suction. * Please bring VAC sponge dressing supplies to your follow-up appointment with your surgeon. Followup Instructions: Please call Dr [Last Name (STitle) 32310] office for a follow-up appointment in [1-10] weeks. Please follow up with your podiatrist at [Hospital1 18]. Please call and arrange a follow up appointment with your primary care physician in about 1 week. Completed by:[2123-8-31]	[ "403.91", "300.00", "730.07", "E912", "530.81", "518.0", "682.7", "250.40", "438.10", "162.9", "933.1", "412", "041.04", "V45.11", "250.60", "E915", "250.70", "707.14", "440.24", "041.6", "285.21", "585.6", "427.31", "458.29", "357.2", "244.9", "730.17", "250.80" ]	icd9cm	[ [ [] ] ]	[ "86.22", "84.11", "93.90", "39.95", "84.12" ]	icd9pcs	[ [ [] ] ]	15437, 15480	8718, 12450	294, 384	15574, 15574	2511, 8695	21435, 21729	1465, 1470		12783, 15414	15501, 15553		12476, 12760			15796, 17121							1485, 2492																229, 256					17133, 20045	20068, 21412		412, 712								15589, 15772					734, 1216	1232, 1449
22,025	132,006	27159+57527	Discharge summary	report+addendum	Admission Date: [2191-6-7] Discharge Date: [2191-6-24] Date of Birth: [2122-2-20] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2159] Chief Complaint: Pt originally transferred [2191-6-7] from [Hospital3 25148] in NH to MICU for management of respiratory failure, hemodynamic instability, pericardial tamponade, ?adrenal hemorrhage. Transferred to medical floor on [2191-6-14]. Major Surgical or Invasive Procedure: Pericardiocentesis [2191-6-8] History of Present Illness: 69F transferred on [2191-6-7] from [Hospital3 25148] in NH to MICU for management of respiratory failure, hemodynamic instability, pericardial tamponade, and ?adrenal hemorrhage. Pt had been at [Hospital1 ] for evaluation/tx of chest pain on [2191-5-17]. She had negative MIBI on [5-18], and later in her hospital stay developed worsening CP and was found to have pericardial effusion on echo. She began to develop pericardial tamponade, resp failure, and hypotension with a question of adrenal hemorrhage, and was transferred to [Hospital1 18] for further management on [2191-6-7]. . At [Hospital1 18] the pt underwent cardiac cath on [6-8] for pericardiocentesis. She also had an elevated WBC count to 79.8 with 99% neutrophils. CT scan showed colitis and she was continued on antibiotics while C.diff Cx were sent. Despite the unclear etiology of her cardiac tamponade and sepsis-like physiology, the patient's hemodynamic status improved over the course of the next two days. In the afternoon of [6-11], the patient self-extubated; following extubation her ABG was 7.40/138/75. Over the course of the evening and following day [6-12], she was intermittently agitated, crying out to/naming people not in the room, and was unable to follow commands or recall her name. Since that time the pt has been followed by Psychiatry, receiving Valium and now Haldol, with improving mental status / decreasing agitation. HD status has been improving, though with somewhat labile BPs. Pulmonary status improving with reduced O2 requirements. Past Medical History: CAD (s/p cardiac cath [2190] w/ RCA stent; EF 56%) AF-RVR myelodysplastic syndrome/chronic anemia sigmoid diverticulosis duodenal lipoma dementia of unknown duration anxiety major depression s/p cholecystectomy s/p hernia repair Social History: Pt lives in nursing home, denies EtOH, smoking. At baseline, ambulates with walker w/o assistance. Family History: non-contributory Physical Exam: VS: T 96.7 HR 89 BP 150/76 RR 23 O2 95% on 5L NC Gen: NAD, in arm restraints, looking around room, able to converse HEENT: o/p clear, poor dentition, no bleeding gums, anticteric sclerae CV: RRR S1 S2 no murmurs appreciated, JVP slight elevation Pulm: b/l crackles, distant BS Abd: soft NT ND +BS Extrem: 1+ pitting edema to ankles/shins Neuro: alert, oriented x 1, able to carry on partial conversation, sometimes distracted. Motor nonfocal on limited exam [3-10] uncooperative. No focal weakness Pertinent Results: [2191-6-7] 10:45PM FIBRINOGE-782* [2191-6-7] 10:45PM PT-15.9* PTT-34.8 INR(PT)-1.5* [2191-6-7] 10:45PM PLT COUNT-450* [2191-6-7] 10:45PM WBC-64.8* RBC-3.60* HGB-10.6* HCT-32.1* MCV-89 MCH-29.4 MCHC-32.9 RDW-16.7* [2191-6-7] 10:45PM NEUTS-86* BANDS-6* LYMPHS-5* MONOS-2 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 OTHER-1* [2191-6-7] 10:45PM IgG-1194 [2191-6-7] 10:45PM CORTISOL-85.4* [2191-6-7] 10:45PM TSH-3.0 [2191-6-7] 10:45PM ALBUMIN-2.8* CALCIUM-9.6 PHOSPHATE-5.0* MAGNESIUM-1.9 URIC ACID-6.2* [2191-6-7] 10:45PM CK-MB-NotDone cTropnT-<0.01 [2191-6-7] 10:45PM LIPASE-33 [2191-6-7] 10:45PM ALT(SGPT)-48* AST(SGOT)-48* LD(LDH)-277* CK(CPK)-34 ALK PHOS-114 AMYLASE-155* TOT BILI-1.0 [2191-6-7] 10:45PM GLUCOSE-160* UREA N-24* CREAT-1.1 SODIUM-132* POTASSIUM-4.3 CHLORIDE-94* TOTAL CO2-19* ANION GAP-23* [2191-6-7] 11:29PM freeCa-1.25 [2191-6-7] 11:29PM LACTATE-3.3* [2191-6-7] 11:29PM TYPE-ART TEMP-37.6 RATES-[1-17] TIDAL VOL-500 PEEP-5 O2-100 PO2-153* PCO2-33* PH-7.36 TOTAL CO2-19* BASE XS--5 AADO2-544 REQ O2-88 -ASSIST/CON INTUBATED-INTUBATED [2191-6-7] 11:42PM URINE COLOR-Amber APPEAR-Clear SP [Last Name (un) 155]-1.044* [2191-6-7] 11:42PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-8* PH-6.0 LEUK-NEG [2191-6-7] 11:42PM URINE RBC-[4-10]* WBC-[4-10] BACTERIA-FEW YEAST-NONE EPI-<1 RENAL EPI-[4-10] [2191-6-7] 11:50PM HGB-8.9* calcHCT-27 O2 SAT-42 Brief Hospital Course: 69W w/MDS admitted to OSH [5-17] with her usual complaint of chest pain at ECF which was relieved with ntg in OSH ED. She was anemic w/hct 25.4. Her hospital course was notable for dementia. CTA showed large pericardial efussion w/?adrenal hemorrhage. Also of note, her WBC increased from Bl of 1.9 to 42.5 this AM and to 64.4 at time of xfer. She had negative MIBI [5-18]. . Pt nods her head to indicate lack of pain, lack of SOB. . PMH: MDS major depression personality do anxiety do Fe deficiency anemia sigmoid diverticulosis Duodenal lipoma . Home meds: Singularir 10mg PO QD Lipitor 80mg QD Plavix 75mg PO QD Altace 5mg QD Effexor 150mg QD Alprazolam .5mg [Hospital1 ] . Meds on xfer: Troprol 50mg QD Altace 5mg QD Effexor 150mg QD Clinda 900mg QD Ambien 5mg QD Fentanyl Hydrocrt 200 mg X 1 on [6-7] Vanco 1g on [6-7] levoquin 500 mg on [6-7] Lexapro 10mg QD Morphine Nitrostat Phenergan Risperdal .5mg QD Midazolam Imipenim/Cilastin [6-7] Tylenol MOM [Name (NI) 66646] [Name (NI) ] Folic acid Combivent . SH: Obtained from OSH records. Lives in nursing home. At bl ambulates w/walker w/o assistance. Denies smoking or current EtOH use. . PE 99.5 SR104 101/52 27 94% on AC 500X14 w/fio2 1 and PEEP Intubated, not sedated, not in distress Coarse BS Cardiac sounds difficult to ascultate over BS Soft, tender in LUQ, palpable spleen tip, +BS Cool LEs; warm UEs Responding to commands; answers yes/no questions; moving all 4 ext . Smear- Elevated WBC consists mostly of segs and bands. Rare metamyelocytes and atypical lymphocytes seen. No blast forms noted. . CXR: ETT in place. R subclav line at junction of SVC and R atria. Bil pleural efussions, R>>L. Cannot exclude infiltrates in bil LLs. . Labs: See end of note . ECG: SR @ 108 w/diffuse ST elevations and PR depression in I c/w pericarditis. . Bedside echo: Grossly nl LV wall motion. No RVD collapse. ?under-filling of LV. . [6-12]. A/P: 69W w/MDS, hypotension, pericardial efussion, pleural efussions, and elevated WBC count with transverse colitis . #hypoxic resp insufficiency. Pt. w/ pneumonia/atelectasis as likely precipitant. ?ARDS. Pt. self extubated 2 nights ago. - Check ABG - Check CXR today - Cont IV abx. Cont Zosyn/Flagyl for pneumonia . Hypotension-resolved, due to sepsis and tamponade, s/p pericardiocentesis with transient improvement. source of infxn: abd vs lung -cont IV abx to cover cdiff. (zosyn/flagyl) -keeps MAPs>60s, gently diurese (total body overloaded) -TTE: effusion stable . HTN - pt. w/ increased bps throughout the night - worse w/ agitation. Pt. not tolerating home bp meds so will continue IV lopressor. Will increase this dose . Infx: colitis on CT. cdiff spec pending (x3)- so far negative, but 1 specimen is pending . Elevated WBC- acute leukemic process unlikely. WBC elevation likely a leukemoid rxn [3-10] infection, likely cdiff. This is resolving -cont to trend . FEN- NPO for now. On TFs. Repleting lytes. . Code- presumed full . Dispo- ICU . Access- PIV, TLC, Will d/c A-line b/c pt. pulling at it and pt. doing well after extubation . Psych - pt. w/ depression, ? bipolar - re-started some of pt's home meds, but she will not consistently take these meds by mouth - consider psych consult . Dispo - pt. not requiring ICU care so can consider call out to the floor w/ a sitter. ------------ [2191-6-14] update: At [Hospital1 18] the pt underwent cardiac cath on [6-8] for pericardiocentesis. She also had an elevated WBC count to 79.8 with 99% neutrophils. CT scan showed colitis and she was continued on antibiotics while C.diff Cx were sent. Despite the unclear etiology of her cardiac tamponade and sepsis-like physiology, the patient's hemodynamic status improved over the course of the next two days. In the afternoon of [6-11], the patient self-extubated; following extubation her ABG was 7.40/138/75. Over the course of the evening and following day [6-12], she was intermittently agitated, crying out to/naming people not in the room, and was unable to follow commands or recall her name. Since that time the pt has been followed by Psychiatry, receiving Valium and now Haldol, with improving mental status / decreasing agitation. HD status has been improving, though with somewhat labile BPs. Pulmonary status improving with reduced O2 requirements. Other issues discussed below. . LABS: CBC: WBC 14.0 (peak 79.8 on [6-8]); Hct 25.8; Plt 342 Chem10: Na 146 K 3.1 Cl 106 CO2 28 BUN 14 Cr 0.5 Glu 116 Ca 8.3 Mg 1.9 P 2.5 LFTs: ALT 34 / AST 33 / AP 80 / TBili 0.5 / [Doctor First Name ] 205 / Lip 901 ([6-14]) Other: Lactate 1.6 ([6-13]); B12 875; folate 4.3; TSH 3.0 U/A: [6-14]: SF 1.014, sm bld, ket 15, 0-2 RBC, 0-2 WBC Cultures: BCx pnd UCx (+) streptococcus pericardial fluid Cx neg C.diff Cx neg x 3, toxin B pnd . . Update [2191-6-21]: . A/P: 69F w/ CAD, MDS, dementia who was admitted [6-7] for pericardial tamponade, HD instability, respiratory failure, now s/p pericardiocentesis [6-8] and transferred out of MICU [6-14]. . ## Anemia. Mild fluctuations in Hct that has persistently on low side since transfer to medical floor. Hct of 23.2 on [6-19] and guaiac pos, increase to > 25 by [6-20] without intervention, and again on low end at 23.8 on [6-21]. Always asymptomatic. Unclear source; did have pan-colitis on colonoscopy earlier in stay, no clinical sx and C diff neg x 3, awaiting C diff toxin B, on Flagyl. Has Iron studies c/w ACD. Pt is typed and crossed, consented for blood if necessary. GI was aware of case, did not feel need for intervention. . ##. Pancreatitis. Pain in epigastrium [6-15], somewhat tender exam, non-surgical, with high amylase and lipase. Pain/tenderness absent [6-16] after being NPO/IVF/d/c Flagyl. Improving amylase and lipase since [6-17]. Possibly secondary to Flagyl. Now with no pain, no tenderness on exam. Advanced diet from clears to sips, now to full liquids. Written for morphine, anzemet PRN in house. . ##. Leukocytosis. Resolved from ~80 down to WNL since admission, with increase to 27 on [6-19], afebrile. Presumed leukomoid / septic reaction. Increase on [6-19] possibly [3-10] C diff since switched off Flagyl to Vanco for pancreatitis. WBC down to WNL x 2 days at time of discharge, afebrile. On Flagyl. Pending blood ctx, C diff toxin B. . ##. Arrhythmia. Tachycardic intermittently, with one 'trigger' event of tachycardia to 160, pt felt a chest flutter, no chest pain or pressure, resolved with already-scheduled Metoprolol dose. EKG showing MAT vs. WAP, not necessarily AF-RVR. Continue on Metoprolol, now po, increased to 50 tid on [6-19]. . ##. Hypoxia/Pulmonary. CXR [6-15] w/ continued mild/moderate pulmonary edema / effusions, no focal process. On Lasix for several days to diurese, currently with much reduced crackles on exam, off Lasix. Improved O2 requirement since admission. PNA is less likely currently. Afebrile. Off of oxygen. . ##. Pericarditis. S/p percardiocentesis [6-8], with unclear etiology. No residual tamponade/effusion physiology since transfer to the medical floor. Idiopathic/viral/autoimmune as likely etiologies but uncertain. CMV negative, parvovirus negative, with pending mycoplasma serologies, urine histo, adeno stool ctx. With mild b/l upper extremity weakness, mild RF elevation, consider outpatient Rheum evaluation . ##. Blood Pressure. SBPs initially fluctuating coming out of the MICU, then with many days stable blood pressure. On Metoprolol for rate control, which may help BP. . ##. Colitis. With diarrhea and guaiac positive stool originally, colonoscopy showed ascending, transverse, and descending colon involvement with sigmoid sparing. Presumed infectious vs. ischemic etiologies most likely, with recent antibiotic use but also recent hypotensive episodes. Stable for several days, with one guaiac positive stool on [6-19] and no frank blood, Hct stable but low, around 23-27. C diff negative x 4, with toxin B result still pending at time off discharge. On Flagyl from [Date range (1) 17430], with brief switch to Vanco for ? pancreatitis etiology from [Date range (1) 66647], then back to Flagyl since [6-18] when WBC increased when pt was off Flagyl. Now [6-21] has completed Flagyl therapy. . ##. Mental status. Pt has an unclear history of some baseline dementia. In the ICU, the patient became agitated with delirium requiring Haldol, restraints, and a sitter. On the medical floor, her agitation resolved each day and her IV Haldol [Hospital1 ] was reduced to po Haldol qhs on [6-19], still with improving mental status. A head CT showed a non-acute left basal ganglia lacune and probable older multi-infarct/ischemia-related changes, no acute bleed or change seen to explain delirium. Likely sepsis-related delirium. Psychiatry and Neurology teams were consulted during her stay to guide care. Neurology commented that delirium should improve daily, and noted unrelated mild b/l upper extremity weakness, and said to consider cervical MRI at some point if further workup of the UE weakness was indicated. . ##. DM. Pt received RISS while in house. . ##. FEN. Pt's diet was switched to IVF / NPO for 2-3 days during her pancreatic enzyme elevation and abdominal pain/tenderness, then advanced to sips to clears and currently to full liquids on discharge, with pancreatic enzymes trending down and no clinical signs of pancreatitis. The Nutrition service has left recommendations regarding nutrition goals. . ##. PPx. Pt had heparin SC and bowel regimen PRN in house. . ##. Access. Pt pulled out central line on [6-20], no complications, has peripheral IV . ##. Code. Presumed full. Guardianship now established: [Name (NI) 5969] and R- [Known lastname 11679]. Medications on Admission: HOME MEDS: [Known lastname ] 10mg qd Lipitor 80mg qd Plavix 75mg qd Altace 5mg qd Effexor 150mg qd Alprazolam 0.5mg [Hospital1 ] . MEDICATIONS ON TRANSFER: Toprol 50mg QD Altace 5mg QD Effexor 150mg QD Clindamycin 900mg QD Ambien 5mg QD Fentanyl Vancomycin 1g on [6-7] Hydrocortisone 200mg x1 on [6-7] Levoquin 500mg on [6-7] Lexapro 10mg QD Morphine Nitrostat Phenergan Risperdal 0.5mg QD Midazolam Imipenim/Cilastin [6-7] Tylenol MOM [Name (NI) ] [Name (NI) ] Folic acid Combivent Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day) as needed. 5. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR (AS DIRECTED). 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. Haloperidol 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. 9. Haloperidol Lactate 5 mg/mL Solution Sig: One (1) Injection Q4H (every 4 hours) as needed. 10. Dolasetron 12.5 mg/0.625 mL Solution Sig: One (1) Intravenous Q8H (every 8 hours) as needed for n/v. 11. Morphine 2 mg/mL Syringe Sig: One (1) Injection Q4-6H (every 4 to 6 hours) as needed for abdominal pain. Discharge Disposition: Extended Care Facility: [Hospital 3145] Nursing Home - [Location (un) 3146] Discharge Diagnosis: Pericardial tamponade Coronary artery disease Atrial fibrillation with rapid ventricular response Myelodysplastic syndrome Sigmoid diverticulosis Colitis Anemia Pancreatitis Respiratory failure Dementia Major depression Discharge Condition: Stable. Discharge Instructions: Please go to the Emergency Department if you experience chest pain, persistent racing heartbeat, chest flutter, shortness of breath, new confusion, new weakness, slurred speech, blurry vision, bloody stools, severe abdominal pain, nausea/vomiting, or any other concerning symptom. You have come to [Hospital1 18] and had fluid drained from around your heart, with breathing problems and a probable infection that have been gradually resolving. You should continue to take all medications as prescribed. You have been started on some new medications. Please take Metoprolol for control of your heart rate and heart rhythm, folic acid for cardiovascular health, insulin as needed for blood sugar control, and Haldol for agitation. Followup Instructions: You are going from the [Hospital1 18] to a rehabilitation center. You should follow up with your primary care doctor in the next 1 week to discuss your recent hospitalization. Please be sure to discuss the management of your atrial fibrillation, your pericarditis, and your colitis, all of which are currently under control. Also please discuss with your primary care doctor the possibility of seeing a rheumatologist for your upper extremity bilateral weakness in the context of your recent hospital course. You can also discuss whether to get a cervical spine MRI to evaluate this weakness. Completed by:[2191-6-21] Name: [Known lastname ],[Known firstname ] C. Unit No: [Numeric Identifier 11591] Admission Date: [2191-6-7] Discharge Date: [2191-6-24] Date of Birth: [2122-2-20] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4143] Addendum: Patient waited several days for a [Hospital1 1354] bed to become available. In the meantime her HCT slowly declined to 22. She was transfused 2units of PRBCs on [2191-6-23] and her post-transfusion HCT was 29. Etiology of her anemia is felt to be a slow, resolving GIB related to her resolving episode of ischemic colitis. She has remained hemodynamically stable throughout. Additionally she was started on a PPI. Discharge Disposition: Extended Care Facility: [Hospital 3743] Nursing Home - [Location (un) 3744] [Name6 (MD) ] [Name8 (MD) 4144] MD [MD Number(2) 4145] Completed by:[2191-6-24]	[ "401.9", "557.9", "276.8", "577.0", "785.52", "578.9", "428.0", "414.01", "290.41", "518.81", "427.31", "238.7", "420.90", "427.89", "038.9", "296.20", "V63.2", "300.00", "263.9", "437.0", "995.92", "280.8" ]	icd9cm	[ [ [] ] ]	[ "38.93", "96.71", "00.17", "37.21", "99.04", "37.0" ]	icd9pcs	[ [ [] ] ]	18760, 18971	4702, 14586	553, 588	16502, 16512	3149, 4679	17297, 18737	2588, 2606		15152, 16129	16259, 16481		14612, 14751			16536, 17274							2621, 3130																275, 515								616, 2200												14776, 15129	2222, 2456	2472, 2572
31,589	125,212	1244	Discharge summary	report	Admission Date: [2171-6-14] Discharge Date: [2171-6-18] Date of Birth: [2110-3-6] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1406] Chief Complaint: Chest pain, dyspnea Major Surgical or Invasive Procedure: [2171-6-14]: Coronary artery bypass grafting x4 with the left internal mammary artery to the left anterior descending artery and reverse saphenous vein graft to the distal right coronary artery, obtuse marginal artery and a high diagonal artery. History of Present Illness: 61 year old M with PMH significant for hypertension, known CAD s/p RCA and LAD BMS in [2169] who presented to cardiologist with complaints of dyspnea with rest and exertion and exertional substernal chest pain daily. Stress echo was abnormal and he presents today for cardiac catheterization which revealed 3 vessel coronary artery disease. Cardiac surgery was asked to evaluate for surgical revascularization. Past Medical History: Hypertension Crohn's Disease GERD Social History: He is married and lives with his wife. [Name (NI) ] is self-employed as a consultant to food wholesale retailers. He quit smoking >30 years ago. He drinks socially. Family History: There is no family history of sudden cardiac death. He has a half-brother who suffered an MI in his 60's. His mother had a pacemaker placed in her 70's for unclear reasons. Physical Exam: Pulse:77 Resp:18 O2 sat: 100% RA B/P Right:159/94 Left: 173/83 Height:5'6" Weight:157 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [] EOMI [x] Neck: Supple [x] Full ROM [] cervical disc disease Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur II/VI SEM @LUSB Abdomen: Soft non-distended non-tender [x] Extremities: Warm well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: nd Left: nd DP Right: 2+ Left: 2+ PT [Name (NI) 167]: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit Right: - Left: - Pertinent Results: [2171-6-17] 04:50AM BLOOD Hct-26.8* [2171-6-16] 06:00AM BLOOD WBC-10.5 RBC-3.04* Hgb-9.3* Hct-27.3* MCV-90 MCH-30.5 MCHC-34.0 RDW-13.3 Plt Ct-184 [2171-6-17] 04:50AM BLOOD UreaN-17 Creat-0.9 K-4.1 [2171-6-16] 06:00AM BLOOD Glucose-131* UreaN-23* Creat-1.1 Na-139 K-4.5 Cl-105 HCO3-29 AnGap-10 [2171-6-14]; Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Post-CPB: The patient is AV-Paced, on low dose phenylephrine. Normal biventricular systolic fxn. No AI. MR is now trace - 1+. Aorta intact. Brief Hospital Course: The patient was admitted to the hospital and brought to the operating room on [2171-6-14] where the patient underwent Coronary artery bypass grafting x4 with the left internal mammary artery to the left anterior descending artery and reverse saphenous vein graft to the distal right coronary artery, obtuse marginal artery and a high diagonal artery. 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. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. Percocet was discontinued and Ultram started for pain due to confusion and hallucinations. 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 VNA services in good condition with appropriate follow up instructions. Medications on Admission: ASA 325mg po daily Quinapril 40mg po daily Pravastatin 20mg po daily Mesalamine 250mg capsule, 4 capsules po BID Cyanocobalamin 1000mcg/mL- 1 injection monthly Plavix - last dose:600mg [2171-6-7] Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:100 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 4. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:0 5. Mesalamine 250 mg Capsule, Sustained Release Sig: Four (4) Capsule, Sustained Release PO BID (2 times a day). Disp:240 Capsule, Sustained Release(s) Refills:0 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/temp. 7. Sodium Chloride 0.65 % Aerosol, Spray Sig: [1-26] Sprays Nasal QID (4 times a day) as needed for congestion. 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:0 9. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: tba Discharge Diagnosis: Coronary Artery Disease Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Ultram as needed Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. No 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 until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] 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: Dt. [Doctor Last Name ] Wed [7-17] at 1:45 PM Please call to schedule appointments with your Primary Care Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 7774] in [1-26] weeks Cardiologist Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in [1-26] 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:[2171-6-18]	[ "530.81", "401.9", "V58.66", "293.0", "414.01", "555.9" ]	icd9cm	[ [ [] ] ]	[ "36.13", "39.61", "36.15" ]	icd9pcs	[ [ [] ] ]	5846, 5880	3087, 4469	341, 593	5947, 6172	2141, 3064	6927, 7488	1301, 1477		4721, 5823	5901, 5926		4495, 4698			6196, 6904							1492, 2122																281, 303								621, 1038													1060, 1095	1111, 1285
44,490	157,694	3775	Discharge summary	report	Admission Date: [2166-2-13] Discharge Date: [2166-2-19] Date of Birth: [2111-10-10] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 922] Chief Complaint: bacteremia/endocarditis Major Surgical or Invasive Procedure: [2166-2-13] 1. Aortic valve replacement with a 25-mm On-X mechanical valve. 2. Aortic root reconstruction with a bovine pericardial patch. 3. Replacement of the ascending aorta with a 28 mm Vascutech Dacron tube graft. 4. Limited concomitant Maze procedure with pulmonary vein isolation bilaterally using the AtriCure synergy system with resection of left atrial appendage. History of Present Illness: 54 year old male with a history of aortic stenosis and aortic arch aneurysm, who was admitted for fevers, myalgia and positive blood cultures. Pt has had symptoms since [Holiday 1451] which PCP felt was viral. Had worsening of symptoms and wasd started on Tamiflu and blood cultures drawan. Sent to ED from PCP for positive blood culutres. ECHO revealed vegetation on aortic valve. Now consulted for surgical intervention of AS/AI and endocarditis Past Medical History: -Aortic stenosis, followed by Dr. [Last Name (STitle) 911] [Name (STitle) 16974] arch aneurysm -Tinnitis -Diplopia -Depression -Catarcts -Hernia repair -Root canal -Dental work consisting of bridge placement in right upper molars, multiple filling of caries done in [2163] Social History: Currently works by renovating his building. He admits to drinking 1 glass of wine or beer a night, approximately 5 times per week. He denies any illicit drug use or tobacco use. He traveled to [Country 6257] and [Country 12649] in [Month (only) ] and [Month (only) ]. Lives with his male partner. Was HIV negative and PPD negative several years ago, but has not been tested since. Family History: Non-Contributory Physical Exam: Physical Exam Pulse: 65 Resp:18 O2 sat: 97 RA B/P 120/70 Height:6ft 1 in Weight:175 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur III/VI SEM Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: +2 Left: +2 DP Right: +2 Left: +2 PT [Name (NI) 167]: +2 Left: +2 Radial Right: +2 Left: +2 Carotid Bruit Right/Left: transmitted murmur Pertinent Results: [2166-2-18] 06:40AM BLOOD Hct-28.2* [2166-2-17] 07:55AM BLOOD WBC-7.3 RBC-2.84* Hgb-8.2* Hct-24.1* MCV-85 MCH-28.9 MCHC-34.0 RDW-14.4 Plt Ct-226 [2166-2-19] 05:20AM BLOOD PT-23.5* PTT-34.4 INR(PT)-2.2* [2166-2-18] 06:40AM BLOOD Glucose-105* UreaN-13 Creat-1.2 Na-141 K-4.5 Cl-102 HCO3-31 AnGap-13 [2166-2-18] 06:40AM BLOOD Mg-2.1 PRE-BYPASS: 1. The left atrium is markedly dilated. No spontaneous echo contrast is seen in the left atrial appendage. No thrombus is seen in the left atrial appendage. 2. A patent foramen ovale is present. A left-to-right shunt across the interatrial septum is seen at rest. 3. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). 4. Right ventricular chamber size and free wall motion are normal. 5. The aortic root is moderately dilated at the sinus level. There are complex (>4mm) atheroma in the aortic root. The ascending aorta is moderately dilated. There are simple atheroma in the ascending aorta. The descending thoracic aorta is mildly dilated. 6. The aortic valve is bicuspid. The aortic valve leaflets are severely thickened/deformed. There is moderate aortic valve stenosis (valve area 1.4 cm2). Moderate to severe (3+) aortic regurgitation is seen. A probable root abscess is seen close to the aorto-mitral junction. 7. Trivial mitral regurgitation is seen. POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including phenylephrine and is being AV paced 1. A well-seated bioprosthetic valve is seen in the aortic position with normal leaflet motion and gradients (mean gradient = 8 mmHg).Trace washing jets are seen. 2. Bi ventricular function is unchanged. 3. Arch and descending aorta appear intact post decannulation. 4. Other findings are unchanged. Dr. [Last Name (STitle) 914] was notified in person of the results Brief Hospital Course: The patient was admitted to the hospital and brought to the operating room on [2166-2-13] where he underwent aortic valve replacement, ascending aorta replacement, patch closure of aortic root abscess, maze procedure, and left atrial appendage resection with Dr. [Last Name (STitle) 914]. Please see op note for further details. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU on propofol and phenylephrine in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. He was neurologically intact and hemodynamically stable, weaned from vasoactive support. Beta blockade and diuresis were initiated and the patient was transferred to the telemetry floor. Chest tubes and pacing wires were discontinued without complication. Physical therapy worked with the patient on post-op mobility and strength. Anti-coagulation was started with coumadin/heparin bridge for mechanical valve. Post-op course was uneventful and the patient was discharged home on POD 6 with INR 2.2. Medications on Admission: Heparin 5000 units sc tid PCN G 4 million units IV q4h Gentamycin 80mg IV q8h 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. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:40 Tablet(s) Refills:0 3. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day: take 400mg daily for 7 days, then decrease to 200mg daily ongoing. Disp:60 Tablet(s) Refills:2 4. Coumadin 5 mg Tablet Sig: 1.5 Tablets PO once a day: titrate daily for an INR goal of 2.5-3.5 for a mechanical AVR. Disp:45 Tablet(s) Refills:2 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 1 weeks. Disp:7 Tablet(s) Refills:0 7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 1 weeks. Disp:7 Tab Sust.Rel. Particle/Crystal(s) Refills:0 8. Outpatient Lab Work serial PT/INR goal INR 2.5-3.5 dx: mechanical aortic valve Results to Dr. [Last Name (STitle) ] Discharge Disposition: Home with Service Discharge Diagnosis: aortic stenosis ascending aortic aneurysm atrial fibrillation Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with percocet prn Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: Please call to schedule appointments Surgeon Dr [Last Name (STitle) 914] in 4 weeks [Telephone/Fax (1) 170] Primary Care Dr [Last Name (STitle) ],[First Name3 (LF) ] C. [Telephone/Fax (1) 798] in [2-8] weeks Cardiologist Dr. [Last Name (STitle) ] [Telephone/Fax (1) 62] INR/coumadin management: [Hospital1 778] Health [Location (un) ], [Telephone/Fax (1) ]- have INR drawn here Thurs. [2-20] (confirmed with [Doctor First Name ]) Wound check appointment - [Hospital Ward Name 121] 6 ([Telephone/Fax (1) 3071]) - your nurse will schedule Completed by:[2166-2-19]	[ "458.29", "V12.54", "421.0", "V58.61", "746.4", "441.2", "041.09", "V58.83", "427.31", "424.1", "416.8", "300.4" ]	icd9cm	[ [ [] ] ]	[ "37.34", "38.45", "39.61", "37.36", "35.22" ]	icd9pcs	[ [ [] ] ]	7076, 7095	4667, 5782	346, 726	7201, 7297	2645, 4644	7922, 8550	1949, 1967		5911, 7053	7116, 7180		5808, 5888			7321, 7899							1982, 2626																282, 308								754, 1209													1231, 1518	1534, 1933
52,302	128,868	40175	Discharge summary	report	Admission Date: [2126-1-10] Discharge Date: [2126-1-22] Date of Birth: [2069-1-8] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1711] Chief Complaint: Ventricular Tachycardia Major Surgical or Invasive Procedure: placement of internal cardiac defibrillator: St. [Male First Name (un) 923] Fortify History of Present Illness: 57 yo M w/ no sig PMH p/w SOB x 1week, found to be in VT at [Location (un) ]. He appeared stable but BP was in the 80s so cardioverted him w/ one shock and has been in sinus since w/ BPs in 110s to 120s and HR in the 110s. He was started on amio drip and heparin drip, got plavix loaded and ASA. Sinus EKG w/ TWI inferiorly and anterior Qs Trop I was 0.59 and CK 139. Pt. now asymptomatic. He says that he was feeling well until 10 days ago when he started noticing DOE a/w palpitations, his dyspnea would resolve w/ rest and he also noted that his rapid heart rate would resolve w/ rest. He says that his DOE was intermittent and did not reliably occur to the same degree every time. He did not have any chest pain at any time. Today he had acute onset of SOB at rest a/w cold sweat, he tried to drink some water but vomitted. These Sx persisted for several hours w/o improvement and he presented to [Location (un) ] ED. . surgical Hx. He has had chronic RLE swelling and duskiness for several years, slowly progressive but noticed about 10 days ago that his LLE also started swelling and turning purplish. . On review of systems, he denies any f/c/ns, cough. Cardiac review of systems is notable for presence of one episode of syncope which occured about 1.5 yrs ago when he was doing work outside in the heat and felt dehydrated, he lost consciousness and his neighbors called 911, he did not revive until EMS arrived and refused hospital transport at that time. . Past Medical History: None, denies surgeries. Social History: -Tobacco history: Quit 25yrs ago, 14pack year Hx -ETOH: 4 gin and tonics/night (1-2shots each) -Illicit drugs: Remote, denies cocaine Works as an organist and in horse maintainence Lives with wife, daughter (26) and son in law Family History: adopted Physical Exam: On Admission: VS: T=97.7 BP= 115/80 HR= 118 RR= 28 O2 sat= 100% 4L NC GENERAL: NAD. Oriented x3. Mood, affect appropriate. Tachypneic HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. 18g PIV in R EJ NECK: Supple with JVP not visible [2-20] habitus CARDIAC: regular tachycardic, distant heart sounds LUNGS: Decreased breath sounds in the bases bilaterally ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: bilateral venous stasis in the Lower extremities with tender woody edema w/ 3x2cm venous stasis ulcer on the R and 1+ pitting edema on the left . On discharge: Gen: alert, oriented, conversant HEENT: supple, no JVD, MM moist CV:RRR, no M/R/G RESP: CTAB ABD: soft, NT, pos BS EXTR: No further edema. right LE with distinct varicocites. Wound covered. NEURO: alert, oriented Extremeties: Pulses: Right: DP 1+ PT 1+ Left: DP 1+ PT 1+ Pertinent Results: [2126-1-10] 05:06AM GLUCOSE-140* LACTATE-3.8* NA+-136 K+-6.4* CL--107 [2126-1-10] 05:06AM TYPE-ART PO2-116* PCO2-27* PH-7.35 TOTAL CO2-16* BASE XS--8 INTUBATED-NOT INTUBA COMMENTS-NASAL [Last Name (un) 154] [2126-1-10] 05:21AM PT-22.3* PTT-42.8* INR(PT)-2.1* [2126-1-10] 05:21AM PLT COUNT-139* [2126-1-10] 05:21AM WBC-15.3* RBC-5.14 HGB-16.3 HCT-49.0 MCV-95 MCH-31.6 MCHC-33.3 RDW-14.8 [2126-1-10] 05:21AM CK-MB-23* MB INDX-5.4 cTropnT-0.35* [2126-1-10] 05:21AM ALT(SGPT)-3526* AST(SGOT)-4044* LD(LDH)-4050* CK(CPK)-425* ALK PHOS-80 TOT BILI-2.7* [2126-1-10] 05:21AM estGFR-Using this [2126-1-10] 05:21AM GLUCOSE-143* UREA N-30* CREAT-3.1* SODIUM-136 POTASSIUM-6.5* CHLORIDE-105 TOTAL CO2-17* ANION GAP-21* ========STUDIES====================== . ECHO [2126-1-10] The left atrium is markedly dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is severely depressed (LVEF= 15-20%). The right ventricular cavity is markedly dilated with severe global free wall hypokinesis. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is a very small pericardial effusion. The effusion appears circumferential. . IMPRESSION: Biventricular dilatation with severe hypokinesis. The lateral wall of the LV has relatively better function. No significant valvular abnormality seen. Very small pericardial effusion. . CHEST XRAY [2126-1-10] FINDINGS: Moderate cardiomegaly with slight tortuosity of the thoracic aorta. No pulmonary edema. No pneumonia, no pleural effusions. . Bilateral Lower Extremity Doppler [2126-1-10] IMPRESSION: No evidence of DVT. . Cardiac MR: [1-17] Findings: Structure and Function There was normal epicardial fat distribution. The pericardial thickness was normal. There was a small pericardial effusion. There were no pleural effusions. The indexed diameters of the ascending and descending thoracic aorta were normal. The main pulmonary artery diameter index was normal. The left atrial AP dimension was moderately increased. The right and left atrial lengths in the 4-chamber view were moderately increased. The coronary sinus diameter was normal. The left ventricular end-diastolic dimension index was normal. The end-diastolic volume index was moderately increased. The calculated left ventricular ejection fraction was severely decreased at 29% with global systolic dysfunction. The anteroseptal and inferolateral wall thicknesses were normal. The left ventricular mass index was mildly increased. The right ventricular end-diastolic volume index was normal. The calculated right ventricular ejection fraction was moderately decreased at 35%, with global hypokinesis. The aortic valve was poorly visualized but did not appear stenotic. Impression: 1. Moderately increased left ventricular cavity size with global left ventricular systolic dysfunction. The LVEF was severely decreased at 29%. 2. Normal right ventricular cavity size with global hypokinesis. The RVEF was moderately decreased at 35%. 3. The indexed diameters of the ascending and descending thoracic aorta were normal. The main pulmonary artery diameter index was normal. 4. Moderate biatrial enlargement. 5. Small pericardial effusion. . Labs on Discharge: WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct 10.0 4.99 15.7 46.8 94 31.5 33.5 12.9 240 Glucose UreaN Creat Na K Cl HCO3 AnGap 1061 38 1.8* 139 4.6 102 30 12 Brief Hospital Course: ASSESSMENT AND PLAN 57 yo M with no known prior cardiac history presented with monomorphic VT and likely underlying dilated cardiomyopathy. . # Monomorphic VT/CHF: Likely that the patient had an ischemic event in the past week or so which lead to scarring and ventricular tachycardia as anterior qwaves apparent on EKG and troponin I only 0.59 and CK in the 130 130s. Underlying dilated cardiomyopathy likely given significant alcohol use. He was transferred to the CCU due to stable ventricular tachycardia on telemetry on the floor. In the CCU he was given IV lasix and metolazone with significant urine output. He continued to autodiurese in the hospital with weight at discharge 125.7 kg. He was started on hydralazine and isosorbide dinitrate in the CCU, later changed to low dose Lisinopril and his home metoprolol was titrated up. Cardiac MR was completed showing severely depressed EF. Decision was made place ICD for secondary prevention prior to discharge. Patient tolerated procedure well without any complications. he will follow up with Dr. [Last Name (STitle) 11493] and the device clinic here at [Hospital1 18]. . # Renal failure: Renal failure likely secondary to poor forward flow in the setting while hypotensive in VT. [Month (only) 116] have been in VT for a prolonged. Renal failure initially worsened with diuresis and improved off diuretics per recommendation of nephrology consult. His creatinine . # Elevated transaminases: Likely shock liver in the setting of hypotension. Unclear if baseline elevated LFTS. Liver function enzymes improved throughout CCU stay. Amiodarone held until liver function improved. . # Hypoxia: Likely secondary acute pump failure from VT. Improved. . # Venous stasis - He presented with bilateral lower extremity non-pitting edema, which he reported as chronic. He also had a large (4cm by 8cm) ulcer over medial aspect of the right ankle, which was there since [Month (only) 216]. Vascular surgery was consulted and decided against debridement and favored wound care and compression. . #Metabolic acidosis: Likely lactic acidosis from poor perfusion from what was likely in the setting of prolonged VT and hypotension. . Medications on Admission: none Discharge Medications: 1. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. metoprolol succinate 100 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:60 Tablet Sustained Release 24 hr(s) Refills:2 4. collagenase clostridium hist. 250 unit/g Ointment Sig: One (1) Appl Topical DAILY (Daily). Disp:1 tube Refills:2 5. Outpatient Lab Work Please check Chem-7 and LFT's on [2126-1-25] at Dr.[Name (NI) 27809] office. 6. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. cephalexin 500 mg Capsule Sig: One (1) Capsule PO three times a day for 2 days. Disp:6 Capsule(s) Refills:0 8. Vicodin 5-500 mg Tablet Sig: One (1) Tablet PO four times a day as needed for pain. Disp:10 Tablet(s) Refills:0 9. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [Last Name (LF) 486], [First Name3 (LF) 487] Discharge Diagnosis: Ventricular Tachycardia Acute Systolic dysfunction: EF 29% Acute Kidney Injury Acute liver Failure Chronic Vascular Disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You had ventricular tachycardia that required a defibrillation. Your heart was very weak and volume overloaded when you were admitted but you responded well to diuretics and other medicines to help your heart pump better and your heart function has improved. We are not sure why your heart was so weak but you should not drink any more alcohol and will need to see a cardiologist regularly. A cardiac MRI was done which showed that your heart function is improved but still weak. You should watch your legs closely to monitor for any swelling. Weigh yourself every morning, call Dr. [Last Name (STitle) 11493] if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. You should eat a low sodium diet. While your heart was not working well, your kidneys and liver were also impacted and you developed liver and kidney failure. This has improved tremendously and should normalize in time. You should follow up with your new primary care doctor and cardiologist on a regular basis and also see Dr. [First Name (STitle) ] [Name (STitle) ] here at [Hospital1 18] to evaluate and treat your right leg ulcer. . You should take the following medicines at home every day: 1. Aspirin, a mild blood thinner, to prevent blood clots 2. Thiamine, a B vitamin 3. folic acid, another B vitamin 4. Metoprolol, a beta blocker to prevent irregular heart beats and help your heart pump better. 5. Lisinopril, to lower your blood pressure and help your heart pump better. 6. Collagenase: to help remove dead tissue from the wound. Followup Instructions: Name: [Last Name (LF) 11493], [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 6105] MD Address: [Apartment Address(1) 28703], [Location (un) ],[Numeric Identifier 28704] Phone: [Telephone/Fax (1) 11650] Appt: [1-25] at 2:30pm Department: CARDIAC SERVICES When: THURSDAY [2126-1-31] at 11:40 AM With: [Name6 (MD) ] [Name8 (MD) ], MD [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage . Please talk to Dr. [Last Name (STitle) 11493] about getting a primary care physician. Department: CARDIAC SERVICES When: THURSDAY [2126-1-31] at 10:30 AM 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 Completed by:[2126-1-26]	[ "276.7", "794.31", "276.2", "428.21", "V15.82", "584.5", "303.91", "458.8", "428.0", "355.8", "459.81", "570", "427.1", "414.01", "707.13", "425.5" ]	icd9cm	[ [ [] ] ]	[ "37.94" ]	icd9pcs	[ [ [] ] ]	10287, 10370	7017, 9214	327, 417	10538, 10538	3257, 6817	12248, 13187	2230, 2239		9269, 10264	10391, 10517		9240, 9246			10689, 12225							2254, 2254											2965, 3238					264, 289			6837, 6994					445, 1923							2268, 2951	10553, 10665					1945, 1970	1986, 2214
50,991	113,931	36234	Discharge summary	report	Admission Date: [2167-7-7] Discharge Date: [2167-7-15] Date of Birth: [2093-3-2] Sex: M Service: CARDIOTHORACIC Allergies: Ampicillin / Golytely Attending:[First Name3 (LF) 2969] Chief Complaint: Esophageal cancer Major Surgical or Invasive Procedure: Esophagoscopy, Transhiatal esophagectomy and feeding tube jejunostomy. History of Present Illness: Pt is a 74 y/o male who presents with T1/2 NO Mx Esophageal cancer needing treatment. This was discovered after a GIB presumably from the esophagus as a result of aspirin usage. He required 7 units of blood for this bleed. At that time the patient had an EGD which showed a concerning GE junction lesion. Once the patient improved from his acute event, EGD/EUS was re-performed with path showing adenocarcinoma Past Medical History: Emphysema, Cardiomyopathy, "Extra beats",Pre op for left fem-[Doctor Last Name ], Bilateral lower extremity stents, Claudication - can't go more that [Age over 90 ] yards, No rest pain, Cataracts, HTN, Reportedly passed stress last yr, Carotid doppler reportedly ok couple yrs ago, Horseshoe kidney, Basal Cell CA, Bladder Stricture, Hepatitis in [Country 26231] - unknown type Social History: Cigarettes: [x] current Pack-yrs:_80 ETOH: [x] No Exposure: [x] No Marital Status: [x] Married Lives: [x] w/ family Family History: Non-ontribitory Pertinent Results: [2167-7-14] 06:55AM BLOOD WBC-11.4* RBC-3.76* Hgb-10.3* Hct-33.3* MCV-89 MCH-27.4 MCHC-31.0 RDW-14.8 Plt Ct-299 [2167-7-12] 07:30AM BLOOD WBC-10.8 RBC-3.96* Hgb-11.3* Hct-35.6* MCV-90 MCH-28.6 MCHC-31.8 RDW-14.4 Plt Ct-223 [2167-7-10] 02:38AM BLOOD WBC-10.0 RBC-3.57* Hgb-10.3* Hct-31.1* MCV-87 MCH-28.9 MCHC-33.2 RDW-14.2 Plt Ct-151 [2167-7-8] 03:03AM BLOOD WBC-11.4* RBC-4.03* Hgb-11.9* Hct-33.7* MCV-84 MCH-29.6 MCHC-35.3* RDW-14.6 Plt Ct-144* [2167-7-7] 02:24PM BLOOD WBC-8.7 RBC-4.11* Hgb-11.9* Hct-34.9* MCV-85 MCH-29.0 MCHC-34.1 RDW-13.8 Plt Ct-177 [2167-7-9] 04:22AM BLOOD PT-15.2* PTT-46.3* INR(PT)-1.3* [2167-7-14] 06:55AM BLOOD Glucose-124* UreaN-27* Creat-0.7 Na-145 K-3.8 Cl-112* HCO3-27 AnGap-10 [2167-7-12] 07:30AM BLOOD Glucose-111* UreaN-22* Creat-0.8 Na-145 K-3.8 Cl-108 HCO3-28 AnGap-13 [2167-7-9] 04:22AM BLOOD Glucose-93 UreaN-28* Creat-0.9 Na-138 K-4.6 Cl-108 HCO3-24 AnGap-11 [2167-7-8] 03:03AM BLOOD Glucose-111* UreaN-25* Creat-1.3* Na-138 K-4.5 Cl-107 HCO3-21* AnGap-15 [2167-7-7] 02:24PM BLOOD Glucose-116* UreaN-19 Creat-1.1 Na-141 K-4.2 Cl-109* HCO3-24 AnGap-12 [2167-7-9] 04:22AM BLOOD Calcium-7.4* Phos-2.8 Mg-2.2 [2167-7-7] 02:24PM BLOOD Calcium-7.1* Phos-3.3 Mg-1.6 [2167-7-9] 12:59AM BLOOD Type-ART pO2-86 pCO2-47* pH-7.34* calTCO2-26 Base [2167-7-14] chest x/ray: The mediastinal contours are stable. There is no evidence of pneumothorax or pneumomediastinum. The post-surgical drain in the upper mediastinum is unchanged in location. There is interval minimal change in bilateral small pleural effusion. There is improvement of the atelectasis of the right middle lobe. There is no evidence of new consolidations and there is no evidence of failure. [2167-7-11] Head CT: IMPRESSION: 1. No hemorrhage, edema, or evidence of other acute intracranial abnormalities. Please note that MRI would be more sensitive for metastatic disease, infection, or acute infarction. 2. Mild parenchymal involutional change and mild chronic small vessel ischemic disease. [2167-7-8] 03:12AM BLOOD Type-ART pO2-102 pCO2-38 pH-7.40 calTCO2-24 Base XS-0 Intubat-INTUBATED [2167-7-7] 12:47PM BLOOD Type-ART Tidal V-700 PEEP-3 FiO2-55 pO2-153* pCO2-45 pH-7.36 calTCO2-26 Base XS-0 Intubat-INTUBATED Vent-CONTROLLED [2167-7-7] 09:47AM BLOOD Type-ART pO2-146* pCO2-46* pH-7.34* calTCO2-26 Base XS--1 Intubat-INTUBATED Vent-CONTROLLED [2167-7-7] 12:47PM BLOOD Glucose-135* Lactate-1.3 Na-135 K-4.3 Cl-104 [2167-7-8] 03:12AM BLOOD freeCa-1.13 [2167-7-7] 09:47AM BLOOD freeCa-1.07* Brief Hospital Course: Pt is a 74 y/o male who presents with T1/2 NO Mx Esophageal cancer needing treatment. This was discovered after a GIB presumably from the esophagus as a result of aspirin usage. He required 7 units of blood for this bleed. At that time the patient had an EGD which showed a concerning GE junction lesion. Once the patient improved from his acute event, EGD/EUS was re-performed with path showing enocarcinoma. On [2167-7-7] was taken to the operating room for Esophagoscopy, Transhiatal esophagectomy and feeding tube jejunostomy. Patient remained intubated over night and extubated thed next morning Tx to the ICU follow air-way. Patient remained NPO, cervical JP to bulb suction. Did well in the ICU on [2167-7-11] transfered to F9 med [Doctor First Name ] floor. [2167-7-12] Placement of right pigtail catheter now with bilateral pleural effusions, right greater than left. the eve of [2167-7-12] night patient developed delirum patient pulled his own pig tail catheter out. Geriatric consult placed reccomended: Check UA and culture, Risperidone 0.25mg QPM (Do not discharge patient on this medication, Repeat ECG in am to monitor QT, and Recommendations for non-pharmacologic delirium prevention: a) Remove all lines and catheters as soon as possible, esp Foley b) Avoid sedatives, especially antihistamines and benzodiazepines c) Encourage family to be at bedside, with familiar home objects d) Explore and encourage baseline religious/spiritual coping mechanisms for illness. e) Preserve sleep wake cycle by minimizing overnight interruptions and allowing for stimulation and activity during the day ie cancelling midnight vitals unless medically indicated f) OOB for meals if/when eating TID g) Reorient frequently h) Ensure BM at least once every other day, if not daily. i) Providing hearing aids as needed glasses and dentures to trazadone at night. resiradol with good effect by [2167-7-14] A+O. Interventional pulmonolgy felt pig-tail drained enough of effussion on insertion (600cc). [2167-7-14]; Patient remains A+O x3 all day, neck staples removed and stay-sutures placed. Neck drain bulb removed from catheter and sponged attached. Every other staple from abd removed and replaced with stay-suture. Grape Juice test performmed and no leakaged noted patients diet advanced to clear liquids. Medications on Admission: Advair 250/50'', Carvedilol 12.5'', Digoxin 0.25', Lisinopril 10', Lipitor 10', Spironolactone 12.5', Timolol', Prednisolone eye gtts' Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheeze. 3. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML Miscellaneous Q6H (every 6 hours). 4. Oxycodone 5 mg/5 mL Solution Sig: [12-19] PO Q3H (every 3 hours) as needed for PAIN. 5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheeze. 6. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q6H (every 6 hours) as needed for pain. 7. Risperidone 0.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 9. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Insulin sliding scale Insulin SC Sliding Scale - Accept or Override Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Regular Regular Regular Regular Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose 0-50 mg/dL 4 oz. Juice 4 oz. Juice 4 oz. Juice 4 oz. Juice 51-150 mg/dL 0 Units 0 Units 0 Units 0 Units 151-200 mg/dL 2 Units 2 Units 2 Units 2 Units 201-250 mg/dL 4 Units 4 Units 4 Units 4 Units 251-300 mg/dL 6 Units 6 Units 6 Units 6 Units 301-350 mg/dL 8 Units 8 Units 8 Units 8 Units 351-400 mg/dL 10 Units 10 Units 10 Units 10 Units 13. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Disposition: Extended Care Facility: Life Care Center of [Location (un) 5165] Discharge Diagnosis: esophageal cancer Discharge Condition: good Discharge Instructions: Please call Dr. [Last Name (STitle) ] office with any questions or concerns [Telephone/Fax (1) 4741]. Call with fevers greater than 101.5 Call with increased shortness of breath, chest pain and or secretions Call with increased drainage, redness or swelling from incisions Followup Instructions: You have a follow up appointment first you are to report to the [Hospital Ward Name ] on [7-24] at 10 am to radiology in the RABS building 3 rd floor for your esophagram which you need to be NPO after midnight. After your test you need to go to the [Hospital Ward Name 517] [Location (un) 453] chest disease center for your follow up appointment with Dr [Last Name (STitle) ] at 11:30 am or right after your test. Completed by:[2167-7-15]	[ "293.0", "305.1", "707.21", "440.21", "458.29", "753.3", "151.0", "425.4", "511.9", "707.07", "401.9", "492.8" ]	icd9cm	[ [ [] ] ]	[ "34.91", "34.09", "42.52", "43.99", "46.39", "96.6" ]	icd9pcs	[ [ [] ] ]	8299, 8370	4030, 6378	304, 377	8432, 8439	1426, 3190	8768, 9232	1390, 1407		6564, 8276	8391, 8411		6404, 6541			8463, 8745																							247, 266								405, 820				3199, 4007									842, 1233	1249, 1374
4,603	125,188	28575	Discharge summary	report	Admission Date: [2190-10-18] Discharge Date: [2190-10-24] Date of Birth: [2117-12-1] Sex: M Service: UROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 11304] Chief Complaint: Renal Cell Carcinoma Major Surgical or Invasive Procedure: Laparoscopic L partial nephrectomy History of Present Illness: 72yM w/ L RCC 3.1 cm in transverse x 2.9 cm in AP x 3.3 cm Baseline Crt 1.4 Past Medical History: CHF, afib, dm, htn hypothyroid. PSH: hydrocele nkda Social History: non contributory Family History: non contributory Physical Exam: HEENT: no significant abnormalities noted CV: RRR no MRG appreciated RESP: CTA b/l, no RRW ABD: soft, tender appropriately to palpation, BS +, non distended, wounds CDI, JP site sraingin some SS fluid, adequately controlled with dressing changes. EXT: no CCE, peripheral pulses palpable b/l Pertinent Results: [2190-10-18] 06:45PM WBC-10.5 RBC-4.15* HGB-12.5* HCT-36.5* MCV-88 MCH-30.2 MCHC-34.2 RDW-12.9 [2190-10-18] 06:45PM PLT COUNT-201 [2190-10-18] 02:15PM GLUCOSE-154* UREA N-24* CREAT-1.4* SODIUM-140 POTASSIUM-3.4 CHLORIDE-102 TOTAL CO2-29 ANION GAP-12 [2190-10-18] 02:15PM CALCIUM-9.4 PHOSPHATE-2.8 MAGNESIUM-1.8 [2190-10-23] 04:07AM BLOOD WBC-8.7 RBC-3.35* Hgb-10.4* Hct-29.3* MCV-87 MCH-31.1 MCHC-35.7* RDW-13.9 Plt Ct-236 [2190-10-23] 04:07AM BLOOD Plt Ct-236 [2190-10-23] 04:07AM BLOOD Glucose-98 UreaN-36* Creat-1.2 Na-142 K-4.0 Cl-106 HCO3-26 AnGap-14 [2190-10-20] 03:30PM BLOOD CK(CPK)-1020* [2190-10-20] 05:30AM BLOOD CK(CPK)-1278* [2190-10-19] 09:10PM BLOOD CK(CPK)-1741* [2190-10-20] 03:30PM BLOOD CK-MB-13* MB Indx-1.3 cTropnT-0.02* [2190-10-20] 05:30AM BLOOD CK-MB-22* MB Indx-1.7 cTropnT-0.02* [2190-10-19] 09:10PM BLOOD CK-MB-36* MB Indx-2.1 cTropnT-0.04* Brief Hospital Course: PT admitted for Laparoscopic R partial nephrectomy. On POD 1 pt had distended abdomen, tymapnic, with tenderness to palpation. HCt dropped from 36 ro 26 without evidence clinically as pt was normocardic and normotensive. Ct scan showed no evidence of acute bleed. IR was consulted but decision was made not to intervene. Pt was transfused two units and decision was made to transfer to MICU. Over course of nest tow days pt was transfused three more times, without incident. Pts HCt stablized on POD3. Pt hd history of chronic AF, and during MICU stay had two runs of Persistent PVC's and cardiology was consulted. Cardiology's recomendations were put in to effect and pt did well. Pt passed flatus and had a BM on POD 3, and continued normal bowel movements throughout the rest to hospital stay. PT was cleared for transfer to floor on POD 3, but bed was not available until POD 5. ON POD5 foley was removed without complication, pt voided, and JP drain output did not significantly increase. On POD 6 pt was cleared for discharge with proper follow up. JP drain Crt was 1.6 and fluid output was minimal. Jp was d/c'd prior to discharge. PT's pain was well controlled throughout hospital stay. Medications on Admission: Digoxin 0.125 mg p.o. daily, glyburide 10 mg p.o. q.a.m. and 5 mg p.o. q.p.m., lisinopril 20 mg p.o. daily, furosemide 40 mg p.o. q.a.m. and 20 mg p.o. q.p.m., levothyroxine 0.175 mg p.o. daily, warfarin 10 mg p.o. q.h.s. daily except for Wednesdays 5 mg. Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain for 10 days. Disp:40 Tablet(s) Refills:0 2. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q4-6H (every 4 to 6 hours) as needed. 3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:60 Tablet Sustained Release 24HR(s) Refills:2 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 9. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). 10. Glyburide 5 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 11. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: renal tumor Discharge Condition: stable Discharge Instructions: Return to ER if: - persistent temp > 101.4 - severe abdominal, flank or pelvic pain - persistent nausea, vomiting or diarrrhea - pus or bloody discharge from wound or urine Followup Instructions: 1) DR. [Last Name (STitle) ] - in 1 - 2 weeks call for appt [Telephone/Fax (1) 3752] 2)[Last Name (LF) ],[First Name3 (LF) ] J [Telephone/Fax (1) 66697] - please see your PCP to follow up and to set up a Cardiology appt to discuss Statin use and change in BP medications	[ "236.91", "997.5", "V58.61", "V70.7", "E878.6", "285.1", "428.20", "427.89", "428.0", "584.9", "427.31", "276.52", "998.11", "250.00", "425.4" ]	icd9cm	[ [ [] ] ]	[ "59.8", "55.4", "99.04" ]	icd9pcs	[ [ [] ] ]	4535, 4584	1903, 3114	338, 375	4639, 4648	951, 1880	4869, 5164	607, 625		3420, 4512	4605, 4618		3140, 3397			4672, 4846							640, 932																278, 300								403, 481													503, 557	573, 591
24,023	175,248	23455	Discharge summary	report	Admission Date: [2190-12-16] Discharge Date: [2191-2-18] Date of Birth: [2142-11-26] Sex: M Service: HISTORY OF PRESENT ILLNESS: This is a 48-year-old male with a known history of endocarditis who was recently discharged from [Hospital1 18] on [2190-12-2] on ampicillin and gentamicin for an enterococcal bacteremia. He represented to the hospital on [2190-12-16] with a 101.3 temperature with ibuprofen use. PAST MEDICAL HISTORY: Hepatitis C virus x12 years with interferon treatment. GERD. Enterococcal bacteremia and endocarditis. Mitral regurgitation with torn mitral chordae. History of IV drug use with [2190-11-27] being the last stated use. Congestive heart failure. Anemia. MEDICATIONS ON ADMISSION: 1. Ampicillin 2 grams IV q.8h. 2. Gentamicin 80 mg IV q.8h. 3. Lasix 20 mg once a day. 4. Ferrous sulfate 325 mg once a day. 5. Ibuprofen 400 mg p.o. 3x a day. 6. Colace. 7. Nicoderm patch TD 21 mg once a day. 8. Seroquel 12.5 mg twice a day with an additional 25 mg dose every evening. 9. Multivitamins and vitamin E. SOCIAL HISTORY: Patient is a current smoker with a 20-pack- year history and admitted to remote IV cocaine use, remote alcohol abuse, and he is a resident of a facility for rehabilitation. He was admitted to the hospital on [2190-12-16] for evaluation of his fever on double IV antibiotics. Admission labs were a white count of 11.1, hematocrit 29, platelet count 438,000. Sodium 140, K 4.5, chloride 104, bicarbonate 27, BUN 14, creatinine 1.2 with a blood sugar of 119. Peak and trough gentamicin studies were done. Additional blood cultures were done. Patient had a long preoperative course. Over the course of the approximately 8 weeks prior to his surgery, he completed a 56-day course of ampicillin IV and a 56-day course of gentamicin IV. He had minor complications from this which included an episode of acute renal failure with his creatinine trending up to 2.1 and then back down again before prior to surgery. His blood cultures did show enterococcus which was treated with double antibiotic therapy. He also developed vertebral osteomyelitis during his hospital stay, which was diagnosed by MRI and evaluated by neurosurgery which recommended only antibiotic therapy and no need to biopsy or pursue at this time. He was followed daily by the infectious disease service as well as by cardiology service and was maintained for CHF with originally Lasix and ACE inhibitor. Over the course of his stay, preoperatively he also developed a right lower extremity peroneal vein DVT for which he was initially heparinized and then placed on Coumadin at therapeutic doses for coverage of the DVT. PICC line was also placed during that 8 weeks stay. Prior to surgery, ultimately the patient also had a cardiac catheterization on [2191-1-28] which showed clean coronary arteries, severe mitral regurgitation, severe tricuspid regurgitation, and severe pulmonary hypertension. Over the course of this stay, it was also discovered the patient required dental extractions. He was seen by the OMFS service. He was then transitioned from Coumadin to Lovenox and then ultimately as the INR dropped down to IV Heparin in preparation for 4 teeth extraction which took place on [2-11]. In addition, during that time period, he did complete his 8 weeks course of antibiotics. After his extractions, he went back on Coumadin. On[2-10], 4 days prior to surgery, he had a repeat TEE which showed severe MR, mild-to-moderate TR, and no abscess present in his heart. The patient was finally cleared for surgery. A repeat MRI was done in late [Month (only) 404] which showed essentially no change in the vertebral osteomyelitis. But with the official radiology [Location (un) 1131] that clinical findings often precede MR findings which lag behind. Dr. [Last Name (Prefixes) ] accepted evaluation and when the patient had approximately 14 days of negative blood cultures, he agreed to do the mitral valve prolapse. The patient had been off all antibiotics approximately 10 days at that time. Laboratory studies the day prior to operation were as follows: Sodium 137, K 4.6, chloride 104, bicarbonate 26, BUN 24, creatinine 1.3 with a blood sugar of 110, anion gap 12. White count 7.4, hematocrit 35.0, platelet count 256,000. PT 12.8, PTT 79.4 on Heparin drip with an INR of 1.0. [Last Name (STitle) 2708]was then officially cleared for surgery, and on [2191-2-14], the patient underwent mitral valve prolapse with a 29-mm porcine mitral valve by Dr. [Last Name (Prefixes) 411]. He was transferred to cardiothoracic ICU in stable condition. On postoperative day 1, patient had been extubated, had a respiratory rate of 19, saturating 96% on nasal cannula. Postoperatively, white count was 10.8, hematocrit 31, platelet count 156,000. INR 1.0, creatinine 1.3, K 4.8. His exam was unremarkable. He began Lopressor beta-blockade and Lasix diuresis again. Patient was transferred out to the floor that afternoon. He was seen again by cardiology postoperatively and case management to help him set up his living situation postoperatively. He had also been followed repeatedly by social work services preoperatively about 2 months before surgery. On postoperative day 2, his creatinine remained stable at 1.3. His white count rose slightly to 13.6. He was sleepy, but appropriate and with a nonfocal neurological exam. He had some nausea and vomiting early that morning. He continued on perioperative vancomycin. His Foley was removed. His pacing wires were removed. He started Heparin for his DVT after his pacing wires were removed later that day. ID was again reconsulted for clarification of postop antibiotics. White count was rechecked the following morning with a plan to panculture the patient if patient developed any fever. However, the patient had a temperature of only 98.9 that morning. Patient was seen and evaluated by physical therapy and began to work on ambulation with support from PT and the nurses. On postoperative day 3, patient had already ambulated to level 3. Was on Heparin at 800 units an hour. Received his first dose of Coumadin 5 mg later that evening. His Lasix was switched over to p.o. He was encouraged to increase his activity level with a plan to discharge him to his outside living situation in approximately the next 1-2 days. Central venous line was removed. Pacing wires had already been removed. Heart was regular rate and rhythm with a grade 2/6 systolic ejection murmur. Sternum was stable. Incision was clean, dry, and intact. He had a nonfocal neurologic exam, and his lungs were clear bilaterally. His weight was below his preoperative weight by 1.3 kilograms. Re[Last Name (STitle) 60120]reening was completed on postoperative day 4. The day of discharge, he did a level 4. His blood pressure was 111/76, in sinus rhythm at 87 with a respiratory rate of 20, saturating 97% on room air. He continued on his Heparin and received his Coumadin to get him therapeutic. From his dose the night prior, he continued with his beta-blockade with metoprolol 25 mg p.o. b.i.d. His exam was unremarkable. The patient did have a bowel movement. He was ready for discharge home and was progressing very well. He had been receiving Heparin and Coumadin for his DVT prior to surgery. But the nurse practitioner spoke with a primary care group, Dr. [Last Name (STitle) 1270] who felt the patient did not need to be anticoagulated. Surveillance blood cultures were drawn and the patient was given instructions to followup with ID in [12-26] weeks, with Dr. [Last Name (Prefixes) ] in 4 weeks for his postop surgical visit and with Dr. [Last Name (STitle) 1270] in [1-27] weeks postdischarge. Labs prior to discharge showed a white count of 8.7, hematocrit 29.1, platelet count 254,000. Creatinine 1.2. Coumadin was discontinued. DISCHARGE DIAGNOSES: Status post mitral valve replacement with 29-mm porcine mitral valve. Hepatitis C x12 years. Intravenous drug abuse. Vertebral osteomyelitis. Enterococcus bacteremia with endocarditis. Mitral regurgitation with torn mitral chordae. Congestive heart failure. Anemia. Right lower extremity deep venous thrombosis. Status post 4 dental extractions. DISCHARGE MEDICATIONS: 1. Lasix 20 mg p.o. once daily x7 days. 2. Ferrous sulfate 325 mg p.o. once a day for 1 month. 3. Quetiapine fumarate 12.5 mg p.o. twice a day. 4. Nicotine 21 mg 24-hour patch apply 1 patch transdermally daily. 5. Metoprolol 50 mg p.o. twice a day. 6. Potassium chloride 20 mEq p.o. once a day for 7 days. 7. Colace 100 mg p.o. twice a day. 8. Aspirin enteric coated 81 mg p.o. once a day. 9. Percocet 5/325 one to two tablets p.o. p.r.n. q.4-6h. for pain. CONDITION AT DISCHARGE: Again, the patient was discharged in stable condition on [2191-2-18] to his rehab facility. [Doctor Last Name ] [Last Name (Prefixes) ], M.D. [MD Number(1) 1288] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2191-4-11] 13:17:55 T: [2191-4-12] 09:15:37 Job#: [Job Number 60121]	[ "421.0", "428.20", "041.04", "429.5", "530.81", "721.3", "V15.82", "730.28", "453.42", "428.0", "070.54", "305.63", "V58.61", "V58.83", "424.0", "550.90", "584.9", "280.9", "721.2", "276.5", "453.8" ]	icd9cm	[ [ [] ] ]	[ "88.56", "37.23", "35.23", "88.72", "38.93", "39.61", "23.09", "99.04", "89.68" ]	icd9pcs	[ [ [] ] ]								7928, 8284	8307, 8783			767, 1091																				8798, 9147														162, 455													478, 741	1108, 7906
30,340	100,563	32842	Discharge summary	report	Admission Date: [2145-1-24] Discharge Date: [2145-2-23] Date of Birth: [2092-9-19] Sex: M Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3645] Chief Complaint: Motor vehicle accident Major Surgical or Invasive Procedure: 1. Open reduction treatment of C7-T1 fracture/dislocation with spinal cord injury. 2. Posterior decompression, C6-7, C7-T1, T1-T2 laminectomy, facetectomy and foraminotomy. 3. Posterior cervical arthrodesis, C5-T2. 4. Posterior segmental instrumentation, C5-T2. 5. Left ICBG 6. Application of local Autograft 7. Application and removal of tongs for traction/reduction. History of Present Illness: 52 yo male trauma transfer who was rear ended at 30mph with neck pain and LE paralysis. Past Medical History: None Social History: Married. Living at home with wife Family History: Non contributory Physical Exam: A+O x 3, mildly confused PERRLA C-collar intact Lungs CTA/B Reg Rate Rhythm Abd soft non-tender Pelvis stable CN 3-12 intact, Motor L1 spinal level decreased strength 1/5, neuro intact to light touch, DTR decreased Pertinent Results: [2145-1-24] 12:30PM BLOOD WBC-8.0 RBC-4.85 Hgb-14.4 Hct-41.9 MCV-87 MCH-29.6 MCHC-34.2 RDW-13.7 Plt Ct-146* [2145-1-24] 11:47PM BLOOD WBC-9.3 RBC-4.63 Hgb-13.8* Hct-40.0 MCV-86 MCH-29.8 MCHC-34.5 RDW-13.9 Plt Ct-143* [2145-1-26] 05:55AM BLOOD WBC-12.0* RBC-3.79* Hgb-11.1* Hct-33.4* MCV-88 MCH-29.2 MCHC-33.2 RDW-14.3 Plt Ct-138* [2145-1-27] 04:57AM BLOOD WBC-8.4 RBC-3.64* Hgb-10.7* Hct-31.5* MCV-87 MCH-29.5 MCHC-34.0 RDW-13.9 Plt Ct-119* MRA Cervical Spine [2145-1-24] FINDINGS: The examination was performed with the patient's neck in a collar. This prevented using an optimal coil configuration and resulted in a low signal to noise for this study. Within these limitations, no vascular injuries are identified. Specifically, the carotid arteries and their cervical branches, and the vertebral arteries appear to be patent. Although no stenoses or pseudoaneurysms are detected, sensitivity for such abnormalities will be severely limited by the technical limitation as discussed above. Sensitivity for mural dissection will be quite low, although no such dissections are detected. CONCLUSION: Limited study for the reasons described above. No evidence of arterial injury on this limited examination. MRI Cervical Spine [2145-1-24] FINDINGS: This study is of very poor quality due to extremely limited signal- to-noise ratio secondary to the lack of employment of the neck coil, due to the patient's injuries, as well as the marked anterior subluxation of C7 upon T1. Within these limitations, the grade 3 traumatic subluxation of C7 upon T1 is clearly demonstrated. There may be a small amount of cord edema immediately cephalad to this level, but again, interpretation is extremely limited by virtue of the reduced signal-to-noise ratio. For similar reasons, it is not possible to state with certainty if there is any intramedullary hematoma present. At C3-4, there is a shallow left paracentral disc protrusion causing mild indentation upon the left ventrolateral cord margin. At C4-5, there is a shallow posterior disc protrusion causing mild cord compression, exacerbated by congenital narrowing of the AP diameter of the bony spinal canal. Uncovertebral spurs appear to produce moderate left and prominent right foraminal stenosis. At C5-6, there is a probable shallow posterior spondylytic ridge along with infolding of the ligamentum flavum, creating a moderate degree of spinal cord compression, exacerbated by congenital narrowing of the AP diameter of the bony spinal canal. At C7-T1, the cord is sharply angulated over the grade III anterior subluxation. The wedge fracture of T1 is visible, but not nearly as clearly as that seen on the accompanying CT scan. There is marked splaying of the C7 and T1 spinous processes. There is widening of the epidural space anterior to the thecal sac at the C7 level. It is likely that this represents the consequences of the subluxation, although an accompanying hematoma in this area cannot be excluded. Best seen on the STIR images is marked edema within the posterior paraspinal soft tissues, including the interspinous region between C7 and T1. Clearly, these findings represent the effects of trauma, including disruption of the intraspinous ligament at C7-T1. There does also appear to be edema extending between the C1 posterior arch and the C2 spinous process, again likely representing some ligamentous injury. There is prevertebral soft tissue swelling seen only at the level of the C7-T1 subluxation. CONCLUSION: 1. Grade 3 traumatic subluxation of C7 upon T1. 2. Technically very limited study, precluding precise analysis of the signal pattern of the spinal cord by either edema or hematoma. These findings were discussed in detail at the time of this examination by the resident, Dr. [Last Name (STitle) 12919], with the team caring for the patient. CT C spine [2145-1-24] IMPRESSION: 1. Grade [3-14] traumatic subluxation of C7 on T1 with anterior wedge compression fracture of T1 vertebral body, with bilateral locked facets of C7 on T1. Widening of the interspinous distance between C7 and T1 at this level suggests underlying ligamentous injury. 2. Possible right T1 transverse process fracture along with anterior and posterior tubercle fractures at this level. Right C7 transverse process fracture. Possible right T1 and T2 right-sided rib fractures which are minimally displaced. These findings were discussed in detail with the trauma team shortly after examination acquisition. The diagnosis of "perched" was changed to "locked" facets after attending review, by which time the patient was already in the operating room for spinal surgery. [2145-1-27] Ultrasound bilateral lower extremity Findings: Grayscale, color flow and Doppler images of both lower extremities were obtained. The common femoral veins, superficial femoral veins, and popliteal veins demonstrate normal compressibility, respiratory variation in venous flow and venous augmentation. IMPRESSION: No evidence of DVT in both lower extremities. Blood Cultures MRSA MRSA SCREEN (Final [2145-1-27]): No MRSA isolated. Urine culture: URINE CULTURE (Final [2145-1-27]):NO GROWTH. Brief Hospital Course: Mr. [Known lastname 76462] was [Last Name (un) 4662] to [Hospital1 18] from [Hospital3 4107] after being rearended by a vehicle moving at approximately 30 mph. There was no loss of consciousness. Pt complaining of low back pain and inablity to move legs. CT of c-spine showed C7 perched over T1 with central cord compression. C7-T1 subluxation- Mr. [Known lastname 76462] was brought to the OR to undergo a posterior decompression, C6-7, C7-T1, T1-T2 laminectomy, facetectomy and foraminotomy with posterior cervical arthrodesis, C5-T2. He was brought to the TSICU after the procedure intubated. On POD #1 he was extubated without complication and transfered to the floor. On POD#2 an IVC filter was placed without complication. The rest of his hospital course was unremarkable. He was then transfered to an outside rehab facility. Dural Tear- Mr. [Known lastname 76462] continued to have a presistant drainage from his posterior cervical incision. He was brought to the OR and was found to have a non-iatrogenic cervical dural tear. fibrin glue and Duragen patch were applied. A lumbar drain was placed to decrease CSF leakage. The head of bed was kept at greater than 30 degress. His posterior incision continued to heal. Medications on Admission: None Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever. 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 3. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 4. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for breakthrough pain. 5. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours) as needed for pain. 6. Famotidine 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 8. Diphenhydramine HCl 50 mg/mL Solution Sig: One (1) Injection Q6H (every 6 hours) as needed for itching. 9. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1) Injection Q8H (every 8 hours) as needed for nausea. 10. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever. 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. 14. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed. 15. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed. 16. Lorazepam 0.5 mg IV Q4H:PRN Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: 1. Motor vehicle accident. 2. Fracture/dislocation C7-T1 with incomplete spinal cord injury. 3. Obesity Discharge Condition: Stable to rehab facility Discharge Instructions: Please keep incision clean and dry. You may shower in 48 hours, but please do not soak the incision. Change the dressing daily with clean dry gauze. If you notice drainage or redness around the incision, or if you have a fever greater than 100.5, please call the office at [Telephone/Fax (1) ]. Please resume all home mediciation as prescribed by your primary care physician. [Name10 (NameIs) ] have been given additional medication to control pain. Please allow 72 hours for refills of this medication. Please plan accordingly. You can either have this prescription mailed to your home or you may pick this up at the clinic located on [Hospital Ward Name 23] 2. We are not allowed to call in prescriptions for narcotics to the pharmacy. If you have questions concerning activity, please refer to the activity sheet. Followup Instructions: Please follow up with Dr. [Last Name (STitle) 1352] at THREE weeks from the date of your discharge. You can make that appointment by calling [Telephone/Fax (1) ] Completed by:[2145-2-22]	[ "278.00", "998.83", "997.09", "806.09", "344.1", "E812.0", "314.01", "041.04", "907.2", "518.0", "707.05", "599.0", "997.3", "997.5" ]	icd9cm	[ [ [] ] ]	[ "81.03", "03.53", "83.39", "81.62", "77.79", "03.59", "03.09", "88.65", "88.51", "03.79", "38.7" ]	icd9pcs	[ [ [] ] ]	9212, 9282	6405, 7667	342, 721	9434, 9461	1203, 6382	10349, 10551	934, 952		7722, 9189	9303, 9413		7693, 7699			9485, 10326							967, 1184																280, 304								749, 838													860, 866	882, 918
67,265	136,850	44692	Discharge summary	report	Admission Date: [2129-10-13] Discharge Date: [2129-10-16] Date of Birth: [2077-8-20] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2108] Chief Complaint: Abdominal pain, GI Bleed Major Surgical or Invasive Procedure: EGD [2129-10-13]: cauterization of non-bleeding visible blood vessel History of Present Illness: Mrs. [Known firstname 14880] [Known lastname ] is a 52 year old female with a past medical history of peptic ulcer disease and gastric bypass who presents with abdominal pain, recent melena, and decreased hematocrit. She reports doubling over with epigastric pain last sunday that has intermittantly come and gone since and is similar to her abdominal discomfort when she had peptic ulcers in the past. She has also had dark black stools on several occasions since last sunday, very prolific and loose on two occasions. She did not have a bowel movement today. She has also had some intermittant lightheadedness and has felt quite fatigued and cool. She reports increased stress in her life recently and she has not been eating as well. She saw her PCP today and was reportedly guaiac positive in the office with a hematocrit of 28, down from a baseline of 36+. Patient was sent to the ED for further evaluation. In the ED, initial vs were: pain 2, T 98.3, HR 72, BP 115/79, RR 14, O2 sat 100% RA. There was no stool in the rectal vault to guaiac on exam. Exam was otherwise unremarkable. Labs were notable for a hematocrit of 27.8. NG lavage was deferred given altered gastric anatomy and assumption that patient would require EGD regardless. Case was discussed with GI who requested patient be kept NPO for EGD in am. Patient declined blood transfusion in the ED as she is a Jehovah's witness. She received 2L NS, pantoprazole 80 mg IV and 30 cc of viscous lidocaine PO. Patient remained hemodynamically stable throughout her time in the ED. Vital signs on sign-out were BP 106/65, HR 57, RR 19, O2 sat 100% RA. Repeat hct prior to leaving the ED was 23.9. On arrival to the ICU the patient was sleepy, denying any current abdominal pain. She was somewhat thirsty but otherwise felt well. Review of systems: (+) Per HPI, + 100 pound weight loss since gastric bypass surgery, + headache x 2 days, left eye swelling 2 days ago (no vision changes) that has since resolved. + sore throat 2 days ago that has resolved. + intermittant nausea. (-) Denies fevers, night sweats, vision or hearing changes, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations. Denies vomiting, constipation. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: - Peptic ulcer disease with hx of 4 ulcers in stomach and small bowel, requiring emergent endoscopy in the past (presented with syncope and blood per rectum). s/p treatment for H. pylori - s/p gastric bypass 2-3 years ago (@ [Hospital1 92021] hospital) - Fatty liver disease - Obstructive sleep apnea - Hyperparathyroidism - Depression Social History: Patient is a teacher and going to school part-time at nights. She lives with her 16 year old son who has mental retardation and is struggling with a legal issue with her son currently. She is a Jehovah's witness. - Tobacco: Less than 1 ppd until early 30s - Alcohol: Occasional, 1-2 times per month - Illicits: None Family History: Non-contributory Physical Exam: Physical Exam on Admission: Vitals: T: 96.9 BP: 114/64 P: 62 (lying down, 72 sitting up) R: 16 O2: 100% RA General: Obese African-American female in no acute distress, drowsy HEENT: Sclera anicteric, MM dry, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, no clubbing, cyanosis or edema Pertinent Results: Imagings: [2129-10-13] - EGD: Previous Billroth II of the stomach. Both limbs were identified. One [Year (4 digits) 3099] on the left side was unable to be entered although no obvious ulceration was seen. At the entrance to the other [Last Name (LF) 3099], [First Name3 (LF) ] approx 2cm ulcer with overlying clot and no active bleeding was identified. This apparent visible vessel was cauterized. Just proximal to this region was a 4mm steel U-shaped clip protruding from the mucosa. No active bleeding or ulceration was associated with this clip. Otherwise normal EGD to third part of the duodenum. Recommendation: High risk to re-bleed, and if does re-bleed would need emergent EGD to re-assess. Given that she had bleeding on acid therapy without being on NSAID or aspirin therapy, would recommend starting carafate as well as continuing high dose PPI therapy. Will need follow-up EGD in [3-22] weeks time to re-assess. [2129-10-14] - UGI/SBFT/BAS: Unremarkable appearance of gastric pouch status post previous gastric bypass. No evidence of gastrogastric fistula. [2129-10-15]: AC joint subluxation, concerning for ligamentous injury. No acute fracture detected. Brief Hospital Course: 52 yo Jehovah??????s witness female with history of significant PUD and history of gastric bypass presented with several days of epigastric discomfort, melenic stool, lightheadedness and Hct drop. GIB/Anemia secondary to PUD with a visible vessel: The patient was treated with cautery to vessel, IV and PO iron. She is a Jehovah's witness and refused blood transfusion. Despite this her hct remained stable after treatment to the bleeding ulcer. She was discharged on carafate, [Hospital1 ] PPI and PO iron. She was told to contact hematology to discuss IV iron as an outpatient. In addition she will need a repeat endoscopy to evaluate healing of the ulcer at the anastomotic site per GI, the GI team will contact the patient to schedule this, in case she was also given the number if she does not hear from the GI team after she leaves the hospital. H pylori stool antigen and serum gastrin level also sent and pending at the time of discharge. In addition the patient is at risk of rebleed, she will follow up with her PCP [Name Initial (PRE) 176] 1 week for a hct check but more importantly was given very clear instructions on warning signs including increasing melena or melena continuing for 3-4 days after discharge from the hospital, red blood in stool, nausea, vomiting, abdominal pain lightheadedness or generally feeling fatigued or unwell. AC JOINT SUBLUXATION: mild symptoms. possibly related to arm positioning during EGD as EGD preceeded onset of pain. Treated conservatively with OTC pain medications and symptoms improved. Medications on Admission: Omeprazole 20 mg daily Citalopram 40 mg daily Erythromycin eye ointment QID Multivitamin Vitamin D Calcium Omega-3 fatty acids B complex Selenium Iron supplement - occasionally, not currently taking Discharge Medications: 1. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Disp:60 Capsule, Delayed Release(E.C.)(s) Refills:2 2. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:120 Tablet(s) Refills:2 3. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Vitamin D Oral 7. B Complex Oral 8. selenium Oral 9. omega-3 fatty acids Oral 10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): take while taking iron supplements. Disp:60 Capsule(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Bleeding gastric ulcer anemia, acute blood loss Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with a bleeding ulcer in your stomach. This was treated with medications and cautery to the bleeding ulcer via endoscopy. Please continue to take your medications as prescribed and make your follow up appointments. Followup Instructions: Please follow up with your primary care physician [Name Initial (PRE) 176] 1 week of your discharge from the hospital. [Last Name (LF) ],[First Name3 (LF) ] [Telephone/Fax (1) 2261]. Please follow up with the gastroenterologists to have your endoscopy repeated in 6 weeks to make sure that the ulcer is healing - The gastroenterologists stated that they will call you to schedule this, if you do not hear from them please call Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] office ([Telephone/Fax (1) 12401]. Please follow up with a hematologist within 2 weeks to discuss IV iron infusions. ([Telephone/Fax (1) 14703]	[ "V45.86", "311", "252.00", "831.04", "571.8", "285.1", "327.23", "E879.8", "534.40", "E849.7" ]	icd9cm	[ [ [] ] ]	[ "44.43" ]	icd9pcs	[ [ [] ] ]	8001, 8007	5413, 6972	342, 416	8118, 8118	4185, 5390	8528, 9202	3544, 3562		7221, 7978	8028, 8028		6998, 7198			8269, 8505							3577, 3591														2281, 2828		278, 304								444, 2262						8047, 8097	3605, 4166	8133, 8245					2850, 3192	3208, 3528
45,589	168,856	33720	Discharge summary	report	Admission Date: [2172-7-23] Discharge Date: [2172-8-4] Date of Birth: [2138-8-3] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) Attending:[First Name3 (LF) 3276] Chief Complaint: Neutropenic fever, atrial fibrillation Major Surgical or Invasive Procedure: none History of Present Illness: The patient is a 33 year old female with a recently diagnosed thymoma. She is s/p her first round of chemotherapy with cyclophosphamide, doxorubicin and cisplatin which she underwent [2172-7-13]. Now, she has been referred to the ED by her Oncologist, Dr. [Last Name (STitle) 3274], for her febrile neutropenia. At home her temperature was 101.9. Of note, she was also recently admitted from [Date range (1) 23466] for Afib with RVR. At that time she was complaining of chest pain at the biopsy site. She was found to be in Atrial flutter on f/up EKG and ruled out for MI. n ECHO during that admission revealed an effusion but was negative for tamponade. She was rate controlled with metoprolol and a digoxin load. A CTA showed large mediastinal mass and cardiothoracic surgery did not feel there was any need for intervention as it was not felt to be hematoma. A repeat ECHO during admission showed decrease in size of her pericardial effusion. During her admission she had episodes of hypoxia requiring supplemental O2 which was felt to be due to combination of Afib and pulmonary edema and atelectasis. She had a port placed during the admission for chemotherapy. Following her discharge, she returned to the ED on [2172-7-20] for low BPs found by VNA services. She was rehydrated with IVFs and her hypotension soon resolved. . On the current admission, she presented to ED w/fevers to 101.9 F. She was tachycardic with HR up into the 200s. She had blood cultures drawn and received vancomycin and cefepime, as well as ibuprofen 600mg x 1. She received 3L IVF. Labs were significant for anemia, neutropenia, thrombocytopenia, and a transaminitis, which has been stable and extensively worked up on a prior admission but exact etiology still unknown. Brief Oncology History : Ms. [Known lastname 78024] [Last Name (Titles) ] presented with Afib in [3-/2172] that began during a LEEP procedure for HGSIL. She presented again with Afib/RVR in [5-/2172] to [Hospital 1474] Hospital. At that time CXR showed a large anterior mediastinal mass. She was referred to Dr. [Last Name (STitle) ] at [Hospital1 18] and underwent biopsy on [2172-6-22] with pathology showing a lymphocyte [Doctor First Name ] thymoma. Flow Cytometry showed a non-specific T cell dominant lymphoid profile with diagnostic immunophenotypic features of involvement by a B cell non-Hodgkin lymphoma seen in specimen. She was initially evaluated at [Hospital1 18] Oncology on [2172-7-2] and recommendations were made for neoadjuvant chemoradiation prior to surgical resection. As per HPI above she is s/p her 1st course of chemo on [7-13] including cyclophosphomide, doxurubicin, cisplatin. The plan for her is chemo-radiation and then surgical intervention. B1 thymoma has a good prognosis and Rx is curative. Past Medical History: # Thymoma ([6-30]) and status post chemotherapy [7-13] (cyclophosphamide, doxorubicin and cisplatin regimen) #Afib/flutter, diagnosed [3-/2172] # h/o transaminitis/LFT elevations - liver Bx from [Hospital1 1474] in [1-/2172] nonspecific minimal lobular and portal mononuclear cell inflammation w/ rare hepatocyte necrosis. - negative for Hep A, B, and C # anemia, etiology [Last Name (un) 5487] # h/o high grade cervical SIL Social History: Previously worked as a case manager for a home care company, out of work since recent diagnosis of Thymoma. Lives with her mother in [Name (NI) 701]. History of social alcohol use, none current. No tobacco or illicits. Unmarried but has boyfriend currently. Family History: Sister has atrial fibrillation and elevated liver enzymes, unknown cause. Father with DM-2, HTN, hypercholesterolemia. Mother-GERD. [Name2 (NI) ] other cancers per patient. Physical Exam: On admission/[Hospital ] transfer to the ICU the patient's Physical Exam was as follows: Physical Exam: T: 98.8 BP: 104/54 HR: 104 RR: 16 O2 100% RA Gen: ill appearing, pale, anxious affect HEENT: + conjunctival pallor. No icterus. MM dry. OP clear, no thrush. NECK: Supple, No LAD, No JVD. No thyromegaly. CV: irregularly irregular. nl S1, S2. No murmurs, rubs or [Last Name (un) 549] LUNGS: CTAB, good BS BL, No W/R/C ABD: NABS. Soft, NT, ND. No HSM EXT: WWP, NO CCE. 2+ DP pulses BL SKIN: No rashes/lesions, ecchymoses. NEURO: sleepy, but arousable and appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 4+/5 strength throughout, but nonfocal. [12-25]+ reflexes, equal BL. Gait assessment deferred . Pertinent Results: Pertinent Past Studies: ECHO [2172-7-14]: Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%) Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. The mitral valve leaflets are structurally normal. There is a small to moderate sized pericardial effusion subtending primarily the posterior and lateral walls of the left ventricle. There are no echocardiographic signs of tamponade. No right atrial or right ventricular diastolic collapse is seen. Compared with the findings of the prior study (images reviewed) of [2172-7-10], the pericardial effusion is smaller. . CTA Chest [2172-7-10]: IMPRESSION: 1. No PE but limited study due to large anterior mediastinal mass. 2. Rounded hyperdense swirling density arising from site of prior biopsy, extending through the right anterior chest wall into the subpectoral soft tissues, most c/w hematoma; however, concerning for possible superinfection vs residual air related to bx. Also possible contiguous tumor extension and invasion through the chest wall, though unlikely 3. No significant interval change in appearance of biopsy-proven thymoma 4. Increased small to moderate pericardial effusion, and small bilateral pleural effusions. [1-/2172]: liver Bx from [Hospital1 1474] in [2172-1-24] showed nonspecific minimal lobular and portal mononuclear cell inflammation w/ rare hepatocyte necrosis. Current Admission [2172-7-23]: EKG [7-23]: aflutter 2:1 block @ 125, right bundle pattern in V1-V2 and III. Normal axis. Good r wave progression. . CXR [7-23]: Wide mediastinum with known anterior mediastinal mass. No other focal infiltrates or edema noted. [2172-7-23] 10:35PM DIGOXIN-0.4* [2172-7-23] 11:26PM LACTATE-2.0 [2172-7-23] 11:02PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2172-7-23] 11:02PM URINE RBC-0 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2 [2172-7-23] 10:35PM GLUCOSE-111* UREA N-5* CREAT-0.5 SODIUM-139 POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-28 ANION GAP-14 [2172-7-23] 10:35PM ALT(SGPT)-62* AST(SGOT)-60* ALK PHOS-451* TOT BILI-0.7 [2172-7-23] 10:35PM CALCIUM-9.5 PHOSPHATE-2.5* MAGNESIUM-2.0 [2172-7-23] 10:35PM PT-15.8* PTT-43.8* INR(PT)-1.4* [2172-7-23] 03:00PM UREA N-9 CREAT-0.6 [2172-7-23] 03:00PM DIGOXIN-0.5* [2172-7-23] 03:00PM WBC-0.6* RBC-2.71* HGB-8.7* HCT-25.1* MCV-93 MCH-32.0 MCHC-34.6 RDW-11.9 [2172-7-23] 03:00PM GRAN CT-40* [2172-7-23] 02:34PM ALBUMIN-3.8 CALCIUM-9.7 PHOSPHATE-2.4* MAGNESIUM-2.0 [2172-7-23] 02:34PM WBC-0.7# RBC-2.96 HGB-9.5* HCT-27.6* MCV-93 MCH-32.0 MCHC-34.4 RDW-12.1 [2172-7-25] - Throat culture pending [2172-7-26] - Final Blood and Urine Cx pending from [2172-7-24] and [2172-7-25], negative to date as of [2172-7-26]. Brief Hospital Course: # SIRS : On admission, the patient met SIRS criteria of fever, leukopenia, and tachycardia plus suspected infection on initial presentation. BLood, urine and throat cultures were negative and CXR remained without evidence of infiltrates. The patient has a left sided subclavicular placed port which appeared clean and without bleeding, discharge on daily exams so it is an unlikely infection source. UAs and cultures do not reveal any UTI sources to date nor are there any clinical symptoms to suspect GI source (no diarrhea, abdominal pains, occasional nausea likely chemo related). She completed a course of IV vancomycin and cefepime, and remained afebrile for the remainder of her admission. . # Fevers: persistent fevers alongside neutropenia s/p recent chemotherapy ([7-13])prior to admission. As of [2172-7-27], the patient is no longer neutropenic. She remained afebrile for the duration of her admission. . # Afib: with RVR in ED on [7-23]. Etiology of A-fib thought to be due to tumor burden irritation on pericardium, pulmonary vessels. Ddx also includes fevers, tamponade, hypovolemia, sepsis. Currently her plan for ablation at [Hospital 1474] Hospital is on hold until patient stabilizes. Anemia may be contributing to afib/tachycardia also, thus was transfused 2 u pRBCs on [2172-7-27] - volume replete with NS IVFs - monitored UOP, keeping >35cc/hr - rate control attained through beta blocker, increased dose during ICU stay and continued home level Digoxin. No evidence of tamponade on exam currently. - CHADS score of 0 so ICU team felt there was no need for systemic anticoagulation. #Anxiety - patient had crying and appeared extremely anxious during her stay so a psychiatric consult obtained and per recs she began Remeron as it was felt this would not only help her anxiety and mood but boost her poor appetite too. She was also given PRN Ativan as dosing of Remeron will take several weeks for full effects/benefits. #Chest pain: patient c/o intermittent [2174-2-24] chest pain throughout her ICU stay. It was felt this pain was due to mediastinal mass or recent biopsy or combination of both. There is possible contribution of pericardial inflammation from mass. Unlikely ischemic in nature given pattern and presentation. Pain was control with Oxycontin and Oxycodone prn and later Morphine PRN given as her nausea seemed to increase with oxycontin dosing. . # Anemia: Current Hct consistent with prior values during recent admission. TSH, B12, folate nl. Retic was 1.8% in setting of anemia suggesting poor erythropoiesis. Currently no suggestion of hemolysis with low normal K, Tbili of 0.7. Ddx includes myelosuppression s/p chemo, thymoma/MDS(pure red cell aplasia). GI source less likely. Her hematocrit was trended without further need for transfusion. # Thrombocytopenia: Trended upward throughout ICU stay. Suspect this change was due to myelosuppression from chemotherapy. She was given transfusions Plts for Plts<10. She had no evidence of bleeding during stay and by HD#4, on [7-26] her Plts had come back up to 170s range. They remained stable and no further transfusions were needed. . # Transaminitis: LFTs c/w recent values. Per liver c/s, ddx includes congetive, autoimmune, drug induced. Hepatitis serologies were negative. Hemochromatosis ruled out by Fe/TIBC < 45. TSH normal. GGT significantly elevated suggesting possible biliary process. RUQ u/s showed only cholelithiasis. Anti-smooth muscle negative. IgG normal. Mitochondrial M2 IgG normal. Ceruloplasmin normal. TTG-IgA was normal. Had liver bx at OSH which was unrevealing. Liver had also recommended checking LKM-1, [Doctor First Name ], AMA Abs to r/o autoimmune hepatitis but cannot find record of those in system. LFTs were trended during her admission and remained stable. Tylenol and other hepatotoxic agents were avoided during admission. . # B1 Thymoma: s/p her 1st course of chemo on [7-13] including cyclophosphomide, doxurubicin, cisplatin. The overall plan for her is chemo-radiation and then surgical intervention. B1 thymoma has a good prognosis and Rx is curative. She has a follow-up appointment with Dr.[Last Name (STitle) 3274] in clinic the week after her discharge to continue with chemotherapy. Medications on Admission: Medications on admission: cyclophosphomide doxurubicin cisplatin Oxycodone SR 20 mg Q12H Docusate Sodium 100 mg [Hospital1 ] prn Senna 8.6 mg [Hospital1 ] prn Oxycodone 10 mg Q4H prn Metoprolol Tartrate 50 mg [Hospital1 ] Digoxin 125 mcg DAILY Prochlorperazine 10 mg Q6H prn Ondansetron 4 mg Q8H prn Lactulose 30 ML PO Q6H prn Discharge Medications: 1. Digoxin 125 mcg 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. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). 4. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 5. Ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed. 6. Metoprolol Tartrate 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 7. Lorazepam 0.5 mg Tablet Sig: one-half Tablet PO Q4H (every 4 hours) as needed for anxiety. 8. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO five times a day for 8 days: Take 1 tablet five times per day for eight days. Then take 1 tablet three times per day. Disp:100 Tablet(s) Refills:0 9. Mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital1 1474] VNA Discharge Diagnosis: Thymoma Atrial fibrillation Anxiety Depression Discharge Condition: stable, afebrile Discharge Instructions: You were admitted with neutropenia, fever and atrial fibrillation (an irregular heart beat). You were treated with antibiotics, IV fluids and rate control medication for your heart rate (metoprolol, digoxin). Please continue to take your heart rate medications as ordered. You were also started on medications for your depression and anxiety (lorazepam and remeron). Please make sure to follow up with your outpatient psychiatrist to continue these mediations. If you experience any dizziness, racing heart beat and/or shortness of breath, chest pains or any other concerning symptoms please contact your doctor or return to the hospital. Followup Instructions: Provider: [First Name8 (NamePattern2) 251] [Name11 (NameIs) ], MD Phone:[0-0-] Date/Time:[2172-8-4] 11:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 10921], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2172-8-4] 11:00 Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 10384], RN Phone:[Telephone/Fax (1) 22] Date/Time:[2172-8-4] 12:00 [First Name8 (NamePattern2) 251] [Name8 (MD) ] MD [MD Number(1) 3282] Completed by:[2172-8-7]	[ "E933.1", "995.93", "054.9", "164.0", "564.00", "296.20", "790.4", "786.59", "288.00", "427.31", "276.52", "427.32", "780.6", "284.89" ]	icd9cm	[ [ [] ] ]	[ "99.25" ]	icd9pcs	[ [ [] ] ]	13530, 13585	7919, 12188	318, 324	13676, 13695	4912, 7896	14383, 14946	3964, 4142		12577, 13507	13606, 13655		12240, 12554			13719, 14360							4267, 4893																240, 280								352, 3196													3218, 3668	3684, 3948
14,434	147,348	26361	Discharge summary	report	Admission Date: [2155-11-11] Discharge Date: [2155-11-20] Date of Birth: [2116-12-12] Sex: M Service: [Last Name (un) ] CHIEF COMPLAINT: Abdominal pain. HISTORY OF PRESENT ILLNESS: The patient is a 48-year-old male with acute onset of abdominal pain at 4 p.m. on [11-10]. He had positive nausea and vomiting. He denied any diarrhea. No bright red blood per rectum. A CT scan done at an outside hospital demonstrated his SMV portal vein thrombosis with small bowel ischemia. He had periumbilical sharp constant pain, nonradiating. Positive nausea and vomiting, nonbilious. No flatus. No bowel movement x1 day. He denied any fever or chills. No chest pain or shortness of breath. PAST MEDICAL HISTORY: Significant for appendectomy. ALLERGIES: No known drug allergies. MEDICATIONS: He denied any medications. SOCIAL HISTORY: He denied any alcohol or smoking. FAMILY HISTORY: No history of DVT, PE's, clots. Father died at 62 of an MI. Grandfather died of an MI. Mother is healthy. PHYSICAL EXAMINATION: VITAL SIGNS: 97.8, 80 for heart rate, 157/63, respiratory rate 12, 100% on room air. He was alert and oriented. LUNGS: Clear to auscultation bilaterally. HEART: Regular rate and rhythm. ABDOMEN: Moderately firm, nondistended. Positive tender, positive rebound. No guarding. Guaiac negative. RECTAL: Normal tone. CT demonstrated SMV thrombosis, thickened small bowel with edema and fat stranding. Lung bases were clear. He had an extensive superior mesenteric venous thrombosis involving the main branch and most of its branches associated with increasing diameter of the veins and surrounding fat stranding. No apparent mass seen on the CT scan, however with this degree of venous thrombosis, it was felt that underlying malignancy could not be totally occluded especially at the level proximal to the SMV where its diameter measured 1.5 cm. Dilated small bowel was noted with wall thickening and edema surrounded by ascites representing bowel ischemia due to venous thrombosis. There was a moderate amount of ascites seen in the upper abdomen as well. Branching low density opacities in the peripheral portion of the right lobe of the liver were noted, possibly representing clots in the peripheral portal vein, associated with heterogeneous perfusion of the liver. ADMISSION LABORATORY DATA: White count of 13.7, hematocrit 42.8, platelet count 237, lactate 1.2, potassium 4.4, creatinine 1.1, glucose 163, AST 15, ALT 37, alkaline phosphatase 73, total bilirubin 1.8. The patient was admitted to the hospital. He came in through the emergency room and admitted to the hospital. He was admitted to the general surgery service with a vascular consult. He was made NPO. An NG tube was placed as well as a Foley. He was started on IV fluids and IV Levaquin and Flagyl. He was preop'd. He was taken to the OR on [2155-11-11]. He underwent an exploratory laparoscopy and resection of the small bowel and temporary abdominal closure. Surgeon was Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], assisted by Dr. [First Name (STitle) ] [Name (STitle) ] and Dr. [First Name (STitle) 19047] [Name (STitle) 19048]. Mesenteric venous occlusion and intestinal ischemia was noted. EBL was minimal. Complications none. Please see operative report. The patient received general anesthesia, taken to the PACU where he was recovered. He was placed on IV heparin, IV propofol and fentanyl. Urine outputs approximately 16 to 38 cc. He was bolused with fluid. Urine output picked up to 220 to 120 cc per hour. He had 2 JPs draining approximately 100 to 450 cc serosanguineous fluid. He was medicated with IV morphine, propofol and fentanyl. He was transferred to the SICU, intubated and paralyzed. He was maintained on a heparin drip. He returned to the OR on [11-12] for a second laparotomy and small bowel anastomosis. Small bowel ends were viable. The remainder of the bowel was viable. Please refer to operative note regarding final closure. He was returned to the SICU and he was maintained in Levofloxacin and Flagyl IV. Minimal EBL. His sedation was weaned. He was made NPO. He had an NG tube in place. He was continued on IV Heparin with a goal of keeping the heparin in the range of 60 to 80. His abdomen was soft. His hematocrit was stable at 38.2. His vital signs were stable. Temperature 99.7, heart rate 80 to 90 and in sinus rhythm, BP 120 to 140/75 to 90 with a respiratory rate of 8 to 14, saturating at 97 to 100% on 2 liters nasal cannula. White blood cell count was 5.2, hematocrit was 32.3, platelet count 148. PTT was 156.3, heparin was adjusted. The patient was extubated on postoperative day [2-5]. He was maintained on a PCA. He was out of bed with this. He was NPO. His IV fluid was replaced but was decreased. Coags were monitored. Heme consult was obtained. IMPRESSION: A 38-year-old male with mesenteric venous thrombosis and ischemia of unclear etiology, status post infection. No antecedent infection or evidence of bacteremia or strong family history of thrombosis or suggestive evidence of PNH for underlying malignancy. The most common forms of inherited thrombophilia result in mesenteric venous occlusion included P and H, protein CNS deficiency, and antithrombin-3 deficiency. RECOMMENDATIONS: Recommendations at this time included checking an anticardiolipin antibody, and a beta-2 glycoprotein. Recommendations included checking genetic testing for Factor V Leiden and prothrombin gene mutation. Other testing was recommended to be deferred to the outpatient setting of anticoagulation. Anticoagulation was recommended to continue, potentially for life given the high stakes of recurrent mesenteric thrombosis. It was noted that he should be taken off the anticoagulation temporarily to facilitate testing at some point. This was recommended to be arranged in follow up as an outpatient. Consultant was [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], MD, co-signed by Dr. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ]. The patient was transferred to the medical surgical unit on [11-14], postoperative day 3 and 2. IV heparin was continued. Rate was adjusted. Vitals remained stable. He continued to be NPO with an NG tube in place receiving IV fluids. PCA morphine was used for comfort. Urine output was excellent. Coumadin was started on postoperative day [4-9]. Foley was disconnected. The patient was able to void independently. Bowel sounds were hypoactive. Diet was advanced to sips. Hematocrit was stable at 38.4. He continued to receive 5 mg of Coumadin once daily. His IV fluid was Hep- Lock'd on postoperative day [5-11]. He was passing flatus. He was continued on sips of fluid. Vital signs were stable. Abdomen was soft, mildly distended with positive bowel sounds. Incision was opened to air, it was stable with no signs of infection. Hematology followed during this hospital course. It was felt that it was reasonable to defer genetic testing and further testing until the outpatient setting. His INR was 2.9 on postoperative day 6 after 2 days of Coumadin. His Coumadin was held on [11-19], postoperative day 7 and 8. His diet was advanced to regular diet on postoperative day [9-14]. His INR was 3.5. His Coumadin was adjusted to 2 mg per day. He was ambulatory, tolerating a regular diet. Incision was intact with clips. No signs of infection. Hematocrit was stable at 34.4. Of note pathology report of small intestine on [2155-11-11] with final report on [2155-11-16] was notable for transmural hemorrhagic infection of the small bowel and mesentery (clinical acute thrombotic event). The resection margins were viable. No malignancy was identified. DISCHARGE LABORATORY DATA: White blood cell count 4, hematocrit 34.2, platelet count 242, PT 20.7, PTT 34.7, INR 3.1, Sodium 138, potassium 4, chloride 104, bicarbonate 27, BUN 13, creatinine 1.0, glucose 91. DISCHARGE MEDICATIONS: 1. Coumadin 2 mg PO once daily. The patient was scheduled to have PT/INR drawn on Friday, [11-21], with results to be followed up by Dr. [First Name (STitle) ]. 2. Protonix 40 mg PO once daily. 3. Percocet 5/325 mg tablet one tab PO p.r.n. q4 to 6 hours as needed for pain. 4. Prescription was provided for outpatient PT/ INR to be done. He was scheduled to follow up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] on [11-21]. His lab work and then follow up appointment was scheduled for Monday, [2155-11-24], at 1:30 with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. He was also scheduled to follow up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] from hematology on [1-9] at 9 a.m. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], [MD Number(1) 3432] Dictated By:[Name8 (MD) 4664] MEDQUIST36 D: [2155-11-27] 11:14:19 T: [2155-11-28] 12:27:14 Job#: [Job Number 65224]	[ "557.0", "789.5" ]	icd9cm	[ [ [] ] ]	[ "45.62", "45.93", "54.12" ]	icd9pcs	[ [ [] ] ]							926, 1033		8039, 9104																					1056, 8016								175, 192								221, 723													746, 857	874, 909
6,805	189,950	5987	Discharge summary	report	Admission Date: [2122-6-2] Discharge Date: [2122-6-11] Date of Birth: [2074-1-7] Sex: M Service: Neurosurgery HISTORY OF PRESENT ILLNESS: This is a 48-year-old HIV positive right-handed male with a known right MCA aneurysm size of 13 mm was status post cerebral angiogram on [2122-6-1] and complained of right leg numbness at angio site and headache status post angio. He was admitted to the surgical floor for further workup and eventual coiling of his right MCA aneurysm. PAST MEDICAL HISTORY: 1. HIV diagnosed in [2115] and CD4 260 and a viral load of 170. 2. He also has urinary frequency. ALLERGIES: Penicillin. MEDICATIONS: 1. Gabapentin 400 mg one tablet two times a day. 2. Terazosin HCL 2 mg one capsule at h.s. 3. Divalproex sodium 500 mg delayed release one tablet q.d. 4. Didanosine 200 mg delayed release two tablets q.d. 5. Lamivudine 150 mg two tablets q.d. 6. Folic acid 1 mg tablet p.o. q.d. 7. Multivitamin one p.o. q.d. 8. Thiamine 100 mg one p.o. q.d. 9. Fluconazole 100 mg p.o. q.24h. 10. Atazanavir sulfate 200 mg two capsules p.o. q.d. Patient has a longstanding history of memory deficits. He has had workup and a MRI, the last one was done [2122-4-17], where he was found to have a right MCA aneurysm approximately 13 mm. He underwent an angiogram on [2122-6-1], which showed a right MCA aneurysm - left/CA 4.5 mm. Patient reports recently having increased anxiety and depression over aneurysm. Did complain of transient right leg numbness and weakness. No headache on admission. No meningeal signs. Vital signs: 99.3, blood pressure 112/68, pulse 88, respirations 22, and 98%. PHYSICAL EXAM: Patient is awake, alert, and oriented times three, fluent speech. EOMI intact. Pupils are equal, round, and reactive to light and accommodation to ambient light. Cranial nerves II through XII were intact. Motor exam was [6-10] throughout. His sensation was intact bilaterally to lower extremities. He has no Hoffmann sign. Reflexes were 3 throughout. HOSPITAL COURSE: The patient was admitted to the Surgical Unit, and he had routine laboratory work performed, which was within normal limits and EKG and chest x-ray for preop for his coiling. He underwent a coiling on [2122-6-9]. Denied any headache pain, chest pain, or shortness of breath. Vital signs were 96.4, pulse 54, blood pressure 131/71. Lungs were clear. Cardiac: Regular rate and rhythm. Incision to his groin was intact. Neurologically: V1 through V3 sensation was intact. Face is symmetric. Motor exam was [6-10] in his upper extremities and his lower extremities, his quad on his right was 4-, left was 3+. ATs and gastrocs are [6-10]. No drift noted. He was monitored in the ICU overnight. His blood pressure was kept in the 100-150 range. A follow-up check at midnight showed that his upper extremities remained [6-10]. His right lower extremity hip flexors were [5-11]. His ATs and gastrocs are [6-10]. His left lower extremity, hip, and quads were [4-10] and AT and gastrocs were [6-10]. His PTT at that time was 104.5. Heparin was at a 1000 units an hour. He had Nipride to maintain blood pressure of 100-150. His neuro checks were within normal limits. On his first postoperative day in the morning, his vital signs are blood pressures 110-145/45-65. His temperature is 98.5. Hematocrit was 38.2. Sodium 138, potassium 3.7. His PTT was 42.6. He is alert, awake, oriented. Face was symmetric, and his strength in both his upper and lower extremities are [6-10]. He was transferred to the floor that day, and his Heparin was stopped. He was ambulating on the floor on the day of discharge tolerating a regular diet. Had some slight complaints of a headache, and was started on Fioricet with good relief. Patient will be discharged back to his shelter with instructions that he should return if he develops a significant headache, but is not relieved with the Percocet or Fioricet that he is going home on. He should not lift anything greater than 10 pounds for one month. Should watch his groin for redness, drainage, or swelling. DISCHARGE MEDICATIONS: 1. Gabapentin 400 mg one tablet p.o. b.i.d. 2. Terazosin 2 mg one tablet p.o. h.s. 3. Divalproex 500 mg one p.o. q.d. 4. Didanosine 200 mg two tablets p.o. q.d. 5. Lamivudine 150 mg two tablets q.d. 6. Folic acid 1 mg p.o. q.d. 7. Multivitamin one p.o. q.d. 8. Thiamine 100 mg p.o. q.d. 9. Fluconazole one tablet p.o. q.d. 10. Atazanavir sulfate 200 mg two tablets p.o. q.d. 11. Percocet 1-2 tablets p.o. q.4-6h. 12. Aspirin 325 mg one q.d. 13. Fioricet 1-2 tablets p.o. q.4h. prn headache, no more than six tablets per day. CONDITION ON DISCHARGE: Patient was discharged neurologically stable. [Name6 (MD) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 1133] Dictated By:[Last Name (NamePattern1) 23588] MEDQUIST36 D: [2122-6-11] 09:33 T: [2122-6-12] 05:03 JOB#: [Job Number 23589]	[ "042", "355.9", "348.39", "305.1", "304.21", "296.7", "V60.0", "437.3", "303.91" ]	icd9cm	[ [ [] ] ]	[ "39.72" ]	icd9pcs	[ [ [] ] ]									4188, 4714				2059, 4165									1679, 2041																								167, 509													531, 1663		4739, 5042
11,456	140,396	6377	Discharge summary	report	Admission Date: [2155-6-3] Discharge Date: [2155-6-12] Date of Birth: [2102-3-7] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1283] Chief Complaint: Asymptomatic, found to have enlarging aortic aneurysm on routine followup Major Surgical or Invasive Procedure: [2155-6-4] Redo sternotomy, Replacement of Ascending Aorta and Hemiarch (24 millimeter Gelweave) and Coronary Artery Bypass Grafting utilizing left internal mammary artery to left anterior descending artery History of Present Illness: Mr. [Known lastname 24641] is a 53 year old male who first underwent an AVR in [2145] for congenital aortic stenosis. In [2147-12-22], he underwent an urgent redo AVR for prosthetic valve endocarditis. Since that time, he has done quite well on medical therapy and remains asymptomatic. Routine follow up scans have found dilated aortic root and ascending aortic aneurysm. Serial scans have found that the diameter has progressively increased. His most recent MRI was from [2155-3-22] which found the aortic root measured 5.2 centimeters(which increased from 4.2 centimeters). Based upon the above results, he was referred for cardiac surgical intervention. Further workup included a cardiac catheterization which revealed single vessel coronary artery disease, specifically in his left anterior descending artery. Past Medical History: Dilated Aortic Root and Ascending Aortic Aneurysm, Congential Aortic Stenosis - s/p AVR [2145], History of Prosthetic Aortic Valve Endocarditis - s/p Redo mechanical AVR [2147], Hypertension, Hypercholesterolemia, History of Electrical Burn Injury - s/p Right arm amputation and skin grafting, History of Left Testicular Cancer - s/p removal Social History: Lives alone. Denies tobacco history. Admits to [1-24] ETOH drinks per day. He works as an excavating contractor. Family History: Father had MI at age 45. Physical Exam: Vitals: T 98.0, BP 110/60, HR 70, RR 14, SAT 96% on room air General: well developed male in no acute distress HEENT: oropharynx benign, Neck: supple, no JVD, Heart: regular rate, normal s1s2, crisp valve sounds Lungs: clear bilaterally Abdomen: soft, nontender, normoactive bowel sounds Ext: cool, no edema, no varicosities Pulses: 1+ distally Neuro: nonfocal Pertinent Results: [2155-6-3] 03:15PM BLOOD WBC-5.2 RBC-5.12 Hgb-16.5 Hct-46.8 MCV-92 MCH-32.3* MCHC-35.3* RDW-12.7 Plt Ct-195 [2155-6-3] 03:15PM BLOOD PT-12.5 PTT-22.4 INR(PT)-1.1 [2155-6-3] 03:15PM BLOOD Glucose-104 UreaN-6 Creat-0.8 Na-140 K-4.2 Cl-103 HCO3-28 AnGap-13 [2155-6-10] 08:27AM BLOOD WBC-6.2 RBC-3.63* Hgb-11.5* Hct-32.7* MCV-90 MCH-31.8 MCHC-35.3* RDW-12.9 Plt Ct-304 [2155-6-12] 05:35AM BLOOD PT-25.1* PTT-109.2* INR(PT)-2.5* [2155-6-11] 09:20AM BLOOD PT-16.6* PTT-64.2* INR(PT)-1.5* [2155-6-11] 05:17AM BLOOD PT-18.6* PTT-150* INR(PT)-1.8* [2155-6-10] 08:27AM BLOOD PT-15.2* PTT-70.6* INR(PT)-1.4* [2155-6-9] 02:30AM BLOOD PT-14.8* PTT-66.0* INR(PT)-1.3* [2155-6-12] 05:35AM BLOOD UreaN-14 Creat-1.1 K-4.8 [2155-6-10] 08:27AM BLOOD Glucose-115* UreaN-18 Creat-1.0 Na-140 K-4.2 Cl-104 HCO3-26 AnGap-14 [Last Name (NamePattern4) 4125]ospital Course: On admission, Mr. [Known lastname 24641] was started on intravenous Heparin for his mechanical aortic valve. He underwent routine preoperative evaluation. Workup was unremarkable and he was cleared for surgery. On [6-4], Dr. [Last Name (Prefixes) ] performed a redo sternotomy, coronary artery bypass grafting with replacement of his ascending aorta and hemiarch. For surgical details, please see operative note. Following the operation, he was brought to the CSRU for invasive monitoring. On postoperative day one, when weaning from sedation, Mr. [Known lastname 24641] became acutely agitated and self extubated. He concomitantly experienced language and comprehension difficulties. No focal motor deificts were noted. Given concern for stroke, a head CT scan was obtained and the neurology service was consulted. The head CT scan found no evidence of hemorrhage or mass effect. Hypodensities in the left basal ganglia and possibly the left occipital lobe were noted but of unknown chronicity. Based on the above results and concern for postoperative stroke, intravenous Heparin was initiated. Over the next 24 hours, his language and comprehension difficulities quickly improved. Further evaluation included a bedside swallow examination which found no evidence of aspiration. His CSRU course was otherwise unremarkable and he transferred to the SDU on postoperative day five. He experienced no further neurological insults. His speech and comprehension difficulties completely resolved. He was tranistioned from Heparin to Warfarin. Warfarin was dosed daily for a goal INR between 2.0 and 3.0. He temporarily required PICC line for venous access. As medical therapy was optimized, he continued to make clinical improvements with diuresis and made steady progress with physical therapy. Once his INR became therapeutic, he was medically cleared for discharge on postoperative day eight. At discharge, his room air saturations were 96%, his BP was 100/60 and HR of 78. He remained in a normal sinus rhythm and tolerated low dose beta blockade. Medications on Admission: Warfarin, Lisinopril 5 qd, Crestor 5 qd, Amoxicillin prn prophylaxis Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as needed for pain. Disp:50 Tablet(s) Refills:0 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 3. Rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 8. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:30 Cap(s) Refills:2 9. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:100 Tablet, Delayed Release (E.C.)(s) Refills:2 10. Warfarin 5 mg Tablet Sig: Two (2) Tablet PO qpm: Take as directed by MD. Dose may vary according to INR. Disp:120 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Ascending Aortic Aneurysm, Aortic Insufficiency, Coronary Artery Disease - s/p Redo sternotomy, Replacement of Ascending Aorta and Hemiarch and Coronary Artery Bypass Grafting, Transient Postoperative Neurological deficits PMH: AVR(mech '[45] redo for endocarditis '[47]),HTN, ^chol, L testicular CA s/p testiculectomy, electrical burn resulting in RUE amputation and mult skin grafts Discharge Condition: Good Discharge Instructions: Patient may shower, no baths. No creams, lotions or ointments to incisions. No driving for at least one month. No lifting more than 10 lbs for at least 10 weeks from the date of surgery. Monitor wounds for signs of infection. Please call with any concerns or questions. Resume Warfarin managment with Dr. [Last Name (STitle) 1295](as preop @ [Hospital1 ]). Please have INR checked within 2-3 days of discharge if possible. Goal INR between 2.0 - 3.0. [Last Name (NamePattern4) 2138]p Instructions: Dr. [Last Name (Prefixes) ] in [3-26] weeks - call for appt Dr. [First Name (STitle) 9959] [Name (STitle) ] in [1-24] weeks - call for appt Dr. [Last Name (STitle) 1295] in [1-24] weeks - call for appt [Hospital ] [Hospital 197] clinic - appt on Monday [6-16] Completed by:[2155-6-12]	[ "414.01", "V58.83", "272.4", "V10.47", "401.9", "V49.65", "E878.2", "441.2", "997.09", "V43.3", "424.1", "V58.61", "435.9" ]	icd9cm	[ [ [] ] ]	[ "88.72", "38.93", "39.61", "99.05", "38.45" ]	icd9pcs	[ [ [] ] ]	6664, 6713		393, 606	7150, 7157	2414, 3259		1991, 2017		5492, 6641	6734, 7129		5399, 5469			7181, 7641			7692, 8023				2032, 2395									3310, 5373							280, 355								634, 1468													1490, 1841	1857, 1975
14,611	139,464	50244	Discharge summary	report	Admission Date: [2135-7-28] Discharge Date: [2135-8-3] Date of Birth: [2085-10-21] Sex: F Service: MEDICINE Allergies: Bactrim Ds / Dicloxacillin Attending:[First Name3 (LF) 898] Chief Complaint: hypotension checked by VNA Major Surgical or Invasive Procedure: none History of Present Illness: Pt is a 49F w/ a h/o DM1 (c/b amputations), UC (on steroids chronically) s/p CVA found by VNA to have a SBP of 80. Brought to OSH and SBP was 66. Previous to this had been discharged from [Hospital1 ] on [7-23] after being treated for a foot infection following a TMA revision surgery of the left foot. She went home on PO cipro and PO linezolid. She started feeling run down on Monday [7-25] and sleeping more than usual. She also states she checked her temp and had a fever of 102. In addition she admits to feeling "groggy" in the a.m. and early afternoon for past 6 months and blames it on polypharmacy. No pressors were needed and BP responded to 4L fluid at OSH. ROS: Patient had fever, possibly chills, but denied nausea, vomiting, or abdominal pain. She was eating well until last two days. She denies chest pain. Single episode of SOB yesterday. No edema, urinary sx. No HA/dizziness Past Medical History: 1. Raynauds 2. DM type 1 complicated by peripheral neuropathy 3. HTN 4. CRI 5. CVA 6. UC 7. R partial hallux amputation 8. Laparoscopic distal pancreatectomy for neuroendocrine tumor 9. R 2nd toe amputation 10. PVD 11. s/p L TMA [2135-4-6] 12. s/p L TMA revision [2135-7-18] 13. s/p R BKA Social History: occasional alcohol former tobacco (15 pack years) Family History: non contributory Physical Exam: VS: 95.7 67 120/65 (art line) 98% 2L I/O 16hrs 2500/1450 GEN: NAD, AOX3 HEENT: MMM, NCAT, PERRL, EOMI CV: [2-8] cresc-decresc harsh systolic murmur heard @USB radiates to carotids, [2-8] holosystolic murmur heard @ apex PULM: slight bibasilar rales L>R ABD: soft, NT, ND, obese, No masses EXT: R BKA, L TMA- sutures intact, no discharge, dressing c/d/i. Pertinent Results: Lower Extremity Ultrasound: IMPRESSION: No evidence of DVT bilaterally [7-28] portable CXR: Left basilar opacity likely representing pneumonia. Follow-up chest radiograph should be performed to ensure resolution. [7-29] portable CXR: Increase caliber of the mediastinum is probably due to progressive venous engorgement, accompanied by lower lung volumes and probable increase in vascular congestion and mild pulmonary edema, all point to cardiac decompensation. Pleural effusion, if any, is small. No pneumothorax. portable abdomen [7-28]: No evidence of obstruction. ECHO [2135-8-1] Conclusions: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2135-4-7], no resting LVOT gradient is identified on the current study. [4-9] ECHO Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Left ventricular systolic function is hyperdynamic (EF 70-80%). Right ventricular chamber size and free wall motion are normal. There is no pericardial effusion. [2135-8-3] 05:00AM BLOOD WBC-4.5 RBC-2.66* Hgb-8.9* Hct-27.0* MCV-101* MCH-33.5* MCHC-33.1 RDW-14.5 Plt Ct-103* [2135-7-30] 04:24AM BLOOD PT-11.8 PTT-29.4 INR(PT)-1.0 [2135-7-31] 06:15AM BLOOD Ret Aut-1.7 [2135-8-3] 05:00AM BLOOD Glucose-85 UreaN-13 Creat-0.8 Na-146* K-3.8 Cl-111* HCO3-29 AnGap-10 [2135-7-29] 02:12AM BLOOD ALT-18 AST-19 LD(LDH)-170 CK(CPK)-323* AlkPhos-49 Amylase-18 TotBili-0.3 [2135-7-29] 02:12AM BLOOD CK-MB-11* MB Indx-3.4 cTropnT-0.04* [2135-8-3] 05:00AM BLOOD Calcium-9.0 Phos-2.3* Mg-1.7 [2135-7-31] 06:15AM BLOOD VitB12-247 Folate-GREATER TH Hapto-323* [2135-7-29] 02:13AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.020 [2135-7-29] 02:13AM URINE Blood-SM Nitrite-NEG Protein-NEG Glucose-500 Ketone-15 Bilirub-NEG Urobiln-0.2 pH-5.0 Leuks-NEG [2135-7-29] 02:13AM URINE RBC-0-2 WBC-0-2 Bacteri-RARE Yeast-NONE Epi-0-2 FECES NEGATIVE FOR C. DIFFICILE TOXIN URINE CULTURE (Final [2135-7-30]): NO GROWTH AEROBIC BOTTLE (Final [2135-8-4]): NO GROWTH. ANAEROBIC BOTTLE (Final [2135-8-4]): NO GROWTH AEROBIC BOTTLE (Final [2135-8-3]): NO GROWTH. ANAEROBIC BOTTLE (Final [2135-8-3]): NO GROWTH Brief Hospital Course: A/P: 49 year old female s/p recent TMA revision being treated with antibiotics for lower extremity ulcer and then developed hypotension and hyperglycemia, with a finding of LLL opacity on CXR. 1. Sepsis- The patient presented from the OSH with a picture of Sepsis/SIRS. Her blood cultures from [Hospital1 ] [Location (un) ] and [Hospital1 18] were all negative for growth during her hospital admission. A chest xray performed showed a left lower lobe infiltrate which was characterized later as most likely being atelectasis rather than pneumonia. When the patient was admitted, she had what looked like a cellulitis of her left lower extremity. She was started on vancomycin and levofloxacin and given IV fluids. She responsed well to treatment and at discharge she was afebrile with normal blood pressures. She will continue with her course of antiobiotcs on Linezolid PO and Levofloxacin PO for a complete 14 day course of antibiotics. An echo performed during her hospital admission did not reveal any signs of endocarditis. 2. Anemia- Patient's anemia is most consistent with anemia of chronic disease based on her labwork (see labs). She will continue on her iron, folate, and vitamin 12 as she's been doing. Her HCT was in her baseline throughtout her hospital admission. She will followup with her PCP for her anemia. 3. ARF- The acute renal failure was likely due to her hypotension and hypoperfusion. She was given IV fluids at admission with correction of both her hypotension and her creatinine. Prior to discharge, her creatinine was at her baseline. 4. Hypoalbuminemia- This was likely due to her poor nutritional state. Nutrition saw the patient and gave her recommendations on proper diet. 5. DM- On admission, the patients glucose was very high. She was started on an insulin drip, but was then converted to her home insulin doses. She was sent home on her Lantus and ISS based on [Last Name (un) ] recommendations. She will follow with her PCP regarding improvement in glucose control which will also help with her foot infections. 6. Decreased Platelets- During the [Hospital 228] hospital admission, she was noted to have a Plt count in the 300s in mid [Month (only) ], but prior to discharge she had dropped to the low 100s. We sent Heparin Dependent Antibodies since the patient was maintained on heparin due to her inability to ambulate. At discharge, the results were still pending. We have sent the patient home with instructions to VNA nursing to draw a repeat platelet level 2 days after discharge and inform her PCP of the result. Patient will be discharged home with VNA services. Medications on Admission: 1. Cilostazol 50 mg daily 2. Metoprolol Tartrate 25 mg [Hospital1 ] 3. Aspirin 81 mg DAILY 4. Mesalamine 1600mg TID 5. Calcium Carbonate 500 mg [Hospital1 ] 6. Citalopram 20 mg DAILY 7. Pantoprazole 40 mg Q24H 8. Simvastatin 10 mg PO DAILY 9. Nifedipine 30 mg Sustained Release DAILY 10. Prednisone 15 mg DAILY 11. Folic Acid 1 mg DAILY 12. Hexavitamin DAILY 13. Hydrochlorothiazide 50 mg DAILY 14. Duloxetine 20 mg Delayed Release DAILY 15. Acetaminophen 650 mg Q4H 16. Ascorbic Acid 500 mg [Hospital1 ] 17. Tizanidine 2 mg TID 18. Docusate Sodium 100 mg [Hospital1 ] 20. Hydromorphone 4 mg Q4H prn 21. Morphine 30 mg Sustained Release Q8H 22. Cipro 500 mg PO BID 23. Zyvox 600 mg PO BID 24. Humalog Sliding Scale Insulin 25. Glargine 22unit SQ qbedtime Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Four (4) Tablet, Delayed Release (E.C.) PO TID (3 times a day). 3. Cilostazol 50 mg Tablet Sig: One (1) Tablet PO daily (). 4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 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. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 10. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 11. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 12. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q4H:PRN as needed for fever or pain. 13. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Tizanidine 2 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID:PRN as needed for constipation. 16. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 17. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO every eight (8) hours as needed for pain. 18. Insulin Glargine 100 unit/mL Solution Sig: Twenty Four (24) units Subcutaneous QHS. 19. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1) units Subcutaneous four times a day: Please see attached sliding scale. 20. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:6 21. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 8 days. Disp:8 Tablet(s) Refills:0 22. Nicotine 7 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 23. Pregabalin 150 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 24. Linezolid 600 mg Tablet Sig: One (1) Tablet PO twice a day for 8 days. Disp:16 Tablet(s) Refills:0 25. Outpatient Lab Work Please draw platelet count and communicate results to Dr. [Last Name (STitle) 395],[First Name3 (LF) 25] M. [Telephone/Fax (1) 3070]. Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Primary Diagnosis: Systemic inflammatory response syndrome secondary to left lower extremity cellulitis Secondary Diagnosis: Peripheral Vascular Disease Ulcerative colitis Discharge Condition: stable. Discharge Instructions: You were admitted to the hospital because of a low blood pressure. Your blood pressure was brought up with fluids and you received antibiotics to fight infection. You will be discharged with two types of antiobiotics which you will complete at home on [2135-8-11] with followup on [2135-8-8] with Dr. [Last Name (STitle) 17751]. Please call your doctor or return to the hospital if you have: fevers, chills, worsening pain, shortness of breath, change in mental status, redness or discharge from foot wound. Followup Instructions: Please follow up with your primary care physican within 2 weeks of your discharge from the hospital. You have the following appointment: [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern4) 2604], MD Phone:[Telephone/Fax (1) 1237] Date/Time:[2135-8-8] 1:30	[ "285.21", "486", "V49.75", "403.90", "250.63", "556.9", "443.9", "038.9", "997.62", "584.9", "V58.65", "995.92", "443.0", "357.2", "682.7", "287.4", "585.9" ]	icd9cm	[ [ [] ] ]	[ "38.93" ]	icd9pcs	[ [ [] ] ]	10768, 10817	4857, 7519	313, 319	11034, 11044	2088, 4834	11615, 11901	1668, 1686		8343, 10745	10838, 10838		7545, 8320			11068, 11592							1701, 2069																247, 275								347, 1263			10964, 11013			10857, 10943							1285, 1584	1600, 1652
14,840	142,861	46816	Discharge summary	report	Admission Date: [2134-12-26] Discharge Date: [2135-1-2] Date of Birth: [2055-6-16] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 6029] Chief Complaint: leg pain Major Surgical or Invasive Procedure: none History of Present Illness: Pt is a 79 yo female with chf, htn, chronic venous stasis of legs who comes in with inability to ambulate since friday due to pain in her legs. She says that the pain is much worse in the right leg ("like a knife") and worsened with ambulation. She denies fevers, chills, n/v/d. On further questioning she does report intermittant sob and cp with ambulation. Past Medical History: -ischemic cardiomyopathy, EF 30-35% on echo in [1-7] -chronic lower extremity cellulitis -Diabetes mellitus -Hypertension -Coronary artery disease -S/P TKR in [2127] -hyperlipidemia Social History: The pt. is widowed and lives alone in an apartment. She is originally from [Country 532] but has lived in the US for 35 years. She has two children. She has a remote history of tobacco use. She denied use of alcohol or IV drugs. Family History: Noncontributory. Physical Exam: V/S T 97 BP 185/75 P 97 O2 100 RA Gen: alert and oriented x 3 Skin: erythema and scaling in multiple intriginous areas such as under breasts, flank skin folds, and stomach skin folds Neck: no jvp, RIJ in place lungs: cta heart: s1 s2 2/6 SEM abd: obese, nl bs, nt/nd ext: 3+ edema and erythema bilaterally, venous stasis changes from feet to knees, tender to touch R>L, warmth R>L, dp pulses + bilaterally (doppler) Pertinent Results: U/S- no dvt CT ab/pelvis- [2135-1-1] 1. Small bowel obstrcution, with transition point at the base of a bowel- containing anterior abdominal hernia. This finding was discussed with the surgical team, including doctors [Name5 (PTitle) 1299] and [Name5 (PTitle) ], at the time of image acquisition and interpretation. 2. Distention of the ascending, transverse, and a portion of the descending colon. This finding is of uncertain etiology and could possibly relate to mass effect upon the descending colon by an adjacent distended loop of small bowel, or, alternatively, could represent focal colonic ileus due to inflammation within the adjacent obstructed small bowel. Although this is a noncontrast examination and limited in the evaluation of the mucosa, there is no definite evidence of bowel wall thickening. The possibility of bowel ischemia cannot be entirely excluded, although there are no definite signs of ischemia such as gas within the portal mesenteric circulation. These findings were also discussed with Dr. [Last Name (STitle) ]. 3. Distention of the gallbladder, without evidence of pericholecystic stranding and with normal caliber of the common bile duct. 4. Ascites. 5. Bilateral pleural effusions and bibasilar atelectasis. Brief Hospital Course: Pt is a 79 yo female with mult med problems who presents with bilat LE swelling and erythema. Ddx: cellulitis vs. chronic venous stasis vs. ischemic disease LE Cellulitis- seemed chronic, however the pain in right leg was new. Cellulitis on right more likely since pain was present at all times and RLE was warm. She was treated with IV abx and there was great improvment with elevation and ace wrap. Cutaneous fungal infection- multiple areas of fungal type infection in intriginous regions especially right flank skin folds. -nystatin powder and a wound care nurse visited the patient every day. CHF- ischemic cardiomyopathy, EF 30-35% on echo in [1-7], legs seem very edematous, neck veins hard to evaluate. She was treated with lasix, aldactone, ace, bb Diabetes mellitus -cont'd glypizide -RISS -diabetic diet Hypertension -cont'd ace, [Last Name (un) ], bb Coronary artery disease- -cont'd outpt ASA -EKG showed no new changes Hyperlipidemia -continued outpt lipitor Depression -she was cont on outpt zoloft Diarrhea- patient developed diarrhea on [2134-12-29] and wbc count was increased on to 19.5 on [2134-12-30], c. diff and stool cultures were sent and came back neg. Patient's condition started to deteriorate on [2135-1-1], becoming more somnelant and a markedly tender abdomen and her abdominal hernia was not longer reducible. She was promptly evaluated by the surgery team to reduced her hernia and an ng tube was placed to send her for CT scan. At that time, patient's daughter insisted that the patient be full code although she was noted to be dnr/dni. Patient confirmed in the presence of an interpreter that she did NOT want to be resuscitated or intubated. Finally CT scan showed incarcerated hernia and patient was transferred to the MICU. In the MICU she was treated supportively, however, her condition deteriorated and she passed away on [2135-1-2]. Medications on Admission: lasix aldactone toprol xl lisinopril diovan asa zoloft lipitor Discharge Disposition: Expired Discharge Diagnosis: incarcerated hernia diarrhea CHF hypothyroid Depression CAD Diabetes type 2 hyperlipidemia Discharge Condition: Death [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 6035] Completed by:[2135-2-3]	[ "707.14", "244.9", "278.01", "557.0", "110.5", "584.9", "785.52", "552.1", "428.0", "995.92", "401.9", "682.6", "518.81", "V43.65", "459.81", "250.00", "038.9" ]	icd9cm	[ [ [] ] ]	[ "38.93", "00.17", "96.07" ]	icd9pcs	[ [ [] ] ]	4989, 4998	2957, 4875	324, 330	5132, 5259	1670, 2934		1201, 1219			5019, 5111		4901, 4966										1234, 1651																276, 286								358, 720													742, 933	949, 1185
75,668	133,337	21802	Discharge summary	report	Admission Date: [2125-6-18] Discharge Date: [2125-6-20] Date of Birth: [2075-1-31] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 613] Chief Complaint: Hyperkalemia Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: History of Present Illness: Mr [Known lastname ] is a pleasant 50 year old gentleman with hx ESRD, CAD s/p CABG, DM, now presenting with chief complaint of dizzy s/p fall, hyperkalemia at OSH. Pt states that he has been feeling weak for a couple of days, was scheduled for dialysis today however did not make the appointment because of fall. He did go to his dialysis on Wed. Pt fell down one stair, did hit his head but denies LOC. He states he fell because his legs were weak. He then presented to [Hospital1 3494] ED where he was found to be hyperkalemic with a K of 8.3. At [Location 57226], insulin and bicarb were given. He was transfered to [Hospital1 18] for continuity of care. . On arrival to our ED, vitals were 98.5 45 117/89 16 98%. Labs were notable for Na of 131, K of 8.7, creatinine fo 10.1. EKG was notable for sinus bradycardia with QRS widening; pt continued to c/o weakness. He was given ca gluc, insulin, bicarb, kayexylate. EKG did not show any improvement, therefore he was given an additional dose of calcium gluconate, HR improved to the 50s. Due for need for urgent HD patient admitted to the MICU. On transfer, BP was 148/71, pt was satting 100% RA. . In the MICU pt was comfortable but continued to feel weak. He denies neck pain, SOB or chest pain. On arrival VSS, exam notable for soft tissue swelling however neuro exam non-focal. He underwent urgent HD with improvement of K to 3.6. ACEI held. Repeat K demonstrated improvement in QRS duration however notable for persistent T wave inversions. Decision made to transfer to the floor for continued monitoring. . Review of systems: (+) Per HPI, + nausea, c/o "weak" in stomach (-) 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. Denies vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Denies neck pain. Past Medical History: -CKD stage V, on HD, on transplant list, s/p left brachiocephalic AV fistula [12-16], s/p angioplasty [5-16], s/p thrombectomy in [8-16], left upper extremity [Date Range ] [11-15] -CABG x4 [2123-3-9]: Left internal mammary artery grafted to the left anterior descending, reverse saphenous vein [Month/Day/Year ] to the diagonal branch, third marginal branch, and acute marginal branch. -Diabetes Mellitus type II c/b neuropathy -Dyslipidemia -Hypertension -Cardiomyopathy secondary to Chagas -Gastritis, GERD -History of pancreatitis, ? [1-10] gallstones, s/p CCY -Obstructive Sleep Apnea, not currently on cpap -Depression -Hyperuricemia Social History: Social History: Denies tobacco, no EtoH use and no h/o abuse, no illicits. Lives with wife. On disability x5 years. Family History: Family History: Mother and father with diabetes. Denies family history of CAD Physical Exam: Vitals: T:97.1 BP:129/69 P:53 R:7 O2: 98% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear. Soft tissue swelling on posterior aspect of cranium Neck: supple, non-tender to palpation posteriorly Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Irrecular rate, bradycardic, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: AAOx3. CNs2-12 intact. Moves all extremities freely. Diminished reflexes throughout. Pertinent Results: [2125-6-18] 07:35PM BLOOD WBC-6.2 RBC-4.13# Hgb-13.0 Hct-40.2# MCV-97 MCH-31.3 MCHC-32.2 RDW-15.7* Plt Ct-170 [2125-6-18] 07:35PM BLOOD PT-14.0* PTT-28.9 INR(PT)-1.2* [2125-6-18] 07:35PM BLOOD Glucose-259* UreaN-118* Creat-10.1# Na-131 K-8.7* Cl-100 HCO3-16* AnGap-24* [2125-6-18] 10:15PM BLOOD Glucose-114* UreaN-120* Creat-10.4* Na-139 K-7.1* Cl-100 HCO3-20* AnGap-26* [2125-6-19] 01:45AM BLOOD Glucose-73 UreaN-44* Creat-4.8# Na-136 K-3.6 Cl-92 HCO3-26 AnGap-22* [2125-6-19] 06:20AM BLOOD Na-131* K-4.1 Cl-93* [2125-6-18] 10:15PM BLOOD Calcium-9.1 Phos-7.3# Mg-3.2 [2125-6-19] 01:45AM BLOOD Calcium-9.0 Phos-2.8# Mg-2.4 [2125-6-18] 07:48PM BLOOD K-8.2* REPORTS: TTE [2125-6-19]: REPORT PENDING Brief Hospital Course: MICU Course: 50 year old gentleman with CKD stage V on HD, CAD s/p CABG, DM II, now presenting with chief complaint of dizzy s/p fall, hyperkalemia at OSH. He arrived to the MICU on the evening of [2125-6-18] with a potassium of 8.7 with associated bradycardia and QRS widening on EKG. In the MICU, he was emergently dialyzed and was not given any further medication to treat his hyperkalemia. His repeat potassium in the morning was 4.1. He had no other active medical issues and was called out to the medical floor the following morning on [2125-6-19]. CC7 Medicine: # symptomatic hyperkalemia: attributed to dietary indiscretion/ lack of knowledge of proper renal diet; resolved - Pt was given a nutrition consult, who educated both him and his wife regarding appropriate dietary modifications to prevent hyperkalemia # CKD stage V: Pt was dialyzed, and his potassium levels remained stable throughout the remainder of his course, indicating his suitability for continuing his outpatient dialysis schedule. # s/p fall: Final reports of CT confirmed with OSH, no acute intracranial process or cervical spine fracture/dislocation. . Medications on Admission: Medications (confirmed with wife): 1. lisinopril 20 mg PO DAILY. 2. fenofibrate micronized 145 mg PO daily. 3. insulin lispro 100 unit/mL Cartridge Subcutaneous qachs: Please follow prior sliding scale. 4. omeprazole 20 mg PO DAILY (Daily). 5. cinacalcet 30 mg PO DAILY 6. pravastatin 10 mg PO HS. 7. calcium acetate 667 mg PO TID W/MEALS. 8. insulin glargine 6 units Subcutaneous once a day. 9. aspirin 81 mg PO DAILY (Daily). 10. B complex-vitamin C-folic acid 1 mg PO DAILY. 11. carvedilol 25 mg PO BID Discharge Medications: 1. lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. 2. insulin lispro 100 unit/mL Cartridge Sig: One (1) Subcutaneous as per sliding scale: Please follow sliding scale. 3. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO three times a day: with meals. 4. insulin glargine 100 unit/mL Cartridge Sig: Six (6) units Subcutaneous once a day. 5. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Capsule PO once a day. 6. fenofibrate micronized 145 mg Tablet Sig: One (1) Tablet PO daily (). 7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. pravastatin 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 10. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 12. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 13. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: hyperkalemia CKD stage V, on HD s/p fall 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 helping with your health care this hospital visit. You were admitted after a fall. Your labs were notable for an elevated potassium thought secondary to dietary indiscretion. This elevation of potassium is thought to have caused your weakness and fall. This was a dangerous condition, but has been corrected by dialysis. Please contnue to go to your dialysis appointments on Mondays, Wednesdays, and Fridays. Your next dialysis session will be on Friday [2125-6-22]. In order to prevent high potassium from being a problem again, you should follow the diet you discussed with your nutritionist here. Please limit fresh fruits and vegetables, as these contain a lot of potassium. . NO CHANGES WERE MADE TO YOUR MEDICATIONS . Again it was a pleasure taking care of you. Followup Instructions: Department: TRANSPLANT CENTER When: THURSDAY [2125-6-28] at 1 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1330], MD [Telephone/Fax (1) 673] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: CARDIAC SERVICES When: FRIDAY [2125-6-29] at 9:00 AM With: [Name6 (MD) ] [Last Name (NamePattern4) ], MD [Telephone/Fax (1) 62] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 617] Completed by:[2125-7-5]	[ "V58.67", "E885.9", "585.6", "V02.53", "327.23", "250.40", "272.4", "403.91", "414.00", "425.9", "311", "276.7", "790.6", "V45.81", "357.2", "250.60", "535.50", "530.81", "V45.11" ]	icd9cm	[ [ [] ] ]	[ "39.95" ]	icd9pcs	[ [ [] ] ]	7691, 7748	4872, 6018	317, 331	7832, 7832	4100, 4849	8830, 9557	3331, 3394		6575, 7668	7769, 7811		6044, 6552			7983, 8807							3409, 4081														1990, 2468		264, 279								387, 1971								7847, 7959					2490, 3164	3196, 3299
28,050	198,063	28554	Discharge summary	report	Admission Date: [2145-2-22] Discharge Date: [2145-3-16] Date of Birth: [2069-7-23] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 668] Chief Complaint: Renal cell carcinoma invading and obstructing the duodenum with the vena caval encasement by a tumor. Pneumonia (resolved) Major Surgical or Invasive Procedure: Exploratory laparoscopy, right hemicolectomy, duodenal resection, cholecystectomy and primary duodenal repair. History of Present Illness: 75M c metastatic renal cell CA and near-obstructing duodenal mass, transfer from the medical service (admitted initially with pneumonia) on the [Hospital Ward Name 516] in preparation for likely surgery on Tuesday of next week. Mets to liver, IVC, lungs. H/o GI bleed. Past Medical History: PMHx: Clear cell renal cell carcinoma - dx [2143-10-21]. Right kidney, metastatic to lungs. Initially on Sorafenib and Avastin. Currently being treated with perifosine on study (started [2144-8-24]). Followed by Drs. [Last Name (STitle) 39628] and [Name5 (PTitle) ]. HTN Memory loss Cataract surgery BPH CRI - baseline Cr=1.8 Social History: Married for 37 years, no children. Unemployed, prior administrative work in [Location (un) ], has lived in US for 4 years. Smoked [12-27] cigarettes per day for 5 years, quit 5 years ago. Family History: Denies cancer in family members. Physical Exam: Vitals- T 97.7, P 76, BP 124/75, RR 20, O2sat 98% RA Gen- NAD, alert Neck- soft, supple, no masses Heart- RRR, no murmurs Lungs- CTAB, no R/R Abd- soft, NT, ND Ext- no edema, warm, well-perfused Pertinent Results: On admission: [2145-2-22] WBC-12.9* RBC-3.36* Hgb-9.9* Hct-29.1* MCV-87 MCH-29.5 MCHC-34.1 RDW-13.9 Plt Ct-195 Glucose-125* UreaN-35* Creat-2.5* Na-135 K-4.3 Cl-102 HCO3-24 AnGap-13 ALT-19 AST-21 AlkPhos-48 Amylase-168* TotBili-0.4 Calcium-9.1 Phos-3.8 Mg-2.1 At discharge: [2145-3-14] WBC-5.1 RBC-3.67* Hgb-10.7* Hct-32.4* MCV-88 MCH-29.1 MCHC-33.0 RDW-16.0* Plt Ct-260 [2145-3-16] Glucose-109* UreaN-14 Creat-1.8* Na-137 K-4.3 Cl-99 HCO3-33* AnGap-9 [2145-3-12] ALT-21 AST-30 AlkPhos-67 TotBili-0.4 [2145-3-15] Calcium-8.6 Phos-4.2 Mg-2.2 Brief Hospital Course: 75 y/o male who was initially admitted to medicine service for treatment of pneumonia. He was treated with Levaquin with good response and then was transferred to the surgical service. He was transferred to the [Hospital Ward Name 517] in preparation for resection with Dr [First Name (STitle) ]. This patient is well known to the surgical service following recent hospitalization for workup of his renal cell cancer following a GI bleed. Last year he was evaluated and the tumor was abutting but not invading the duodenum and the hepatic flexure and at that time he did not proceed with surgery. Now following extensive workup it was presumed that the GI bleed was due to tumor erosion into the duodenum. At this time, the patient has elected to proceed with the surgery. He was taken to the OR on [2145-3-2] with Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] for Exploratory laparoscopy, right hemicolectomy, duodenal resection, cholecystectomy and primary duodenal repair. Please see the operative note for surgical detail. He was transferred oto the SICU following the procedure still intubated in serious but stable condition. He was extubated on POD 2. He was afebrile throughout his post-op course. NGT was d/c'd on POD 7, prior to the tube being discontinued he had an upper GI study showing: -Approximately 100 cc of Conray was first injected through the NG tube which passed freely into the loops of jejunum with no extravasation. This was followed by administration of approximately 120 cc of barium which did not demonstrate any leak. The barium passed freely into the loops of jejunum. IMPRESSION: Status post resection of the extrinsic duodenal mass with no evidence of leakage or obstruction. Following NG removal his diet was slowly advanced. His bowel function was slow to return. An abdominal CT was obtained on [3-13] due to continued slow return of bowel function, although bowel movements had been reported. The CT showed post-surgical changes and normal caliber loops of bowel. No free fluid or air seen in the pelvis. He was continued on a bowel regimen. He had intermittent c/o nausea with occasional vomiting reported. He was ambulating, tolerating regular diet. All JP drains had been removed by the time of discharge. Clips to be removed at clinic visit on [3-18]. Medications on Admission: protonix 40'', Centrum Silver, Norvasc 10' Discharge Medications: 1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:30 Tablet(s) Refills:0 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:2 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 6. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). Disp:120 Tablet(s) Refills:2 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:0 8. Multiple Vitamin Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Renal cell carcinoma invading and obstructing the duodenum with the vena caval encasement by a tumor. Now s/p resection Discharge Condition: Stable/Good Discharge Instructions: Please call Dr.[Name (NI) 670] office [Telephone/Fax (1) 673] if fever (temperature over 101) , chills, nausea, vomiting, diarrhea or if not having bowel movements at least every other day. Monitor incision for redness, drainage or bleeding. Clips to be removed at clinic visit. Followup Instructions: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1330], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2145-3-18] 1:10 Completed by:[2145-3-25]	[ "285.9", "584.9", "197.4", "197.0", "197.5", "276.2", "799.02", "537.3", "578.9", "276.50", "486", "197.7", "600.00", "403.90", "198.89", "189.0", "585.2" ]	icd9cm	[ [ [] ] ]	[ "45.62", "45.73", "54.21", "51.22" ]	icd9pcs	[ [ [] ] ]	5592, 5650	2300, 4637	436, 549	5814, 5828	1715, 1715	6163, 6335	1450, 1484		4730, 5569	5671, 5793		4663, 4707			5852, 6140							1499, 1696										1993, 2277						274, 398								577, 854							1729, 1979						876, 1220	1236, 1434
12,823	162,958	45738	Discharge summary	report	Admission Date: [2109-11-19] Discharge Date: [2109-11-20] Service: NEUROSURGERY Allergies: Aspirin / Iodine; Iodine Containing Attending:[First Name3 (LF) 1835] Chief Complaint: unresponsive Major Surgical or Invasive Procedure: none History of Present Illness: 82F fell in bathroom, unresponsive, right pupil dilated. Brought to [Hospital1 18] ED, agonal breathing - intubated. CT done showing large right intraparenchymal hemmorrhage extending into lateral, 3rd, 4th ventricles, 1.9cm shift Past Medical History: cardiac stents,htn,inc chol Social History: married , lives with husband Family History: noncontributory Physical Exam: : BP:120 /54(200's upon arrival) HR:51 O2Sats100 Gen: WD/WN, comfortable, NAD. HEENT: Pupils:R 6mm nonreactive, L 2mm Neck: hard collar Extrem: Warm and well-perfused. No C/C/E. Neuro:Intubated Pupils R 6mm fixed, L 2mm NR Motor: no movement to noxious UE's, triple flexion in LE's Toes upgoing bilaterally Brief Hospital Course: Pt was admitted to the ICU after a long discussion with family and her devastating injury. On HD#1 family decided to make her CMO. She expired [11-20]. Medications on Admission: unknown Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: cerebral hemorrhage Discharge Condition: expired Completed by:[2109-11-20]	[ "V45.82", "431", "V66.7", "401.9", "414.01", "412" ]	icd9cm	[ [ [] ] ]	[ "96.04", "96.71" ]	icd9pcs	[ [ [] ] ]	1273, 1282	1028, 1186	263, 269	1345, 1384			648, 665		1244, 1250	1303, 1324		1212, 1221										681, 1005																210, 225								297, 534													556, 586	602, 632
18,020	156,274	47821	Discharge summary	report	Admission Date: [2161-3-13] Discharge Date: [2161-3-24] Service: HISTORY OF PRESENT ILLNESS: The patient is a 79 year old woman transferred from [Hospital1 ] for suspicion of compression fracture causing lower back pain times two weeks. The patient also had numbness around her abdomen and both legs. She reported weakness times one day with difficulty standing up from the sitting position and falls times three the day before admission secondary to leg weakness. The patient has had weight loss times the last four months greater than 50 pounds. PAST MEDICAL HISTORY: Depression, hypertension and seizure disorder. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Amitriptyline, Dilantin. SOCIAL HISTORY: The patient has a history of ethyl alcohol abuse and 30 year pack history of smoking. PHYSICAL EXAMINATION: On physical examination her temperature was 98.8, her heart rate was 80, blood pressure 182/76, respiratory rate 14. On physical examination she was in no acute distress. She was awake, alert and oriented times three. Her chest was clear to auscultation bilaterally with coarse upper airway sounds. Her heart was regular rate and rhythm and the abdomen was soft, nontender. Pupils were 2.5 down to 2 and briskly reactive. Cranial nerves II through XII were intact and symmetric. Her strength, grasp was 5 out of 5, biceps 5 out of 5, triceps 5 out of 5, RPs 3-, quads 5 out of 5, AT 5 out of 5, gastrocs 5 out of 5. She had no drift. Reflexes were 3+ at the knees, 2+ at the ankles or toes, on the right were upgoing and on the left were equivocal. Sensation was decreased in the right lower extremity and the left lower extremity at the lateral thigh, medial thigh, anterior shin and soles of the feet. LABORATORY DATA: Her magnetic resonance imaging scan showed an extradural lesion at the T6, T7 level with cord compression, probably metastatic. Chest x-ray showed lung lesion. HOSPITAL COURSE: The patient was taken to the Operating Room for urgent T6, T7 laminectomies and decompression on [2161-3-13]. Postoperatively the patient's vital signs were stable. She was awake following commands. Her grasp was 5 out of 5. Her legs were 4+ on the right, 5 on the left in the IPs, the ATs 5- on the right, 5 on the left, gastrocs 5 on the right and 5 on the left. Sensation was grossly intact to light touch to the feet and arms. Her toes were downgoing bilaterally. She continued on Decadron 6 mg q. 4 hours. Her vital signs were stable and she was monitored in the Recovery Room over night. On [2161-3-15], the patient was awake and alert. Her numbness continued to the right lateral leg, greater than the left. Her strength was 5 out of 5 in all muscle groups and she was transferred to the regular floor. Her postoperative magnetic resonance imaging scan showed good decompression. She was assessed by physical therapy and occupational therapy and felt to require acute rehabilitation. She was also seen by the Hematology/Oncology Service for her treatment of her small cell cancer of the lung with spine metastases. Hematology/Oncology recommended an magnetic resonance imaging scan of the head which was negative except for a bony lesion in the left frontal area. Radiology Oncology was also consulted and the patient will require chemotherapy as well as radiation therapy as an outpatient after healing. The patient was doing well until [2161-3-18], when she had an episode of unresponsiveness, dropped her blood pressure, heart rate and her oxygen saturations. The patient was taken down for a computerized tomography scan of the chest which showed bilateral subsegmental pulmonary emboli and the patient was transferred to the Intensive Care Unit for close monitoring. She stayed in the Intensive Care Unit for two days where she remained stable without any further episodes of unresponsiveness or drop in her saturations. Her blood pressure and heart rate were stable and she was transferred to the regular floor. On [2161-3-19], she was transferred to the regular floor. She was again stable and then on [2161-3-20], had another episode of unresponsiveness after walking with physical therapy. She dropped her blood pressure slightly to 96/60, her heart rate remained in the 80s. Her saturations were 96% on 2 liters. She was sitting in a chair at the time. She was put back to bed, woke up, was talking and moving all extremities. She had an electrocardiogram that showed no changes. She was sent back down for another computerized tomographic angiography which showed improvement of her pulmonary emboli with no new evidence of pulmonary emboli. She had no further episodes of decreased heart rate or oxygen saturation drops and her blood pressure remained stable. Laboratory data were sent emergently during this episode. Her white count was 10.1, hematocrit 35, platelets were 176. Her electrolytes were within normal limits, sodium 137, potassium 3.45, chloride 102, BUN 12, creatinine .7, glucose 109. On [3-20], at 4 PM, at the time of this episode, CPKs were sent. Her first CPK was 80, her second one was 289, her third one 255. The fourth set which was 403 with an MB of 2. Her MB when her CPK was 255 was 3. Troponin was less than .01. She had no bump in her troponin level. She has remained neurologically and hemodynamically stable since the episode on [3-20]. She has had no further episodes of unresponsiveness. Her vital signs have remained stable, though her blood pressure on [3-24] has been in the low 90s. She has received two 500 cc normal saline fluid boluses. The patient will follow up in Hematology/[Hospital ] Clinic on [2161-3-26], but will get her radiation therapy first. She remained neurologically stable, continues to have some back pain. Her staples will be removed before she is discharged. MEDICATIONS ON DISCHARGE: 1. Lisinopril 20 mg p.o. q. day, hold for blood pressure less than 120 2. Diazepam 2 mg p.o. q. 8, hold for sedation. 3. Heparin 5000 units subcutaneously q. 12 hours. 4. Hydromorphone 2 to 6 mg p.o. q. 4 hours prn. 5. Famotidine 20 mg p.o. b.i.d. 6. Hydrochlorothiazide 75 mg p.o. q. day 7. Colace 100 mg p.o. b.i.d. 8. Amitriptyline 25 mg p.o. q.h.s. 9. Mirtazapine 15 mg p.o. q.h.s. 10. Dilantin 200 mg p.o. b.i.d. 11. Tylenol 650 p.o. q. 4 hours prn CONDITION ON DISCHARGE: Stable. FOLLOW UP: She will follow up in the Hematology/[Hospital ] Clinic on [2161-3-26] for follow up. She will follow up with Dr. [Last Name (STitle) 739] in four weeks in his office, #[Telephone/Fax (1) 3571] for follow up. Will discuss radiation oncology therapy follow up with Dr. [Last Name (STitle) 3929] and make arrangements for the patient's follow up treatment. [Name6 (MD) 742] [Name8 (MD) ], M.D. [MD Number(1) 743] Dictated By:[Last Name (NamePattern1) 344] MEDQUIST36 D: [2161-3-24] 11:27 T: [2161-3-24] 12:27 JOB#: [Job Number 100945]	[ "198.3", "V11.3", "198.5", "415.11", "780.39", "401.9", "162.3", "V15.82" ]	icd9cm	[ [ [] ] ]	[ "03.4", "38.91", "03.09" ]	icd9pcs	[ [ [] ] ]											5922, 6386	711, 737	1975, 5896															6432, 7048		864, 1957																113, 575													598, 684	754, 841	6411, 6420
6,170	162,681	25913	Discharge summary	report	Admission Date: [2185-12-9] Discharge Date: [2185-12-26] Date of Birth: [2143-7-1] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 425] Chief Complaint: found down at work with ST-elevation myocardial infarction. Major Surgical or Invasive Procedure: cardiac catheterization, [2185-12-9]. History of Present Illness: 42 year old male with DM, current TOB use who presented to OSH with ST elevation MI (inferior and posterior MI). Patient was at work (painter) when his colleagues found him down and unresponsive, unclear for how long, called EMS. Patient was in Vfib arrest and was coded, shocked 7 times, intubated and transferred here for urgent cardiac catheterization. During cath, patient was found to have 3VD, stents placed in totally occluded prox RCA, LAD and OM1 of LCx. Patient also with pH 7.2, metabolic acidosis, anion gap 23, blood sugar 316 likely DKA with WBC 21. Past Medical History: 1. diabetes mellitus 2. hypercholesterolemia Social History: Lives with wife (not legally married), no children, (+)tobacco. Family History: Unknown. Physical Exam: Gen: Sedated, intubated, not responsive. HEENT: Pupils equal minimally reactive from 4 to 3mm, intubated CV: RRR/ST, nl S1/S2, no murmurs Pulm: CTAB Abd: (+) BS, soft, ND/NT Ext: WWP, no edema, 1+ DP pulses b/l Neuro: pupils reactive to light and accomodation, no tone, intact gag/swallow, hypo/a-reflexic, downgoing toes b/l. Pertinent Results: EEG [2185-12-21]: Abnormal EEG due to the slow and relatively low voltage background with occasional bursts of generalized slowing. These findings indicate a widespread encephalopathic condition affecting both cortical and subcortical structures. Medications, metabolic disturbances, infection, and anoxia are among many possible causes. There were no areas of persistent focal slowing, and there were no epileptiform features. . Brain MR [2185-12-18]: There is no MR evidence of subacute hemorrhage, edema, midline shift, mass effect or hydrocephalus or extraaxial collections. Moderate brain atrophy noted. Periventricular deep white matter ischemic changes noted suggestive of mild small vessel disease. Diffusion-weighted images demonstrate no definite evidence of restricted diffusion to suggest acute infarct. Mucosal thickening is noted in the maxillary, ethmoid and sphenoid sinuses. . EEG [2185-12-13]: Mildly abnormal EEG due to a reduced voltage and mildly slowed posterior background indicating a mild diffuse encephalopathy. . CXR [2185-12-13]: Heterogeneous opacification in the left infrahilar lung represent early pneumonia. Pulmonary vascular congestion indicates borderline cardiac function. The heart size is normal and there is no pleural effusion. Nasogastric tube tip projects over the region of the pylorus. No pneumothorax or appreciable pleural effusion. . Echo [2185-12-12]: LVEF 45-50%; The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction. Overall left ventricular systolic function is mildly depressed. Resting regional wall motion abnormalities include basal septal hypokinesis and inferior and inferolateral hypokinesis. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets appear normal. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. . Cath [2185-12-9]: 1. 3VD in this R dominant circulation. The LMCA was without angiographically apparent flow limiting disease. The mid LAD had an 80% stenosis spanning the origin of a moderate sized D2. The D1 was a small vessel without flow limiting disease. The LCX gave off a large OM1 that had a 90% thrombotic stenosis in its lower pole. The RCA had a 100% proximal stenosis consistent with fresh thrombus. 2. Resting hemodynamics demonstrated markedly elevated left and right sided filling pressures and depressed cardiac output/index (4 L/min and 2.0 L/min/m2) consistent with cardiogenic shock. 3. The patient had 2 episodes of unstable ventricular tachycardia which responded to 200 J cardioversion. 4. Left ventriculogram was not performed to decrease contrast load. 5. Successful PCI of the RCA with two overlapping Cypher DES (2.5 x 28 mm distally and 3.0 x 33 mm proximally), and rescue of the jailed marginal branch with a 1.5 mm balloon. 6. Successful placement of an 8 French 40 cc IABP in the RFA. 7. Successful PCI of the LCX with a 3.0 x 28 mm Cypher DES. 8. Successful PCI of the LAD with a 2.5 x 28 mm Cypher DES. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Severe LV systolic and diastolic ventricular dysfunction. 3. Cardiogenic shock. 4. Acute inferior ST elevation myocardial infarction, managed by PCI of proximal RCA, mid OM1 and mid LAD with Cypher stents. 5. Unstable ventricular tachycardia requiring DC cardioverion. 6. Placement of intra-aortic balloon pump via right femoral artery. Brief Hospital Course: 42 year old male with DM, [Hospital ] transferred from OSH for emergent cath found to have 3VD s/p stents to 100% RCA ([Name Prefix (Prefixes) ] [Last Name (Prefixes) ] 2), LAD ([Name Prefix (Prefixes) ] [Last Name (Prefixes) ] 1), OM ([Name Prefix (Prefixes) ] [Last Name (Prefixes) ] 1). . Cardiac: Pt. treated with ASA, Plavix, BB, statin, ACE-i, and CCB. BB and ACE-i doses titrated up for HTN. Echo revealed LVEF=45-50% with basal septal hypokinesis and inferior and inferolateral hypokinesis. Pt. was monitored continuously on telemetry and remained in NSR/ST with only occasional PVCs. Pt. may undergo repeat TTE in [2-4] months to evaluate interval changes in EF/valve function. . Pulmonary: Pt. was intubated upon arrival to the hospital. During a pressure-support trial off sedation, the Pt. bit through the cuff inflator tube, and was therefore extubated. Anesthesia saw the Pt. immediately and the Pt. was able to protect his airway. He was weaned down to room air, although did initially require frequent suctioning. At the time of discharge, Pt. had strong gag and cough reflex, and had O2 saturations in the high 90s. . Neuro: Pt. was initially sedated in the setting of STEMI s/p cath and intubation. Sedation discontinued after the Pt. was extubated to attempt to assess neurologic status. Concern was for anoxic brain injury. EEGs revealed mild diffuse encephalopathy and no evidence of seizure activity. MRI showed no evidence of infarct. Pt. was evaluated by neurology service. Approximately 10 days after admission, Pt. transitioned from a non-responsive persistent vegetative state to awake, responsive, moving all four extremities. At the time of discharge, his neurologic status was continually improving, but clearly [Hospital 4820] rehabilitation and physical/occupational therapy will be needed to maximize recovery of function. Patient has been enrrolled in a study with behavioral neurology. This service is aware of him going to rehab. Patient will be contact[Name (NI) ] for a follow up. . Diabetes mellitus: Pt. had an elevated anion gap on admission, concerning for ketoacidosis. This gap closed with IV-fluid resuscitation and insulin, and the Pt. had no other signs of ketoacidosis. His fingersticks were checked regularly and an insulin sliding scale was used in addition to a morning and evening dose of NPH 24qAM/24qPM. . Infection: Pt. was found to have an elevated WBC and fever, a CXR was consistent with early PNA involving L infra-hilar area. Sputum cultures grew coagulase-positive staph aureus and streptococcus pneumoniae. The Pt. was treated with levofloxacin for 10-days and flagyl for 7-days. Urine and blood cultures were checked and were negative. . Dental: Pt. has very poor dentition including several missing teeth (likely secondary to no dental insurance). The Pt. was seen by the hospital dental service, who recommended routine mouth hygeine. The Pt. was also treated with oral chlorhexidine. . FEN: Tube feeds were initiated after placement of an NG-tube, but were stopped after one day due to high residuals and aspiration risk post-extubation. TPN was started while Pt. underwent G-tube placement. Tube feeds were reinitiated through G-tube, and were well tolerated. The Pt. did become hypernatremic, likely due to free water deficit and concentrated tube feeds; this resolved with free water repletion. Medications on Admission: humalog mix 75/25 actos 15mg QD Discharge Medications: 1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML Mucous membrane [Hospital1 ] (2 times a day). 4. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Clopidogrel 75 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 11. Lansoprazole 15 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 12. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for fever. 13. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 14. Pioglitazone 15 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Humalog insulin sliding scale, NPH 24U QAM / 24U QPM 16. Metoclopramide 5 mg/mL Solution Sig: One (1) Injection Q6H (every 6 hours) as needed. 17. G-tube care per routine Discharge Disposition: Home with Service Discharge Diagnosis: 1. inferior ST-elevation MI, s/p stenting. 2. non-persistent vegetative state. Discharge Condition: fair, stable. Discharge Instructions: Please continue all medications as prescribed. If you experience chest pain, shortness of breath, or severe nausea/vomiting, please return to the hospital. Followup Instructions: Please follow up with your PCP after rehab. Please call Cardiology clinic to make an appointment with Dr [Last Name (STitle) ] in about 2-3 months ([Telephone/Fax (1) 2037] Follow up with Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] with behavioral neurology - [Numeric Identifier 64444] Completed by:[2185-12-26]	[ "E917.9", "482.41", "482.30", "410.31", "250.11", "348.1", "276.0", "V58.67", "305.1", "785.51", "873.63", "427.1", "518.5" ]	icd9cm	[ [ [] ] ]	[ "38.93", "00.42", "37.61", "88.56", "99.20", "99.62", "00.17", "97.44", "37.23", "00.48", "36.07", "96.6", "96.71", "99.15", "43.11", "00.66" ]	icd9pcs	[ [ [] ] ]	9965, 9984	5097, 8522	331, 375	10107, 10123	1510, 4675	10328, 10684	1138, 1148		8604, 9942	10005, 10086		8548, 8581		4692, 5074	10147, 10305							1163, 1491																232, 293								403, 972													994, 1040	1056, 1122
7,429	110,364	35	Discharge summary	report	Admission Date: [2126-8-23] Discharge Date: [2126-9-19] Date of Birth: [2048-6-6] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 371] Chief Complaint: HISTORY OF PRESENT ILLNESS: Seventy-eight-year-old female involved in a motor vehicle accident. She was an unrestrained driver with no loss of consciousness, but was hit by a dump truck with significant intrusion into the car. She has complaint of chest pain and systolic blood pressure of 88 and heart rate of 100 in the field. 78F re-admit (s/p MVC with c spine fx/pulm contusions/rib fx s/p trach/spenic lac s/p splenectomy/pelvic fx) - from rehab, septic picture likely aspiration pneumonia secondary to dobhoff being placed into lung. Major Surgical or Invasive Procedure: placement of G tube History of Present Illness: HISTORY OF PRESENT ILLNESS:78F re-admit (s/p MVC with c spine fx/pulm contusions/rib fx s/p trach/spenic lac s/p splenectomy/pelvic fx) - from rehab, septic picture likely aspiration pneumonia secondary to dobhoff being placed into lung. Seventy-eight-year-old female involved in a motor vehicle accident. She was an unrestrained driver with no loss of consciousness, but was hit by a dump truck with significant intrusion into the car. She has complaint of chest pain and systolic blood pressure of 88 and heart rate of 100 in the field.admitted to [Hospital1 18] on [7-29] with C2 fracture, bilateral pleural hematomas, L breast implant rupture, rib fractures, splenic laceration s/p splenectomy and s/p nephrostomy tube placement, who returned to [Hospital1 18] from rehab on [8-23] with hypoxia and respiratory distress. Past Medical History: PMH: Amyloidosis, depression, kidney stones, hx of tubal ligation, L hip replacement Social History: SH: 2 cigs per day, 1-2 drinks per day Family History: FH: daughter [Name (NI) 372] is currently undergoing temporary guardianship Physical Exam: Tc afebrile HR 96, BP 161/67, RR 34, 99% on PS [7-5], 40% FI02 Gen: lying in bed, eyes open, minimal mvmt. HEENT: trach in place, copious sputum out of trach opening, coughing,mmm, OP benign Neck: in C collar CV: RRR, difficult to auscultate given breath sounds Resp: coarse upper airway sounds bilaterally Abd: multiple dressings covering postop incisions, ileostomy bag c/d/i Ext: warm, well perfused Skin: ecchymoses on legs and arms. MS: Awake, opens eyes to voice but not command and looks to right at calling of name, not consistently to left. Wiggles toes to commands, will not squeeze hands to command, will not lift arms to command. CN: PERRLA, blinks to threat bilaterally. Full eye movements horizontally but seems to have R gaze preference. No evidence of nystagmus, no ptosis. Grimaces to stim on both sides of face. Corneal reflex present. Face symmetric but difficult to assess wtih collar. Hears voice. No speech. +cough. Motor: Nl bulk, perhaps increased tone to passive motion in bilateral upper extremities. Spontaneously wiggles toes R more briskly than L, and spontaneously flexes R arm at elbow. Otherwise, no spontaneous movements. ON passive flexion she does resist my motion in both upper extremities. On painful stimulation she grimaces but only withdraws in RUE and RLE. Reflexes: [Hospital1 ] Tri BR Pat Ach Plantar L 2 2 1 1 1 down R 2 2 1 2 1 down [Last Name (un) ]: feels pain in all four extremities. Pertinent Results: [2126-8-23] 04:10AM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-6.5 LEUK-NEG [2126-8-23] 04:10AM URINE RBC->50 WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0 [2126-9-18] 02:30AM BLOOD WBC-12.0* RBC-3.14* Hgb-9.6* Hct-28.1* MCV-90 MCH-30.5 MCHC-34.0 RDW-15.3 Plt Ct-465* [2126-9-17] 02:13AM BLOOD WBC-10.7 RBC-2.87* Hgb-9.0* Hct-26.0* MCV-91 MCH-31.3 MCHC-34.5 RDW-15.3 Plt Ct-457* Brief Hospital Course: ID: Patient has been consistently febrile, initially started on vancomycin and zosyn for presumed pneumonia, sputum cultures and blood cultures positive for yeast. She was treated with meropenam, vancomycin, flagyl, and then on [8-31] caspofungin added. She continues to be febrile. Since [8-30] blood cultures have been negative, sputum continues to grow yeast. GI: On [8-29] she was noted to have rise in her LFT's and abdominal tenderness, she was taken to the OR for an exploratory laparotomy and found to have an ischemic colonic perforation. R colectomy and ileostomy placement was performed at that time. She is still not receiving feeds through the G tube. Heme: Initially anemic, now hct has been stable in mid-20's. Neuro: Pt when admitted on [8-23] was noted to follow commands and express pain. She was on her home regimen of paxil for anxiety. On day of admission she was started on propofol for agitation, it caused hypotension and it was weaned. She was at that time noted to be sedated but still following commands. On [8-24] she was switched to a versed drip. On [8-26] she was unarousable, versed stopped and only given morphine PRN. She was noted on [8-27] to follow commands and "awake and alert." [8-29] went to the OR, and afterwards was treated with propofol and fentanyl. On [8-30] she was noted to have minial movement of her LUE and none of her RUE, but moved both lower extremities in response to pain. On [9-1] she was reported to be "following commands" and responding to painful stimuli. She has been on a fentanyl drip until [9-5], when she was switched to a fentanyl patch. On [9-7] fentanyl patch was d/c'ed and she has only been receiving fentanyl prn dressing changes. Today, it was noted that despite being off sedation for several days, she has not been awake or following commands initially However this status has continues to improve and patient had remained afebrile on trach trial up to 5 hours, she will need continued wound care to incision with wet to dry dressing Medications on Admission: M A H : p r o z a c , t y l , [Initials (NamePattern5) 373] [Last Name (NamePattern5) 374],[First Name3 (LF) ],dulcolax,diazepam,colace,lovenox,prevacid,lopressor, oxycodone Discharge Medications: 1. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 2. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 3. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 5. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 6. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed. 7. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QID (4 times a day). 8. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [12-2] Drops Ophthalmic Q2H (every 2 hours). 9. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 10 days. 10. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) PO DAILY (Daily). 11. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 12. Magnesium Sulfate 50 % Solution Sig: One (1) Injection PRN (as needed) as needed for <2.0. 13. Caspofungin 50 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours) for 7 days. Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: 78F re-admit (s/p MVC with c spine fx/pulm contusions/rib fx s/p trach/spenic lac s/p splenectomy/pelvic fx) - from rehab, septic picture likely aspiration pneumonia secondary to dobhoff being placed into lung. ventilator dependent respiratoy failure, chronic anemia, sepsis, poor nutritional status, tube feed dependence Discharge Condition: Stable Discharge Instructions: Please continue to ween ventilatory status (pt has been on trach trial for 4-5 hr windows, continue local wound care, to midline incicion, continue to monitor urine output via nephrostomy tube and ostomy ourtput, please continue to ensure that she does not become dehydrated. Followup Instructions: F/U recommended with interval CT scan [1-3] weeks to evaluate fluid collection in right pelvis for catheter to be removed if fluid is no longer draining as weel as be evaluated by Dr. [Last Name (STitle) 375] please call regarding f/u and progress Trauma Clinic Trauma W/LMOB 3a [Hospital1 18] ([Telephone/Fax (1) 376]. TRAUMA OUTREACH NURSE TRAUMA OUTREACH W/LMOB 2G [Hospital1 18] ([Telephone/Fax (1) 377] Completed by:[2126-9-19]	[ "998.59", "038.9", "557.0", "401.9", "995.92", "V44.0", "569.83", "285.9", "567.22", "507.0", "518.81", "496" ]	icd9cm	[ [ [] ] ]	[ "33.24", "38.91", "46.21", "96.6", "43.19", "45.73", "99.04", "87.75", "96.72", "99.15", "38.93", "54.91" ]	icd9pcs	[ [ [] ] ]	7443, 7522	3952, 6018	853, 874	7888, 7897	3491, 3929	8221, 8685	1926, 2007		6254, 7420	7543, 7867		6044, 6231			7921, 8198							2022, 3472																273, 273								929, 1746													1768, 1854	1870, 1910
61,163	196,345	53135	Discharge summary	report	Admission Date: [2110-10-10] Discharge Date: [2110-10-13] Service: MEDICINE Allergies: Plaquenil / Glyburide Attending:[First Name3 (LF) 7651] Chief Complaint: Fatigue, SOB, chest pain Major Surgical or Invasive Procedure: Cardiac catheterization with drug eluting stent to the distal left main artery with right femoral artery angioseal History of Present Illness: Mrs. [Known lastname 90256] is a [Age over 90 ] y/o female with h/o HTN, and a previous STEMI on [2110-7-10] which was treated with a BMS of the LMCA into LAD origin and complicated by a hemopericardium during that admission. She presented on [10-10] with 2 day history of heavy breathing, chest pain with associated DOE and fatigue for several days. She describes the pain as a mild mid sternal burning sensation that radiated to her throat and down her left arm. She reports the pain is in the same area as her previous MI, but not as severe. On [10-10] she felt that her breathing was heavy and she activated EMS. In the the [Hospital1 18] ED and she was found to have ECG demonstrating small ST elevations in V1-3 with T-wave inversions laterally. Urgent coronary angiography on [2110-10-10] demonstrated severe restenosis (80%) of the previous BMS from the distal LMCA into the LAD. She was given ASA 325 mg and Clopidogrel 300 mg and a DES was placed inside the previous stent. Post PCI, no remaining stenosis of LAD, prx LMCA lesion (40%), prx LCx lesion (60%) Unchanged from [7-8]. The RCA was not injected (normal in [7-8]). Given her history of hemoparicardium s/p stemi she was transferred to the CCU for monitoring. On arrival to the unit She was in no distress and hemodynamically stable. Past Medical History: - Hypertension - Rhematoid arthritis - Gallstones - s/p hysterectomy - s/p appendectomy Social History: Lives with her sister (also in her 90s) in [Location (un) 1468], MA. Formerly worked in a school nursery, post office, and Navy ship yards. She is still completely independent at home with all ADLs, cooks her own food and cleans the home herself. # Tobacco: never # Alcohol: none # Illicit: none Family History: Brother died of an MI in his 70s. Brother died of unknown causes in his 60s. Sister died of AD at 91. Sister died at age 7 durng tonsillectomy from ether use. Physical Exam: ADMISSION EXAM: VS: 97.8, 156/92, 89, 14, 99% RA GENERAL: Elderly woman in NAD. Intermittently oriented x3 then sleepy/lethargic. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Dry MM. +Thrush. NECK: Supple, no meningismus, flat 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: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Decreased BS at bases with a few crackles at both bases. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: WWP. Trace pedal edema. NERUO: CN II-XII intact, strength 4-5/5 in UE and LE, equal bilaterally, sensation grossly intact 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 EXAM: HEENT: no JVD, neck supple CV: RRR, no Murmurs ascultated Chest: Clear bilat ABD: no swelling, tenderness, pos BS Ext: Right groin site without hematoma, no peripheral edema Pertinent Results: [2110-10-10] 10:19PM GLUCOSE-124* UREA N-25* CREAT-0.9 SODIUM-135 POTASSIUM-4.9 CHLORIDE-101 TOTAL CO2-21* ANION GAP-18 [2110-10-10] 11:57AM WBC-6.6 RBC-3.81* HGB-12.3 HCT-37.8 MCV-99* MCH-32.4* MCHC-32.6 RDW-16.0* [2110-10-10] 11:57AM NEUTS-61.6 LYMPHS-31.0 MONOS-5.8 EOS-0.5 BASOS-1.2 [2110-10-10] 11:57AM cTropnT-0.52* [2110-10-10] 10:19PM CK-MB-2 cTropnT-0.43* [2110-10-10] 11:57AM ALT(SGPT)-208* AST(SGOT)-150* ALK PHOS-186* TOT BILI-0.5 2-D ECHOCARDIOGRAM [2110-10-10]: The right atrium is moderately dilated. Overall left ventricular systolic function is profoundly depressed (LVEF = 20%) with severe hypokinesis of all segments, with relative preservation of basal posterior and lateral wall contractility. The estimated cardiac index is profoundly depressed (1.1 L/min/m2). The right ventricular free wall is hypertrophied. The right ventricular cavity is dilated with depressed free wall contractility. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are moderately thickened. Significant aortic stenosis is present (not quantified - low flow/low gradient physiology). The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. There is severe mitral annular calcification. Moderate (2+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] Severe [4+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] There is no pericardial effusion. Compared with the findings of the prior report (images reviewed) of [2110-9-8], there has been marked intercurrent worsening of all of the following: left ventricular contractile function (due to marked intercurrent worsening of anterior, septal, and apical contractile function), right ventricular function, pulmonary hypertension, and tricuspid regurgitation. The echocardiographic estimate of cardiac index is profoundly reduced. Brief Hospital Course: [Age over 90 ] y/o female with h/o HTN, and a previous STEMI on [2110-7-10] which was treated with a BMS of the LMCA into LAD origin and complicated by a hemopericardium during that admission, presents with 1 day history of chest pain with associated SOB and fatigue for several days, found to have LAD instent-restenosis. # CORONARIES: Patient found to have in-stent thrombosis of LMCA in to LAD s/p DES to previous stent. She was placed on ASA 81mg, Plavix, and metoprolol. She was not started on a statin during this hospitalization due to elevated liver function tests. Her liver function should be monitored as an outpatient and a statin started when LFTs normalize or at least a low dose statin should be considered. She was diuresed with Lasix IV to which she responded very well. She was in the CCU overnight and was called out to the regular cardiology floor for continued monitored. She had a uncomplicated hospital stay, was evaluated by PT who recommended that she be discharged home. Additionally, an ACEI/[Last Name (un) ] was not started due to low blood pressures during her hospital stay. Her BPs should be monitored as an outpatient and an ACE or [Last Name (un) ] should be initiated when appropriate. # PUMP: Status post PCI with h/o hemopericardium and ICM s/p STEMI in [Month (only) ]. Last EF was 35% in 8/[2110]. Repeat TTE on this admission showed worsening of all of the following: left ventricular contractile function (due to marked intercurrent worsening (severe hypokinesis) of anterior, septal, and apical contractile function; EF 20%), right ventricular function, pulmonary hypertension, and tricuspid regurgitation (4+). 2+ MR. We suspect that the deterioration in the right ventricle is likely due to acute on chronic diastolic HF with consequent RV dysfunction. The right coronary artery was not examined during catheterization as the LAD was felt to be the culprit vessel. There was no clinical evidence of pulmonary embolism. Follow up echo to assess RV status as an outpatient will be done. She was treated with medical management as outlined above. An ACEI/[Last Name (un) ] was not started due to low blood pressures during her hospital stay. Her BPs should be monitored as an outpatient and an ACE or [Last Name (un) ] should be initiated when appropriate. TRANSITIONAL: [x] no statin because of inc LFTs and no ACEi because of low BP [x] Pt should be on ACEi in the future because of low EF and MI. Was not started in hospital because of low BP. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientPharmacywebOMR. 1. Aspirin 162 mg PO DAILY 2. Clopidogrel 75 mg PO DAILY 3. Metoprolol Tartrate 12.5 mg PO BID 4. Fluticasone Propionate NASAL 2 SPRY NU DAILY 5. Vitamin D 50,000 UNIT PO 1X/WEEK ([Doctor First Name ]) Discharge Medications: 1. Aspirin 162 mg PO DAILY 2. Clopidogrel 75 mg PO DAILY 3. Acetaminophen 650 mg PO Q6H:PRN pain do not exceed more than 2 grams a day 4. Metoprolol Succinate XL 50 mg PO DAILY 5. Nitroglycerin SL 0.4 mg SL PRN chest pain Take 1 tab for chest pain, wait 5 min, then take 1 more tab. Call 911 if chest pain persists after 2 tabs. 6. Fluticasone Propionate NASAL 2 SPRY NU DAILY 7. Vitamin D 50,000 UNIT PO 1X/WEEK ([Doctor First Name ]) Discharge Disposition: Home With Service Facility: Greater [Location (un) 1468] VNA Discharge Diagnosis: ST elevation myocardial infarction Acute on Chronic systolic congestive heart failure Hypertension Rheumatoid arthritis 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 18]. You had a heart attack and a blockage was found in a previous stent. The blockage was removed and another stent was placed to keep the artery open. You will need to remain on plavix for at least one year and likely forever to prevent the stents from clotting off and causing another heart attack. Do not stop taking plavix or miss [First Name (Titles) 691] [Last Name (Titles) 4319] unless Dr [Last Name (STitle) 171] says that it is OK. An echocardiogram showed that your heart is weaker after the heart attack and you had some extra fluid in your lungs and heart. You received some diuretic to get rid of the extra fluid and it has resolved for now. You need to weigh yourself every morning, call Dr. [Last Name (STitle) 171] or [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] NP if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. Also call Dr. [Last Name (STitle) 171] if you have trouble breathing, swelling in the legs or swelling in the belly. Followup Instructions: Department: [State ]When: MONDAY [2110-10-20] at 12:00 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 8428], MD [Telephone/Fax (1) 2205] Building: [State ] ([Location (un) ], MA) [Location (un) ] Campus: OFF CAMPUS Best Parking: On Street Parking Department: CARDIAC SERVICES When: WEDNESDAY [2110-11-5] at 9:30 AM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2003], NP [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: CARDIAC SERVICES When: WEDNESDAY [2110-12-3] at 1 PM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 62] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "414.01", "V58.66", "412", "428.23", "401.9", "996.72", "410.91", "V45.82", "714.0", "414.8", "785.51", "428.0" ]	icd9cm	[ [ [] ] ]	[ "88.56", "00.66", "00.45", "36.07", "00.44", "00.41" ]	icd9pcs	[ [ [] ] ]	9192, 9259	5821, 8359	256, 373	9423, 9423	3604, 5798	10661, 11577	2197, 2357		8727, 9169	9280, 9402		8385, 8704			9574, 10638							2372, 3393					3409, 3585											192, 218								401, 1748								9438, 9550					1770, 1859	1875, 2181
31,279	166,635	30274	Discharge summary	report	Admission Date: [2157-6-25] Discharge Date: [2157-7-1] Date of Birth: [2081-5-6] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2387] Chief Complaint: SOB and nausea. Found to have polymorphic VT shortly after admission. Major Surgical or Invasive Procedure: Cardiac catheterization History of Present Illness: 76 yo female with hx of afib s/p recent dofetilide and DCCV, HTN, hyperlipidemia who presented to OSH with nausea. Pt was admitted to NEBH [Date range (1) 32334] during which she was given tikosyn initially 500mg [Hospital1 ] and had DCCVx2 with success and discharged on 250mg [Hospital1 ]. She continued to take her medications at home at 8am and 8pm without missing a dose or taking extra doses. She felt well until 2d PTA when she awoke with worsening SOB which progressed throughout the day. This evolved into nausea and at 4pm had an episode of nonbloody nonbilious emesis after which SOB resolved. She report some chest tightness w/o palpitations or chest pressure, no presyncope but did report feeling feverish. She denied dysuria but did have urinary frequency and notice mild nonproductive cough. She awoke with similar symptoms this am with nausea again at 4pm so presented to NEBH ED. In the ED she was thought to have mild CHF with UTI. She was given a dose of Levofloxacin and transferred to [Hospital1 18] for further treatment as there were no available telemetry beds. She was directly admitted to the floor and vital signs were initially stable. She developed worsening SOB, hypertension and sinus tachycardia so was given metoprolol 5mg IV and 20mg IV lasix, and nitroglycerin gtt with improvment in her SOB. She then developed bigeminy and eventual runs of nonsustained polymorphinc VT so was transferred to the CCU for further treatment. Past Medical History: Atrial fibrillation-s/p dofetilide with DCCV ? [6-8] HTN DMII Mild COPD Interstitial lung disease Hyperlipidemia AR Social History: Lives with her son and his family. Very functional at baseline walking [4-14] blocks with no DOE. No EtoH or smoking history. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: VS: T 100.6 BP 125/80 HR 75 RR 25 O2 6l by facemask Gen: WDWN elderly female male in mild resp distress. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVP of 8cm CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. [3-15] SM at RUSM no appreciable diastolic murmur. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were labored w/o accessory muscle use. CTAB, crackles 1/3 up bilat, 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: EKG demonstrated sinus tachycardia at 110, 1st degree heart block, LAD, new TWI in I, Avl, V4-6 QTC 545 TELEMETRY demonstrated: polymorphic ventricular tachycardia CXR-enlarged heart, bilateral lower lobe opacities and . Admission CBC WBC-8.9 RBC-4.48 Hgb-12.0 Hct-35.7 Plt Ct-252 Admission Lytes: Glucose-231* UreaN-30* Creat-1.4* Na-136 K-4.2 Cl-100 HCO3-23 . Trends: WBC 8-21-13-9 Hct 28 - 29 INR 2.7 - 1.3 Creatinine 1.4 - 1.3 [2157-6-26] 12:55AM BLOOD CK(CPK)-25* [2157-6-26] 06:02AM BLOOD CK(CPK)-19* [2157-6-27] 01:52AM BLOOD CK(CPK)-12* [2157-6-28] 06:15AM BLOOD CK(CPK)-11* . [2157-6-26] 12:55AM BLOOD cTropnT-0.04* [2157-6-26] 06:02AM BLOOD cTropnT-0.06* [2157-6-27] 01:52AM BLOOD cTropnT-0.04* [2157-6-28] 06:15AM BLOOD cTropnT-0.03* . Iron-24 calTIBC-254* Ferritn-56 TRF-195* TSH-1.1 Free T4-0.96 . Admission CXR: Bilateral interstitial infiltrates consistent with edema. . Echo: The left atrium is elongated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The ascending aorta is moderately dilated. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is a trivial/physiologic pericardial effusion. . [6-30]: RHC and cardiac cath 1. Selective coronary angiography ofthis right dominant system revealed 2 vessel coronary artery disease. The LMCA had mild disease. Teh LAD had minimal disease. The LCX had a 50% stenosis distal to the previous placed stent. The RCA had a moderate 50% lesion in the mid vessel. 2. Resting hemodynamics revealed mildly elevated right and left sided filling pressures, systemic hypertension and mild pulmonary hypertension. There was no transoartic gradient upon pullback of the catheter from the left ventricle to the aorta. 3. Left ventriculography was deferred. 4. Pressure wire interrogation of teh mid RCA lesion with infusion of IV adenosine revealed an FFR of 0.86 suggesting a non hemodynamically significant lesion. FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Mildly elevated filling pressures. 3. Mild pulmonary hypertension. 4. Systemic hypertension. Brief Hospital Course: Pt is a 76 yo female with hx of afib s/p recent dofetilide and DCCV, HTN, hyperlipidemia who presented to OSH with nausea now transferred to the CCU for polymorphic VT. Hospital course by problem: . #) Rhythm: Pt had markedly prolonged QT due to dofetilide and exacerbated with quinolone use. Pt also had very prolonged PR interval. Telemetry revealed polymorphic VT so she was transferred to the ICU. She received magnesium and potassium to treat Torsade de Pointes. All QTc prolonging agents were held, including the dofetilide. We monitored her lytes closely and obtained serial ECGs. Her QTc improved considerably to the normal range. Tele demonstrated that she was then going into AVNRT and we were concerned that she would revert to Afib. Amio and metoprolol were added to her regimen. She was seen by the EP service and we determined to treat her afib medically to remain in sinus. We bridged patient with heparin while inpatient but restarted coumadin upon dispo. We discharged patient with [Initials (NamePattern4) ] [Last Name (NamePattern4) ] of hearts monitor to *********** . #) CAD: Pt was chest pain free with mild elevation in CE at OSH likely related to tachycardia. New lateral TWI were noted on the ECG after her TDP. They were thought to represent memory T waves from automated ventricular rhythm prior to admission. However, given her persistent TWIs and her slight troponin leak, she was considered an NSTEMI and was brought to the cath lab after plavix, heparin, asa, metoprolol, and statin. Report as above. She received balloon angioplasty of her RCA. Otherwise, no LAD lesion noted. . #) Pump: Pt was in acute CHF clinically as corroberated by elevated BNP and CXR on admission. This was thought [2-11*] arrhythmia and improved when her rhythm improved. She was temporarily treated with a nitro gtt for BP control and lasix for diuresis. Her symptoms improved. TTE as above. . #) Hyperlipidemia:Cont on pravastatin . #) HTN: Held on HCTZ in setting of adjusting cardiac meds. . #) DM: Held on glipizide and covered with humalog sliding scale. Home regimen restarted on dispo. . #) Hyperthyroidism-on stable dose of levothyroxine for extended period of time. TSH normal. Medications on Admission: Levothyroxine Sodium 100 mcg PO DAILY Aspirin 325 mg PO DAILY Magnesium Oxide 400 mg PO DAILY Benicar NF* 40 mg Oral evening Pravastatin 20 mg PO DAILY Calcium Carbonate 500 mg PO DAILY Dofetilide 250 mcg PO BID Vitamin D 400 UNIT PO DAILY Hydrochlorothiazide 12.5 mg PO DAILY Glipizide ER 10mg Discharge Medications: 1. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Olmesartan 20 mg Tablet Sig: Two (2) Tablet PO evening (). 6. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). [Month/Day (2) ]:30 Tablet(s) Refills:2 7. Glipizide 2.5 mg Tab,Sust Rel Osmotic Push 24hr Sig: Four (4) Tab,Sust Rel Osmotic Push 24hr PO DAILY (Daily). [Month/Day (2) ]:120 Tab,Sust Rel Osmotic Push 24hr(s) Refills:2 8. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. [Month/Day (2) ]:90 Tablet(s) Refills:2 9. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. [Month/Day (2) ]:30 Tablet Sustained Release 24 hr(s) Refills:2 10. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO twice a day for 1 weeks. [Month/Day (2) ]:14 Tablet(s) Refills:0 11. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO once a day for 1 weeks: please take 1 pill per day x 1 week AFTER you have taken 1 pill twice daily for a week. [Month/Day (2) ]:7 Tablet(s) Refills:0 12. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day: please take 200mg daily after you have taken 400 mg [Hospital1 ] (1 week) and 400 mg daily (1 week). [Hospital1 ]:30 Tablet(s) Refills:2 13. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day: note, this is a lower dose than your previous, since you are on amiodarone * Please adjust per your PCP. [Name Initial (NameIs) ]:30 Tablet(s) Refills:2 14. Outpatient Lab Work please have your INR checked on [7-4] by your PCP and your coumadin adjusted as needed. 15. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: family care extended Discharge Diagnosis: Primary: - Torsades De Points - Atrial Fibrillation - Coronary Artery Disease: NSTEMI eval by c cath - Urinary tract infection - HTN Secondary: - DMII - mild COPD - interstitial lung disease - hyperlipidemia - aortic regurg Discharge Condition: Ambulating Tolerating POs Discharge Instructions: You were admitted with nausea and shortness of breath. You were noted to have an irregular heart rate which became dangerously irregular so you were treated in the cardiac intensive care unit. We made some adjustments to your medications and your heart rate/rhythm improved. We were also concerned that you had a mild heart attack so you underwent a cardiac catheterization. You tolerated this well and had a balloon angioplasty of one of your heart arteries. . It is very important that you take all of your medicines as prescribed in these discharge instructions. Please also attend all follow up appointment. Some important changes in your medications include: 1. Decreased coumadin dose to 2.5mg daily since amiodarone will increase the effect of this medication. Please followup your coumadin level with your PCP on [Name9 (PRE) 766], [7-4]. 2. Started Toprol XL and hydralazine for your blood pressure 3. Started amiodarone with a tapering dose. 4. In terms of your hydrochlorothiazide this was discontinued . Please contact your PCP or cardiologist of you experience shortness of breath, chest pain, palpitations, dizziness, nausea or syncope. Followup Instructions: Please followup with your PCP within the next 2 weeks - Provider: [Name10 (NameIs) ],[Name11 (NameIs) ] [Name Initial (NameIs) ]. [Telephone/Fax (1) 11144] Appointment should be in [7-19] days . Please have your INR (coumadin level) checked on [Date Range 766], [8-3] with your PCP . Please followup with your cardiologist, Dr. [Last Name (STitle) ] on [7-18] @ 3:45 PM . Please wear your heart monitor ([Doctor Last Name ] of Hearts) and have results faxed to your cardiologist, Dr. [Last Name (STitle) ].	[ "599.0", "427.1", "428.0", "427.31", "416.8", "250.00", "414.01", "426.82", "496", "401.9", "424.0", "272.4", "515", "410.71" ]	icd9cm	[ [ [] ] ]	[ "00.66", "00.40", "88.56", "37.23" ]	icd9pcs	[ [ [] ] ]	10328, 10379	5785, 8015	384, 409	10647, 10675	3144, 5608	11892, 12448	2220, 2302		8362, 10305	10400, 10626		8041, 8339		5625, 5762	10699, 11869							2317, 3125																274, 346								437, 1914													1936, 2057	2073, 2204
77,083	156,896	38984	Discharge summary	report	Admission Date: [2101-1-31] Discharge Date: [2101-2-10] Date of Birth: [2076-1-25] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 598] Chief Complaint: Motor Vehicle Crash Major Surgical or Invasive Procedure: Bilateral Chest tube placement Angiography History of Present Illness: 25 year old male presented as a transfer status post rollover motor vehicle crash and ejection with stable, non-operative spleen and kidney lacs, bilateral Pneumothoraces status post bilateral chest tubes and intubation at an outside hospital. Past Medical History: denies Physical Exam: On discharge: afebrile, VSS. Gen- AOx3, NAD HEENT- NCAT Pulm- B/l Sym BS, CTAB CV- S1/S2 w/o MGR Abd- soft, NTND. Ext- no [Location (un) ] Neuro- CN II-XII intact, b/l sym strength and sensation throughout Pertinent Results: On admission: [2101-1-31] 10:33PM UREA N-22* CREAT-1.4* [2101-1-31] 10:33PM HCT-36.6* [2101-1-31] 07:26PM UREA N-21* CREAT-1.4* [2101-1-31] 07:26PM HCT-36.5* [2101-1-31] 05:59PM TYPE-ART PO2-132* PCO2-50* PH-7.36 TOTAL CO2-29 BASE XS-2 [2101-1-31] 05:59PM freeCa-1.09* [2101-1-31] 02:31PM TYPE-ART PO2-130* PCO2-54* PH-7.31* TOTAL CO2-28 BASE XS-0 [2101-1-31] 02:31PM LACTATE-1.2 [2101-1-31] 02:25PM GLUCOSE-101* UREA N-20 CREAT-1.3* SODIUM-141 POTASSIUM-4.7 CHLORIDE-108 TOTAL CO2-27 ANION GAP-11 [2101-1-31] 02:25PM CALCIUM-7.8* PHOSPHATE-4.1 MAGNESIUM-1.6 [2101-1-31] 02:25PM WBC-13.8* RBC-4.58* HGB-13.9* HCT-39.6* MCV-87 MCH-30.3 MCHC-35.0 RDW-13.6 [2101-1-31] 02:25PM NEUTS-81.9* LYMPHS-11.4* MONOS-6.2 EOS-0.1 BASOS-0.5 [2101-1-31] 02:25PM PLT COUNT-187 [2101-1-31] 02:25PM PT-13.5* PTT-26.8 INR(PT)-1.2* [2101-1-31] 01:38PM URINE HCT-2.5 [2101-1-31] 12:48PM TYPE-ART TEMP-37.9 TIDAL VOL-500 PEEP-5 O2-100 PO2-444* PCO2-54* PH-7.29* TOTAL CO2-27 BASE XS--1 AADO2-215 REQ O2-44 -ASSIST/CON INTUBATED-INTUBATED [2101-1-31] 12:48PM LACTATE-1.3 [2101-1-31] 10:10AM HCT-35.2* [2101-1-31] 08:32AM COMMENTS-GREEN TUBE [2101-1-31] 08:32AM GLUCOSE-85 LACTATE-5.3* NA+-144 K+-3.7 CL--103 TCO2-22 [2101-1-31] 08:25AM UREA N-19 CREAT-1.5* [2101-1-31] 08:25AM estGFR-Using this [2101-1-31] 08:25AM LIPASE-161* [2101-1-31] 08:25AM ASA-NEG ETHANOL-19* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2101-1-31] 08:25AM URINE HOURS-RANDOM [2101-1-31] 08:25AM URINE HOURS-RANDOM [2101-1-31] 08:25AM URINE GR HOLD-HOLD [2101-1-31] 08:25AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2101-1-31] 08:25AM WBC-21.1* RBC-4.87 HGB-14.6 HCT-42.6 MCV-87 MCH-30.0 MCHC-34.3 RDW-12.7 [2101-1-31] 08:25AM PLT COUNT-157 [2101-1-31] 08:25AM PT-13.7* PTT-25.9 INR(PT)-1.2* [2101-1-31] 08:25AM FIBRINOGE-115* [2101-1-31] 08:25AM URINE COLOR-Red APPEAR-Cloudy SP [Last Name (un) 155]-<1.005 [2101-1-31] 08:25AM URINE BLOOD-LG NITRITE-POS PROTEIN->300 GLUCOSE-100 KETONE-15 BILIRUBIN-LG UROBILNGN-2* PH-8.5* LEUK-LG [2101-1-31] 08:25AM URINE RBC->50 WBC-[10-8]* BACTERIA-MANY YEAST-NONE EPI-0-2 Imaging: CXR [1-31]: Multiple left rib fractures and lung contusions. Chest tubes in place. Please refer to CT chest from OSH for further details. CT Head [1-31] from OSH: Subcentimeter hyperdense focus in the left occipital lobe is atypical in location for traumatic hemorrhagic contusion, suggestive of underlying occult vascular malformation. Close followup is recommended for further evaluation. No mass effect, no midline shift. Paranasal sinuses are clear. No sign of osseous fracture. CT C-spine [1-31] from OSH: 1. Within limitation of significant motion artifacts, no evidence of fracture or malalignment within the cervical spine. 2. Biapical pneumothoraces with multiple minimally displaced posterior rib fractures involving bilateral first and second ribs and medial left third rib. There are likely to be additional rib fractures beyond the scope of current study. Please correlate these findings with accompanying chest CT. CT abd/pelvis [1-31] from OSH: 1. Left posterior rib fractures with diffuse lung contusions and small left hemothorax. Bilateral pneumothoraces. Small right lung opcity suggests aspiration vs. contusion. 2. Splenic lacerations with active extravasation. 3. Shattered left kidney with large hematoma and no definite active bleeding or disruption of the collecting system. CT Face [1-31] from OSH: No evidence of maxillofacial fracture. Minimal mucosal thickening within ethmoidal air cells on the left. Brief Hospital Course: Patient was admitted intubated to the TICU. He had bilateral chest tubes in place. His Hcts were trended and were stable after 3 units of blood. He was extubated the following day and his left right chest tube was removed, and his c-collar was also removed after clearing his c-spine. His mental status improved and the following day his other chest tube was removed and he was later transferred to the floor. On the floor, a repeat chest xray revealed reaccumulation of his pneumothorax, so another left chest tube was placed. Due to chest tube position, a small apical pneumothorax was not accessible to the chest tube. After two days of the apical pneumothorax being stable, the chest tube was pulled. Subsequent chest xrays showed the pneumothorax to be stable. His diet was advanced after the patient was kept NPO for 3 days. His pain was controlled using oral dilaudid. Medications on Admission: None Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:40 Tablet(s) Refills:0 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:30 Tablet(s) Refills:0 4. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain, fever. Discharge Disposition: Home With Service Facility: [Hospital1 1474] VNA Discharge Diagnosis: Splenic laceration Renal Laceration Left hemo/pneumothorax Right pneumothorax Left pulmonary contusion Intraparenchymal hemorrhage Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: You were admitted to the hospital after a motor vehicle crash. On discharge you were tolerating a normal diet. You must retrun to the hospital for any increase in abdominal or flank pain, dizziness or lightheadness, fevers, or shortness of breath. Take pain medications as prescribed, but do not drive or operate heavy machinery while taking narcotic pain medications. Because of the injury to your spleen, do not participate in any contact sports or any rough activities. Followup Instructions: Follow up with Dr. [Last Name (STitle) ] in clinic in 2 weeks, call to make an appointment: ([Telephone/Fax (1) 2300]. [First Name8 (NamePattern2) ] [Name8 (MD) ] MD [MD Number(2) 601]	[ "807.05", "861.21", "958.4", "E816.0", "851.40", "866.00", "285.1", "276.51", "860.4", "865.00", "599.0" ]	icd9cm	[ [ [] ] ]	[ "96.71", "88.47", "34.04" ]	icd9pcs	[ [ [] ] ]	6162, 6217	4742, 5626	333, 378	6392, 6392	927, 927	7038, 7275			5681, 6139	6238, 6371		5652, 5658			6540, 7015							696, 696											711, 908					274, 295								406, 651							942, 4719	6407, 6516					673, 681
13,688	126,251	47424	Discharge summary	report	Admission Date: [2138-9-9] Discharge Date: [2138-9-12] Date of Birth: [2080-1-17] Sex: F Service: ORTHOPAEDICS Allergies: Latex Gloves Attending:[First Name3 (LF) 64] Chief Complaint: Tricompartmental osteoarthritis with avascular necrosis Major Surgical or Invasive Procedure: Right total knee replacement History of Present Illness: 58y/o female with tricomaprtmental osteoarthritis and avascular necrosis presents for definitive treatment. Past Medical History: GERD Depression Tension headaches Bronchitis Heart murmur Social History: Non-contributory Family History: Non-contributory Physical Exam: Afebrile, All vital signs stable Gen: Alert and oriented, No acute distress Lungs: CTA bilaterally Abd: benign Extremities: right lower Incision: no swelling/erythema/drainage Dressing/Cast: clean/dry/intact +[Last Name (un) 938]/FHL/AT +SILT 2+ pulse, moves toes Capillary refill brisk Brief Hospital Course: Ms. [Known lastname 3501] was admitted on [2138-9-9] for an elective right total knee replacement. Pre-operatively, she was consented, prepped, and brought down to the operating room for surgery. She received an epidural catheter from the Anesthesia service to manage her postoperative pain. Intra-operatively, she was closely monitored and remained hemodynamically stable. She tolerated the procedure well without any difficulty or complication. Post-operatively, she was extubated and transferred to the PACU for further stabilization and monitoring. In the PACU, she had an episode of apnea possibly secondary to increased narcotics to control her postoperative pain. She was transferred to the MICU for monitoring. She was transfused 1 unit of PRBC for postoperative anemia. She was closely monitored and remained hemodynamically stable. The following morning, she was transferd to the floor for further recovery. On the floor, she remained hemodynamically stable with her pain controlled. She progressed with physical therapy to improve her strength and mobility. She continues to make steady progress without any incidents. She was discharged to a rehabilitation facility in stable condition. She has a follow up appointment with Dr. [Last Name (STitle) ] on [2138-9-22]. Medications on Admission: Wellbutrin Amitriptyline Cymbalta Ritalin Methadone Synthroid Cyclobenzaprine Geodon Ibuprofen Oxycodone Colchicine Albuterol Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 2. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours) for 4 weeks. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO BID (2 times a day) as needed. 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 7. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed. 8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Methadone 5 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 11. Methadone 5 mg Tablet Sig: 0.5 Tablet PO QAM (once a day (in the morning)). 12. Bupropion 100 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO BID (2 times a day). 13. Amitriptyline 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 14. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Ziprasidone HCl 40 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 16. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for SOB/wheezing. 17. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 18. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed. 19. Methylphenidate 20 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). 20. Cetirizine 10 mg Tablet Sig: One (1) Tablet PO every 12 hours prn () as needed for itching. 21. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3 to 4 Hours) as needed for pain. 22. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 23. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 24. Aspirin EC 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day for 4 weeks: Start after completing Lovenox injections. Discharge Disposition: Extended Care Facility: [Hospital3 2558] - [Location (un) ] Discharge Diagnosis: Osteoarthrits Postoperative anemia Discharge Condition: Stable Discharge Instructions: Keep the incision/dressing clean and dry. You may apply a dry sterile dressing as needed for drainage or comfort. If you have skin staples, they can be removed 2 weeks after surgery. If you are experiencing any increased redness, swelling, pain, or have a temperature >101.5, please call your doctor or go to the emergency room for evaluation. Resume all of your home medication and take all medication as prescribed by your doctor. Continue your Lovenox injections as prescribed for anticoagulation. Please take aspirin as prescribed after completing your course of Lovenox injections for anticoagulation. You have a scheduled follow up appointment with Dr. [Last Name (STitle) ] on [2138-9-22]. Feel free to call our office with any questions or concerns. Physical Therapy: Activity: Out of bed w/ assist Pneumatic boots Right lower extremity: Full weight bearing Treatments Frequency: If you are experiencing any increased redness, swelling, pain, or have a temperature >101.5, please call your doctor or go to the emergency room for evaluation. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 10486], MD Phone:[Telephone/Fax (1) 1228] Date/Time:[2138-9-22] 11:10 Provider: [Name10 (NameIs) 251] [Last Name (NamePattern4) 252], M.D. Phone:[Telephone/Fax (1) 253] Date/Time:[2139-3-16] 11:00 Completed by:[2138-9-12]	[ "244.9", "585.9", "493.90", "733.90", "715.36", "285.1", "530.81", "733.42", "311" ]	icd9cm	[ [ [] ] ]	[ "81.54", "99.04" ]	icd9pcs	[ [ [] ] ]	4764, 4834	996, 2291	330, 361	4913, 4922		6032, 6360	629, 647		2467, 4741	4855, 4892		2317, 2444			4946, 5712							662, 973	5730, 5825	5847, 6009														235, 292								389, 498													520, 579	595, 613
79,664	161,109	41259	Discharge summary	report	Admission Date: [2196-4-4] Discharge Date: [2196-4-26] Date of Birth: [2128-10-6] Sex: M Service: UROLOGY Allergies: Shellfish / hayfever / Heparin Agents Attending:[First Name3 (LF) 6440] Chief Complaint: Prostate CA s/p Open radical prostatectomy Bilateral inguinal hernias s/p inguinal herniorraphies with mesh Cardiac Arrest (Puleseless Electrical Activity) Pulmonary Embolism s/p thrombolysis and IVC filter placement Heparin Induced Thrombocytopenia (HIT) Abdominal Compartment Syndrome s/p decompressive laparotomy Acute Tubular Necrosis (Acute Renal Failure) s/p hemodialysis Major Surgical or Invasive Procedure: [2196-4-6]: OPERATION: Radical retropubic prostatectomy, bilateral pelvic lymphadenectomy, bilateral nerve-sparing, bilateral inguinal hernia repairs with mesh. [2196-4-7]: OPERATION: 1. Decompressive laparotomy. 2. Attempted right femoral groin dialysis catheter placement. [2196-4-8]: OPERATION PLANNED: 1. Takedown of dressing, washout of abdomen, replacement of dressing. 2. Placement of a left internal jugular central line. 3. Attempted placement of an inferior vena cava filter. 4. Placement of a dialysis catheter in the right internal jugular. [2207-4-13]: OPERATION: Retropubic washout, clot evacuation, and vesicourethral reanastomosis and 1. Opening of recent laparotomy with attempted closure and placement of [State 19827] patch. 2. Placement of IVC filter. [2196-4-14]: OPERATION: Ventral hernia repair with mesh. History of Present Illness: Mr. [Name14 (STitle) 89862] is a 67 man s/p radical prostatectomy, whose post op course was complicated by PEA arrested on floor on POD 1. He was transferred to MICU for further management, started on IV heparin and TPA for presumptive pulmonary embolism. Upon arrival to MICU, he arrested again and was resusciatated in the MICU. He was hypotensive and received multiple liters of IVF for resuscitation. The then developed abdominal distension, oliguira and reduced pedal pulses, elevated peak pressures and elevated bladder pressures. Surgery was called for an acute abdominal compartment syndrome. Past Medical History: Childhood Asthma Social History: Lives at home with wife in [Name (NI) 89863], [Name (NI) ] Family History: Non-contributory Physical Exam: WdWn male, NAD, AVSS Appears well but frail, mucus membranes moist pleasant demeanor and affect abdomen appropriately tender, soft, non-distended three drains in place and secured to abdomen: two JP drains to bulbsuction and one Pelvic drain to drainage (non-compressed bulb). Foley catheter in place draining yellow urine--secured in place at medial thigh lower left extremity with flexed left knee and decreased plantar flexion (approx [3-15] vs [4-14] on right). No gross peripheral edema, pitting edema at bilateral lower extremities. Pertinent Results: [2196-4-26] 07:10AM BLOOD WBC-14.1* RBC-3.52* Hgb-10.9* Hct-33.1* MCV-94 MCH-31.1 MCHC-33.1 RDW-14.5 Plt Ct-557* [2196-4-26] 07:10AM BLOOD Glucose-126* UreaN-52* Creat-2.6* Na-141 K-3.6 Cl-104 HCO3-26 AnGap-15 [2196-4-26] 07:10AM BLOOD PT-19.9* PTT-24.8 INR(PT)-1.8* [2196-4-25] 07:00AM BLOOD PT-19.7* PTT-25.1 INR(PT)-1.8* [2196-4-24] 04:56AM BLOOD PT-27.0* PTT-28.5 INR(PT)-2.6* [2196-4-26] 07:10AM BLOOD Glucose-126* UreaN-52* Creat-2.6* Na-141 K-3.6 Cl-104 HCO3-26 AnGap-15 [2196-4-25] 07:00AM BLOOD Glucose-103* UreaN-59* Creat-3.1* Na-140 K-4.1 Cl-103 HCO3-28 AnGap-13 [2196-4-24] 04:56AM BLOOD Glucose-90 UreaN-62* Creat-3.6* Na-140 K-3.4 Cl-103 HCO3-28 AnGap-12 [2196-4-23] 06:07AM BLOOD ALT-36 AST-27 AlkPhos-122 TotBili-1.0 [2196-4-19] 06:00AM BLOOD ALT-42* AST-35 AlkPhos-131* TotBili-1.2 [2196-4-20] 03:11PM ASCITES Creat-3.5 [2196-4-26] 07:10AM BLOOD Calcium-8.2* Phos-3.5 Mg-1.7 [2196-4-25] 07:00AM BLOOD Calcium-7.4* Phos-3.7 Mg-1.7 [2196-4-23] 06:07AM BLOOD Albumin-2.6* Calcium-7.1* Mg-1.8 [2196-4-6] 01:15PM URINE Color-Red Appear-Cloudy Sp [Last Name (un) ]-1.027 [2196-4-6] 01:15PM URINE Blood-LG Nitrite-NEG Protein-100 Glucose-TR Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM [2196-4-6] 01:15PM URINE RBC->182* WBC-1 Bacteri-NONE Yeast-NONE Epi-0 [2196-4-26] 9:45 am URINE Source: Catheter. URINE CULTURE (Pending): FUNGAL CULTURE (Pending): [2196-4-18] 9:00 am STOOL CONSISTENCY: FORMED Source: Stool. FINAL REPORT [2196-4-18] CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [2196-4-18]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). [2196-4-14] 2:35 pm URINE Source: Catheter. FINAL REPORT [2196-4-15] URINE CULTURE (Final [2196-4-15]): YEAST. 10,000-100,000 ORGANISMS/ML.. Brief Hospital Course: 67 year old male with diagnosis of prostate cancer, s/p prostatectomy, post-op course c/b by PEA arrest [1-13] presumed pulmonary embolus, profound hypotension, multi-system failure, post-operative hematoma, increasing abdominal distension requiring emergent laparatomy Patient was transferred to the [Hospital Unit Name 153] from the Urology service in the setting of s/p radical retropubic prostatectomy c/b POD#1 PEA arrest, thought to be [1-13] to PE, for which the patient was given tPA and started on a heparin drip. Patient's course was complicated by hypotension (MAPs 50s), requiring frequent fluid boluses (26L over 2d course) as well as levophed and neosynephrine. Concurrent with this, patient became increasingly difficult to ventilate, with concern for ACS. He became acutely anemic (10pt drop in 12hrs) and was found to have 16cm hematoma at his operative drain site without signs of intra-abdominal or retroperitoneal bleeds. ICU stay also c/b ARF (thought to be [1-13] to ACS), w rising creatinine and worsening acidosis, requiring bicarbonate drip. LFTs also were also noted to be rising, thought to be [1-13] to shock liver in the setting hypotension. On POD#3, patient was noted to have worsening abdominal distenion. Bladder pressure was found to have risen from 20 to 40. In conjunction with general surgery and urology, the patient was taken to the OR for urgent laparatomy on [4-7]. The following day, the patient was weaning down from his pressor requirement, the PEEP was decreased from 20 to 10, he went back to the OR for a washout and placement of an HD line. Femoral venous line was obtained. CVVHD was initiated. On [4-9], bedside cystogram showed disruption of the bladder anastamosis. On [4-10] his vent was weaned to pressure support, he was restarted on a heparin gtt and tube feeds were started. He was transfused 1u PRBC for Hct 23.1. On [4-11] the patient went back to the OR for washout and placement of [State ] patch by ACS, IVC filter placement, and urethrovesicular anastamosis by urology. On [4-12], the white count was elevated and there was concern for possible VAP so a Bronch/BAL was performed and showed no purulent secretions. On [4-13] the HD line was replaced as it was no longer working. On [4-14] the patient went back to the OR for abdominal closure with mesh. Given concern for HIT (decreased plts), Argatroban was started. On [4-15] the patient was extubated. . On [4-17], he was tolerating a regular diet and TF were held for copious diarrhea. Cdiff was sent. On [4-18] the patient remained stable and was transfered to the floor after HD. He was then transferred back to the Urology service. Once back on the urology floor, he continued to do well, argatroban was stopped once INR in therapeutic range, and pt maintained on Coumadin. He was noted to have LLE weakness and proprioceptive deficit for which neurology was reconsulted. Pt's renal function continued to improve and finished hemodialysis on [2196-4-22]. He was maintained on telemetry in sinus tachycardia throughout his stay on the floor. Due to length of hospital stay and complexity of his hospital course, a summary is also provided by systems. HOSPITAL COURSE BY SYSTEMS: NEUROLOGIC: Post-op, patient did well initially with pain controlled with IV morphine PCA. On POD#1, pt got out of bed for first walk, c/o acute SOB/dizziness and collapsed with PEA cardiopulmonary arrest. Pt resuscitated and during resuscitation was noted to move all 4 extremities intermittently. Pt brought to ICU where he was kept sedated with combinations of Propofol, Versed/Fentanyl until ready for extubation. Neurology consult initiated upon admission to ICU for evaluation. Post-code CT scan included a CT of the head, which showed no acute intracranial hemorrhage but a possible early acute infarction in the left frontal lobe. After extubation, pt was comfortable with minimal pain medications. He was noted to be grossly deconditioned from prolonged ICU stay, but able to move all 4 extremities. He was noted to have decreased LLE strength and proprioception for which neurology re-consult was requested. Per neurology, MRI Head, thoracic/Lumbar spine was obtained which showed: MRI Head: a ??????tiny subacute infarct in the left posterior parietal lobe with no evidence of an acute intracranial infarction or hemorrhage. Sequelae of microvascular ischemia. Intracranial and cervical arterial vasculature does not demonstrate evidence of significant flow limiting stenosis, aneurysm or vascular malformation. MRI T/L-Spine: No evidence for cord ischemia. Mild lumbar spondylotic changes. Heterogeneous marrow which could represent chronic anemia or other infiltrative disorders. Neurology initially requested EMG of LLE for prognostic purposes, however this was deferred by the patient, as it would not have changed his management. Neurology felt that his LLE deficits were consistent with root/plexus injury from compression due to hematoma, and that his prognosis was excellent with regard to recoverable function. His LLE was noted to have improving strength and position sense toward the end of his hospitalization. CARDIOVASCULAR: Initially post-operatively, his cardiac function was excellent without issues. On POD#1, after he got out of bed to ambulate for the first time, he suddenly became dizzy and SOB and collapsed (witnessed by RN and family). A code blue was immediately initiated and ACLS protocol was followed. He was initially noted to be in PEA cardiac arrest and was pulseless for approximately 7 minutes. CPR was conducted and he was intubated and given medications per ACLS protocol, which ultimately resulted in return of palpable pulses. During his cardiac arrest, the surgery team attempted right femoral line placement, with inadvertent placement of triple lumen catheter into right femoral artery instead of the vein. This line was kept in place and used as an arterial line. Given the high suspicion for pulmonary embolus, he was bloused with Heparin. He was noted to have continued hypotension requiring pressors, and shortly after transfer to the ICU, he became pulseless again. Chest compressions and ACLS medications resulted in return of pulses and a bedside cardiac Echo was performed which showed: ??????dilated hypocontractile right ventricle with small hyperdynamic left ventricle (these findings are consistent with acute pulmonary embolism or isolated right ventricular infarction with major hemodynamic compromise). After patient was stable post-arrest, he was taken for emergent CT scan of the head, chest, abdomen, and pelvis with the primary concern being a large pulmonary embolus. CT of the chest showed: 1. Multifocal segmental and subsegmental pulmonary emboli involving all lobes with CT findings suggestive of right ventricular strain. 2. Multifocal dependent pulmonary opacities with dense consolidation of the left lower lobe likely related to aspiration pneumonitis/pneumonia. 3. Trace amount of simple free fluid within the abdomen and pelvis with post-surgical changes from prior prostatectomy noted. Soft tissue induration and edema noted from the right groin extending into the right thigh subcuatenous tissues and rectus femoris is most consistent with hematoma from recent line placement. 4. Venous aneurysms/varix involving the left common femoral vein and deep femoral vein with nidus of vessels noted within the mid left thigh highly suggestive of an underlying venous malformation. This can be better evaluated with a conventional or CT angiogram if desired. 5. Slit-like appearance to portions of the IVC may suggest underlying volume depletion or increased intrabdominal pressure. Probable mixing artifact (non-occlusive clot is felt to be less likely) in the left saphaneous, DFV and SFV. 6. Mildly displaced mid sternal and right/left anterior rib fractures presumably related to resuscitative efforts. Small adjacent anterior mediastinal hematoma. After Chest CT confirmed bilateral Pulmonary Emboli, it was felt that despite the patient being in the immediate post-op period, he would likely not survive without drastic attempts at clot lysis. He was therefore administered systemic TPA for clot lysis, understanding the high risk for resultant bleeding. His cardiopulmonary function was noted to be improved after administration of TPA, but his hematocrit was noted to drop to a level of 16, for which he was emergently transfused. He required intermittent transfusions and fluid boluses to maintain a HCT in the low 20??????s and his abdomen was noted to be distended. This was felt to be from a retroperitoneal bleed around the surgical site. Further details in the GI/ABD section. He was maintained on 2 pressors and required massive boluses of IVF to keep pressures up after his arrest, resulting in total body volume overload (approximately 30 liters fluid positive). Despite maximal pressors and almost continuous fluid boluses, he remained hypotensive, and his abdomen and extremities were noted to be dusky and tight. The Acute Surgery Service was consulted, and felt that he likely had abdominal compartment syndrome for which he underwent emergent decompressive laparotomy. After this procedure, he was able to be weaned off of pressors fairly quickly. During the post-op/post-extubation period, he was noted to be tachycardic and hypertensive, for which oral metoprolol 25mg TID was initiated. His hypertension was felt to be secondary to his renal failure and was followed by the nephrology team. It was felt that unless his systolic blood pressures rose above 160, there was no need to increase the dose of his beta-blockers. PULMONARY: Per above, the patient sustained a cardiac arrest likely secondary to large pulmonary embolus. CT of the chest post-code and intubation is detailed above and showed bilateral pulmonary emboli. He was given systemic TPA for clot lysis after PE was found on his CT scan. He was kept intubated from [Date range (2) 89864] while his abdomen remained open. After his abdomen was closed, he was extubated and did well from a respiratory standpoint. He was encouraged to use an incentive spirometer after transfer out of the Trauma/SICU. GASTROINTESTINAL/ABDOMINAL: After administration of TPA. Patient was noted to bleed into retroperitoneum. CT scan of Abd/Pelvis after TPA noted: ??????Large midline hematoma seen involving the rectus sheath and the adjacent anterior abdominal wall around the drain insertion site as described. As compared to the prior CT scan, there is increase in the extent of bilateral pleural effusions, pericardial effusion and intraperitoneal free fluid. There is increased subcutaneous abdominal and chest wall edema??????. Attempts at fluid resuscitation failed to improve his blood pressure, and his abdomen was noted to become more distended and tight with bladder pressures increasing to the mid 60??????s. ACS team consulted due to concern for abdominal compartment syndrome. Surgery team recommended emergent decompressive laparotomy, which was carried out with abdomen left packed and open. Pt transferred to T/SICU under ACS team for further care. BP noted to improve after abdomen opened. Several attempts made to close abdomen, but initially unable due to massive generalized edema. CRRT initiated due to anuria and large amounts of fluid removed daily at rate of about 200-400 cc/hr. Eventually, abdomen closed with large prolene mesh on [2196-4-14], as unable to bring rectus muscles back together. While abdomen was open, pt given enteral tube feeds through orogastric tube. Once abdomen closed, NGT placed and tube feeds continued until patient passed speech and swallow eval. After speech and swallow eval, pt tolerated oral intake and able to maintain adequate nutrition. The patient will be discharged with 2 abdominal JP drains (on bulb suction), which reside in the subcutaneous space of the abdomen on the left and right. He also has a 19 Fr [Doctor Last Name 406] drain in the pelvis around the urethral anastomosis (bulb not to suction). NUTRITION: Patient NPO until he was stabilizing in the T/SICU, at which time he was given enteral tube feeds in the form of Nutren 2.0 at goal of 40cc/hr. After extubation, he underwent a speech and swallow study, which cleared him for thin liquids and thus a Regular diet was initiated with supplemental nutrition in the form of Ensure three times daily. RENAL: After his cardiac arrest, the patient became anuric likely felt to be a result of ATN secondary to hypovolemia, increased intraabdominal pressures, and systemic shock. He was followed by the renal team and was started on Continuous Renal Replacement Therapy after transfer to the T/SICU. Once his BP stabilized and pt able to tolerate fluid removal, he had a large amount of fluid removed with approximately 2-3 liters of fluid per day removed. After enough fluid was removed to allow closure of abdomen, he was transitioned to intermittent hemodialysis three times a week. He was closely followed by the nephrology team, who felt that he had an excellent prognosis with regard to recovery of his renal function. His urine output slowly recovered such that his daily UOP was >1000cc. He was dialysed intermittently until it was felt that his renal function had recovered enough to keep him euvolemic with stable electrolyte values. At the time of discharge, his BUN and creatinine continue to decrease, and UOP is excellent. GENITOURINARY: Pt underwent uneventful open radical retropubic prostatectomy. After thrombolysis was carried out, he had a retroperitoneal bleed likely from the surgical bed. This unfortunately caused a urethral disruption of his anastomosis, as seen on portable cystogram. During his first attempt at abdominal closure, an attempt to reanastomose the urethra to the bladder neck was performed, which unfortunately resulted in disruption again while general surgery was attempting to close abdomen. The urethra was re-repaired, although there was a urine leak noted at the time of closure. A 19 Fr [Doctor Last Name 406] drain was left in the pelvis to collect and urine leakage. The [Doctor Last Name ] drain was kept on bulb suction for many days, but as UOP increased and drain output decreased, the bulb was taken off suction. Repeated creatinine values taken from the pelvic drain fluid showed a creatinine value consistent with serous fluid and NOT urine. A portable cystogram performed on the day of discharge did show a presumed urine leak after instillation of around 60 cc of cystograffin. The foley will be left in place, secured at all times on no tension with 2 catheter secure devices with plan to leave foley in place until follow up with urology ?????? DO NOT ATTEMPT TO CHANGE OR MANIPULATE FOLEY CATHETER WITHOUT FIRST DISCUSSING WITH PATIENT??????S UROLOGIST! At the time of discharge, the patient??????s urine was slightly malodorous, and urine culture is pending. Pt was started on brief 3 day course of Fluconazole and Cipro for presumed UTI. HEMATOLOGY: During his initial surgery (prostatectomy), the patient was noted to have a very large and dilated left external iliac vein at the time of his lymph node dissection. After his cardiac arrest, he was given a heparin bolus. After his pulmonary embolus was found on PE-protocol CT, he was thrombolysed with TPA. He then was maintained on Heparin Gtt after TPA activity was felt to be completed. His course was complicated by retroperitoneal bleed, as detailed above. His platelets were noted to drop after heparin started, for which HIT antibody assay was sent, which ultimately returned positive ([2196-4-14]). He was then transitioned to Argatroban for anticoagulation. During an abdominal washout procedure, he had a retrievable IVC filter placed by the ACS team ([4-11]). He was started on Coumadin once he was able to tolerate an oral diet. Argatroban was discontinued once INR was between [3-15], at which point his INR returned in the mid-3??????s 6 hours after stopping Argatroban. He was then given between 1-5 mg of Coumadin daily for anticoagulation with a goal INR of [1-14]. At the time of discharge, his INR was slightly sub-therapeutic at 1.8. He required many transfusions of blood products during his hospital stay. At the time of discharge, his HCT is stable above 30 and is slowly rising. ENDOCRINE: He was maintained on a RISS for goal BS < 150 (scale increased [4-16], all FS < 150 after). INFECTIOUS DISEASE: His hospitalization was relatively uncomplicated with regard to ID issues. He was given perioperative infection prophylaxis for his procedures. During his ICU stay, his foley was noted to have yeast growing in the tubing, for which a urine Cx was sent, which was positive for yeast. He was given Fluconazole for this. His WBC was noted to be quite elevated in the mid 30??????s while his abdomen was opened, but this slowly resolved after abdominal closure. WBC at the time of discharge was 14. On the day of discharge, he was noted to have malodorous urine during cystogram, so urine sent for culture and pt started on renally-dosed ciprofloxacin for 3 days and fluconazole for 3 days. Microbiology: [2196-4-26] Urine Cx - Pending [2196-4-18] CDIFF Neg [2196-4-14] Bcx Neg [2196-4-14] UCX YEAST. 10,000-100,000 ORGANISMS/ML.- RX with Fluconazole [2196-4-14] SPUTUM- Rare Yeast [2196-4-14] CDIFF negative [2196-4-12] BAL resp flora YEAST. ~[2184]/ML. [2196-4-7] bcx negative [2196-4-6] bcx negative [2196-4-6] ucx negative . TUBES / LINES / DRAINS: Foley (16 Fr Council), 19 Fr [Doctor Last Name 406] in pelvis (no suction to bulb), JP x2 (subcutaneous tissues of abdomen) ?????? both to bulb suction. DRAINS TO REMAIN IN PLACE UNTIL FOLLOW UP WITH UROLOGY AND TRAUMA SURGERY TEAMS! Removed T/L/D: R femoral A-line ([4-8]), R femoral venous catheter, R IJ HD line ([4-13] - [4-16]), R axillary aline ([4-7] - [4-17]), L IJ HD line ([Date range (1) 67108]), NGT, PIV WOUNDS: Midline abdominal incision c/d/i at time of discharge with non-absorbable nylon mattress sutures in place ?????? to stay in place until follow up with general surgery Lower suprapubic pfannensteil incision with steri-strips in place (staples removed), well-healing with no erythema or swelling noted. FOLLOW UP APPOINTMENTS NEEDED: Urology ?????? Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 365], MD [First Name (Titles) 4289] [Last Name (Titles) ] Surgery ?????? Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 853], MD Neurology - Dr. [First Name8 (NamePattern2) 39215] [Last Name (NamePattern1) ], MD [First Name (Titles) ] [Last Name (Titles) ] - Dr. [Last Name (STitle) ] [Name (STitle) 89865], MD Nephrology - Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 4920], MD OPERATIVE DATES: [2196-4-14] abdominal closure with mesh [2196-4-11] washout, urethral anastomosis, [State ] patch [2196-4-8] washout, place L IJ, R HD cath placement [2196-4-7] decomp exlap, evac of RP and rectus sheath hematoma [2196-4-4] Radical retropubic prostatectomy with Bilateral Pelvic Lymph Node Dissection, Bilateral inguinal hernia repair with mesh DAILY EVENTS: [2196-4-26] Urine malodorous, urine Cx sent, started Cipro and fluconazole for 3 day course. [2196-4-25] Renal function improved slightly, PT worked with patient, Neuro rec EMG, but declined due to results unlikely to change plan/management, Rehab screen initiated [2196-4-24] Left IJ Dialysis TLC removed [2196-4-23] Transfused 1 u PRBC, MR T/L-spine no evidence of spinal cord ischemia [2196-4-22] Hemodialysis. Per Neuro Consult, MR of thoracic and lumbar spine. Pelvic JP taken off suction and placed to gravity drainage. [2196-4-21] Neurology reconsulted for left lower extremity weakness and decreased proprioception, difficulty with adduction. Pfanensteil staples removed and staples placed over incision. MR brain w/o contrast negative for acute stroke. [2196-4-20] Hemodialysis. JP creatinine from pelvic drain = 3.5 (serum creat 6.2), Urine Creat (from foley) = 93, Argatroban Gtt stopped, INR therapeutic [2196-4-19] Transferred to Urology Service from ACS Service [2196-4-18] Transferred to floor [2196-4-18] HD uneventful today [2196-4-18] NG tube d/ced -> PO [2196-4-18] Axillary line D/Ced [2196-4-16] TF advanced to goal.Given coumadin 2 mg x1, Switched to oxycodone for pain [2196-4-16] HD line removed. Argatroban continued [2196-4-15] extubated [2196-4-11] CT-venogram this AM prior to OR. To OR for washout of abd and [State ] patch by ACS, IVC filter placement by ACS, urethrovesicular anastamosis by urology. EBL 900, IVF 4500. Transfused PRBCs 1U. To OR for attempted closure, reapproximation of bladder [2196-4-10]: CMV -> CPAP. Therapeutic on heparin drip. [Last Name (un) 18821] monitor dc'ed. TF 20 -> 40cc/hr. Transfused 1u PRBC for Hct 23.1. [2196-4-9]: pelvic JP drain fell out, catheter placed into right femoral vein. Start 25% albumin 25g TID and take off 150-200cc/hr. Removed esophageal balloon. IVC filter not today, will start tube feeds at low rate. Bedside cystogram showing bladder disruption - will need repair on Monday. [2196-4-8]: weaned off pressors, PEEP decreased to 10, to OR for washout + HD line + right HD line + left IJ TLC, IVC filter unable to be placed, CRRT started [2196-4-7]: Given elevated abd pressure (45-50 based on bladder pressure) need for HD line --> heparin gtt turned off in anticipation of OR, to OR for decompressive laparotomy - open abdomen, transfer from [Hospital Unit Name 153] to trauma ICU, esophageal balloon placed. LFTs continued to increase shock liver most likely, returned from OR w abdomen open and packed; HD line unable to be placed in OR; drain to suction, stable w SBPs 130s, transferred to [Hospital Ward Name 517] post-op to TSICU [2196-4-6]: In AM aggressively bolused w IVF w plan to f/u CVP and CO (placed NICOM), sedation briefly weaned for neuro exam (intact), started vanco/zosyn given concern for potential infection, c/s ortho, vascular consult resident - would not intervene for thigh hematoma while lytics are still active, supportive care and pull line only when lytics are out of system, Loose insulin SS, Neuro reccs: MRI when clinically stable, Ab/Pelvis CT: Large hematoma 15x5x11 cm around rectal sheath near drain new from yesterday. Hemoperitoneum with increased fluid but not c/w compartment syndrome. Small amt fluid in RP. Mild pericardial effusion, moderate pleural effusion, no significant thigh hematoma x72745. VASCULAR SURGERY and UROLOGY notified, NTD, q4h HCT, ECHO with bubble: After intravenous injection of agitated saline at rest x 2, there was no appearance of saline contrast in the left heart. No envidence of resting right-to-left intracardiac flow, Loss of DP pulse at 4:30 PM with cold toe; evaluated by Vascular-- many possible etiologies given coagulopathy, would not pull line at this time; might do percutaneous closure in the future, At 5:30 PM: HR 130s, BP 80s/40s- > Gave Fentanyl bolus for ? contribution of pain, 5 PM CBC: HCT 31, plt 60 stable, 9PM PTT 150. Turned off heparin gtt; check PTT q2h; plan to hold until PTT 60-80 then restart at 250/h, K5.5 in am, repleted calcium, EKG unchanged from [2-6], Neurorads: questionable area of acute infarction in L frontal lobe (loss of [Doctor Last Name 352]-white differentiation), but no hemorrhage, Levophed for pressor support, CTA torso with segmental PEs bilaterally, L saphenous vein thrombosis, LLL dense consolidation, substernal 1.8x5.5cm hematoma, R thigh hematoma (R rectus femorus with soft tissue stranding), L external cluster of vessels with mid-thigh malformation [2196-4-5]: Post-arrest HCT 24.2 --> 2units pRBCSs --> 28.3 --> 22.5 --> 2units pRBCs --> 30.4, given additional 1L NS bolus for lactate of 7.3 (received 3L NS and 1L LR total since admission + 4 units PRBCs), PTT 50.4 so restarted heparin gtt at 1000 units/hr Medications on Admission: albuterol prn, fluocinolide 0.05% cream daily prn, red yeast rice 600mg daily, centrum silver, fish oil 1000mg daily Discharge Medications: 1. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation QID (4 times a day) as needed for SOB/per RT . 2. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [12-13] Drops Ophthalmic PRN (as needed) as needed for dry eyes. 3. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day): [Month (only) ] HOLD for loose stools/diarrhea. 4. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 5. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever. 6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day for ONCE days: MD TO ORDER DAILY BASED ON INR. Tablet(s) 10. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and PRN. 11. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 12. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 13. fluconazole 100 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours) for 2 days: Started date [4-26] Complete date [2196-4-28]. 14. insulin regular human 100 unit/mL Solution Sig: QS units Injection ASDIR (AS DIRECTED): SLIDING SCALE COVERAGE. 15. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) puff Inhalation twice a day as needed for allergy symptoms. 16. fluocinonide 0.05 % Cream Sig: One (1) application Topical once a day as needed. 17. Cipro 250 mg Tablet Sig: One (1) Tablet PO twice a day for 3 days: start date [4-26] complete date [4-28]. 18. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 1 days: ONE TABLET IN THE AM AND THEN THE PM ON DATE OF SCHEDULED FOLEY REMOVAL. Disp:2 Tablet(s) Refills:0 Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Prostate CA s/p Open radical prostatectomy Bilateral inguinal hernia s/p inguinal herniorraphy with mesh Cardiac Arrest (Puleseless Electrical Activity) Pulmonary Embolism s/p thrombolysis and IVC filter placement Heparin Induced Thrombocytopenia (HIT) Abdominal Compartment Syndrome s/p decompressive laparotomy Acute Tubular Necrosis (Acute Renal Failure) s/p hemodialysis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Minimally Ambulatory - requires assistance or aid (walker or cane) and requires physical assistance Out of Bed to chair or wheelchair or commode. He requires assistance with transferring to chair, bed, commode. Discharge Instructions: Use Tylenol for pain control. The maximum dose of Tylenol (ACETAMINOPHEN) is 4 grams (from ALL sources) PER DAY. -If you have been given narcotic pain medications (percocet example) these may sometimes be combined with Tylenol (acetaminophen). This needs to be considered when monitoring your daily dose and maximum. -You are being discharged on a medication called COUMADIN (WARFARIN). This medication MUST NOT be taken with other blood thinning medications or products; including aspirin and non-steroidal anti-inflammatories (NSAIDS). Examples of NSAIDs include but are not limited to ibuprofen, advil, motrin, excedrin. --Your coumadin dosing will be monitored while you are at rehab but will need to ultimately be monitored by your PCP. --In addition to the blood thinner, you have been fit with an IVC (inferior vena cava) filter to help reduce the risk of thrombus traveling past it. -Please do not drive, operate dangerous machinery, or consume alcohol while taking narcotic pain medications. -Do NOT drive while Foley catheter/Leg bag are in place -Colace has been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication. Discontinue if loose stool or diarrhea develops. Colace is a stool softener--it is NOT a laxative. -You may shower 2 days after surgery, but do not tub bathe, swim, soak, or scrub incision for 2 weeks or while you have "drains" in place -??????Steristrips?????? have been applied to close the wound where your hemodialysis catheter was (left anterior neck). Allow these bandage strips to fall off on their own over time. You may get the steristrips wet. -No heavy lifting for six weeks (no more than 10 pounds) and only after you've been advised by your physical therapists with regard to advancing to progressive resistance -Your Foley should be secured to the catheter secure on your thigh at ALL times until your follow up with the surgeon. - Wear Large Foley bag for majority of time, leg bag is only for short-term when leaving house/etc. -Complete a short term course (three days) of antibiotics as prescribed on discharge (ciprofloxacin and fluconazole). Please note that these two antibiotics can sometimes decrease metabolism of coumadin (increasing your INR) -When you are scheduled for your FOLEY CATHETER REMOVAL, please take CIPROFLOXACIN in the morning and again in the evening. Please save TWO tablets of CIPRO to take on the date of your Foley removal. [Hospital 16237] medical attention for fevers (temp>101.5), worsening pain, drainage or excessive bleeding from incision, chest pain or shortness of breath. -You may resume your regular home diet but remember to drink plenty of fluids to keep hydrated and to avoid foods that may cause constipation -Incidentally noted was a LEFT atriovenous malformation. You should avoid having catheterizations/procedures done at these inguinal veins and arteries (from the radiology report: Venous aneurysms involving the left common femoral vein and deep femoral vein with nidus of vessels noted within the mid left thigh highly suggestive of an underlying AV malformation) --Heparin Induced Thrombocytopenia (HIT)is a serious condition that can be lethal. You should consider AND discuss with your PCP the appropriateness of obtaining a MedicAlert type bracelet or device to warn others of this condition. Followup Instructions: *1)Follow up ONLY with Dr. [Last Name (STitle) 365] as instructed for Foley catheter removal and Pelvic Drain romoval. DO NOT have anyone else other than your Surgeon remove your Foley for any reason. Call Dr.[Name (NI) 6444] office ([Telephone/Fax (1) 6441] for follow-up AND if you have any urological questions. 2) Please arrange follow up in neurology clinic with Dr. [First Name8 (NamePattern2) 39215] [Last Name (NamePattern1) ] (and residents/staff) in [1-14] weeks after discharge for post-operative evaluation. Appointment Scheduling for Department Neurology: ([Telephone/Fax (1) 2528]. 3) Please call to arrange follow-up with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 853], MD with regard to your general surgery and post-operative evaluation and bilateral JP Drain removal. Division: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 853] at Acute Care Surgery Phone:([Telephone/Fax (1) 36338] 4) You will need to follow-up with your PCP to review your overall posteperative and rehabilitation course, your medications and for oversite of your INR monitoring and coumadin dosing and renal function. Please call to arrange follow up w/ [Name6 (MD) ] [Name8 (MD) 89865] MD 240 S. [Location (un) ]., [Apartment Address(1) ] [Apartment Address(1) 89863], [Numeric Identifier 89866] Ph: [Telephone/Fax (1) 89867] Fax: [Telephone/Fax (1) 89868] Web: [URL 89869] 5) You [Month (only) ] NOT need to have a follow-up appointment with NEPHROLOGY based on your monitoring labs but please call Dr. [Last Name (STitle) 4920]. Please have your PCP monitor your labs. Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 4920], staff nephrologist, Medicine/Renal Organization: [Last Name (un) ] Office Location:[Last Name (un) 3911], [Location (un) 86] [Numeric Identifier 718] Office Phone:([Telephone/Fax (1) 817**]	[ "998.89", "V16.42", "518.81", "286.6", "E878.6", "747.69", "289.84", "434.91", "427.5", "276.2", "584.5", "570", "995.92", "285.1", "276.4", "550.92", "185", "415.19", "998.12", "729.73", "997.5", "997.1", "553.21", "038.9" ]	icd9cm	[ [ [] ] ]	[ "54.25", "96.72", "39.95", "99.60", "53.14", "96.04", "54.62", "60.5", "38.91", "38.93", "40.3", "53.61", "33.24", "56.74", "38.7", "99.10", "96.6", "54.19", "38.95" ]	icd9pcs	[ [ [] ] ]	31356, 31426	4901, 8152	674, 1534	31845, 31845	2910, 4878	35555, 37555	2310, 2328		29369, 31333	31447, 31824		29227, 29346			32164, 35532				8180, 29201			2343, 2891																257, 636								1562, 2169								31860, 32140					2191, 2210	2226, 2294
3,798	123,875	19813	Discharge summary	report	Admission Date: [2153-10-12] Discharge Date: [2153-10-25] Service: CCU CHIEF COMPLAINT: Chest pain and irritation. HISTORY OF PRESENT ILLNESS: Of note the history of present illness is from outside hospital records and the family of the patient was unable to provide a history directly to the team. The patient is an 86 year-old man with a history of atrial fibrillation, hypertension who had chest pain early in the early morning hours on [2153-10-11] with intermittent symptoms over a 24 hour period with radiation to both arms. The patient initially ignored his symptoms believing indigestion. The patient went to bed and then woke with shortness of breath and dialed 911. The patient became unresponsive upon arrival to the Emergency Department. The patient had been brought to [Hospital6 ] System and was emergently intubated. After evaluation there the patient was transferred here for cardiac catheterization and arrived on intravenous nitro drip, heparin drip as well as after receiving a dose of per rectal aspirin. Of note the records transferred with the patient from [Hospital3 1280] Hospital noted the rhythm on route to the hospital by EMT was sinus tachycardia with multiple premature ventricular contractions. Electrocardiogram done there showed evidence of acute inferior postural lateral myocardial infarction. PAST MEDICAL HISTORY: 1. Hypertension. 2. Atrial fibrillation. 3. Coronary artery disease. ALLERGIES: No known drug allergies. MEDICATIONS PER OUTSIDE HOSPITAL: The patient had been on some doses of Atenolol, Procardia and Warfarin, which the doses are not clear. Attempts to contact the transferring physician at [Hospital3 1280] Hospital were unsuccessful. SOCIAL HISTORY: The patient is a veteran of World War II, living at home at the time and main contact is his daughter. FAMILY HISTORY: Unknown. The patient was transferred emergently to the catheterization laboratory and underwent cardiac catheterization on the day of admission. Cardiac catheterization was notable for 80% mid segmental lesion of the left anterior descending coronary artery, 80% lesion in the mid segment of the right coronary artery and also a mid occlusion within the left circumflex with obvious thrombus. A wire was crossed without difficulty across the left circumflex lesion, angiojet thrombectomy times two was performed and stenting with [Initials (NamePattern4) ] [Last Name (NamePattern4) ] coat stent was performed. Further intervention for the right coronary artery lesion was deferred and the patient was returned to the Coronary Care Unit. Cardiac output during the procedure was 3.78 with index of 1.91. The mean capillary wedge pressure was 21, the mean right atrial pressure was 11. Approximately 190 cc of Optiray contrast was used during the procedure. Upon arrival to the Coronary Care Unit after cardiac catheterization the patient's initial vital signs were temperature 97.2, blood pressure 105/58, respirations 16 and the patient was breathing on ventilator set at assist control, tidal volume set at 500, respiratory rate 16 with PEEP setting of 5 and FIO2 60%. The patient was noncommunicative and sedated, though was noted to move and respond to touch and pain. He is a well developed elderly man otherwise intubated and sedated. Pupils are equal, round and reactive to light. Mucous membranes are moist. There is no obvious adenopathy. Neck was supple. JVP is estimated to be 9 to 10 cm. Lung examination was omitted by ventilator noise, but otherwise clear on examination. Normal S1 and S2 on examination. Abdomen was notable for obese, soft abdomen, positive bowel sounds. ............ intact and .......... hematoma. No obvious blood. Extremities notable for 2+ bilateral lower extremity edema and no mean palpable dorsalis pedis pulses bilaterally. Initial laboratories, white blood cell count was 15, hematocrit 43 and platelets are 292. The electrolytes were within normal limits. Of note cardiac enzymes, the patient had a peak CK of over 11,000 on presentation and peak MB greater then 500 with a peak troponin greater then 25. HOSPITAL COURSE: The patient was continued on Plavix 75 mg a day, 325 daily aspirin as well as Atorvastatin 10. He was continued on Metoprolol 25 mg twice a day and Captopril 25 mg three times a day and also on a heparin drip initially at 1000 units per hour for a PTT goal of 60 - 100 seconds. Her plan is of right coronary artery lesion on subsequent days. The patient had a transthoracic echocardiogram on admission and EF was 30%. There was noted left atrial ............ dilatation as well as decreased right ventricular systolic function. There was also 1+ aortic regurgitation, 4+ mitral regurgitation, 3+ tricuspid regurgitation, but no effusion as well as moderate pulmonary hypertension. The patient's rhythm was noted to be in atrial fibrillation as consistent with his past medical history. Current ventilator settings were kept on the first day with plans for extubation on day two pending his blood gases. Other events, the patient successfully extubated on [2153-10-13], however, on the evening of the subsequent day on [10-14], the patient had an episode of ventricular tachycardia and required 300 joule shock and was shocked back into sinus rhythm. Further ventricular tachycardia as well as mental status changes and is reintubated. Received a further 300 joule shock and then was put on Amiodarone at 1 mg per hour as well as Lidocaine drip with 1 mg per kilogram bolus and then 1 microgram per hour and required sedation Propofol. Subsequently became hypotensive required Dopamine to support his blood pressure. Right IJ line was placed. The patient underwent intervention of his RC lesion on [2153-10-15]. The lesion was successfully intervened on with [Initials (NamePattern4) ] [Last Name (NamePattern4) ] coat stent. Cardiac output initially was 2.72 with an index of 1.37. The mean capillary wedge pressure was 36, mean RA pressure 16 and a total of 190 cc obturator was used for this procedure. Of note, the LCX lesion intervened on a few days prior was also found to be widely patent at this time and intact. The patient also because of the poor cardiac index an intra-aortic balloon pump was placed to help maintain cardiac output and perfusion. Subsequently the inotropic support successfully weaned off and the balloon was gradually weaned off and this continued altogether on the [10-19]. Subsequently, however, the patient's mental status failed to improved despite decreasing the patient's ventilator settings. Attempts to keep the patient off all Propofol sedation prior to weaning attempts were unsuccessful initially even despite aggressive diuresis. The patient was successfully extubated on the [10-23] at 6:00 p.m. and was placed on a neb mask requiring Haldol for agitation. However, subsequent to extubation the patient's neurological status failed to improve despite being off sedation and minimal amounts of Haldol for agitation. During this whole time the patient's proxy his daughter had been contact[Name (NI) ] and determination of her father's wishes were he were to speak for himself was slowly formulated. After a family meeting on the [2153-10-24] the family decided the patient did not want sustained mechanical support. The patient's status was never made DNR/DNI. The patient also at this time developed increasing white blood cell count with left shift and bandemia and also temperatures to 101.9. Blood and urine sputum cultures have remained negative at this point. There was one out of four bottles of blood cultures positive for coag staphylococcus and these were believed to be cutaneous contamination that failed to appear on subsequent cultures. The patient was put on Zosyn for sepsis with approval from infectious disease, however, continued to spike fevers and leukocytosis at this time. Levofloxacin was initially added and discontinued. Concern for MRSA was raised and so the patient was given Vancomycin, which was subsequently renally dosed, because of the patient's increased BUN and creatinine. The patient's acute renal failure believed to be multifactorial partially due to aggressive diuresis, plus the ATN. Chest films during this time were read as failure with subsequent improvement seen and as of this dictation the plan now is to evaluate the patient's declined neurological responsiveness for a noncontrast head CT to rule out intracranial bleed. Further details of this [Hospital 228] hospital course will be dictated as an addendum to the initial discharge summary. DR.[Last Name (STitle) ],[First Name3 (LF) ] 12-927 Dictated By:[Last Name (NamePattern1) 8442] MEDQUIST36 D: [2153-10-25] 02:14 T: [2153-10-26] 12:22 JOB#: [Job Number 34691]	[ "427.5", "785.51", "482.40", "428.0", "584.9", "427.31", "414.01", "427.1", "410.31" ]	icd9cm	[ [ [] ] ]	[ "37.23", "37.61", "00.13", "38.93", "88.72", "96.72", "96.04", "36.01", "36.06", "88.56" ]	icd9pcs	[ [ [] ] ]							1879, 4158						4176, 8915																									107, 135								164, 1369													1391, 1741	1758, 1862
30,178	157,569	5380	Discharge summary	report	Admission Date: [2137-3-21] Discharge Date: [2137-3-26] Date of Birth: [2078-11-21] Sex: F Service: MEDICINE Allergies: Erythromycin Base Attending:[First Name3 (LF) 905] Chief Complaint: CC: chest pain Major Surgical or Invasive Procedure: none History of Present Illness: The patient is a 58F w/ chronic cough since [Month (only) 404] who presents with intermittent L sided chest pain radiating to the back. In [Month (only) 404] she developed a productive cough while travelling in [Location (un) 6847] and [Country 651] and was diagnosed with pneumonia and treated with numerous courses of antibiotic with persistence of her symptoms. She was seen by pulmonary and had a CT chest suggestive of bronchietasis. Given her history of being born premature, the suggestion was made that she may have an anatomic abnormality that may predispose her to having pulmonary infections. She presented recently again with sinus symptoms and was referred to ENT who diagnosed acute sinusitis and started moxifloxacin. She was scheduled for a followup sinus CT in 2 weeks and followup with Dr. [First Name (STitle) ] (ENT). For the past week or two she has developed a sharp stabbing intermittent pain that started in the front of her left chest and is made worse when she moves, walks, or coughs. She had chest pain similar to today's presentation at her pulmonologist's office on [3-12], and intercostal muscle strain was diagnosed. . In the ED, EKG was normal, CTA was negative, no pneumonia was seen on CTA. She got cefepime. She was unable to be observed in the CDU given her "complicated cough history". Past Medical History: 1. Hypertension. 2. Hypercholesterolemia. 3. Benign fibrocystic breast disease status post multiple breast biopsies. 4. Hypothyroidism. 5. Menopause at age 50 with night sweats since that time. 6. Lumbar spine with three herniated discs for which she sees a chiropractor and is under good control. 7. Chronic cough: started [Month (only) 956], abnormal CXR, started on doxycycline, switched to Levaquin, restarted on doxycycline, later given Augmentin for sinus symptoms. Had minimal atelectasis on CT. Recently diagnosed with acute sinusitis, on moxifloxacin. Social History: The patient quit smoking approximately 20 years ago. She drinks a vodka [Doctor Last Name ] every night. She works as a shoe designer and sells wedding shoes. She often travels to [Country 651] to sell her shoes. Family History: The patient has three children who are healthy and are doing well except her youngest one who is 20 and has asthma. The patient's paternal grandfather died of leukemia as did his four brothers. It is unclear whether this leukemia was acute or chronic in nature. However, all five brothers had leukemia in their 60s. The patient's maternal grandfather also had cancer, but it is unclear what type of cancer. The patient's mother is on dialysis. The patient has one twin brother who is obese and has other medical problems. The patient is of Ashkenazi [Hospital1 ] descent. Physical Exam: VS: 99.5, 90/54, 86, 18, 94% RA Gen: alert, interactive, pleasant woman in NAD lying in bed HEENT: PERRL, EOMI, MM dry, OP clear, mild maxillary tenderness Neck: supple, no LAD Lungs: CTAB CV: RRR, nl S1S2, no m/r/g Abd: +BS, S/NT/ND MSK: TTP intercostal space below left breast, around to left side Ext: no c/c/e Pertinent Results: ADMISSION LABS [2137-3-20] 11:45PM BLOOD WBC-12.6# RBC-4.84 Hgb-13.8 Hct-38.9 MCV-80 MCH-28.6 MCHC-35.6* RDW-14.4 Plt Ct-150 [2137-3-20] 11:45PM BLOOD Neuts-90* Bands-5 Lymphs-3* Monos-2 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2137-3-20] 11:45PM BLOOD Plt Ct-150 [2137-3-21] 08:00PM BLOOD Plt Ct-215 [2137-3-22] 03:59PM BLOOD Fibrino-436* D-Dimer-1731* [2137-3-20] 11:45PM BLOOD UreaN-24* Creat-1.2* Na-141 K-3.1* Cl-101 HCO3-28 AnGap-15 [2137-3-21] 08:00PM BLOOD Glucose-103 UreaN-15 Creat-1.1 Na-145 K-4.5 Cl-106 HCO3-22 AnGap-22* [2137-3-20] 11:45PM BLOOD CK(CPK)-87 [2137-3-21] 08:00PM BLOOD Calcium-9.0 Phos-3.0 Mg-1.8 [2137-3-22] 12:48AM BLOOD TSH-0.74 [2137-3-21] 01:50AM BLOOD Lactate-0.9 [2137-3-21] 08:23PM BLOOD Lactate-3.1* K-3.6 [2137-3-22] 02:00AM BLOOD Lactate-1.1 [2137-3-20] 11:45PM BLOOD cTropnT-<0.01 [2137-3-21] 09:20AM BLOOD CK-MB-NotDone cTropnT-<0.01 [2137-3-23] 05:52AM BLOOD ALT-128* AST-99* LD(LDH)-197 AlkPhos-68 TotBili-0.4 [2137-3-22] 03:45AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.022 [2137-3-22] 03:45AM URINE Blood-TR Nitrite-NEG Protein-30 Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [2137-3-22] 03:45AM URINE RBC-1 WBC-4 Bacteri-NONE Yeast-NONE Epi-2 TransE-<1 [2137-3-22] 03:45AM URINE Mucous-OCC MICRO Blood cultures-no growth to date fecal cultures-negative legionella urinary antigen-negative urine culture-negative IMAGING CXR [3-21]-Lung volumes are lower and subsegmental atelectasis at the left base is new, but lungs are clear of any findings of pneumonia or cardiac decompensation. Heart size is normal. No pleural effusion is evident. No pneumothorax. CTA chest 4/24-1. No pulmonary embolism. No acute abnormality in the chest. 2. Unchanged appearance of focal left lower lobe bronchiectasis. CXR [3-21]-No acute cardiopulmonary process. No change from [2137-3-12]. KUB [3-22]-No evidence of obstruction or megacolon. If suspicion remains high, CT would allow better evaluation of the colon. CXR [3-23]- Probable bilateral aspiration pneumonia Brief Hospital Course: 58 yo woman with 3 months of chronic productive cough, presented to the ED with fever, chest pain. . #C.diff-Pt presented with fever, leukocytosis. She has had a chronic cough for three months and has been on a prolonged course of antibiotics. She was on doxycycline, levofloxacin, doxycycline and then augmentin. She was transferred from the medical floor (where she was initially admitted to) to the ICU for hypotension to the 70's. She also had diarrhea (See below), and was started on flagyl empirically given recent antibiotic use. She received fluids (2L NS) and was transferred. The differential included hypovolemia, sepsis, hypothyroid, adrenal insufficiency. Her beta blocker, diuretic, sedating medications were held. Her SBP improved somewhat after fluid rescucitation, and she did not require pressors. She became febrile again and sinus disease was considered as a cause. A chest x ray showed likely aspiration pneumonia and levofloxacin was started for treatment. Her fevers and hypotension as well as her diarrhea were improving on [3-23] and she was transferred back to the medical floor. Continued flagyl. Pt continued to improve though had persistent cough. . #Chest Pain-The character of her chest pain on admission was most consistent with muscle strain from coughing. She was ruled out with three sets of cardiac biomarkers, an EKG was unchanged. She also had a CTA of her chest which was negative for pulmonary emboli but did show some bibasliar bronchiectasis. Her pain is felt to be secondary to muscle strain from coughing. . #Cough: Chronic. She has been on multiple Abx without much improvement. CT shows bronchiectasis. Could consider an atypical pneumonia, but has had trial doxy. DDx: PND, GERD, Atypical pneumonia, cough variant asthma, Bronchiectasis, ABPA, viral. It is also noteworthy that the patient was born prematurely and was often sick as a child. Pt could have had some congental anomolies that have predisposed her to this prolonged course. Pt had a barium swallow that was negative for reflux. . #Sinusitis: FLQN at home, will need repeat CT in future. Was put on levaquin. Has scheduled follow up with ENT. . #HTN: Not currently an issue. Patient initially hypotensive in setting of diarrhea requiring transfer to the ICU, however, pressure came back up and home anti-hypertensives restarted. . #Hypothyroidism: stable. TSH normal. Continued home regimen. . #Hypercholesterolemia: Continued statin. . Medications on Admission: Levoxyl 50mcg qd HCTZ 12.5mg qd Toprol XL 50mg qd Ambien 5-10mg qhs prn Prilosec 20mg qd Zocor 20mg qd moxifloxacin 400mg qd ibuprofen 800mg tid prn (has only been taking 400-600mg qd) Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 2. Levothyroxine 25 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for upset stomach. 6. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 25 days. Disp:54 Tablet(s) Refills:0 8. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 9. Pseudoephedrine HCl 30 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 10. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for as needed for thrush. Disp:1 bottle Refills:0 11. Hydrochlorothiazide 12.5 mg Tablet Sig: One (1) Tablet PO once a day. 12. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 13. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 11 days. Disp:11 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: C.difficle diarrhea Aspiration pneumonia/pneumonitis Chronic cough Chest pain secondary to muscle strain Discharge Condition: Stable, ambulatory, good po intake, good oxygenation on room air Discharge Instructions: You were admitted for chest pain that was felt to be due to muscle strain from coughing, you had blood tests and monitoring that were negative. You also had a fever, developed low blood pressure and diarrhea. You were treated for C.difficle diarrhea, which is usually the result of antibiotic use. You also had a pneumonia/pneumonitis and likely sinus disease which was treated with antibiotics. Your symptoms improved and you were felt to be stable for discharge. . Please take your medications as prescribed. You will need to continue the levaquin for a total of 14 days inluding your doses here in the hospital. You will also need to continue to take Flagyl with the Levaquin and then 14 days beyond. . It is important to follow up as outlined below. . Please seek medical attention if you have shortness of breath, chest pain, dizzyness, diarrhea, fevers, chills or any other concerning symptoms. Followup Instructions: Provider: [Name Initial (NameIs) ] Phone:[Telephone/Fax (1) 10164] Date/Time:[2137-4-8] 10:30 Provider: [Name10 (NameIs) ],[First Name8 (NamePattern2) 2352] [Last Name (NamePattern1) 2352] - ADULT MEDICINE (SB) Phone:[Telephone/Fax (1) 1144] Date/Time:[2137-11-11] 9:30 . Provider: [Name10 (NameIs) ], [Name11 (NameIs) ] ([Telephone/Fax (1) 513], his office will call you tomorrow for your follow-up appointment. If you do no hear from them, please call them at the above number and schedule follow-up within the next 14 days [Name6 (MD) 251] [Name8 (MD) ] MD [MD Number(1) 910]	[ "008.45", "276.1", "610.1", "786.59", "473.9", "507.0", "244.9", "458.9", "276.52", "401.9", "786.2", "272.0" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	9592, 9598	5611, 8086	293, 299	9747, 9814	3448, 5588	10769, 11438	2520, 3097		8322, 9569	9619, 9726		8112, 8299			9838, 10746							3112, 3429																239, 255								327, 1677													1699, 2266	2282, 2504
6,222	149,953	12402	Discharge summary	report	Admission Date: [2132-8-20] Discharge Date: [2132-8-23] Date of Birth: [2079-9-6] Sex: M Service: [Hospital Unit Name 196] Allergies: Iodine Containing Agents Classifier / Penicillins Attending:[Location (un) 1279] Chief Complaint: hypotension Major Surgical or Invasive Procedure: cardiac catheterization intubation cardioversion for V. fib arrest History of Present Illness: This is a 52 year old man with CAD and multiple PCI, with a history of vagal episodes following these, who had a PTCA with a LCX/OM intervention. He has a history of multiple vagal episodes post catheterization, responding to atropine in past. In the holding area, he became hypotensive and reqired atropine and then dopamine, had a v. fib arrest and was defibrillated, and got a CT to rule out retroperitoneal bleed. A TTE was neg for tamponade or mass. He was intubated in holding area with hypoxia x 3 hrs and was transferred to the CCU. Past Medical History: Coronary artery disease peripheral vascular disease s/p aorto-bifem, r. fem-at, r fem-[Doctor Last Name ] Hypertension hypercholesterolemia Transient ischemic attacks Physical Exam: V: BP 111/66 HR 81 R22 O2 sat 100% intubated, on ventilator Gen: sedated, intubated HEENT: pupils dilated bilaterally, intubated Neck: no JVD Resp: bibasilar rhonchi, intubated CV: RRR, nl S1S2, no MGR Abd: soft NT, obese, +BS Groin: no hematoma bilaterally, with sheaths present Ext: 2+ DP pulse L, no DP right. Pertinent Results: ABG: [2132-8-20] 1:53p 7.13 / 56 / 69 / 20 / -11 [2132-8-20] 4:59p 7.29 / 34 / 144 / 17 / -8 [8-20] basic labs: 138 \| 110 \| 14 / --------------- 194 4.1 \| 18 \| 0.8\ Ca: 6.8 Mg: 1.4 P: 2.2 [2132-8-20] 01:50PM WBC-12.0* RBC-4.32* HGB-13.3* HCT-39.9* MCV-92 MCH-30.8 MCHC-33.4 RDW-12.7 [2132-8-20] 04:34PM WBC-17.8# RBC-4.75 HGB-14.4 HCT-41.9 MCV-88 MCH-30.3 MCHC-34.3 RDW-13.3 [2132-8-21] 1:00 pm 1.45 / 37 / 129 / 27 / 2 CATH- [2132-8-20] 1. One vessel coronary artery disease. 2. Unsuccessful recanalization of the occluded mid LCX. 3. Successful stenting of the proximal LCX into the OM Echo [2132-8-20] The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). No definite segmental wall motion abnormality identified (views suboptimal). Right ventricular chamber size and free wall motion are normal. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. CT abd/pelvis [2132-8-20] 1) Bilateral lung base consolidation left greater than right concerning for aspiration pneumonia. 2) No evidence of retroperitoneal hematoma. Brief Hospital Course: 1) Vagal response to catheterization: The patient had a hypotensive episode following catheterization and went into ventricular fibrillation and was shocked into normal sinus rhythm. He was intubated and sedated, given solumedrol, and put on a dopamine drip. He was given approximately 8 mg of atropine during the first couple of hours with improvement in his blood pressures. His blood pressures were stable with most SBP > 100 while in the CCU. He was weaned from the dopamine and the ventilator and extubated on [2132-8-21] without problems for the following two days. 2) Coronaries: the patient had cardiac catheterization with 1 stent and no complications. He was not given integrillin due to the concern of an abdominal bleed. He was maintained on plavix and aspirin. He was titrated up on metoprolol and started on captopril. He will follow up with Dr. [Last Name (STitle) 11493], his cardiologist. 3) Pump - He received two echocardiograms which both showed EF >55%. 4) Rhythm - s/p VFIB arrest, but the patient remained in sinus rhythm during the remainder of hospitalization. As the v. fib occurred in the setting of multiple inotropic medications and peri-intubation it was not felt to predict future risk of ventricular arrhythmias in the setting of normal LV function. He will follow up with Dr. [Last Name (STitle) 11493]. 5) Pneumonia - per CT, the patient had aspiration pneumonitis vs pneumonia on CT. He was given 2 days of levo/flagyl, but this was discontinued as the patient never spiked a temperature or had problems with oxygenation. Medications on Admission: lescol XL 80 once po qd pletal 100 poqd plavix 75 poqd norvasc 10 poqd ASA 325 poqd folate 0.4 poqd atenolol 100 poqd nexium 40 poqd isodur 120 poqd vit e, b12, b6 advair 2 puffs qd Discharge Medications: 1. Toprol XL 100 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 2. Ecotrin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 3. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:2 4. Pletal 100 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 5. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:30 Tablet(s) Refills:2 6. Lescol XL 80 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO at bedtime. Disp:30 Tablet Sustained Release 24HR(s) Refills:2 7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:30 Tablet(s) Refills:2 8. vitamins B12 1000 mg / day, B-complex+vit C /day, vitamin E 400 iu/day, B6 50 mg/day, folic acid 5 mg/day 9. Tylenol Arthritis 650 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO once a day as needed for pain. 10. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: Two (2) puff Inhalation once a day. Disp:1 diskus Refills:2 11. NitroQuick 0.3 mg Tablet, Sublingual Sig: [11-23] tab Sublingual as needed as needed for chest pain: can [Name8 (MD) 138] MD or go to ED. Disp:30 units Refills:0 Discharge Disposition: Home Discharge Diagnosis: ventricular fibrillation arrest with cardioversion coronary artery disease vagal hypotension after catheterization peripheral vascular disease Discharge Condition: pt was ambulating, eating, drinking, talking and was eager to go home. Discharge Instructions: Please take all of the medications listed below. You can resume activity as tolerated. Continue to eat a low fat, low salt heart healthy diet. If you have any chest pain, shortness of breath, palpitations, dizziness, or other concerns, call you doctor immediately or return to the ED. Followup Instructions: Within 1 week with Dr. [Last Name (STitle) 11493], [Telephone/Fax (1) 11650], for adjustment of your blood pressure medications as needed.	[ "427.5", "272.0", "427.41", "414.01", "507.0", "458.29", "401.9", "E879.0" ]	icd9cm	[ [ [] ] ]	[ "37.22", "96.71", "99.20", "36.01", "88.55", "88.53", "96.04", "99.62", "36.07" ]	icd9pcs	[ [ [] ] ]	6059, 6065	2742, 4318	338, 407	6252, 6324	1521, 2719	6659, 6809			4551, 6036	6086, 6231		4344, 4528			6348, 6636							1187, 1502																287, 300								435, 977													999, 1172
10,674	131,363	2769	Discharge summary	report	Admission Date: [2191-5-17] Discharge Date: [2191-5-22] Date of Birth: [2129-5-29] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 425] Chief Complaint: Transferred for catheterization in the setting of inferior STEMI. Patient initially complained of chest pressure and epigastric discomfort. Major Surgical or Invasive Procedure: 1. Cardiac Catheterization with PCI and bare metal stent placement to the Right Coronary Artery. 2. Temporary Pacemaker Wire Placement History of Present Illness: 61 year old male with history of LAD stent in [2180], RCA stent in [2186], and stent to the mid-LAD and RPL in [10/2189], all for crescendo angina, who presented to [Hospital1 2436] this morning complaining of 18 or so hours of "indigestion" and some chest pressure. These symptoms began on the day prior to admission, just after lunch. He noted chest heaviness and indigestion, that did feel better with belching. Later that night the indigestion returned and he took alka-seltzer with improvement. He slept through the night but at 4 a.m. on the morning of admission he got up to use the bathroom and noted heaviness in his chest, and persistent "indigestion," unresponsive to TUMS, prompting him to go to [Hospital3 ]. Of note, his typical angina involves a tingling/numbness of his left arm, which he denies in the preceding days. At [Hospital1 2436], initial EKG was without ST elevations, with an isolated TWI in III. He was given a dose of dilaudid with resolution of his pain. However, later in the morning he developed epigastric discomfort and became pale and diaphoretic. An EKG in this setting now revealed 1-[Street Address(2) 1766] elevations in the inferior leads with ST depression in AVL. He was started on heparin and integrillin. He was given Plavix 300 mg x 1. On review of symptoms, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. He complains of thinking he was having a gout flare yesterday because his 1st metatarsal joint was painful. He took Indocin, allopurinol, and colchicine. All of the other review of systems were negative. Cardiac review of systems is notable for absence of chest pain (although did have pressure), dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. He does walk regularly, and does not experience angina. Past Medical History: 1) Coronary artery disease status post multiple stents (see below). 2) Hypertension. 3) Hyperlipidemia. 4) Hepatitis B, has received interferon. 5) Gout. 6) Gastroesophageal reflux disease. CARDIAC RISK FACTORS: (-) Diabetes, (+) Dyslipidemia, (+) Hypertension CARDIAC HISTORY: No history of CABG. Percutaneous coronary intervention, in [7-/2180] anatomy as follows: 1. Coronary arteriography reveals one vessel disease in this right dominant system. The LMCA has no significant stenosis. The LAD has serial 80-90% stenoses of proximal-mid segments. There is also 70-80% of stenoses of small and diffusely diseased D1. The LCx and the RCA have no significant stenosis. 2. Resting hemodynamics reveal mildly elevated right and left sided filling pressures (RVEDP=14 mmHg, LVEDP=14 mmHg). There is mild secondary pulmonary hypertension with mildly elevated mean PCWP of 11 mmHg. 3. Left ventriculography reveals normal wall motions with an EF of 63%. There is no mitral regurgitation visualized. 4. The critical serial stenoses in the mid LAD were successfully treated with Palmaz [Doctor Last Name 8030] stenting. (see PTCA comments) FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Normal ventricular function. 3. Successful stenting of the mid LAD. Percutaneous coronary intervention in [10/2186], done for crescendo angina with mildly positive troponin demonstrated: COMMENTS: 1. Coronary angiography in this right dominant circulation demonstrated two vessel and branch vessel coronary artery disease. The LMCA was normal. The LAD was widely patent at the prior stenting site, but had a 50% distal lesion. The LCX had mild luminal irregularity. The ramus intermedius was a small vessel with an 80% proximal lesion. The RCA had an ulcerated 95% proximal lesion with slow flow into the distal vessel. 2. Resting hemodyanmics demonstrated mildly elevated left-sided filling pressures with an LV EDP of 14 mmHg. 3. Left ventriculography demonstrated EF of 57% with no mitral regurgitatiion. 4. The RCA stenosis was successfully treated with angioplasty and stenting using a 3.5 x 24 mm Express2 stent, with no residual stenosis, no angiographic evidence of dissection, and TIMI 3 flow (see PTCA Comments). FINAL DIAGNOSIS: 1. Two vessel and branch vessel coronary artery disease. 2. Normal ventricular function. 3. Mildly elevated left-sided filling pressures. 4. Successful stenting of the RCA. Percutaneous coronary intervention in [10/2189] prompted by increasing angina and abnormal dobutamine stress demonstrated: COMMENTS: 1. Selective coronary angiography of this right dominant system revealed two vessel coronay artery disease. The LMCA had no angiographic evidence of flow limiting lesions. The LAD had a tubular 30% proximal in stent restenosis and a focal 90% distal lesion after the origin of the D1. The Ramus was a small vessel with a 90% proximal stenosis which was unchanged from previous cath. The LCX was a small caliber vessel with no angiographic evidence of flow limiting stenosis. The RCA was a dominant vessel with 30% in stent restenosis. There were two PLB, the first had no angiographically apparent flow limiting lesions. The second PLB had a 90% proximal stenosis. 2. Limiting resting hemodynamics revealed mildly elevated left sided filling pressures. 3. left ventriculography revealed an ejection fraction of 63%. There was to the aorta. 4. Successful placement of 2.5 x 23 mm Cypher drug-eluting stent in the mid-LAD. Final angiography demonstrated no residual stenosis, no angiographically apparent dissection, and normal flow (See PTCA Comments). 5. Successful placement of 2.25 x 12 mm MiniVision stent in the r-PL. Final angiography demonstrated no residual stenosis, no angiographically apparent dissection, and normal flow (See PTCA Comments). 6. Successful placement of 6 French Angioseal in right femoral arteriotomy at the conclusion of the procedure without complications. FINAL DIAGNOSIS: 1. Coronary angiographic evidence of two vessel coronary artery disease. 2. Preserved left ventricular function. 3. Mildly elevated left sided filling pressures. Social History: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: Blood pressure was 122/70 mm Hg while seated. Pulse was 59 beats/min and regular, respiratory rate was 20 breaths/min, 99% on 2L via nasal cannula. Generally the patient was well developed, well nourished and well groomed. The patient was oriented to person, place and time. The patient's mood and affect were not inappropriate. There was no xanthalesma and conjunctiva were pink with no pallor or cyanosis of the oral mucosa. The neck was supple with jugular venous pressure of about 7 cm H2O. The carotid waveform was normal. The were no chest wall deformities, scoliosis or kyphosis. The respirations were not labored and there were no use of accessory muscles. The lungs were clear to anterior ascultation bilaterally with normal breath sounds and no adventitial sounds or rubs. Palpation of the heart revealed the PMI to be located in the 5th intercostal space, mid clavicular line. There were no thrills, lifts or palpable S3 or S4. The heart sounds revealed a normal S1 and the S2 was normal. He had a [2-5] holosystolic murmur at the apex. There were no rubs, clicks or gallops. The abdominal aorta was not enlarged by palpation. There was no hepatosplenomegaly or tenderness. The abdomen was soft nontender and nondistended. The extremities had no pallor, cyanosis, clubbing or edema. There were no abdominal, femoral or carotid bruits. Inspection and/or palpation of skin and subcutaneous tissue showed no stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ Femoral 2+ DP 2+ PT difficult to palpate Left: Carotid 2+ Femoral 2+ DP difficult to palpate PT 2+ Pertinent Results: Cardiac Cath [2191-5-17]: 1. Coronary angiography of this right dominant system revealed three vessel coronary artery disease. The left main coronary artery had minimal luminal irregularities. The LAD had a 30% stenosis proximally (proximal edge versus in-stent restenosis) with a patent mid LAD stent and diffuse plaquing with TIMI 2 fast flow. The apical LAD had a 90% stenosis with septal collaterals to the RPDA. The LCX had mild diffuse luminal irregularities. The ramus had a proximal 80% stenosis followed by a mid 80% stenosis. The RCA had a proximal tapering to 80% at the proximal edge of the prior stent with TIMI 1 flow distally. 2. Resting hemodynamics revealed moderately to severely elevated right sided filling pressures (mean RA pressure was 16 mm Hg and RVEDP was 20 mm Hg). Pulmonary artery pressures were mildly elevated (PA pressures were 42/22 mm Hg). Left sided filling pressures were moderately elevated (mean PCW pressure was 21 mm Hg). Prominent V waves were noted in the pulmonary artery and pulmonary capillary wedge pressure tracings suggestive of mitral regurgitation. Systemic arterial pressure was normal (aortic pressure was 116/62 mm Hg). Cardiac output was normal (CI was 3.0 L/min/m2). 3. Successful PCI/stent to proximal RCA with a 3.5x15mm Vision stent postdilated with a 3.5x15mm NC Ranger balloon. Excellent result with no resiudal and normal flow down vessel. Patient left cathlab painfree. . TTE [2191-5-19]: The left atrium is mildly dilated. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Mild mitral regurgitation with normal valve morphology. Preserved global and regional biventricular systolic function. Brief Hospital Course: 61 year old male with history of hypercholesterolemia, hypertension, and significant coronary artery disease status post multiple PCIs involving LAD stent in [2180], RCA stent in [2186], and stent to the mid-LAD and RPL in [10/2189], who presented with predominantly epigastric discomfort, found to have ST elevations in the inferior leads and progression of RCA disease on cath, now status post bare metal stent to the RCA. Also with elevated filling pressures. Almost 48 hours after presentation, early in the morning the patient was found to be in complete heart block on telemetry, prompting admission to the CCU and temporary wire placement. The hospital course by problems follows below. 1) STEMI: On arrival he went to the cath lab. Cath revealed that the LAD had a 30% stenosis proximally (proximal edge versus in-stent restenosis) with a patent mid LAD stent; the apical LAD had a 90% stenosis with septal collaterals to the RPDA. The LCX had mild diffuse luminal irregularities. The ramus had a proximal 80% stenosis followed by a mid 80% stenosis, and the RCA had a proximal tapering to 80% at the proximal edge of the prior stent with TIMI 1 flow distally. Given the inferior elevations on EKG the RCA lesion was felt to be the culprit lesion and he received a bare metal stent to RCA. Post catheterization the patient was chest pain free, with resolution of ST elevations on post-cath EKG, new Q waves and TWI. It was unclear why the patient was on amlodipine rather than an ACE-inhibitor (possibly for angina?), therefore his amlodipine was held in favor of an ACE-inhibitor. He tolerated lisinopril well. He was continued on ASA, Plavix (which he needs for at least 1 year), pravastatin 80 mg, Niacin SA, ezetimibe. BBlocker held given CHB as below; may be restarted as an outpatient in several weeks time. He should be referred to cardiac rehabilitation as an outpatient as well as nutrition counseling for diet and lifestyle modification. 2) Complete heart block: He was catheterized on the morning of [5-17]. Early in the morning of [5-19] a code was called when the patient was found to have complete heart block without ventricular escape on telemetry. He regained a rhythm and consciousness very quickly spontaneously. He was transferred to the CCU where he had a temporary pacing wire placed in his right ventricle. He did not require any further pacing during his stay here in teh CCU and the complete heart block was attributed to temporary edema in teh setting of his RV infarct along with a possible contribution from OSA and vagal tone. The temporary pacemaker wire was removed after 36 hours of not requiring any pacing. He was sent to the floor in good condition. His BBlocker was held given concern for AV nodal block and this can be restarted as an outpatient in several weeks. 3) Elevated filling pressures: Filling pressures were elevated in catheterization, however he had no clinical evidence of CHF. Echocardiogram post-cath demonstrated preserved global and regional biventricular systolic function, with mild MR. [Name13 (STitle) ] did not require diuresis. 4) Right groin bruit: A femoral ultrasound was done, which did not demonstrate any AV fistula or pseudoaneurysm. 5) Hypercholesterolemia: As above, continued pravastatin 80 mg, Niacin SA 500 mg QHS, and ezetimibe 10 mg daily. 6) Hypertension: His amlodipine was held in favor of an ACE-inhibitor. He was discharged on his usual medications, plus lisinopril 10mg daily. 7) GERD: Continued pantoprazole. 8) Gout: No signs of gout flare during this admission, although he had taken colchicine and allopurinol and indocin on the day prior to admission. It was explained to him that he should not start taking allopurinol when he thinks he's having a gout flare if he's not already on it (that this can worsen an acute flare). 9) OSA: Given patient's body habitus, clinical history of concern for OSA, as well as possible contribution to nocturnal apnea and CHB as above, patient was set up for a sleep study 1 week after discharge. The results of this study should be followed up with by his PCP. 9) FEN: Cardiac, heart healthy diet. 10) PPx: Given SQ heparin and colace. 11) Code: Full. Medications on Admission: Aspirin 325 mg daily Ezetimibe 10 mg daily Metoprolol XL 50 mg daily Pravastatin 80 mg daily Amlodipine 5 mg daily Niacin SA 500 mg QHS Pantoprazole 40 mg daily Indocin prn Allopurinol prn Colchicine prn Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 4. Niacin 500 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO QHS (once a day (at bedtime)). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:11 7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Clonazepam 1 mg Tablet Sig: 2.5 Tablets PO QHS (once a day (at bedtime)). Discharge Disposition: Home Discharge Diagnosis: Primary: 1. ST-elevation Myocardial Infarction 2. temporary Complete Heart Block - now resolved 3. Hypertension Secondary: 1. Gastroesophagael Reflux Disease Discharge Condition: Stable to be discharged to home. Discharge Instructions: You were admitted and found to have a inferior wall heart attack. You subsequently had complete heart block requiring a temporary pacemaker. It will be extremely important for you to follow-up with your cardiologist and your primary care doctor. In addition, you should plan to see a sleep specialist given that sleep apnea may have caused the heart block (an appointment was made for you on the date below). Your Toprol XL was held - do not restart this until you have seen a cardiologist. You had a stent placed in your right coronary artery - you must take Plavix 75mg every day for a minimum of 1 year. If cannot take your dose of Plavix, you must contact your doctor immediately. Please do not take Norvasc any longer - Lisinopril 10mg daily was started in its place. All of your other home medications remain the same (see list below). If you develop chest pain, shortness of breath, lightheadedness, passing out, or any other concerning symptoms, please call your doctor or report to the nearest ER. Followup Instructions: Please follow up with your cardiologist, Dr. [Last Name (STitle) 5466] in 1 month after dicsharge. Previously scheduled appointments: Provider: [Last Name (NamePattern4) ]. [Last Name (STitle) 13647]/DR. [First Name (STitle) ] Phone:[Telephone/Fax (1) 612] Date/Time:[2191-5-27] 9:00. This appointment is to further evaluate the possibility of obstructive sleep apnea. Please follow up with your primary care physician [Last Name (NamePattern4) ]. [First Name (STitle) 1313] in [2-1] weeks.	[ "272.4", "410.41", "274.9", "E879.0", "401.9", "997.1", "530.81", "426.0", "V45.82", "414.01" ]	icd9cm	[ [ [] ] ]	[ "88.56", "00.45", "00.66", "00.40", "36.06", "38.93", "37.23", "37.78" ]	icd9pcs	[ [ [] ] ]	16186, 16192	10904, 15149	454, 591	16395, 16430	8703, 10881	17494, 18026	6987, 7069		15404, 16163	16213, 16374		15175, 15381		6683, 6846	16454, 17471							7084, 8684																275, 416								619, 2699													2721, 3865	6862, 6971
44,209	189,667	38178	Discharge summary	report	Admission Date: [2150-5-26] Discharge Date: [2150-6-1] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: left main coronary artery disease Major Surgical or Invasive Procedure: coronary artery bypass grafts x 3(LIMA-LAD,SVG-OM,SVG-PDA) [2150-5-27] History of Present Illness: This 88 year old white male underwent as stress test as part of his work up for colon surgery for as precancerous polyp. A 50-60% left main lesion was found and he was referred for revascularization. Past Medical History: hypertension hyperlipidemia precancerous colonic polyp, awaiting surgery, s/p bilateral knee surgies '[39], s/p transurethral prostate resection '[36], eczema Social History: Race:caucasian Last Dental Exam: Lives with:married with 2 sons/1 daughter Occupation: [Name2 (NI) 1139]:denies ETOH:denies Family History: noncontributory Physical Exam: Admission: Pulse:70 Resp: O2 sat: B/P Right: Left: Height:67"/ 170.18cm Weight:191 LB/ 86.64Kg General: Skin: Dry [x] intact [] HEENT: PERRLA [x] EOMI [] 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 [x] Neuro: Grossly intact Pulses: Femoral Right: Left: DP Right: 2+ Left:2+ PT [Name (NI) 167]: Left: Radial Right:2+ Left:2+ Carotid Bruit -none Right: 2+ Left:2+ Pertinent Results: [2150-6-1] 05:00AM BLOOD WBC-9.5 RBC-3.86* Hgb-10.9* Hct-32.1* MCV-83 MCH-28.3 MCHC-34.0 RDW-14.9 Plt Ct-261 [2150-5-30] 05:02AM BLOOD WBC-13.5* RBC-3.80* Hgb-10.6* Hct-31.8* MCV-84 MCH-27.8 MCHC-33.3 RDW-14.7 Plt Ct-214 [2150-6-1] 05:00AM BLOOD Glucose-142* UreaN-29* Creat-1.2 Na-139 K-3.5 Cl-101 HCO3-30 AnGap-12 [2150-5-30] 05:02AM BLOOD Glucose-122* UreaN-24* Creat-1.1 Na-137 K-4.3 Cl-103 HCO3-25 AnGap-13 Brief Hospital Course: Following admission he underwent the usual work up and was begun on Heparin. On [5-27] he was taken to the Operating [Last Name (un) ] where revascularization was accomplished three grafts). Hhe weaned from bypass on Propofol and low dose Neo Synephrine. Postoperative echocardiography demonstrated preserved LV function at >55%. He remained stable, was weaned and extubated easily and pressors were weaned. He was transferred to the floor on POD 1. He was diuresed towards his preoperative weight and CTs and pacing wires were removed per protocol. Physical Thearapy worked with him for mobility and strength. There was transient atrial fibrillation which converted to sinus with Amiodarone. Scant sternal drainage stopped prior to discharge and wounds were clean and healing well. He was discharged on medications listed and instructuions for follow up, and restrictions were discussed as well. Medications on Admission: ASA, Atenolol 25(1),MVI,Proscar 5(1),Zocor 20(1) Discharge Medications: 1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 2. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days. Disp:7 Tab Sust.Rel. Particle/Crystal(s) Refills:0 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever or pain . 7. Amiodarone 200 mg Tablet Sig: as directed Tablet PO BID (2 times a day) for 4 weeks: two tablets twice daily for two weeks, then one tablet twice daily for two weeks, then discontinue. Disp:84 Tablet(s) Refills:0 8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 9. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 10. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:7 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Last Name (LF) 486], [First Name3 (LF) 487] Discharge Diagnosis: coronary artery disease s/p coronary artery bypass grafts colonic polyps s/p bilateral knee replacements hypertension hyperlipidemia Discharge Condition: Alert and oriented x3, nonfocal. Ambulating with steady gait. Incisional pain managed with Percocet Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Edema Discharge Instructions: 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. No lotions, cream, powder, or ointments to incisions. Each morning you should weigh yourself and then in the evening take your temperature, These should be written down on the chart . No driving for approximately one month, until follow up with surgeon. No lifting more than 10 pounds for 10 weeks. Please call with any questions or concerns ([Telephone/Fax (1) 170]). 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: Dr. [Last Name (STitle) ] in 4 weeks ([Telephone/Fax (1) 170]) on Thursday, [7-2] at 1:15pm please call for appointments with: Primary Care: Dr. [Last Name (STitle) 63251] [Name (STitle) 63252] ([Telephone/Fax (1) 34574]in [1-17] weeks Cardiologist: Dr. [First Name4 (NamePattern1) 4597] [Last Name (NamePattern1) 5017] in 2 weeks [Hospital Ward Name 121] 6 wound clinic ([Telephone/Fax (1) ]) in 2 weeks-your nurse [First Name (Titles) ] [Last Name (Titles) 10542]e this appointment Completed by:[2150-6-1]	[ "414.01", "401.9", "427.89", "V43.65", "411.1", "211.9", "285.9", "692.9" ]	icd9cm	[ [ [] ] ]	[ "36.12", "36.15", "39.61" ]	icd9pcs	[ [ [] ] ]	4296, 4379	2084, 2997	301, 378	4556, 4776	1632, 2061	5531, 6097	960, 977		3097, 4273	4400, 4535		3023, 3074			4800, 5508							992, 1613																228, 263								406, 607													629, 798	814, 944
27,894	173,572	30906	Discharge summary	report	Admission Date: [2107-10-14] Discharge Date: [2107-10-21] Date of Birth: [2036-4-3] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5893] Chief Complaint: Hypoxemia Major Surgical or Invasive Procedure: GJ tube placement, previous G tube removed History of Present Illness: 71 year old trached and PEG'd male w/ multiple medical problems including DM, COPD, afib, CAD s/p CABG and locally invasive laryngopharyngeal cancer on chemo and XRT who was admitted to [Hospital3 417] Hospital from [Hospital1 1872] rehab on [10-12] for shortness of breath, chest pain and atrial fibrillation with RVR. During the episode his O2 sat reportedly dropped to 87%. Prior to admission he developed neutropenic fever and was being treated with broad spectrum antibiotics. . While at OSH, continued to have AF with rapid ventricular response. ECG showed diffuse ST depressions during RVR (rate 138). Troponin I elevated at 65.48. For his AF he was treated with diltiazem drip and then converted to PO metoprolol day of transfer. He was not started on anticoagulation due to recent [Hospital1 18] admission for hemoptysis as well as thrombocytopenia. He did report some chest pain during these episodes of rapid HR. CXR revealed cardiomegaly and interstitial pulmonary changes indicative of CHF. . Other notable lab values include neutropenia (ANC 700) with an elevated BUN/Cr (57/2.2) - baseline Cr 0.9-1.0. CXR showed a right middle lobe pneumonia. . Patient was recently admitted here on [9-20] for hemoptysis which was felt due to tumor mass. He was given 1U PRBC. Past Medical History: Diabetes Hypertension Coronary Artery Disease, s/p CABG x 5 Permanent Pacemaker for sick sinus Peripheral Vascular Disease (AAA s/p repair) COPD Spontaneous Pneumothorax s/p chest tube Colon Cancer s/p resection and chemo (pt does not know details of therapy) in approximately [2102] Social History: Patient is single. He does not have any children. He reports he has been an alcoholic for the past 45 years and had been drinking 2 glasses wine per day up to hospitalization in [Month (only) ]. He has a 59 pack year smoking history. Family History: Aunt with breast cancer and uncle with throat cancer. Physical Exam: VITALS: 97.6, BP 117/99, HR97, RR 17, O2sat 100% on trach GEN: Cachectic male lying comfortably in bed, conversant HEENT: NC/AT, + temporal wasting, OP clear, PERRL NECK: trach in place, no JVD CARDIAC: Irregular rhythm, nl s1 s3, no discernible murmur. Heart sounds obscured by lung sounds LUNG: Diffuse rhonchi with some wheezing. ABDOMEN: scaphoid, PEG site erythematous, dry, healing EXT: decreased bulk and tone, no c/c/e NEURO: grossly intact SKIN: erythematous with some breakdown over anterior neck Pertinent Results: [2107-10-14] 09:49PM GLUCOSE-151* UREA N-81* CREAT-2.7* SODIUM-137 POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-23 ANION GAP-16 [2107-10-14] 09:49PM ALT(SGPT)-1014* AST(SGOT)-408* LD(LDH)-736* CK(CPK)-80 ALK PHOS-97 TOT BILI-1.1 [2107-10-14] 09:49PM CK-MB-NotDone cTropnT-4.92* [2107-10-14] 09:49PM ALBUMIN-2.5* CALCIUM-8.1* PHOSPHATE-5.1* MAGNESIUM-2.2 [2107-10-14] 09:49PM WBC-2.5* RBC-3.27* HGB-10.0* HCT-29.1* MCV-89 MCH-30.4 MCHC-34.2 RDW-17.2* [2107-10-14] 09:49PM NEUTS-80.8* BANDS-0 LYMPHS-12.7* MONOS-5.5 EOS-0.4 BASOS-0.4 [2107-10-14] 09:49PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-2+ MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+ BURR-1+ [2107-10-14] 09:49PM PLT COUNT-49* [2107-10-14] 09:49PM PT-19.7* PTT-32.8 INR(PT)-1.9* [2107-10-14] 09:49PM GRAN CT-[2090]* [2107-10-14] 09:48PM HBs Ab-NEGATIVE HBc Ab-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE [2107-10-14] 09:48PM ACETMNPHN-NEG [2107-10-14] 02:26PM GLUCOSE-203* UREA N-83* CREAT-2.7* SODIUM-137 POTASSIUM-4.6 CHLORIDE-101 TOTAL CO2-24 ANION GAP-17 [2107-10-14] 02:26PM CK(CPK)-131 [2107-10-14] 02:26PM CK-MB-14* MB INDX-10.7* cTropnT-6.43* [2107-10-14] 02:26PM CALCIUM-8.0* PHOSPHATE-5.5* MAGNESIUM-2.3 [2107-10-14] 02:26PM PT-20.1* PTT-32.7 INR(PT)-1.9* [2107-10-14] 07:47AM URINE HOURS-RANDOM UREA N-623 CREAT-84 SODIUM-12 POTASSIUM-65 [2107-10-14] 04:21AM TYPE-ART TEMP-36.8 RATES-16/1 TIDAL VOL-500 PEEP-5 O2-40 PO2-88 PCO2-33* PH-7.50* TOTAL CO2-27 BASE XS-2 -ASSIST/CON INTUBATED-INTUBATED [2107-10-14] 02:50AM GLUCOSE-105 UREA N-77* CREAT-2.7# SODIUM-142 POTASSIUM-4.8 CHLORIDE-101 TOTAL CO2-23 ANION GAP-23 [2107-10-14] 02:50AM estGFR-Using this [2107-10-14] 02:50AM ALT(SGPT)-2522* AST(SGOT)-1552* LD(LDH)-1182* CK(CPK)-318* ALK PHOS-111 AMYLASE-26 TOT BILI-1.5 [2107-10-14] 02:50AM LIPASE-27 [2107-10-14] 02:50AM CK-MB-28* MB INDX-8.8* cTropnT-10.43* [2107-10-14] 02:50AM ALBUMIN-2.8* CALCIUM-8.9 PHOSPHATE-5.6# MAGNESIUM-2.3 IRON-190 [2107-10-14] 02:50AM calTIBC-185* VIT B12-GREATER TH FOLATE-GREATER TH FERRITIN-GREATER TH TRF-142* [2107-10-14] 02:50AM WBC-2.3* RBC-3.59* HGB-10.7* HCT-30.9* MCV-86 MCH-29.8 MCHC-34.6 RDW-16.8* [2107-10-14] 02:50AM PLT COUNT-46# [2107-10-14] 02:50AM PT-20.4 PTT-31.2 INR(PT)-2.0* [2107-10-14] 02:50AM GRAN CT-1640* Brief Hospital Course: 71M with head and neck cancer, trach/[Hospital 73098] transferred from an outside hospital with atrial fibrillation with RVR, NSTEMI, acute oliguric renal failure, and acute ischemic hepatitis. . # NSTEMI: Patient has a history of CABG, and had very elevated cardiac enzymes on admission (Trop T 65.48, CKMB 72.1). TTE during this admission shows acute changes, EF from 55-60% on [7-26] to 25-30%, severely depressed LV systolic function, severe LV global HK in inf, post, lat walls, depressed RV systolic function, 3+MR, 2+TR. EKG shows 2 mm STD V3-V5 which is 0.[Street Address(2) 73099] depression laterally from his old EKGs. CXR shows unchanged pleural effusions and atelectasis. He was maintained on aspirin and metoprolol. He was not started on a statin since he was admitted with acute ischemic hepatitis, and LFTs were still decreasing to normal levels. . # AFIB with rapid ventricular rate: He was in AFIB with rapid ventricular rate, with a pacer for sick sinus/tachy-brady, HR 100-140s, controlled on Metoprolol and Diltiazem. He was not anticoagulated since he has head and neck cancer and had pancytopenia from chemo and radiation. . # Hypoxemic respiratory failure: Likely associated with bilateral pleural effusions, cardiac stunning, and COPD. Patient has a trach and was kept on trach mask for most of the day, with intermittent transition to AC and PS ventilatory support during the night or with decreasing O2 saturation. Patient was diuresed here with lasix gtt, 5-10 mg per hour for pleural effusions, but he was not total body fluid overloaded. Patient has COPD and was placed on albuterol inhalers, spiriva, and advair during admission to be continued. . As a note, the patient's lasix regimen was added during this admission, and should be titrated up as appropriate to diurese for his bilateral pleural effusions. Currently at the standing dose, he is running even in his fluid goals daily. . # Acute oliguric renal failure: Patient's acute renal failure was prerenal in etiology and associated with a depressed EF and/or post-ischemic ATN, not responsive to fluid boluses. Renal US showed atrophic L kidney unchanged since [7-14], no stone, no hydro, no mass. Ulytes consistent with prerenal etiology. Renal failure gradually resolved over admission. . # Acute ischemic hepatitis: Patient had LFTs in the thousands, associated with hepatic congestion from NSTEMI. He showed no signs of cholestasis or obstruction. Tylenol tox screen was negative, hepatitis panel was negative. . # Febrile neutropenia/pancytopenia/L piriform sinus SCC: Patient has head and neck cancer, s/p carboplatin/taxol and XRT, last XRT and chemo [10-7]. He was neutropenic for only the first day of admission, and was afebrile throughout admission. He is followed as an outpatient by Hem/Onc: [First Name8 (NamePattern2) 7306] [Last Name (NamePattern1) ], Dr. [Last Name (STitle) ]. He completed a Ceftazidime/Vanco for a 7 day course for neutropenia and coverage in case of pneumonia. He was on neupogen until he was no longer neutropenic. All blood, urine, sputum cultures were negative. His goal Hct was maintained at >28, goal platelets were >30, and these goals were met throughout admission. . # Hypertension: Was unremarkable throughout admission, controlled on Metoprolol and Diltiazem. . # Diabetes mellitus: He was maintained on Lantus 16 qhs and sliding scale. Medications on Admission: MEDICATIONS AT HOME: Imipenem 500mg q8H Vancomycin 1g q12h Zofran 4mg IV PRN Nexium 40mg PO daily Metoclopramide 10mg QACHS Lopressor 50mg q8H PO RISS Albuterol nebs Atrovent nebulizer q6H . MEDICATIONS ON TRANSFER: Ondansetron 4mg q8H PRN Aspirin 325mg daily Metoprolol 50mg TID RISS Lantus 16U qhs Ambien 5mg qhs Colace 100mg [Hospital1 ] Lorazepam 0.5mg q8h PRN Metoclopramide 5mg QACHS Esomeprazole 40mg daily Heparin subq Imipenem 250mg q8H Ceftazidime 1000mg q24H Vancomycin 500mg x1 Filgrastim 480mcg x1 Furosemide 20mg x1 Albuterol nebs Ipratroprium nebs Discharge Medications: 1. Aspirin 325 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 2. Insulin Glargine 100 unit/mL Cartridge [Hospital1 ]: Sixteen (16) units Subcutaneous at bedtime. 3. Insulin Regular Human 100 unit/mL Cartridge [Hospital1 ]: One (1) dose Injection QACHS and bedtime: Please give according to standard insulin sliding scale. 4. Zolpidem 5 mg Tablet [Hospital1 ]: One (1) Tablet PO HS (at bedtime). 5. Docusate Sodium 50 mg/5 mL Liquid [Hospital1 ]: One Hundred (100) mg PO BID (2 times a day). 6. Metoclopramide 10 mg Tablet [Hospital1 ]: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 7. Heparin (Porcine) 5,000 unit/mL Solution [Hospital1 ]: 5000 (5000) units Injection TID (3 times a day). 8. Albuterol 90 mcg/Actuation Aerosol [Hospital1 ]: 4-6 Puffs Inhalation Q4H (every 4 hours) as needed for when on vent. 9. Ipratropium Bromide 17 mcg/Actuation Aerosol [Hospital1 ]: 4-6 Puffs Inhalation Q4H (every 4 hours) as needed for when on vent. 10. Senna 8.6 mg Tablet [Hospital1 ]: 8.6 mg Tablets PO BID (2 times a day). 11. Diltiazem HCl 30 mg Tablet [Hospital1 ]: Three (3) Tablet PO QID (4 times a day). 12. Metoprolol Tartrate 25 mg Tablet [Hospital1 ]: One (1) Tablet PO TID (3 times a day). 13. Furosemide 40 mg Tablet [Hospital1 ]: One (1) Tablet PO BID (2 times a day). 14. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 15. Ondansetron 4 mg IV Q8H:PRN Discharge Disposition: Extended Care Facility: [Hospital1 700] - [Location (un) 701] Discharge Diagnosis: Primary diagnosis: NSTEMI Secondary diagnosis: Head and neck cancer, AFIB, COPD, Trach, PEG Discharge Condition: VSS, on trach mask, comfortable and asymptomatic. Discharge Instructions: 1. Take all medications as prescribed. 2. Return to the ER if you experience increasing shortness of breath, difficulty of breathing, or chest pain. Followup Instructions: Provider: [Name10 (NameIs) 676] CLINIC Phone:[Telephone/Fax (1) 59] Date/Time:[2108-4-2] 2:30 Completed by:[2107-10-21**]	[ "E878.4", "584.9", "195.0", "V44.0", "414.00", "486", "496", "536.40", "427.31", "284.1", "570", "V45.81", "410.71", "250.00", "518.81", "V10.05" ]	icd9cm	[ [ [] ] ]	[ "33.21", "97.02", "96.71" ]	icd9pcs	[ [ [] ] ]	10930, 11002	5331, 8739	326, 371	11138, 11190	2886, 5308	11387, 11526	2289, 2344		9357, 10907	11023, 11023		8765, 8765			11214, 11364					8786, 8956		2359, 2867																277, 288								399, 1705			11070, 11117			11042, 11049						8981, 9334	1727, 2017	2033, 2273
42,811	154,794	13643	Discharge summary	report	Admission Date: [2146-5-11] Discharge Date: [2146-5-24] Date of Birth: [2069-3-5] Sex: F Service: MEDICINE Allergies: Seroquel / Haldol Attending:[First Name3 (LF) 1257] Chief Complaint: AMS, rigidity Major Surgical or Invasive Procedure: endotracheal intubation, mechanical ventilation arterial/venous line placement, PICC placement History of Present Illness: This is a 77 yo F with h/o CAD s/p CABG, CKD, and depression who was transferred from [Hospital3 ] for concern of delirium/AMS and is now being transferred to the [Hospital Unit Name 153] for altered mental status, nonresponsiveness, and total body rigidity. She was initially admitted to OSH on [5-3] c/o SOB and SOB and was ruled out for MI, had a TTE with LVEF 60%, mild inf hypokinesis, and mod MR, and a p-MIBI that showed a fixed inferior defect. She was discharged and represented later that day c/o continued SOB. Due to CKD, a V/Q scan was performed that was low probability for PE. Her symptoms of SOB resolved and she was treated with a course of levaquin and then transitioned to augmentin for a UTI. Her hospital course was complicated by AMS that was thought to be [12-27] delirium that was intermittently treated with haldol 0.5 mg prn and psychiatry was consulted. The patient was also monitored on a CIWA scale out of concern for alcohol withdrawal and received ativan up until yesterday. She had 2 NCHCTs that were ordered for changes in mental status that were both negative for acute pathology. As her AMS status worsened, her family requested transfer to [Hospital1 18]. A LP was not performed prior to transfer. Upon arrival to 11 [Hospital Ward Name 1827], the patient was noted to be non-responsive with eyes wide open and limb extremely rigid and extended. Pt AF, BP initially 220/110s, HR 140s, RR 20-30s, O2 sat 97% 2L NC. Due to initial concern for status epilepticus, she was given ativan 2 mg IV and then 2 mg IM without clear improvement in her rigidity or mental status. Labs revealed WBC 9.5, HCO3 19, AG 16, lactate 1.6, Cr 1.3, CK 579. ABG 7.47/30/112/22. EKG with sinus tachycardia. A review of her med list from the OSH revealed that she had received haldol 0.5 mg as well as ativan prn for CIWA scale. Given concern for possible neuroleptic malignant syndrome, the patient was ordered for dantrolene 120 mg IV X 1. She was also given benadryl 50 mg IV X 1 and benzotropine 1 mg IV x 1 with some improvement in her rigidity. In regards to her BP, she received hydralazine 10 mg IV X 2 with improvement in BPs to 150/60s. Neurology was also consulted who also thought dystonic reaction was a possible diagnostic consideration and recommended repeating head CT and LP. Past Medical History: CAD s/p CABG HTN Hyperlipidemia Chronic Kidney Disease Depression s/p knee replacement s/p left ankle fusion with plates/screws Social History: Reportedly drinks 3 glasses of wine per day. No illicits, IVDA, tobacco. Very independent and functional at baseline per daughter. Family History: non-contributory Physical Exam: T 99.1 BP 184/77 HR 118 RR 18 O2 sat 98% RA Gen - elderly femal, obtunded, grimaces in response to sternal rub, mouth wide open, initially with mouth fasciculations upon arrival to ICU. Very diaphoretic upon initial HEENT - sclerae anicteric, mouth wide open, very dry and erythematous MM, ? area of vesicles over posterior OP CV - tachycardic, no m/r/g Lungs - limited exam, CTA b/l Abd - Soft, NT, mild distention, decreased BS throughout Ext - no LE edema, WWP, 2+ distal pulses, extremely rigid Neuro - obtunded, nonverbal, grimaces to pain and sternal rub. PERRL, unable to test remaining cranial nerves, increased tone throughout with rigidity of all extremities UE > LE. Unable to assess motor strength or sensation. 2+ DTRs in UEs, 3+ DTR in [Name2 (NI) ], upgoing toe on right. Equivocal Babinskis on left. Skin - warm, no rashes Pertinent Results: LABS ON ADMISSION: [2146-5-11] 06:45PM BLOOD WBC-9.5 RBC-3.60* Hgb-11.2* Hct-33.1* MCV-92 MCH-31.0 MCHC-33.8 RDW-13.2 Plt Ct-304 [2146-5-11] 06:45PM BLOOD PT-13.7* PTT-30.7 INR(PT)-1.2* [2146-5-11] 06:45PM BLOOD Glucose-132* UreaN-15 Creat-1.3* Na-144 K-4.3 Cl-110* HCO3-19* AnGap-19 [2146-5-11] 06:45PM BLOOD ALT-43* AST-56* LD(LDH)-360* CK(CPK)-579* AlkPhos-44 TotBili-0.3 [2146-5-11] 06:45PM BLOOD Albumin-4.0 Calcium-8.5 Phos-1.9* Mg-1.6 [2146-5-12] 05:06AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . URINE: [2146-5-12] 01:28AM URINE Color-Yellow Appear-Hazy Sp [Last Name (un) ]-1.013 [2146-5-12] 01:28AM URINE Blood-LG Nitrite-NEG Protein-100 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG . CSF: [2146-5-12] 02:54AM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-0 Polys-0 Lymphs-50 Monos-50 [2146-5-12] 02:54AM CEREBROSPINAL FLUID (CSF) TotProt-43 Glucose-78 . RADIOLOGY: CXR [5-11]: FINDINGS: No previous images. The heart is normal in size, and there is no evidence of vascular congestion or pleural effusion in this patient with intact midline sternal sutures. Minimal streaks of atelectasis are seen at the left base. The study and the report were reviewed by the staff radiologist. . CT Head: IMPRESSIONS: Hypodensity in the right frontal lobe extends to the cortex centrally. Not a lot of volume loss is noted nor mass effect. While this could represent subacute infarction, MRI without and with Gado may be performed to exclude underlying mass. . UE Doppler IMPRESSION: Clot in the right cephalic vein up to the axillary vein, but without extension into the axillary or subclavian vein. No clot in deep venous structures is seen. . CARDIOLOGY: TTE ([5-12]) Conclusions The left atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. There is mild to moderate regional left ventricular systolic dysfunction with infero-lateral akinesis. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([11-26]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. Brief Hospital Course: Ms [Known lastname 41165] is a 77 year old woman with h/o CAD s/p CABG, CKD, EtOH use, and depression who initially was admitted to an OSH with SOB and UTI and transferred to [Hospital1 18] ICU with rigidity and altered mental status. # Neuroleptic malignant syndrome: She was very rigid on presentation and her symptoms were consistent with neuroleptic malignant syndrome, as she also had fever, altered mental status, and a history of recent haldol. Neurology was consulted and recommended the initation of dantrolene. She was transferred to the [Hospital Unit Name 153] and intubated for airway protection, but her symptoms of NMS gradually improved and eventually resolved completely. She also underwent an LP which was negative and a CT head which showed a frontal hypodensity consistent with either subacute infarction or mass, but no acute process. Note that the patient and her family refused an MRI because of claustrophobia, but this can be readdressed in the outpatient setting. Haldol and seroquel were added to her allergy list and she should avoid antipsychotics in the future. # Pneumonia: She developed a ventilator associated pneumonia for which she completed an 8 day course of vancomycin and zosyn. Her respiratory status was stable afterward and she was satting well on room air. # Atrial fibrillation with rapid ventricular response: She developed AF with RVR after extubation in the setting of PICC line placement. The electrophysiology team was consulted. It was believed that the dantrolene may have played a role in her tachyarrhythmia. She was treated with heparin, amiodarone, and DC cardioversion. She converted and remained in sinus rhythm. Warfarin was later started but discontinued because of guaiac positive stools and a gradual Hct decline. Her CHADS score of 4 is associated with a relatively high risk of stroke but because of her risk of a GI bleed, she will be managed with only aspirin for now. This was discussed on [2146-5-23] with her daughter, who agreed with the treatment plan. She also stated that the patient would be undergoing a colonoscopy a few weeks after discharge. She was empirically started on omeprazole though she never had melena or evidence of an UGIB. # Right arm thrombophlebitis: She developed a right superficial vein clot with RUE swelling. An ultrasound was performed and showed not evidence of deep vein involvement. She was therefore managed with warm compresses and elevation. Warfarin was not indicated because of the absence of deep vein involvement. # Anemia: She was transfused two units PRBC on [2146-5-20] because of progressive deciline in her Hct and guaiac positive stools, with [Initials (NamePattern4) ] [Last Name (NamePattern4) 12899] of 21. Her Hct responded appropriately to 30 after transfusion. Further details about her guaiac positive stools are described above, including the rationale for placing the patient only on aspirin and not warfarin in the short term. # Left wrist hematoma: She developed a 5 cm x 3 cm hematoma over her left wrist and was seen by plastics because there was initially concern for abscess. However, it was concluded that the mass was a hematoma and will resolve gradually over time. # CAD/HTN: Stable, continued aspirin and metoprolol as above, along with other antihypertensives. # Depression: Because of the patient's diagnosis of NMS, she will need psychiatry consultation when considering new psychiatric medications. Medications on Admission: Norvasc 5 mg daily ASA 325 mg daily Imdur 60 mg [Hospital1 ] Toprol 100 mg qhs Pravchol 40 mg daily Seroquel 100 mg qhs Ranitidine 150 mg daily Diovan/HCTZ 160/25 mg daily Calcium 2 tabs [Hospital1 ] MVI daily Vit B6 50 mg daily 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. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for rash. 4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever. 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 10 days: Last day [5-30]. Then transition to 200mg daily. . 11. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day: START THIS DOSE 7/7 AFTER 400mg DOSE IS DISCONTINUED. 12. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for pruritis. 13. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 14. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 15. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 16. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 17. Nortriptyline 25 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). Discharge Disposition: Extended Care Facility: [Hospital1 11057] Place Discharge Diagnosis: Neuroleptic Malignant Syndrome Ventilator Associated Pneumonia Deep venous thrombosis Atrial fibrillation with rapid ventricular response Thrombophlebitis Anemia Secondary diagnoses: Hypertension Coronary artery disease Depression Discharge Condition: Vital signs stable, requiring assistance from PT to ambulate, cleared by speech and swallow for pills and regular diet. Discharge Instructions: You were admitted with altered mental status and rigidity. You were determined to have had a syndrome called neuroleptic malignant syndrome, presumably from an antipsychotic medication you received called haloperidol. You should avoid antipsychotic medications in the future. You were given a medication called dantrolene and needed to be temporarily intubated while you recovered from this. While you were hospitalized you developed a pneumonia and were treated with antibiotics. You also developed a rapid irregular heart rate and required cardioversion and the initiation of a new medication called amiodraone. You will need to follow up closely with your cardiologist for management of this issue. You were also found to have a clot in your right arm. Because this clot was not in the deep veins of your arm, you do not need a blood thinner for it. We also found evidence of microscopic blood in your stool, and we recommend follow up with a colonoscopy as an outpatient. Please discuss managment of your anemia with your doctor. Finally, the abnormal heart rhythm you had is usually also treated with a blood thinner called warfarin but because you are at risk of bleeding secondary to the blood in your stool, we stopped this medication and are only treating you with aspirin. You should discuss whether it is safe for you to start warfarin with your primary care doctor and cardiologist. We also recommend that you abstain from future alcohol use as it is hazardous to your health. Please take all medications as prescribed. The following changes were made to your home medication list: -you were started on amiodarone for your heart rhythm -you were started on omeprazole to reduce any risk of bleeding from your stomach -your seroquel was discontinued Please follow up with both your primary care physician and your cardiologist. We also recommend consultation with a psychiatrist for ongoing management of your depression. Call your doctor or return to the emergency room if you experience fevers, chills, decreased alertness, difficulty breathing, increased muscle stiffness or for any other concerning symptoms. Followup Instructions: You have a follow up appointment arranged with your PCP [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] on [2146-6-13] at 3:30. Please call if you need to reschedule [Telephone/Fax (1) 41166]. You have a follow up appointment arranged with your cardiologist Dr [First Name8 (NamePattern2) 487] [Last Name (NamePattern1) 20948] at Cardiovascular Specialists (phone [Telephone/Fax (1) 34149], fax [Telephone/Fax (1) 41167]) on [2146-6-23] 4:10pm please call if you need to reschedule. Completed by:[2146-5-25]	[ "997.31", "414.00", "333.92", "518.81", "E939.2", "285.9", "584.9", "272.4", "427.31", "311", "403.90", "585.9", "451.82", "305.01" ]	icd9cm	[ [ [] ] ]	[ "99.62", "03.31", "96.04", "38.93", "96.72" ]	icd9pcs	[ [ [] ] ]	11987, 12041	6570, 10070	291, 387	12317, 12439	3965, 3970	14625, 15187	3062, 3080		10357, 11964	12062, 12225		10096, 10334			12463, 14602							3095, 3946			12246, 12296													238, 253								415, 2746		5258, 6547					3984, 5249						2768, 2898	2914, 3046
15,301	149,688	51718	Discharge summary	report	Admission Date: [2133-5-31] Discharge Date: [2133-6-4] Date of Birth: [2060-1-15] Sex: M Service: MEDICINE Allergies: Protamine Sulfate Attending:[First Name3 (LF) 9824] Chief Complaint: back pain/SOB/weakness in legs Major Surgical or Invasive Procedure: None History of Present Illness: 73 yo M with CAD, DM, CRI, and neuropathy who presents from home with SOB. He went swimming yesterday but then had a hard time getting out of his wheelchair. Chronically pt has been debillitaed since his AAA repair and knee replacements. Recently, he noticd a decline in his strength. Over the past one and a half months his legs would given out under him, no LOC/syncope or other signs. 3 falls over months. Because of this weakness he now uses a walker, weakness in the buttock. He awoke this morning, and now he couldn't move his legs. No numbness/tingling/bowel/bladder problems. . Baseline DOE with 20-30 ft. Had a cough today and fever. +sick contact. . He was seen on [5-27] by his PCP who noted LE weakness. He was seen by Dr. [Last Name (STitle) ] for this and had an EMG which showed multiple possible etiologies. Lasix recently increased by his PCP. . In the ED, VS 99.4, 103, 151/85, 20, 92% RA. Spiked to 101.8 in the ED. Exam with 2/5 LE strength. A neuro consult was obtained who reccomended an MRI, however pt was too large, in order to r/o an epidural abscess. He did recieved a CT spine/chest which showed a PNA and r/o PE. Ortho spine consulted in the ED. Given 750 mg IV levafloxacin, nitro paste, vancomycin, CTX. For CT scan he got bicarb and mucomyst. . He was admitted to the MICU for q1 hr neuro checks. Past Medical History: CAD s/p angioplasty in [2121], stress echo wnl [8-3] DM II- on insulin HTN Hyperlipidemia CRI AAA s/p rempair, c/b acute renal failure now with CRI Darier disease OA thrombocytopenia of unclear etiology b/l knee replacement peripheral neuropathy lumbar spine stenosis claudication MGUS Social History: Lives with wife. [Name (NI) ] is a retired general contractor. Smoked [2-1] ppd x 50 years, quit in [2116]. [12-30] drinks/week. in wheelchair. Family History: father died at 96. mother died at 93. Physical Exam: VS: afebrile, HR 84, RR 17, 114/64 obese elderly man, o x 3, NAD thick neck, hard to assess JVP PEERLA, anicteric distant HS poor air mvmt thorughout, tight wheezes in upper lung zones, crackels at RLL obese, distended, no R/G, +BS, umbillical hernia 1+ edema bilaterally neuro: please see neuro consult note for full details; sensation in tact to light touch, proprioception in tact, good strength in UE/LE, CN intact MSK: tender over spine in lower spine, no erythema or fluctance Pertinent Results: [2133-5-31] 11:15AM WBC-17.6# RBC-3.64 HGB-11.3* HCT-33.5* MCV-92 MCH-31.0 MCHC-33.7 RDW-14.3 [2133-5-31] 11:15AM NEUTS-91* BANDS-1 LYMPHS-5* MONOS-3 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2133-5-31] 11:15AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [2133-5-31] 11:15AM PLT SMR-VERY LOW PLT COUNT-79* [2133-5-31] 11:15AM PT-13.2* PTT-26.6 INR(PT)-1.2* [2133-5-31] 11:28AM GLUCOSE-260* LACTATE-1.9 NA+-137 K+-4.6 CL--100 TCO2-26 [2133-5-31] 11:15AM cTropnT-0.03* [2133-5-31] 11:15AM CK(CPK)-125 [2133-5-31] 11:15AM CK-MB-3 proBNP-262* PA AND LATERAL CHEST: Cardiomediastinal silhouette is unchanged. Pulmonary vascularity is stable. Opacity at the right base medially is unchanged but not well identified on the lateeral view. No pleural effusion or pneumothorax. Non-contrast head CT scan: There is no evidence of hemorrhage, shift of normally midline structures or hydrocephalus. [Doctor Last Name ]-white matter differentiation appears grossly preserved. Hypodensity in the periventricular white matter of both cerebral hemispheres is seen suggesting chronic microvascular ischemia. Visualized paranasal sinuses appear normally aerated. CT spine: 1. Study is extremely limited by patient body habitus. No definite enhancing lesions identified, however at best CT is a low sensitivity study and epidural abscess cannot be excluded on this study. MRI is more sensitive in evaluation for epidural abscess. 2. Right lung consolidation concerning for pneumonia, better assessed on dedicated chest CT of the same day. 3. Enlarged mediastinal lymph nodes, possibly reactive. 4. AAA, with endoluminal stent. Timing of contrast bolus is not adequate for evaluation for potential leak. 5. Coronary artery calcifications noted. Brief Hospital Course: Pneumonia: Though initially admitted with concern for weakness, it seemed that the patient had a right lower lobe pneumonia in addition. The cause is likely community acquired as he did not have signs of aspiration on evaluation. He was treated with levofloxacin and metronidazole for a total of 10 days (finishes course as outpatient). Sputum cultures were negative. He has increased white count and concerning CXR findings for RLL pneumonia. Has been ruled out for PE. Breathing has significantly improved while he has received antibiotics. Therefore, will continue nebs, antibiotics for community/aspiration pneumonia (levofloxacin/metronidazole). Sputum cultures represent G+ cocci in pairs which was respiratory flora. Lower extremity weakness: Initial description was concerning for disc herniation or epidural abscess and he was evluated by neurology. Recommendations were made to do an MRI however, the patient could not fit into the MRI machine. Therefore he was initially empirically treated for an epidural abscess. However his symptoms improved very rapidly and a WBC scan was negative. Given these, an epidural abscess was ruled out. The patient's strength improved with the improvement in his pneumonia and with diuresis (decrease in LE edema) making deconditioning a possible cause. Nonetheless, he should have an MRI done as an outpatient in a Shields MRI. Acute on chronic CRI: Appears to have a baseline around 2 that was initially elevated but improved during his hospital course. On discharge 2.3. Causes include medication related, progression of diabetic neprhopathy, or IV contrast, though initially thought seconary to dehydration. Diabetes mellitus: He was continued on his home NPH and SS insulin, have decreased dosages as he had episodes of hypoglycemia (likely secondary to his decreased intake in the hospital). Have discussed having smaller intake and need to have tight blood sugar control. Coronary artery disease:He was continued outpt meds,initially he had an elevated tropinin but in the setting of RF, CK/MB normal. No symptoms of chest pain or significant ECG changes. Continued beta-blocker and aspirin. HTN: Was restarted on lisinopril and changed to metoprolol given poor renal function LE edema: Was diuresed with lasix and had improvement in edema with simultaneous improvment in renal function. Medications on Admission: Gemfibrozil 600 mg [Hospital1 ] Lisinopril 20 mg q day Neurontin 900 mg/600 mg Atenolol 25 mg q day Lasix 120 mg qday Amitryptiline 75 mg [Hospital1 ] Pravastatin 10 mg q day Atrovent 2puffs qid Albuterol 2 puffs qid Flovent 2 x day Discharge Medications: 1. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours): Continue as per discussed plan with Dr. [Last Name (STitle) 1968]. 2. Pravastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours). 4. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 6 days. Disp:12 Tablet(s) Refills:0 7. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 6 days. Disp:6 Tablet(s) Refills:0 8. Amitriptyline 25 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). 9. 70/30 Insulin Sig: as dir twice a day: Continue your insulin as per your home dose. However, you must check your glucose 4 times a day for the next few days. 10. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 11. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 12. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:30 Tablet Sustained Release 24 hr(s) Refills:2 14. Gemfibrozil 600 mg Tablet Sig: 0.5 Tablet PO twice a day. Discharge Disposition: Home With Service Facility: [Hospital1 6136] Home Care Discharge Diagnosis: Primary: Pneumonia, community acquired Lower extremity edema Secondary COPD Restrictive lung disease Spinal stenosis Discharge Condition: Improved strength, no oxygen requirement Discharge Instructions: You were admitted with weakness and pneumonia. For your weakness we gave you antibiotics but found that there is no infection in your back. For your pneumonia you were treated with antibiotics and you must continue them for the next week. . Please keep all follow up appointments and take all medications as prescribed. Please check your sugars 4 times a day for the next few days and record these numbers. If the levels are consistently above 200-300 or consistently below 70 you should call Dr.[Name (NI) 11632] office. Please bring these numbers to your appointment on monday. If you have any questions regarding this or having any symptoms such as chest pain, shortness of breath, worsening weakness, fever, chills passing out or any other concerning symptoms, please go to the ER or call Dr.[Name (NI) 11632] office ([Telephone/Fax (1) 250]) Followup Instructions: Primary care appointment: Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], RN, CS Phone:[Telephone/Fax (1) 250] Date/Time:[2133-6-8] 1:30 You have a follow-up appointment with Dr [Last Name (STitle) ] on [7-21] at 1030 in the morning. You will be getting an arterial duplex (Ultrasound) of your AAA. You must not eat anything after midnight. For this will affect the outcome of the test. His office can be reached at [Telephone/Fax (1) 1241]. . Provider: [Name10 (NameIs) 326] UPPER GI (WEST) RADIOLOGY Phone:[Telephone/Fax (1) 327] Date/Time:[2133-6-11] 10:45	[ "428.0", "782.3", "724.02", "403.90", "V45.82", "276.51", "414.01", "441.4", "486", "496", "278.00", "584.9", "250.40", "287.5", "507.0", "585.9", "799.02" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	8736, 8797	4616, 6971	308, 314	8958, 9000	2752, 4593	9914, 10540	2193, 2232		7263, 8713	8818, 8937		6997, 7240			9024, 9891							2247, 2733																238, 270								342, 1681													1703, 1999	2015, 2177
25,581	180,899	54457	Discharge summary	report	Admission Date: [2181-5-5] Discharge Date: [2181-5-9] Date of Birth: [2131-7-26] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 12722] Chief Complaint: shortness of breath, altered mental status Major Surgical or Invasive Procedure: lumbar puncture History of Present Illness: Mr. [Known lastname 10132] is a 49 year old man with h/o HIV/AIDS (last CD4 387 in [2-5]), severe COPD (home O2 4-5LNC), who was admitted with shortness of breath and confusion. . The patient has been having shortness of breath for the past few days that worsened last night. Family has noted that he has been more confused than usual. Also with mild, non-productive cough and generalized abdominal pain. No fevers, chills, nausea, vomiting, constipation, diarrhea. . In the ED, initial VS:99.4 101 133/95 24 99% 4L Nasal Cannula. Initial concern was for possible infection given AMS. BCx were drawn, LP was performed with CSF sent for fungal and regular Cx and crypto Ag. CT head with no acute ICH and no ring enhancing lesions. Patient was given 1LNS, Ceftriaxone 2g, and Vancomycin 1g. Transfer vitals: 98.1, HR 99, BP 142/88, O2 sat 100% 4L NC wears @ home, RR 19-21. . On arrival to the medical floor, the patient was pursed-lip breathing and using his accessory muscles, talking in short sentences with frequent breaks for taking breaths. He was lethargic, although oriented x3. Initial ABG: 7.34/84/99. He was treated with IV steroids and duonebs with some mild improvement. Subsequent ABG: 7.31/77/120. The patient continued to have difficulty breathing, so was transferred to the MICU for non-invasive ventilation. . On arrival to the MICU, the patient complained of chest pain - sharp/stabbing pain in the center of his chest. No radiation to jaw or arm, no associated nausea/vomiting. Pain resolved without intervention. Patient was given ASA 300mg PR, and EKG was obtained -- showed PR depressions inferolaterally, otherwise similar to prior. Currently without chest pain. Patient still feeling short of breath. Past Medical History: -HIV/AIDS - CD4 most recently 387([January 2181]) VL supressed recently. [Year (2 digits) 1074] gastritis, Type II HSV, disseminated toxo, thrush in past. -Severe COPD on home oxygen: 4-5L NC. O2 sat 93% at baseline. "Emphysema-asthma overlap syndrome" managed by pulmonology here at [Hospital1 18]. PFTs from [10/2177]: FEV1 is 0.89 liter (25% of predicted). His FVC is 2.49 liters (3% of predicted). His FEV1/FVC ratio is 48%. Patient uses wheelchair to get around due to SOB from COPD. - HIV polyneuropathy - h/o c.diff colitis - s/p G-tube. (currently takes 3 cans supplement / night through g tube) - dysthymia - chronic pain: neuropathy, back pain - L osteonecrosis of the shoulder - shingles [11-3] (completed acyclovir course) - cataract surgery OD [12-3] - R knee repair s/p fall Social History: Currently lives on home hospice with his mother, [Name (NI) 5627] and his niece. Has visiting nurse 3x/week and hospice nurse at least once a week. He has used cocaine in the past and had resultant crack lung. He denies cocaine use adamantly this admission. He does admit to marijuana use, but denies tobacco and EtOH. Family History: DM and heart dz in maternal aunt and MGM, CVA in maternal uncle Mother with sarcoid. Biological mother and adopted father, no known paternal [Name (NI) 41900]. Physical Exam: ADMISSION EXAM: Vitals: T: 98.2 BP: 124/76 P: 94 R: 16 O2: 96% 4LNC GENERAL - chronically ill appearing man, AOx2, NAD HEENT - NC/AT, EOMI, sclerae anicteric, dry MM, OP clear NECK - supple, no thyromegaly, no JVD LUNGS - minimal air movement throughout, no wheezing, some accessory muscle use HEART - RRR, S1S2, no m/r/g ABDOMEN - NABS, soft, mild periumbilical ttp, ND, no rebound/guarding, g-tube in place, clean, no excoriation EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions LYMPH - no cervical LAD NEURO - A&Ox2, CNs II-XII grossly intact, moving all extremities . DISCHARGE EXAM: Vitals: T: 97.9 BP: 111-128/76-99 P: 81-102 R: 18 O2: 99% 3.5LNC [Telephone/Fax (1) 111456]/750 GENERAL - chronically ill appearing man, AOx3, NAD HEENT - NC/AT, EOMI, sclerae anicteric, dry MM, OP clear NECK - supple, no thyromegaly, no JVD LUNGS - minimal air movement throughout, no wheezing, accessory muscle use, no distress. Barrel chest. Scoliosis. HEART - RRR, S1S2, no m/r/g ABDOMEN - NABS, soft, NTTP, ND, no rebound/guarding, g-tube in place, clean, no excoriation EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions LYMPH - no cervical LAD GU - no foley NEURO - A&Ox3, CNs II-XII grossly intact, strength 4+/5, grip strength on left is [3-1]. Finger to nose intact bilaterally. Gait deferred as patient isnon ambulatory. Pertinent Results: ADMISSION LABS: [2181-5-5] 06:20PM BLOOD WBC-5.1 RBC-3.99* Hgb-12.7* Hct-42.0 MCV-105* MCH-31.9 MCHC-30.3* RDW-15.5 Plt Ct-171 [2181-5-5] 06:20PM BLOOD Neuts-63.8 Lymphs-26.0 Monos-6.6 Eos-2.3 Baso-1.3 [2181-5-5] 06:20PM BLOOD PT-10.7 PTT-36.7* INR(PT)-1.0 [2181-5-5] 06:20PM BLOOD Glucose-124* UreaN-18 Creat-0.6 Na-143 K-4.3 Cl-97 HCO3-41* AnGap-9 [2181-5-5] 06:20PM BLOOD ALT-38 AST-29 AlkPhos-85 TotBili-0.6 [2181-5-5] 06:20PM BLOOD Lipase-18 [2181-5-5] 06:20PM BLOOD Albumin-4.4 Calcium-10.1 Phos-3.6 Mg-1.9 [2181-5-5] 06:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2181-5-5] 06:28PM BLOOD Lactate-1.0 . PERTINENT LABS: CXR [2181-5-5]: The cardiac, mediastinal and hilar contours appear unchanged. Vague upper lung opacities known to reflect architectural irregularity associated with emphysema appear similar to the prior radiographs. There has been no significant change. The lungs appear hyperinflated. There is no pleural effusion or pneumothorax. Mild loss in body heights among several mid thoracic vertebral bodies appears similar to the prior studies. IMPRESSION: Stable appearance of the chest. CT Head [2181-5-5]: No definite ring-enhancing lesions identified. No evidence of acute intracranial hemorrhage. EEG [2181-5-6]: This is an abnormal routine EEG in the awake state due to the presence of a diffusely slow and disorganized background. This finding indicates a moderate to severe encephalopathy which implies diffuse cerebral dysfunction but is non-specific as to etiology. No definite epileptiform discharges and no electrographic seizures are present. Note is made of a regular tachycardia. Interpretation is limited by significant muscle and movement artifact; if the clinical suspicion of seizures is high, a repeat study may be helpful BILATERAL LENI [2181-5-6]: no DVT . MICRO: [2181-5-9] IMMUNOLOGY HIV-1 Viral Load/Ultrasensitive-PENDING [2181-5-8] STOOL C. difficile DNA negative; OVA + PARASITES-negative [2181-5-6] URINE Legionella Urinary Antigen -NEGATIVE [2181-5-6] SEROLOGY/BLOOD RAPID PLASMA REAGIN TEST-NEGATIVE [2181-5-6] MRSA SCREEN NEGATIVE [2181-5-5] BLOOD CULTURE PENDING [2181-5-5] CSF;SPINAL FLUID FUNGAL CULTURE-PRELIMINARY NO FUNGUS ISOLATED [2181-5-5] CSF;SPINAL FLUID CRYPTOCOCCAL ANTIGEN-NEGATIVE [2181-5-5] CSF;SPINAL FLUID GRAM STAIN-NEGATIVE; FLUID CULTURE-NEGATIVE [2181-5-5] BLOOD CULTURE PENDING DISCHARGE LABS [2181-5-9] 12:45PM BLOOD WBC-4.7 RBC-3.60* Hgb-11.2* Hct-37.6* MCV-104* MCH-31.0 MCHC-29.7* RDW-15.8* Plt Ct-169 [2181-5-9] 12:45PM BLOOD Neuts-54.1 Lymphs-35.4 Monos-4.8 Eos-5.3* Baso-0.4 [2181-5-9] 12:45PM BLOOD WBC-PND Lymph-PND Abs [Last Name (un) ]-PND CD3%-PND Abs CD3-PND CD4%-PND Abs CD4-PND CD8%-PND Abs CD8-PND CD4/CD8-PND [2181-5-9] 07:35AM BLOOD Glucose-126* UreaN-16 Creat-0.8 Na-142 K-4.0 Cl-105 HCO3-29 AnGap-12 [2181-5-9] 07:35AM BLOOD Calcium-8.3* Phos-4.3# Mg-2.4 Brief Hospital Course: 49 year old man with HIV on HAART, COPD on home 4L O2, presenting with lethargy and feeling "unwell," transferred to the MICU for increased work of breathing and hypercarbia on the floor, as well as altered mental status. . ACUTE CARE # Altered mental status: Unclear etiology, but resolved by MICU day #2. CT head with contrast negative for acute process. LP negative. Acyclovir was started empirically for possible HSV encephalitis, but was discontinued when the HSV PCR returned negative. Infectious workup including CXR, blood cultures, and urine culture were all negative. No metabolic abnormalities to explain his altered mental status. Tox screen negative. EEG negative for seizure activity. Considering his HIV status and low CD4 count of 28, we considered an MRI head to evaluate for white matter disease (such as PML), however his mental status had improved so after discussion with neuro and ID, this was felt to be low yield. Because [Known firstname ] had since woken up and had improvement in his mental status, we discussed the utility of pursuing MRI brain with him and his mother. It was explained that the differential includes PML, for which the treatment would be HAART, which we are doing, and CNS lymphoma. We said that we feel that it is unlikely that he has CNS lymphoma due to his presentation not being classic, and we also explained that the treatment of this disease would require LPs, chemo, steroids, etc, and if this is not in keeping with his goals of care, then it would not make sense to pursue this test. The patient was given the option of doing the MRI prior to discharge vs thinking about it and possibly doing it in the outpatient setting; he opted for the latter. . # Respiratory distress: Patient with known severe COPD and is on 4L home oxygen. His admission ABG was 7.34/84/99/47, however he is a chronic CO2 retainer, and this was felt unlikely far from his baseline. He was given albuterol and ipratropium nebs and then was restarted on his home medications. No evidence for pneumonia or other acute process on CXR. For his COPD, he was continued on his home regimen of inhalers: albuterol, spiriva, serevent, pulmicort as well as montelukast. . # Chest pain: Patient with episode of chest pain on arrival to the ICU, resolved without intervention. Likely related to COPD exacerbation. EKG with inferolateral PR depressions, but no concerning findings for ACS. He was given a dose of aspirin. Cardiac enzymes were negative x2 and he had no further episodes of chest pain. . # HIV: CD4 was 387 in [1-/2181], but was 28 upon recheck. Unclear whether he was taking all of his HAART as directed. We continued his home regimen of Lopinavir-Ritonavir, Lamivudine, Abacavir, and Viread. HIV was consulted and recommended starting Bactrim 1 DS tab daily for PCP prophylaxis, and azithromycin 1200mg once weekly for MAC prophylaxis. For the possibility of lab error playing a role in his new low level of CD4, we repeated the test as well as his viral load, both of these things need to be followed up in the outpatient setting. He also is going to have a viral load and a genotype tested in about 2 weeks to help guide HAART tx. . # Goals of care: Patient has been receiving home hospice services for the past several years and was full code upon admission to the ICU. After several discussions with the patient and his mother (health care proxy), the decision was made to change his status to DNR/DNI. However, the patient would like to continue to receive all other interventions as needed (such as imaging, antibiotics, pressors etc.) CHRONIC CARE # Depression/Anxiety: Continued on citalopram 10 mg Tab: 1 Tab PO once a day; lorazepam 1mg daily was held for somnolence during his admission. # Pain: Cont home oxycontin 40mg [Hospital1 ]. Held PRN Percocet for recent altered mental status and no complaint of pain, but was continued at time of discharge, his lyrica was continued throughout hospitalization. # Bone Health: alendronate 5 mg Tab: 1 Tab PO DAILY; Calcium 500 + D (D3) 500-125 mg-unit Tab: 1 Tab PO once a day # GERD: famotidine 20 mg Tablet: 1 Tab PO once a day. TRANSITIONS IN CARE PENDING AT TIME OF DISCHARGE: - viral load - CD4 count - blood culture [5-5] x2 - CSF fungal culture ISSUES TO DISCUSS AT FOLLOW UP: - please repeat his viral load and genotype in about 2 weeks (labs ordered) - please consider MRI brain and discuss this with the patient - please consider changing the patient's HAART regimen, if clinically indicated. CODE: DNR/DNI Contact: [Last Name (LF) ],[First Name3 (LF) 2747] [Telephone/Fax (3) 111457] [Last Name (LF) ],[First Name3 (LF) ] [Telephone/Fax (3) 111458] Medications on Admission: 1. abacavir-lamivudine 600-300 mg Tab: 1 Tab PO once a day. 2. lopinavir-ritonavir 200-50 mg Tab: 2 Tab PO twice a day. 3. tenofovir disoproxil fumarate 300 mg Tab: 1 Tablet PO DAILY 4. albuterol sulfate Inhalation 5. Serevent Diskus 50 mcg: 1 Inhalation twice a day 6. montelukast 10 mg Tab: 1 Tab PO DAILY 7. Spiriva with HandiHaler 18 mcg Cap: 1 Inhalation once a day. 8. Pulmicort Flexhaler 180 mcg: 1 Inh twice a day 9. alendronate 5 mg Tab: 1 Tab PO DAILY 10. citalopram 10 mg Tab: 1 Tab PO once a day. 11. lorazepam 1 mg Tablet: 1 Tablet PO once a day. 12. folic acid 1 mg Tablet: 1 Tablet PO DAILY 13. B complex vitamins Cap: 1 Cap PO once a day. 14. pregabalin 75 mg Capsule: 2 Caps PO TID 15. Calcium 500 + D (D3) 500-125 mg-unit Tab: 1 Tab PO once a day. 16. Colace 100 mg Cap: 1 Cap PO twice a day prn for constipation. 17. famotidine 20 mg Tablet: 1 Tab PO once a day. 18. oxycodone 5 mg Tab: 1-2 Tabs PO Q4H as needed for pain. 19. oxycodone 40 mg Tablet ER 12r: 1 Tab PO Q12H 20. sodium phosphates: 1 PO once a day. Discharge Medications: 1. Outpatient Lab Work Please check an HIV viral load and virtual genotype in [2181-5-23]. Please fax results to Dr. [Last Name (STitle) ] Phone: [Telephone/Fax (1) 798] Fax: [Telephone/Fax (1) 21392] 2. abacavir-lamivudine NF 600-300 mg Oral qday 3. Lopinavir-Ritonavir 2 TAB PO BID 4. Tenofovir Disoproxil (Viread) 300 mg PO DAILY 5. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN sob/wheeze 6. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H 7. Montelukast Sodium 10 mg PO DAILY 8. Tiotropium Bromide 1 CAP IH DAILY 9. Pulmicort Flexhaler NF (budesonide) 180 mcg/actuation Inhalation [Hospital1 ] 10. Alendronate Sodium 5 mg PO DAILY 11. Citalopram 10 mg PO DAILY 12. Lorazepam 1 mg PO Q24H 13. FoLIC Acid 1 mg PO DAILY 14. Pregabalin 150 mg PO TID Hold for sedation 15. Azithromycin 1200 mg PO 1X/WEEK (WE) RX Zithromax 600 mg 0 Disp #0 Tablet Refills:0 RX Zithromax 600 mg qweek Disp #8 Tablet Refills:0 16. Nephrocaps 1 CAP PO DAILY 17. Calcium 500 + D (D3) NF (calcium carbonate-vitamin D3) 500-125 mg-unit Oral qday 18. Sulfameth/Trimethoprim DS 1 TAB PO DAILY RX Bactrim DS 800 mg-160 mg qday Disp #30 Tablet Refills:0 19. Docusate Sodium 100 mg PO BID 20. Famotidine 20 mg PO DAILY 21. Oxycodone SR (OxyconTIN) 40 mg PO Q12H hold for sedation or rr<10 22. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain Discharge Disposition: Home With Service Facility: [Hospital 269] Hospice Care Discharge Diagnosis: primary diagnosis: delirium chronic obstructive pulmonary disease acquired immunodefiency syndrome Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr [Known lastname 10132], You were admitted to the hospital, and you developed respiratory distress. You improved but you then developed an alteration in mental status. It is unclear why your mental status was altered, but this also improved. We discuss the possibility of MRI of your brain with you and your mother, and you asked to defer this test. You are being discharged with your hospice and VNA nurses. Please note the following changes to your medications: - START bactrim - START azithromycin - Please have your labs checked in about 2 weeks Please continue the other medications as directed. Followup Instructions: PCP [Name Initial (PRE) 648]:[Last Name (LF) 2974], [5-11] at 9:30am With: Dr. [First Name8 (NamePattern2) 122] [Last Name (NamePattern1) ]( Dr. [Last Name (STitle) ], your PCP is [Name Initial (PRE) ]) Location:[Hospital 778] health Center [Location 57122] [Numeric Identifier 718] Phone: ([Telephone/Fax (1) 111459] Department: ORTHOPEDICS When: [Telephone/Fax (1) ] [2181-6-22] at 12:05 PM With: [Year (4 digits) ] XRAY (SCC 2) [Telephone/Fax (1) 1228] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: ORTHOPEDICS When: [Hospital Ward Name ] [2181-6-22] at 12:25 PM With: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [Telephone/Fax (1) 1228] Building: [Hospital6 29] [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: NEUROLOGY When: [Hospital Ward Name ] [2181-10-26] at 11:30 AM With: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 44] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 858] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) *] DO 12-BWD	[ "518.81", "356.9", "349.82", "300.4", "492.8", "V46.2", "042", "530.81" ]	icd9cm	[ [ [] ] ]	[ "03.31", "33.24", "96.6" ]	icd9pcs	[ [ [] ] ]	15145, 15207	7984, 8229	346, 364	15350, 15350	4937, 4937	16170, 17607	3318, 3485		13764, 15122	15228, 15228		12707, 13741			15533, 15980							3500, 4116					4132, 4918	12280, 12681							16009, 16147			264, 308								392, 2125					4953, 5618	15247, 15329		15365, 15509	5634, 7961				2147, 2961	2977, 3302
15,046	104,752	50743	Discharge summary	report	Admission Date: [2189-7-25] Discharge Date: [2189-8-5] Date of Birth: [2124-2-1] Sex: F Service: MEDICINE Allergies: Tetracyclines / Zinc Attending:[First Name3 (LF) 297] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: intubation with mechanical ventilation History of Present Illness: 65 yo F with h/o multiple admissions for aspiration pna now admitted with SOB. Pt was recently admitted [Date range (1) 17594] with aspiration pna and R elbow osteomyelitis and was treated with vancomycin and Imipenem which then changed to Bactrim x 2 weeks. Pt found this morning by caregiver s/p fall - was put in bed and went to get meds and came back and pt had fallen again, so pt was brought to ED. Of note, pt took all her meds this morning including her atenolol, hx taking a lot of oxycodone. In [Name (NI) ] pt was dyspneic with initial O2sat 68% on RA, T 101. Was placed on NRB and sats improved to mid 80%'s, but pt was not alert or oriented. CXR showed improved RLL pna compared to [7-4]. She was intubated and had copious prurulent sputum. Pt started to receive a dose of vanco and developed a blotchy rash on L arm and vanco was stopped and benadryl was given. Rash began to improve and vanco was restarted. While the vanco was infusing she began to become hypotensive and HR was in the 50's. Therefore Vanco was d/ced (after approx 1/2 dose given), pt was started on meropenem, and given IVF for BP control. Was given a total of 2L NS and sBP improved to low 100's, but she remained with decreased mental status without any sedatives. Head CT showed no acute bleed. During head CT, pt became hypertensive and more agitated. Propofol gtt was increased and BP decreased to SBP 100. Head CT showed no acute bleed, and patient was brought to [Hospital Unit Name 153]. Past Medical History: -Castleman's disease since [2175], followed by Dr. [Last Name (STitle) 410]. Hx mediastinal LAD. -s/p splenectomy -Hx of thyroid cancer as adolescent s/p thyroidectomy and subsequent hypothyroidism -Esophageal stricture and dysmotility s/p esophageal dilation -Recurrent aspiration pneumonia; last admission [Date range (1) 17594], 5/13-5-20; s/p course of Imipenem for most recent episode; [5-22] sputum culture grew AFB -Chronic abnormal lung CT with tree in [Male First Name (un) 239] appearance: NOS (plan to reimage in [8-7]) -Chronic R olecranon bursitis and MRSA osteomyelitis of R olecranon s/p multiple debridement (most recent one on [5-13]) -Hx of MRSA pneumonia -Bipolar disorder with hx of suicide attempt -PVD -HTN -GERD, hx perforated ulcer in past -Seizure disorder (reportedly had generalized seizure several years ago assoc. with hypoglycemia, none since, no meds) -s/p R hip fracture with failed ORIF and redo at [Hospital1 2025] -hx of Grave's dz with ophthalmopathy -Osteoporosis -Herpes Zoster -PFT ([2189-5-4]) w/ restrictive pattern: FVC 62% FEV1 65% FEV1/FVC 105% Social History: Lives alone. Has a visiting nurse that comes for only a few hours each day. [Month/Day/Year 4273] [Month/Day/Year ] or IV drug use. Family History: NC Physical Exam: Physical Exam: Vitals - T 94.5, HR 48, BP 118/43, O2sat 100% on AC/500x22/0.5/8, CVP=13 General - Intubated, sedated but easily arousable by calling name. HEENT - Pupils 4-5mm, equal, sluggishly reactive to light b/l Neck - L IJ in place w/ bandage C/D/I. Right neck w/ scar tissue. No noted JVP CVS - Bradycardic, regular rate, no noted M/R/G Lungs - decreased breath sounds on R base, otherwise vented breath sounds b/l, no noted crackles/wheezes Abd - soft, +BS Ext - No pitting edema in extremities b/l. Some blue discoloration to knee caps b/l. Distal LE cool to touch b/l - rest of body warm, dry (pt under bear-hugger during exam) Neuro - Pt opens eyes to calling name, able to follow commands, answer yes/no questions. Skin - R UE with bandages around elbow and wrist that appear C/D/I. L UE with ulcerations with red base/clean margins on forearm without signs infection (no surrounding erythema, not warm to touch), scattered ulcerations with red base/clean margins on L LE with signs of infection. Scars noted on R neck Pertinent Results: Imaging: Head CT neg for bleed or intracranial mass effect CXR: RLL pna - improved from [7-4]. CXR later on day of admission demostrates diffuse increased markings consistent with pulmonary edema. [2189-8-5] 04:29AM BLOOD WBC-14.5* RBC-3.14* Hgb-9.6* Hct-29.5* MCV-94 MCH-30.5 MCHC-32.5 RDW-15.3 Plt Ct-548* [2189-7-30] 03:38AM BLOOD Neuts-75* Bands-2 Lymphs-12* Monos-6 Eos-4 Baso-0 Atyps-0 Metas-0 Myelos-1* NRBC-2* [2189-8-5] 04:29AM BLOOD Plt Ct-548* [2189-8-5] 04:29AM BLOOD Glucose-82 UreaN-18 Creat-0.9 Na-137 K-5.1 Cl-100 HCO3-29 AnGap-13 [2189-7-30] 05:46PM BLOOD CK(CPK)-145* [2189-7-30] 05:46PM BLOOD cTropnT-<0.01 [2189-8-5] 04:29AM BLOOD Calcium-10.5* Phos-3.6 Mg-2.2 Brief Hospital Course: 1) Respiratory failure: Likely [2-4] aspiration pna (given history of recurrent aspiration pna [2-4] esophageal dismotility) complicated by sepsis. Other possiblities included aspiration pneumonitis vs [2-4] [Month/Day (2) ] (although per Dr. [First Name (STitle) ], [First Name3 (LF) ] has remained stable, therefore less likely diagnosis) vs pulmonary edema (based on rpt CXR later on day of admission - although unlikely primary cause b/c was not apparent in initial CXR, and no known underlying cause - cardiac enzymes negative x 3, EF [5-7] = 55%). Patient was initially intubated in the ED and was maintained on mechanical ventilation with improved respiratory status in the [Hospital Unit Name 153]. CXR showed both RLL infiltrate and signs of CHF. She was agressively diuresed and completed a 10 day course of vancomycin and meropenem to cover aspiration PNA and given her history of MRSA in her rt arm osteomyelitis. Etubation was delayed due to sedation. She underwent a successful spontaneous breathing trial on [2189-8-4] and was subsequently extubated. After extubation she maintained good O2 sats and did not show evidence of respiratory distress. Shortly after extubation she was weaned off of supplemental oxygen and was maintaining good O2 saturations on room air. 2) Sepsis: Pt presented w/ fever to 101 in ED, then to ?hypothermia on presentation to [Hospital Unit Name 153] (initial temp 94.5, increased to 97.8 w/ rectal temp using different thermometer - also on bearhugger), WBC to 23.7 with bandemia, hypotension, ARF w/ decreased UOP. Source likely asp pna, as mentioned above vs other source of infection including recurrent osteomylitis of R olecrenon (unlikely as pt has completed abx therapy) vs other source. Blood cxs, urine cx, sputum cx, stool all were neg other than yeast that grew out of her sputum. BP maintained w/ fluid boluses PRN initially. Patient initially given 10 day course of merepenem and vancomycin. She was then switched to Bactrim as she had been on this at home for positive MRSA cultures. WBC gradually trended downward. 3) HTN: Outpatient meds included Lisinopril and Atenolol. Held while hypotensive, septic. HTN has improved slightly since adding Captopril. Current regimen of metoprolol 25mg TID and Captopril 75mg TID. Previously bradycardic so we were cautious with increasing Metoprolol. If need to go up further would consider increasing Captopril to 100 TID. 4) ARF: Pt had Cr to 3.3 up from baseline of 0.7. Resolved with hydration and currently back to baseline. Diuresed well with lasix, now self diuresing. Closely monitored creatinine and supplemented self diuresis with lasix with daily I/O goal. 5) Anemia: Patient has had anemia in the past with Hct trending in the high 20's in recent months. Closely monitored Hct. No evidence of active bleed. 6) Acid/base status: Has had mixed acid-base disturbances throughout hospitalization. Initially had non AG metabolic acidosis at admission (ABG 7.23/31/78, AG=10) likely [2-4] fluid rescusitation. (chloride elevated @ 117). Now somewhat alkalemic, with elevated pCO2, likely from contraction alkalosis [2-4] diuresis. 8) Right olecranon osteomyelitis s/p treatment with vancomycin + imipenem for 10 day course-> bactrim. Area bandaged - appears C/D/I. Monitored area during daily exams to check for signs/sxs of infection. Dry gauze dressing changes QD as pt has completed a course of anibiotics but with need to follow-up with infectious disease as previously arranged. 9) Atypical Mycobacteria: Pt never been on medication for [Month/Day (2) ] - stable per Dr. [First Name (STitle) ] who follows pt for this. Chest CT does have tree and [Male First Name (un) 239] appearance. Considered rx if pt r/o for all other signs of infection and believed [Male First Name (un) ] to be likely source of sepsis - thought unlikely due to chronice/stable nature. Patient to f/u with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] on d/c 10) Castlemans Disease: Stable, no further workup necessary at this time. Will advise f/u w/ PCP on [Name Initial (PRE) ]/c 11) Hypothyroidism: Patient was continued on levoxyl during admission. 12) Esophageal Dysmotility: stable. Known problem by patient and is cause of her recurrent aspiration pna. Issue of feeding tube addressed w/ pt in past and patient has refused enteral feeding which she has reiterated after this extubation. She understands the risks of reaspiration and reintubation and is willing to assume those risks in order to eat orally. 13) Seizure d/o: None evident during admission. Continued on outpatient regimen of lamotrigine and gabapentin. 14) Osteoporosis: c/w MVI, vitamin D and calcium carbonate 500mg tid 15) FEN: Nasogastric tube was placed and patient received TF and goal rate. Per caregiver, pt not eating well in recent weeks. Nutrition consulted. Lytes were monitored and repleted on an as needed basis. Patient hdpoor nutritional status and was cachetic appearing. In previous speech and swallow evaluations she is noted to have aspirations. Patient has been unable to tolerate a thickened/pureed diet [2-4] nausea. During previous admissions her teams have discussed the possibility of placing a PEG tube and she has refused. Patient was again counseled during her ICU stay as to the risks for future aspirations and the future need for intubation. She adamantly declined a PEG tube and plans to continue po intake. She was also advised to supplement her diet with Boost or Ensure but she reports that she is unable to tolerate these. Medications on Admission: 1. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet [Month/Day (2) ]: One (1) Tablet PO BID (2 times a day) for 2 weeks. Disp:28 Tablet(s) Refills:0 2. Venlafaxine 75 mg Capsule, Sust. Release 24HR [Month/Day (2) ]: One (1) Capsule, Sust. Release 24HR PO DAILY (Daily). 3. Levothyroxine Sodium 100 mcg Tablet [Month/Day (2) ]: One (1) Tablet PO DAILY (Daily). 4. Oxycodone 20 mg Tablet Sustained Release 12HR [Month/Day (2) ]: One (1) Tablet Sustained Release 12HR PO Q12H (every 12 hours). 5. Lamotrigine 25 mg Tablet [Month/Day (2) ]: Two (2) Tablet PO HS (at bedtime). 6. Gabapentin 300 mg Capsule [Month/Day (2) ]: One (1) Capsule PO Q12H (every 12 hours). 7. Cholecalciferol (Vitamin D3) 400 unit Tablet [Month/Day (2) ]: One (1) Tablet PO DAILY (Daily). 8. Benzonatate 100 mg Capsule [Month/Day (2) ]: One (1) Capsule PO BID (2 times a day). 9. Polysaccharide Iron Complex 150 mg Capsule [Month/Day (2) ]: One (1) Capsule PO DAILY (Daily). 10. Albuterol Sulfate 2 mg Tablet [Month/Day (2) ]: Two (2) Puff PO Q6H (every 6 hours). 11. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 12. Docusate Sodium 100 mg Capsule [Last Name (STitle) ]: One (1) Capsule PO BID (2 times a day). 13. Senna 8.6 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO HS (at bedtime). 14. Zolpidem Tartrate 5 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO HS (at bedtime) as needed for trouble sleeping. 15. Aspirin 81 mg Tablet, Chewable [Last Name (STitle) ]: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:2 16. Lisinopril 30 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 17. Atenolol 100 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 18. Humibid LA 600mg PO BID Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Aspiration Pneumonia CHF Discharge Condition: Stable on room air Discharge Instructions: If you experience any increasing cough, fever, chills, shortness of breath, you should call your doctor but if no doctor is available you should go back to the emergency room. We also changed your blood pressure medications which you should take as prescribed. Followup Instructions: You should follow-up with a primary care doctor within the next 1-2 weeks for post hospitalization follow-up. Provider: [Name10 (NameIs) ] SCAN Where: [Hospital6 29] RADIOLOGY Phone:[Telephone/Fax (1) 327] Date/Time:[2189-8-10] 10:00 Provider: [Name10 (NameIs) ] [First Name8 (NamePattern2) 5445] [Last Name (NamePattern1) 1843]/DR [First Name (STitle) ] Where: [Hospital6 29] MEDICAL SPECIALTIES Phone:[Telephone/Fax (1) 612] Date/Time:[2189-9-14] 2:30 Provider: [First Name8 (NamePattern2) 2671] [Last Name (NamePattern1) ], MD Where: [Hospital6 29] MEDICAL SPECIALTIES Phone:[Telephone/Fax (1) 1954] Date/Time:[2189-9-2] 1:20 Completed by:[2189-8-17]	[ "011.94", "276.2", "276.3", "V10.87", "458.9", "785.6", "584.9", "V09.0", "780.39", "041.11", "507.0", "300.00", "401.9", "276.6", "995.92", "733.00", "530.5", "730.13", "427.89", "038.9", "518.81", "443.9", "244.0", "296.80", "530.81" ]	icd9cm	[ [ [] ] ]	[ "96.6", "38.91", "89.61", "96.04", "38.93", "96.72" ]	icd9pcs	[ [ [] ] ]	12678, 12757	5012, 10670	298, 338	12826, 12846	4272, 4989	13155, 13879	3195, 3199			12778, 12805		10696, 12655			12870, 13132							3229, 4253																239, 260								366, 1869													1891, 3021	3037, 3179
6,791	167,906	21259	Discharge summary	report	Admission Date: [2110-11-12] Discharge Date: [2110-11-14] Date of Birth: [2046-2-21] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2704] Chief Complaint: Elective admission for carotid stents Major Surgical or Invasive Procedure: carotid stent History of Present Illness: 64 yo male with hx of HTN, hyperlipidemia, DM, COPD, CAD s/p CABG, PVD, hx of CVA who is being admitted for elective carotid stents. He had an episode of CVA in '[08] with left side weakness with prompt resolution of sx. At that time, the work up showed mild right carotid disease but no left carotid dz. Stroke at that time was thought to be likely due to cardioembolic or archembolic source. No coumadin started. Pt has been experiencing worsening LE cluadication for the past 3-4 years. Follow up carotid and arterial studies showed bilateral 80-99% ICA stenosis, signficiant L SFA dz, mild R tibial dz, ABI on the R 0.97, L 0.66. Pt denies any headache, visual changes, focal weakness, sensory changes, trouble swallowing, or slurred speech. He does have trouble with gait and balance but has been chronic. Pt denies having syncope or seizure in the past. Pt reports he has not had any anginal sx since CABG. Past Medical History: HTN Hyperlipidemia DM CAD-s/p CABG in '[02]: LIMA to LAD, vein graft to PDA, OM and left posterolateral. EF 45% CVA-[2108] with left sided weakness, promptoly resolved. CHF: EF 45% PVD CRI: Cr 1.9 on recent lab Left side deafness Hx of infection to left orbital bone s/p sinus obliteration S/p left stapedectomy (stapedius removal after getting infected) COPD Obesity Urinary urgency Social History: Pt lives with his wife and daughter. [Name (NI) ] works for [State 40074]Division of Taxation. He is a former smoker, used to smoke 3 packs/day x 20 yrs but quit 25 yrs ago. Pt denies alcohol or drugs. Family History: Strong hx of hyperlipidemia, hereditary. Father died of MI at age 61 Paternal grandfather died of MI in his 50's 2 of his brothers with CABG; one in his 50's and one in his 40's. Physical Exam: VS T 98.7 BP 146/56 HR 68 RR 18 O2sat 99% RA GEN: Obese man with right side hearing aid, sitting in chair in NAD. HEENT: NC/AT, +right side hearing air, scar on his left supra-orbital region. Few macular rash on his cheek. OP clear. COR: Distant heart sounds, S1, S2, no murmurs appreciated. No JVD. No carotid bruits bilaterally. LUNGS: Diffusely decreased BS; no crackles or wheezes ABD: soft, NTND, +BS EXT: 1+ femoral pulses bilaterally, no bruits. 1+ DP bilaterally. warm BLE NEURO: Alert & oriented x3, CN III-XII intact except for left hearing. strengths [4-30] major muscle groups. [12-29] reflexes all 4 extremities. Pt with unsteady gait. Pertinent Results: [2110-11-12] 10:22PM GLUCOSE-114* UREA N-41* CREAT-1.4* SODIUM-139 POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-28 ANION GAP-12 [2110-11-12] 10:22PM CALCIUM-9.2 PHOSPHATE-3.1 MAGNESIUM-2.2 CHOLEST-124 [2110-11-12] 10:22PM TRIGLYCER-218* HDL CHOL-29 CHOL/HDL-4.3 LDL(CALC)-51 [2110-11-12] 10:22PM WBC-9.5 RBC-4.17* HGB-12.2* HCT-35.1* MCV-84 MCH-29.2 MCHC-34.7 RDW-13.2 [2110-11-12] 10:22PM PLT COUNT-187 [2110-11-12] 10:22PM PT-13.1 PTT-29.2 INR(PT)-1.1 [2110-11-13] carotid stenting 1. Access was retrograde via the right CFA to the selective carotid arteries. 2. Thoracic aorta: Type I arch. 3. Carotid/vertebral arteries: The RCCA was normal. The [Country ] had a 90% lesion with ipsilateral filling of the MCA only. The LCCA was normal. The [Doctor First Name 3098] had a 90% lesion and filled the MCA, ACA, and contralateral ACA. 4. Stenting of the [Country ] was performed with a [8-1] x 30 mm Acculink. 5. The groin was closed with a Perclose device. FINAL DIAGNOSIS: 1. Severe bilateral carotid disease. 2. Stenting of the [Country ]. 3. Perclose of the groin. Brief Hospital Course: 1)Carotid stenting: The patient underwent carotid stenting on [11-13] by Dr. [First Name (STitle) ] to the [Country ]. Since his recent outpatient lab showed Cr of 1.9, he was admitted for pre-op hydration and mucomyst. During the procedure, he was given morphine in anticipation of pain associated with suturing the groin. After the morphine, he had some mild left sided weakness that was his weakness with is initial CVA. He was given Narcan and this completely resolved. He was transferred to the floor without hypotension. The sheath was pulled without incident and nis neuro exams were normal (with the exception of gait). 2)CAD: Pt s/p CABG and asymptomatic at this time. Continued Norvasc, Toprol, Lisinopril, Plavix, [Last Name (LF) ], [First Name3 (LF) ], Pravachol, Zetia 3)HTN: Continued spironolactone 25 mg qd, Norvasc 10 mg qd, Toprol 50 mg qd, lisinopril 40 mg qd, Lasix 120 mg po bid, [First Name3 (LF) ] 160 mg [Hospital1 ]. 4)Hyperlipidemia: Continued Pravachol 80 mg qd, Zetia 10 mg po qd 5)DM: Continued Humalog 75/25 units 60 units breakfast, 20 units lunch, 60 units dinner, and cover with RISS qid. 6)CHF: EF 45%, no signs of failure. 7)CRI: Cr 1.9 on recent outpt labs. Will repeat LABS. CRI most likely chronic from DM and HTN, and not ARF. gave pre-hydration, mucomyst, peri-cath bicarb to protect the kidneys. 8)Urinary urgency: Pt takes Detrol 4 mg [Hospital1 ]. gave 2 mg [Hospital1 ] since that is the recommended dosage. Medications on Admission: Spironolactone 25 mg po qAM Norvasc 10 mg po qAM Toprol 50 mg po qAM Lisinopril 40 mg po qAM Detrol LA 4 mg po bid Plavix 75 mg qAM Lasix 120 mg po bid [Hospital1 ] 160 mg po bid Pravachol 80 mg qPM [Hospital1 ] 325 mg po qd Humalog 75/25 60 U w/breakfast, 20 U w/lunch, 60 U w/dinner Nitroglycerin 0.2 mg PRN Zetia 10 mg po qd Advair Combivent Discharge Medications: 1. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:6 2. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 3. Pravastatin Sodium 20 mg Tablet Sig: Four (4) Tablet PO HS (at bedtime). 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. 6. Combivent 103-18 mcg/Actuation Aerosol Sig: [12-27] Inhalation twice a day. 7. Advair Diskus 100-50 mcg/Dose Disk with Device Sig: One (1) Inhalation twice a day. 8. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Tolterodine Tartrate 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 11. Enoxaparin Sodium 100 mg/mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours): stop once INR >2.0. Disp:30 qs Refills:2 12. Aldactone 25 mg Tablet Sig: One (1) Tablet PO once a day. 13. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: carotid stenosis s/p right ICA stent atrial fibrillation obstructive sleep apnea Discharge Condition: good Discharge Instructions: Call Dr. [First Name (STitle) ] if you feel dizzy at all. Do not take your amlodipine, valsartan, lisinopril until you hear from Dr [First Name (STitle) ] on Monday. Please follow up with your PCP [2110-11-17] and have your INR checked. Once you become therapeutic with your coumadin, you may stop taking Lovenox. NEVER stop your Plavix or asprin. Followup Instructions: Please follow up with your PCP, [Name10 (NameIs) ] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 56261] on Monday [11-17] at 9:15, at which point you'll have your INR checked and coumadin dose changed accordingly. Provider: [Name10 (NameIs) ] STUDY Where: CC CLINICAL CENTER RADIOLOGY Phone:[Telephone/Fax (1) 327] Date/Time:[2111-2-24] 10:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3184], M.D. Where: [Hospital6 29] CARDIAC SERVICES Phone:[Telephone/Fax (1) 920] Date/Time:[2111-2-24] 1:00	[ "496", "583.81", "428.0", "414.00", "401.9", "V45.81", "427.31", "433.30", "250.40", "593.9" ]	icd9cm	[ [ [] ] ]	[ "00.63", "00.61" ]	icd9pcs	[ [ [] ] ]	7144, 7150	4027, 5528	355, 371	7275, 7281	2869, 3887	7693, 8277	1988, 2168		5932, 7121	7171, 7254		5554, 5909		3904, 4004	7305, 7670							2183, 2850																278, 317								399, 1326													1348, 1742	1758, 1972
82,090	117,066	44003	Discharge summary	report	Admission Date: [2173-10-9] Discharge Date: [2173-10-15] Date of Birth: [2094-5-11] Sex: M Service: MEDICINE Allergies: Iodine Attending:[First Name3 (LF) 3967] Chief Complaint: SOB Major Surgical or Invasive Procedure: OptEase IVC filter placement on [10-9] History of Present Illness: 79 yo M with IgA myeloma s/p velcade (incomplete course) and recent Revlimid, history of PE on warfarin, presented with shortness of breath with minimal exertion x 2 days similar to his prior PE episode in [2169]. . Per patient, he reports that he was having worsening lower extremity edema over the last 3 months. No pain in his legs. He had no recent travel. No cough, pleuritic chest pain, or chest pain. Dyspnea and dyspnea on exertion developed over the course of last 2 days. Patient thought it was similar to his prior episode of PE but milder symptoms; therefore, presented himself to the ED. Of note, he stopped his Revlimid . While in the ED, initial vitals were 98.9 104 194/79 24 92% RA. Per report EKG showed evidence of right heart strain, new TWI III, avF, V2-3, and troponin was mildly elevated to 0.04 Given his symptoms, patient underwent CTA (after receiving IVF) of the chest which showed PE straddling the bifurcation of the left pulmonary artery that extends segmental branches. Per report, patient was guaic negative. Subsequently, patient was started on heparin gtt. Oncology was consulted who agreed with heparin and IVC filter placement with + U/S LENIS. Upon sign out, reported vitals were 97.8, 18, 95% on 2L, 84, 129/87. . On the floor, patient reports feeling better with his breathing. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: - multiple myeloma diagnosed [3-/2171], s/p Velcade (incomplete course) and Revlimid - history of PE in [10/2170] on warfarin, + for prothrombin/facter 2 mutation on gene analysis - OA bilateral knees - BPH, s/p TURP in [2162], complicated by PE - h/o hematuria while on anticoagulation - LE weakness, followed by neuromuscular clinic - HTN - history of phlebitis in the left ankle 20 years ago Social History: - retired business executive - Tobacco: never - Alcohol: non - Lives at home with wife - ambulate with walker/cane Family History: - mother deceased at 101 - father deceased at 59 - Mother and sister with proximal muscle weakness, but no definitive diagnosis. Physical Exam: On Admission: Vitals: T:96.9 BP:121/75 P:83 O2: 93% on 3L NC General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated CV: RRR, no m/r/g Resp: diminished lung sounds at the basis, no wheeze or rhonchi Abd: soft, NT, ND, BS+ Extremities: cool, dry, barely palpable DP bilaterally, edematous up right below the knees, no cyanosis or clubbing GU: no Foley Skin: without rash On Discharge: VSS No change in physical exam other than swelling which was very promienent bilaterally but R>L, had decreased. Lungs CTA Heart RRR with no m/r/g. Presence of premature beats. Pertinent Results: [2173-10-10] 12:00AM WBC-5.4 RBC-4.56* HGB-13.5* HCT-40.9 MCV-90 MCH-29.6 MCHC-33.0 RDW-15.0 [2173-10-10] 12:00AM PLT COUNT-54* [2173-10-10] 12:00AM PT-27.5* PTT-150* INR(PT)-2.6* [2173-10-9] 09:45AM GLUCOSE-110* UREA N-30* CREAT-1.1 SODIUM-141 POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-22 ANION GAP-17 [2173-10-9] 09:45AM CK-MB-4 proBNP-6437* [2173-10-9] 09:45AM cTropnT-0.04* [2173-10-9] 09:45AM CK(CPK)-36* [2173-10-9] 04:10PM cTropnT-0.04* [2173-10-10] 12:00AM CK-MB-3 cTropnT-0.04* Urine after temperature spike: [2173-10-12] 04:58PM URINE Blood-SM Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG [2173-10-12] 04:58PM URINE RBC-4* WBC-1 Bacteri-FEW Yeast-NONE Epi-<1 Urine culture negative Discharge Labs: [2173-10-15] 03:45PM BLOOD LMWH-0.72, this is therapeutic [2173-10-15] 06:30AM BLOOD WBC-4.0 RBC-4.07* Hgb-12.2* Hct-35.9* MCV-88 MCH-30.1 MCHC-34.0 RDW-15.3 Plt Ct-104* [2173-10-14] 06:25AM BLOOD Neuts-36* Bands-4 Lymphs-49* Monos-8 Eos-2 Baso-1 Atyps-0 Metas-0 Myelos-0 [2173-10-15] 06:30AM BLOOD Glucose-85 UreaN-25* Creat-1.2 Na-142 K-4.0 Cl-107 HCO3-28 AnGap-11 [2173-10-11] 01:20AM BLOOD ALT-16 AST-13 AlkPhos-44 TotBili-0.6 [2173-10-15] 06:30AM BLOOD Calcium-8.7 Phos-2.9 Mg-2.1 Microbiology (for fever): Blood culture negative x2 Urine culture negative Imaging: CTA chest: IMPRESSION: Left nonocclusive pulmonary emboli. B/L LE US IMPRESSION: 1. Right posterior tibial deep venous thrombosis. 2. Nonocclusive left popliteal deep venous thrombosis. 3. Left calf veins and right peroneal veins not well evaluated. IVC OptEase filter placement: IMPRESSION: Successful placement of an OptEase IVC filter described above. Echo: The left atrium and right atrium are normal in cavity size. The right ventricular cavity is moderately dilated with depressed free wall contractility. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Left ventricular systolic function is probably normal, a focal wall motion abnormality cannot be excluded. The right ventricle is at least moderately dilated with evidence of pressure/volume overload. Pulmonary artery pressures could not be assessed. Mild aortic regurgitation. Compared with the prior study (images reviewed) of [2171-9-4], the right ventricle is now dilated and hypokinetic with evidence of RV pressure/volume overload. Brief Hospital Course: 79 yo M with IgA myeloma s/p velcade (incomplete course) and recent Revlimid, history of PE ([2169]) on warfarin, presented with shortness of breath with minimal exertion x 2 days found to have left pulmonary artery PE. . # Pulmonary Embolism Patient was initially admitted to the medical ICU for close monitoring for saddle PE as found on CTA. IR was consulted and placed an IVC filter. Pt was started on heparin gtt in setting of thrombocytopenia given clot burden. Pt was monitored overnight and then transferred to the inpatient oncology floor. On the floor, pt remained hemodynamically stable. Echo revealed new right heart strain. Pt transitioned from heparin to lovenox, which he will need life-long as he has failed warfarin. Swelling in lower legs decreased dramatically and patient denied chest pain and endorsed improvement in breathing. However, pt had 82% O2 saturation while ambulating and was set-up for home O2. Will need follow-up as to whether IVC filter should be removed. Because pt will be on life-long anticoagulation, it may be safe to keep in the IVC filter in the hopes of preventing large clots from entering the pulmonary bed, however, if patient is to have more chemo or has other reason for withholding anticoagulation, this will serve as a nidus for future clots. Pt was told to discuss this issue with Dr. [First Name (STitle) ] as this is a retrievable filter, but is often best removed within a month from placement per IR. . # Fever: Pt developed a fever x 1. Cultured and started on zosyn and vancomycin. Pt defervesced. Antibiotics were discontinued one at a time without recurrence in fever. All cultures were negative. Fever was most likely [1-27] to inflammatory response from DVT and PE. . # Thrombocytopenia. This was thought most likely [1-27] Revlimid. Could also be consumption. Unlikely DIC given improving platelets, stable Hct, and normal fibrinogen. Platelets increased over course of stay. . # IgA Myeloma. Currently off Revlimid. Will need to discuss future treatment options with Dr. [First Name (STitle) ] given propensity to develop clots on this medication. On prednisone taper for Hives from revlimid. . # Hypertension. currently normotensive and holding Lasix and Metoprolol for now in setting of PE. Pt's blood pressures are about 120s/80s. . Transitional: Will need follow up regarding the need to keep in IVC filter. Will need to address future MM treatment Tapering down prednisone. Medications on Admission: - Diclofenac sodium 1% gel [Hospital1 ] for shoulder pain - finasteride 5 mg qd - furosemide 20 mg daily - metoprolol succinate 50 mg daily - nystatin 100,000 unit/gram powder to the affected area TID - 20 mEq KCl - prednisone 5 mg daily - warfarin 1 mg or 4 mg daily Discharge Medications: 1. O2 Sig: Two (2) L/Min Ambulation: By NC, for ambulation O2 saturation of 82%. Disp:1 unit Refills:0 2. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Injection Subcutaneous twice a day: Subcutaneously. Disp:60 Injection Refills:2 3. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. prednisone 1 mg Tablet Sig: As directed Tablet PO once a day: 4 tabs x 7 days start [10-16], then 3 tabs x 7 days, then 2 tabs x 7 days, then 1 tab x 7 days. Disp:70 tabs Refills:0 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:60 Capsule(s) Refills:0 6. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for constipation. Disp:30 Tablet(s) Refills:2 7. diclofenac sodium 1 % Gel Sig: Apply to shoulder Topical twice a day as needed for pain. 8. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO once a day: Take both pills with food in AM . 9. nystatin 100,000 unit/g Powder Sig: As directed Topical three times a day: Apply to affected area. Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary: Pulmonary Embolism, Bilateral lower extremity deep vein thromboses Secondary: Multiple Myeloma, Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [Known lastname 23], It was a pleasure taking care of you at [Hospital1 18]. You were admitted for shortness of breath and found to have a pulmonary embolism. You were also found to have bilateral lower extremity deep vein thromboses. A temporary inferior vena cava filter was placed to help prevent further embolism from your legs to your lungs. You were treated initially with heparin and this was transitioned to lovenox, which you must keep taking. In the future, your OptEase IVC filter which was placed on [10-9] be removed. Please address this question with Dr. [First Name (STitle) ]. You also had a fever while you were here and treated with broad spectrum antibiotics. No infectious source was found and you were afebrile after discontinuation of antibiotics. It was felt that this fever was most likely from your DVT and PE. STARTED LOVENOX injections STARTED DOCUSATE STARTED SENNA STOPPED WARFARIN HOLDING METOPROLOL HOLDING LASIX DECREASE PREDNISONE dose Followup Instructions: Department: HEMATOLOGY/BMT When: WEDNESDAY [2173-10-20] at 1:30 PM With: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 3919], RNC [Telephone/Fax (1) 3241] Building: SC [Known lastname 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Known lastname 23] Garage Department: HEMATOLOGY/BMT When: WEDNESDAY [2173-10-20] at 1:30 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4380], MD [Telephone/Fax (1) 3237] Building: SC [Known lastname 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Known lastname 23] Garage Department: BMT CHAIRS & ROOMS When: WEDNESDAY [2173-10-20] at 2:30 PM [Name6 (MD) ] [Last Name (NamePattern4) 3974] MD, [MD Number(3) 3975] Completed by:[2173-10-20]	[ "453.41", "E933.1", "203.00", "716.96", "356.9", "287.49", "780.60", "V58.65", "401.9", "728.87", "V58.61", "724.2", "729.81", "289.81", "415.13" ]	icd9cm	[ [ [] ] ]	[ "38.7" ]	icd9pcs	[ [ [] ] ]	10315, 10373	6356, 8832	273, 318	10535, 10535	3500, 4294	11746, 12594	2704, 2835		9154, 10292	10394, 10514		8858, 9131			10717, 11723		4310, 6333					2850, 2850											3302, 3481			1699, 2125		229, 235								346, 1680							2865, 3288	10550, 10693					2147, 2555	2571, 2688
29,278	163,845	54521	Discharge summary	report	Admission Date: [2139-10-29] [Month/Day/Year ] Date: [2139-11-6] Date of Birth: [2072-5-9] Sex: M Service: MEDICINE Allergies: Ampicillin / Ciprofloxacin / Neomycin Sulfate/Colist Sul/Hc / Afrin Saline Nasal Mist / Clindamycin Attending:[First Name3 (LF) 2181] Chief Complaint: pre-syncope Major Surgical or Invasive Procedure: cardiac catheterization History of Present Illness: Mr. [Known lastname 111544] is a 67yo male with PMH significant for CAD s/p 5V CABG, CHF (EF 20%) s/p ICD placement, mild AS, mod MR, severe TR, HTN, DM2, PVD, hyperlipidemia, thrombocytopenia, pulm [Hospital ] transferred from outside hospital with 3 episodes of lightheadedness on [10-27]. He got up to urinate at 7am on [10-27] and on walking back to his room he felt lightheaded and dizzy. He went back to bed and woke up several hours later, this time feeling dizzy with standing. He caught himself on his bedside table and did not fall, hit his head or lose consciousness. He subsequently developed substernal to right sided chest pain, nonradiating while sitting at the edge of his bed. He took 2 SL NTG with relief of the pain. No associated symptoms at that time aside from the presyncope, ie no SOB, nausea, diaphoresis. Of note, he worked with PT at home the day PTA and felt well with no worsening of sx. He presented to [Hospital3 ] Hospital on [10-27]. Labs there were notable for a BNP of 2429, creatinine 1.6, trop 0.01 and dig level 0.6. CXR showed pulmonary venous hypertension and pulmonary edema c/w CHF, small layering effusion. O2 sat 78% on RA. He was given 80mg IV lasix with UOP of 2300cc. Patient requested transfer to [Hospital1 18] as he is well known here. Upon arrival to the ED, his vital signs were T100, BP 124/60, HR 68, RR 20, O2sat94%on 2L. CXR showed effusions which were improved from prior. EKG showed ?deeper TWI laterally. BNP [Numeric Identifier 111545] (elevated from prior). . Mr. [Known lastname 111544] had been previously admitted to [Hospital1 18] from [Date range (1) 111546] after being found down. He was intubated for respiratory distress and briefly on pressors for hypotension, however he was easily extubated. ICD was interrogated at that time and no arrhythmias were noted. His syncope remained unexplained. BP meds were down titrated. Since that admission he was also seen in the ED on [Location (un) ] for mild congestive heart failure. His lasix dose was increased at that time. . At baseline he is on 3L oxygen and is short of breath with minimal exertion. Baseline weight is 161lbs. He has three pillow orthopnea, chronic fatigue and mild nonpitting leg edema. . On arrival to the floor, he was comfortable with no complaints. No shortness of breath, chest pain, lightheadedness or dizziness. He was weaned to his baseline O2 of 3L. He denies any recent dietary indiscretions. . On AM evaluation, patient short of breath, CP relieved with 2 sl ntg, ECG with increasing depressions laterally. CHF consulted given IV lasix 60 mg IV with good response ~700 cc output. No further CP. Initially desated to 89% on 5L now stable O2 sats >90% on 4L (baseline 3L) Past Medical History: 1)CAD: - s/p MI [2114] - 5 vessel CABG [2119], LIMA to LAD and SVGs to D1, OM1 and OM2, and PDA. - NSTEMI with LCX stent [2-23]. PTCA of proximal circumflex in-stent and peri-stent restenosis [4-25]. - POBA of the proximal LCX and distal LCX/OM lesions [1-27] - Stent to LCx and RCA (bare metal) in [9-29]. MIBI [2137]: Moderate fixed defects in basal anterior wall and lateral wall, previously partially reversible. Similarly poor LV function (LVEF 20%). Dilated cavity (LVEDV 206 mL). 2)Congestive heart failure: EF 20-25% per echo in [2-27]; pMIBI in [10-29] 3)Hypertension 4)Type 2 diabetes complicated by neuropathy and nephropathy 5)Hyperlipidemia 6)CKD (baseline creatinine low 2's, followed by Dr. [Last Name (STitle) ] 7)Remote tobacco abuse 8)Peripheral vascular disease 9)Thrombocytopenia, followed by Dr. [Last Name (STitle) ] and Dr. [Last Name (STitle) 5565], thought to be [12-26] to chronic ITP 10)History of GI bleed with recent EGDs for ulcers 11)Pulmonary fibrosis: HRCT with honeycombing with upper lobe predominance - PFTs [2138-12-12] FEV1 1.89, FVC 2.44, FEV1/FVC 77 on 3L O2 since [1-28] 12)Pulmonary arterial hypertension 13)OSA on home O2 Social History: Significant for the absence of current tobacco use (quit in [2114]). Drinks [11-25] alcoholic beverages/week. The patient has never been married, and does not have any children. He lives with roommate in [Hospital3 ] who helps with food shopping and housework. Roommate went away on Friday and has not returned. Pt seems agitated about this - does not know where he is. Retired communications engineer. Smoked 3ppd for 15 yrs, quit in [2114]. Physical Exam: VS T98.1, BP 142/82, HR 63, RR 18, O2sat 94% on 3L (his baseline). Gen: Appears older than stated age. 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: JVP 10-12cm. CV: Nl s1/s2, no s3/s4, +systolic murmur heard across the precordium but best at the apex Chest: No chest wall deformities, scoliosis or kyphosis. Crackles appreciated posteriorly, halfway up lung fields. No wheezing. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: trace pitting edema of LLE, no edema R. No femoral bruits. 2+ dp pulses Skin: Chronic venous stasis changes Pertinent Results: Admission Labs: [2139-10-28] 10:54PM CALCIUM-9.9 PHOSPHATE-3.2 MAGNESIUM-2.1 [2139-10-28] 10:54PM CK-MB-NotDone cTropnT-0.03* proBNP-[Numeric Identifier 111545]* [2139-10-28] 10:54PM CK(CPK)-19* [2139-10-28] 10:54PM estGFR-Using this [2139-10-28] 10:54PM GLUCOSE-115* UREA N-39* CREAT-1.8* SODIUM-143 POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-30 ANION GAP-17 . Pertient Labs: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MC MCH MCHC RDW Plt Ct [2139-11-6] 07:10AM 7.6 4.18* 12.7* 39.6* 95 30.5 32.2 16.8* 178 [2139-11-5] 07:20AM 7.1 4.13* 12.4* 38.4* 93 30.1 32.4 16.6* 137* [2139-11-4] 03:55AM 8.1 4.16* 12.3* 38.6* 93 29.6 31.9 16.9* 140* [2139-11-3] 08:01AM 7.9 4.07* 12.7* 38.5* 95 31.3 33.1 17.2* 153 [2139-11-3] 06:20AM 7.4 3.94* 12.0* 37.2* 94 30.5 32.4 17.1* 132* [2139-11-2] 06:20AM 6.4 3.73* 11.4* 35.0* 94 30.5 32.5 17.2* 120* [2139-11-1] 05:05AM 8.3 3.72* 11.6* 35.8* 96 31.1 32.3 17.2* 142* [2139-10-31] 07:05AM 8.0 3.97* 12.1* 38.0* 96 30.5 31.9 17.3* 121* [2139-10-30] 06:45AM 8.4 3.77* 11.6* 36.5* 97 30.8 31.8 17.3* 101* [2139-10-29] 06:15AM 9.0 3.81* 11.4* 36.2* 95 29.9 31.5 17.2* 97* [2139-10-29] 12:00AM 7.9 3.71* 11.7* 35.6* 96 31.7 33.0 17.5* 114* . RENAL & GLUCOSE Gluc UreaN Cr Na K Cl HCO3 AnGap [2139-11-6] 07:10AM 135* 62* 2.1* 137 4.1 98 27 16 [2139-11-5] 07:20AM 133* 58* 2.1* 138 4.2 97 30 15 [2139-11-4] 03:55AM 154* 54* 2.4* 136 5.3* 99 26 16 [2139-11-3] 06:08PM 141* 49* 2.3* 137 4.2 98 28 15 [2139-11-3] 08:01AM 200* 47* 2.0* 137 4.2 97 26 18 [2139-11-3] 06:20AM 121* 48* 2.0* 138 4.0 97 26 19 [2139-11-2] 06:20AM 123* 45* 1.9* 136 3.8 98 29 13 [2139-11-1] 05:05AM 116* 39* 2.0* 138 4.0 97 29 16 [2139-10-31] 07:05AM 102 35* 2.0* 140 3.6 97 29 18 [2139-10-30] 06:45AM 109* 34* 1.7* 142 3.6 100 31 15 [2139-10-29] 06:58PM 149* 36* 1.8* 141 3.8 100 28 17 [2139-10-29] 06:15AM 80 37* 1.7* 142 3.3 101 28 16 [2139-10-28] 10:54PM 115* 39* 1.8* 143 3.9 100 30 17 . CK(CPK) [2139-11-4] 03:55AM 181 [2139-11-3] 06:08PM 23 [2139-11-3] 08:01AM 22* [2139-10-30] 06:45AM 191 [2139-10-29] 06:58PM 27 [2139-10-29] 01:20PM 20* [2139-10-28] 10:54PM 191 . [2139-10-29] 06:15AM BLOOD ALT-11 AST-17 CK(CPK)-20 AlkPhos-107 TotBili-1.4 . [2139-10-28] 10:54PM BLOOD CK-MB-NotDone cTropnT-0.03* proBNP-[Numeric Identifier 111545]* [2139-10-29] 06:15AM BLOOD CK-MB-NotDone cTropnT-0.04* [2139-10-29] 01:20PM BLOOD CK-MB-NotDone cTropnT-0.03* [2139-10-29] 06:58PM BLOOD CK-MB-NotDone cTropnT-0.02* [2139-10-30] 06:45AM BLOOD CK-MB-NotDone cTropnT-0.03* [2139-11-3] 08:01AM BLOOD CK-MB-NotDone cTropnT-0.05* . CHEMISTRY Alb Ca Phos Mg [2139-11-5] 07:20AM 9.7 3.9# 2.3 [2139-11-4] 03:55AM 10.4* 5.8# 2.8 [2139-11-3] 06:08PM 9.6 3.8# 2.3 [2139-11-3] 08:01AM 10.1 2.1* 2.1 [2139-11-3] 06:20AM 9.8 2.6* 2.2 [2139-11-2] 06:20AM 9.4 4.0 2.1 [2139-11-1] 05:05AM 9.2 4.2 1.9 [2139-10-31] 07:05AM 9.5 3.2 2.0 [2139-10-30] 06:45AM 9.5 3.6 2.1 [2139-10-29] 06:15AM 4.0 9.3 3.2 2.0 [2139-10-28] 10:54PM 9.9 3.2 2.1 . AUTOANTIBODIES ANCA [2139-11-2] 03:45PM NEGATIVE B1 . IMMUNOLOGY [First Name9 (NamePattern2) 32906] [Doctor First Name ] [2139-11-2] 03:45PM NEGATIVE CHEM S# [Serial Number 111547]C; ADDED 1545 [2139-11-2] [2139-11-2] 06:20AM <31 . BLOOD GASES Type Temp Rates Tidal V PEEP FiO2 O2 Flow pO2 pCO2 pH calTCO2 Base XS Intubat [2139-11-3] 10:07PM ART 35.6 3 73* 45 7.41 30 2 NOT INTUBA1 . [2139-11-3] 01:23PM ART 74* 26* 7.611 27 5 . ANGIOTENSIN 1 - CONVERTING [Last Name (un) ] ANTI-GBM SCLERODERMA ANTIBODY [2139-11-2] 03:45PM Test [2139-11-2] 03:45PM PND [2139-11-2] 03:45PM PND . Pertinent Imaging: . CXR ([2139-10-28]) FINDINGS: The degree of cardiomegaly is stable. Patient is status post median sternotomy with sternotomy wires intact. Mediastinal clips are again seen. Right ventricular pacer defibrillator lead is in a standard placement. Peripheral interstitial increased markings are again seen, and likely correspond to known subpleural fibrosis and honeycombing. Lingular consolidation has improved since [2139-8-24]. IMPRESSION: 1. Stable degree of cardiomegaly. 2. Increased interstitial markings are most likely due to known subpleural fibrosis and honeycombing. No overt CHF. 3. Improved lingular consolidation . pMIBI ([2139-10-30]) SUMMARY OF DATA FROM THE EXERCISE LAB: Dipyridamole was infused intravenously for 4 minutes at a dose of 0.142 mg/kg/min. METHOD: Resting perfusion images were obtained with Tc-[Age over 90 ]m sestamibi. Tracer was injected approximately 45 minutes prior to obtaining the resting images. Two minutes after the cessation of infusion of dipyridamole, approximately three times the resting dose of Tc99m sestamibi was administered IV. Stress images were obtained approximately 45 minutes following tracer injection. Imaging protocol: Gated SPECT. This study was interpreted using the 17-segment myocardial perfusion model. INTERPRETATION: The image quality is adequate. Left ventricular cavity size is moderately dilated and unchanged. Rest and stress perfusion images reveal a moderate sized fixed perfusion defect involving the mid-to-basal anterior and lateral wall. There are no reversible perfusion defects. Gated images reveal marked global hypokinesis. The calculated left ventricular ejection fraction is 23%. Compared with the study of [2138-11-21] there has been no appreciable change. IMPRESSION: Unchanged study. Moderate sized fixed perfusion defect of the mid-to-basal anterior and lateral wall. LVEF 23%. Dilated left ventricle. . STRESS ([2139-10-30]) INTERPRETATION: 67 yo man (h/o MI in [2114] and NSTEMI in [2133], chronic systolic and diastolic heart failure with LVEF ~ 20%; pulmonary HTN and fibrosis and mild aortic stenosis; s/p CABG followed by multiple PCIs) was referred for a CAD evaluation. 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. The ECG changes noted from baseline are uninterpretable in the presence of digoxin therapy. The rhythm was sinus with frequent aea noted during the procedure; frequent APDs, intermittent periods of an accel ectopic atrial rhythm/slow AT with rates ~ 90-100 bpm. In addition, frequent multiformed VPDs were noted. The hemodynamic response to the persantine was appropriate. Three min post-MIBI, the patient received 125 mg aminophylline IV. IMPRESSION: No anginal symptoms with uninterpretable ECG changes. Frequent atrial irritability noted throughout the procedure. Nuclear report sent separately. . LUNG SCAN: ([2139-11-2]) INTERPRETATION: Ventilation images obtained with Tc-[Age over 90 ]m aerosol in 8 views demonstrate diffusely decreased tracer uptake throughout the left lung, with heterogeneous areas of ventilation in the superior portion of the left upper lobe. Perfusion images in the same 8 views show matched decreased perfusion throughout the left lung, also with heterogeneous perfusion in the superior portion of the left upper lobe. Chest x-ray shows mild interstitial edema and subpleural fibrosis, left greater than right, as more easily appreciated on Chest CT [2139-7-16]. The above findings are consistent with a very low likelihood of PE. IMPRESSION: 1. No findings to suggest pulmonary embolism. 2. Matched, diffusely decreased ventilation and perfusion throughout the left lung, likely related to progressive pulmonary fibrosis as seen on Chest CT [2139-7-16]. . ECHO ([2139-11-3]) Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 4.7 cm <= 4.0 cm Left Atrium - Four Chamber Length: 6.4 cm <= 5.2 cm Left Atrium - Peak Pulm Vein S: 0.5 m/s Left Atrium - Peak Pulm Vein D: 0.5 m/s Left Atrium - Peak Pulm Vein A: 0.2 m/s < 0.4 m/s Right Atrium - Four Chamber Length: 6.7 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: 1.2 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.3 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 5.5 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 25% >= 55% Left Ventricle - Stroke Volume: 63 ml/beat Left Ventricle - Cardiac Output: 4.15 L/min Left Ventricle - Cardiac Index: 2.24 >= 2.0 L/min/M2 Left Ventricle - Lateral Peak E': 0.09 m/s > 0.08 m/s Left Ventricle - Septal Peak E': 0.06 m/s > 0.08 m/s Left Ventricle - Ratio E/E': 11 < 15 Aorta - Sinus Level: 3.0 cm <= 3.6 cm Aorta - Ascending: 3.6 cm <= 3.4 cm Aorta - Arch: 3.0 cm <= 3.0 cm Aortic Valve - Peak Velocity: 2.4 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: 24 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 11 mm Hg Aortic Valve - LVOT pk vel: 0.90 m/sec Aortic Valve - LVOT VTI: 20 Aortic Valve - LVOT diam: 2.0 cm Aortic Valve - Valve Area: 1.2 cm2 >= 3.0 cm2 Mitral Valve - E Wave: 0.8 m/sec Mitral Valve - A Wave: 0.9 m/sec Mitral Valve - E/A ratio: 0.89 Mitral Valve - E Wave deceleration time: 126 ms 140-250 ms TR Gradient (+ RA = PASP): 70 to 105 mm Hg <= 25 mm Hg Pulmonic Valve - Peak Velocity: 0.9 m/sec <= 1.5 m/sec Findings This study was compared to the prior study of [2139-7-15]. LEFT ATRIUM: Elongated LA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. A catheter or pacing wire is seen in the RA and extending into the RV. Normal interatrial septum. No ASD by 2D or color Doppler. Normal IVC diameter (<2.1cm) with <35% decrease during respiration (estimated RAP (indeterminate). LEFT VENTRICLE: Mild symmetric LVH. Top normal/borderline dilated LV cavity size. No LV mass/thrombus. Severely depressed LVEF. No resting LVOT gradient. No VSD. RIGHT VENTRICLE: Mildly dilated RV cavity. Moderate global RV free wall hypokinesis. AORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending aorta. Normal aortic arch diameter. AORTIC VALVE: Moderately thickened aortic valve leaflets. Mild AS (AoVA 1.2-1.9cm2). Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral annular calcification. Moderate (2+) MR. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No TS. Moderate to severe [3+] TR. Severe PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: No PS. PERICARDIUM: No pericardial effusion. Conclusions The left atrium is elongated. The right atrium is moderately 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. The left ventricular cavity size is top normal/borderline dilated. No masses or thrombi are seen in the left ventricle. Overall left ventricular systolic function is severely depressed (LVEF= 25 %) with global hypokinesis (the lateral wall moves best). There is no ventricular septal defect. The right ventricular cavity is mildly dilated. There is moderate global right ventricular free wall hypokinesis. The ascending aorta is mildly dilated. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (area 1.2-1.9cm2). 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 to severe [3+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2139-7-15], the overall LV systolic function is similar. The degree of pulmonary hypertension detected has significantly increased. . CXR ([2139-11-4]) UPRIGHT AP CHEST: There is no short-interval change compared to yesterday. The patient is post CABG and ICD device placement. There appears to be a developing consolidation or atelectasis in the lingula, though it is not significantly changed from yesterday. The right lung and left lung apex remain clear, without CHF. No pneumothorax. . Brief Hospital Course: In summary, this is a male with PMH significant for CAD s/p five vessel CABG, Acute on Chronic systolic and diastolic CHF (EF 20%,) s/p ICD placement, mild AS, mod MR, severe TR, HTN, DM2, PVD, hyperlipidemia, thrombocytopenia, pulmonary hypertension and pulmonary fibrosis that transferred from outside hospital following three episodes of lightheadedness on [10-27]. . #Acute on chronic systolic and diastolic heart failure: Upon arrival to the floor the morning after admission he was comfortable with no complaints. No shortness of breath, chest pain, lightheadedness or dizziness. He was weaned to his baseline O2 of 3L. He had denies any recent dietary indiscretions. During the patients evaluation the following morning by the medical team, the patient was acutely short of breath with associated chest pain. The patient initially desated to 89% on and was placed with stable O2 sats >90% on 4-6L (baseline 3L). This chest pain was relieved with two sublingual nitroglycerin, a ECG showed increasing depressions laterally. CHF was consulted and the patient was given IV lasix 60 mg IV with good response and approximately 700 cc output. No further chest pain at that time. The CCU team was called, and since there was no beds in the unit he was held on the floor for observation given that he had stabilized. . Over the subsequent three days the patient had no further episodes of SOB, yet complained of pain in his right shoulder with occasional radiation to his anterior chest. He stated that this pain was different from his previous episodes of angina. The pain was reproducible in nature. He was continued on his diuretics. . On the morning of [11-4] the patient noted that he was feeling lightheaded while his blood sugar was being checked. He does not remember anything after that. A Code Blue was called. Tele showed a long run of VT w/ initial antitachycardia pacing and then a shock with conversion to sinus rhythm. When the medical team arrived, he endorsed heavy breathing and feeling lightheaded but no chest pain. Initial vitals were SBP 150s, O2 sat 93% on 4L (had been 95% on 3L just prior to episode). The patient was then transferred to the MICU. Upon arrival to the MICU he was Chest Pain free with mild dyspnea and SOB. The patient was kept in the MICU for 36 hours for observation. During his MICU stay he was seen by the Electrophysiology consult that felt that the patient's ICD shock was appropriate. They stated there was no indication for revision of pacemaker/ICD to dual chamber, or initiation of antiarrhythmic. EP also recommended the same dose of beta blocker. Should the patient have further episodes of VT he may benefit from a dual chamber ICD but this would require a revision with implantation of another lead. The patient was returned to the floor with no adjustments to the setting of his ICD or to his beta-blocker dose and remained without further episodes of sustained VT. He continued to have ectopy on telemetry. . #Pulmonary Fibrosis / Pulmonary Hypertension: Patient was evaluated by the pulmonary specialists who felt that his underlying lung disease was unchanged. He may benefit from right heart catheterization in the future. His echo showed elevated PA systolic pressures but these were within the range of prior studies (see results). A trial of vasodilators could be considered however this will be limited by his CHF and CAD. Patient remains on 3L O2 by NC. His dry weight is 155 lbs (came in at 163 lbs) . # Coronary Artery Disease s/p 5V CABG and multiple PCI. Patient was evaluated by Dr. [First Name (STitle) ] his interventionalist who felt that repeat cath was not warranted given his fixed defect on nuclear stress testing and his elevated creatinine. Patient has several episodes of chest pain relieved by nitroglycerine. He never had any elevation in his cardiac enzymes (see results). ECG showed possibly worsening lateral depressions with chest pain. . #)Chronic renal insufficiency: Baseline Cr~1.8-2.0. Likely secondary to longstanding diabetes, hypertension, and CHF. Relatively stable, peaked at 2.4 after aggressive diuresis, discharged at 2.1. . # Depression / Anxiety. Patient was extremely anxious throughout his hospitalization and felt that his medical condition was not improving and that the medical team was not doing their part to improve his condition. He was seen by both psychiatry and palliative care given the severity of his medical condition and his ongoing anxiety related to his multiple medical problems. Psychiatry felt strongly that his medication Tranxene for anxiety was not the best choice given its long duration of action but also felt that it would be unsafe to wean him right now. Long term he may benefit from a long taper and transitioning to Ativan prn. He was continued on Celexa. He was also given Ativan 0.5 mg prn and Ambien for sleep. Patient was felt to be safe for [First Name (STitle) ] and able to make appropriate decisions regarding medical care. Palliative care felt that a family meeting would be helpful to assign a health care proxy and to initiate discussions about his future and likely poor long term prognosis. The patient adamantly did not want to burden his family with driving into [Location (un) 86] to arrange a meeting. We emphasized the importance of this but he again refused. Patient is now familiar to the palliative service and would likely benefit from ongoing interactions should he ever return to this hospital. . #)Hyperlipidemia: continued Zocor and Niacin. . #)HTN: Patient on admitted on Toprol, Lisinopril, and nitrate as outpatient. Generally well controlled, goal SBP could be as low as 90 as limited by orthostasis. Transiently on Carvedilol but then changed back to Toprol per the heart failure team. Imdur increased to 60 mg daily. . #)DM: Patient on Glipizide at home. On sliding scale while in house. . #)ITP: Patient is followed closely by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in the hematology clinic here at [Hospital1 18]. He is currently not receiving any treatment. He has been on Prednisone in the past with a minimal response. Per Dr.[Name (NI) 220] last note will not receive any further treatment unless plt count <50. Stable here (see results). . #)Code Status: Patient clearly wanted to remain a full code. . Patient was discharged home with VNA/PT/OT and CHF services. He has arranged follow up with his primary care physician on [Location (un) 28985]. He was advised to try either short term cardiac rehab or to initiate transition to a skilled nursing facility. The patient refused this on multiple occasions and expressed a wish to go home with services. Both the medical team, psychiatry, palliative care and physical therapy felt that this was not ideal but acceptable currently. Medications on Admission: Toprol 50mg PO daily Glipizide 10mg PO BID Niacin 500mg PO BID Digoxin 0.125mg PO QOD Lasix 60mg PO BID - recently increased Plavix 75mg PO daily Nexium 40mg PO BID Vitamin E 400u PO daily Tranxene 7.5mg PO TID Isosorbide 30mg PO daily Vitamin D 400units MVI Tums [Hospital1 ] Acetaminophen 500mg PRN Spirinolactone 25mg PO daily Mucomyst 6mL TID Lisinopril 5mg PO daily Zocor 40mg PO daily Aspirin 325mg PO daily Celexa 60mg daily [Hospital1 ] Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 8. Acetylcysteine 20 % (200 mg/mL) Solution Sig: Six (6) ml Miscellaneous TID (3 times a day). 9. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 10. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. Disp:15 Tablet(s)* Refills:0 11. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. Disp:10 Tablet(s) Refills:0 12. Tums 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO three times a day as needed. 13. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 14. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: [11-26] Tablet, Sublinguals Sublingual PRN (as needed): Can repeat x 3 --if persistent pain call 911. Disp:30 Tablet, Sublingual(s) Refills:0 15. Niacin 500 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO BID (2 times a day). 16. Glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day. 17. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 18. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:30 Tablet Sustained Release 24 hr(s) Refills:0 19. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 20. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 21. Clorazepate Dipotassium 7.5 mg Tablet Sig: One (1) Tablet PO twice a day. [Month/Day (3) ] Disposition: Home With Service Facility: VNA Assoc. of [Hospital3 ] [Hospital3 ] Diagnosis: 1. Congestive Heart Failure EF 25% 2. Coronary Artery Disease s/p MI and 5V CABG s/p multiple PCI 3. Ventricular Tachycardia with ICD 4. Pulmonary hypertension and fibrosis 5. Anxiety/Depression . Secondary: Diabetes [Last Name (un) ] Kidney Disease (baseline Cr 1.5-2.0) Hypertension Hyperlipidemia Peripheral Vascular Disease Thrombocytopenia History of GI bleed OSA on home O2 ---3L baseline [Last Name (un) ] Condition: Stable --patient on 3L oxygen, euvolemic, no further VT on telemetry [Last Name (un) ] Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1500 ml Please take all of your medications as directed. The medication changes are that you are no longer taking Digoxin and Tranxene. Please ensure that you follow up as listed below. It is very important that you also see your primary care doctor within one week of dischage. Followup Instructions: We made an appointment for you with your primary care doctor Dr. [Last Name (STitle) 33734],ZOUHDI A. Tel: [Telephone/Fax (1) 33735] ---Monday [2139-11-9] at 2:30 PM. Please call if this is not convenient for you, they can see you between Monday and Wednesday of next week. . You also have the following appointments scheduled: . 1. Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 435] Date/Time:[2139-11-10] 1:00 . 2. Provider: [Name10 (NameIs) 1571] BREATHING TEST Phone:[Telephone/Fax (1) 609] Date/Time:[2139-11-23] 10:55 . 3. Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 5265], M.D. Phone:[Telephone/Fax (1) 612] Date/Time:[2139-11-23] 11:15 Completed by:[2139-11-6]	[ "V45.81", "515", "585.9", "414.00", "V45.02", "357.2", "250.60", "584.9", "427.1", "416.0", "428.43", "428.0", "250.40", "403.90" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]		18202, 25023	384, 409		5685, 5685	28645, 29451						25049, 25487										4944, 5666																333, 346		25517, 28622						437, 3203					5701, 18179								3225, 4453	4469, 4929
3,830	182,873	45201	Discharge summary	report	Admission Date: [2169-9-14] Discharge Date: [2169-9-25] Service: MEDICINE Allergies: Aspirin / Percocet / Codeine / Ambien / Nutren Pulmonary Attending:[First Name3 (LF) 2387] Chief Complaint: Respiratory failure Major Surgical or Invasive Procedure: Intubation [12-29] to respiratory failure Bronchoscopy History of Present Illness: Patient is an 84 yo female with history of COPD, recurrent aspiration pna, MAT, PVD s/p Left femoral-peroneal bypass, HTN, CAD presented initially to [Hospital1 18] on [2169-9-14] with worsening dyspnea. Pt has had an extended hospital course, beginning in [8-2] when she was admitted to [Hospital1 18] on 2 occasions with respiratory distress, thought due to COPD flare and aspiration pneumonia. Most recently patient was discharged from [Hospital1 18] on [2169-8-25] with what was thought to be COPD flare and aspiration pneumonia. During this hospital course, pt had a failed speech and swallow evaluation with silent aspiration (no cough reflex). She was also transferred to the MICU for increased respiratory distress, but did not require intubation. The patient was discharged from this hospitalization with NG tube in place, as she refused PEG tube placement. . Upon most recent discharge, patient was discharged to [Hospital1 15454] rehab. From here, on [2169-9-5], she was admitted to [Hospital ] Hospital for re-aspiration pneumonia (unclear when NGT was d/ced) which progressed to respiratory failure requiring intubation. Pt was discharged from Caritas to [Hospital1 49145] rehab facility on high dose steroid taper. . Over the following 48 hours post-discharge, patient had worsening dyspnea, increased oxygen requirement to 6L NC with desaturations into the 80's. She given methylprednisolone and lasix 40 IV x2, as dyspnea was thought related to CHF. Pt was then brought to [Hospital1 18] for planned cardiac catheterization. However, pt had increasing respiratory distress in transit, requiring BiPAP. She was initially admitted to the CCU team. Initially pt was treated with prednisone 20mg daily and nebulizers. Morning after admission, the patient had increasing respiratory distress on BiPAP, with an ABG of 7.34/61/67, and she was subsequently intubated. She was started on solumedrol 60mg IV q8hr, Vancomycin, levofloxacin and flagyl. Pulmonary was consulted and performed a bronchoscopy on [2169-9-15] that demonstrated a large amount of mucous and ?contrast/aspiration material that was suctioned out. . She has remained hemodynamically stable, and respiratory status has remained stable on vent. Other notable hospital course events include pt noted to be guaic + on exam, Hct has remained stable. Patient was extubated on [9-17]. She was transferred from MICU to CCU Step Down for further care. Past Medical History: 1)Asthma > 5 hospitalization with no history of intubations. She has been on steroids since the beginning of [Month (only) 216]. Prior to this, she had been steroid free for the past 2 years. 2)Hypertension. 3)Steroid induced hyperglycemia. Discharged on insulin following her [Hospital1 ] admission. 4)Peripheral vascular disease, status post left fem-peroneal bypass in [2162] 5)Multi-focal bacterial pneumonia. 6)Chronic obstructive pulmonary disease- PFT [7-2]- FVC 61% pred, FEV1 56% pred, FEV1/FVC 92%, Reduced FVC related to gas trapping, ~400 cc worse than PFT from one year ago. 7)Multi-focal atrial tachycardia. 8)Oral thrush. 9)Question left hilar mass. Social History: Distant tobacco use. Occasional alcohol use. The patient was living with 24 hour home health aide until [Month (only) ] hospitalization. Since then has been a resident at [Hospital ] [Hospital ] rehab facility. Family History: Asthma in her father Physical Exam: Vitals: Tm: 98.0 Tc:96.9 , BP 156/91, range: 142/156/71-91 HR 80, 98% on 2L nasal canula Gen: A&OX4,WNWD,responsive to commands. HEENT: NCAT,PERRLA, EOMI, 2mm pupils, no rhinorrhea or excessive lacrimation CV: systolic murmur best appreciated over R pul area, JVP normal, no JVD PULM: coarse lung sounds bilaterally much improved since last exam, diffuse expiratory rales Abd: protuberant, soft, nondistended, nontender. GU: foley catheter patent & draining 180cc last hour Extrem: Warm & well perfused, 1+ pitting edema on R LE. DP pulse 1+. Skin: abd bruising consistent with heparin administration, punctate erythematous lesions (h/o zoster) R lumbar region in dermatomal distribution. Pertinent Results: [2169-9-14] 6:31p CK,CPIS,TNT ADDED [2173] [2169-9-14] / PICC 148 106 124 AGap=10 -------------< 223 4.9 37 1.4 CK: 8 MB: Notdone Trop-T: 0.06 Comments: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi Ca: 8.7 Mg: 2.6 P: 4.0 94 11.7 \ 8.5 / 266 D / 26.5 \ N:94.8 Band:0 L:3.6 M:1.5 E:0.1 Bas:0.1 Comments: Verified Hypochr: 2+ Anisocy: 3+ Poiklo: 1+ Macrocy: 2+ Microcy: 1+ Ovalocy: OCCASIONAL Tear-Dr: OCCASIONAL Comments: MANUAL Plt-Est: Normal PT: 11.4 PTT: 21.2 INR: 1.0 Follow up labs: [2169-9-24] 04:15AM BLOOD WBC-4.0 RBC-3.38* Hgb-10.5* Hct-31.6* MCV-94 MCH-31.2 MCHC-33.4 RDW-18.5* Plt Ct-196 [2169-9-19] 09:22PM BLOOD Neuts-94.9* Lymphs-4.1* Monos-0.7* Eos-0.2 Baso-0.1 [2169-9-24] 04:15AM BLOOD Plt Ct-196 [2169-9-24] 04:15AM BLOOD Glucose-239* UreaN-44* Creat-1.1 Na-138 K-3.5 Cl-107 HCO3-20* AnGap-15 [2169-9-24] 04:15AM BLOOD proBNP-PND [2169-9-17] 01:21AM BLOOD calTIBC-233* VitB12-1029* Folate-GREATER TH Ferritn-557* TRF-179* [2169-9-23] 09:30AM BLOOD Vanco-24.9* [2169-9-17] 01:42PM BLOOD Type-ART pO2-96 pCO2-32* pH-7.44 calTCO2-22 Base XS-0 [2169-9-15] 08:25AM BLOOD Type-ART pO2-67* pCO2-61* pH-7.34* calTCO2-34* Base XS-4 Micro: [2169-9-15] 5:34 pm BRONCHIAL WASHINGS GRAM STAIN (Final [2169-9-15]): 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. RESPIRATORY CULTURE (Final [2169-9-18]): 10,000-100,000 ORGANISMS/ML. OROPHARYNGEAL FLORA. STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML.. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ <=1 S [2169-9-23] 10:00 am STOOL CONSISTENCY: SOFT Source: Stool. FINAL REPORT [2169-9-24] CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [2169-9-24]): FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. Reference Range: Negative. For following micro: if no organism noted, culture is negative to date. [2169-9-23] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL INPATIENT [2169-9-20] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC BOTTLE-PENDING INPATIENT [2169-9-19] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL INPATIENT [2169-9-17] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL INPATIENT [2169-9-17] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL INPATIENT [2169-9-15] Rapid Respiratory Viral Screen & Culture Rapid Respiratory Viral Antigen Test-FINAL; VIRAL CULTURE-PRELIMINARY INPATIENT [2169-9-15] BRONCHIAL WASHINGS GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL {STAPH AUREUS COAG +}; LEGIONELLA CULTURE-FINAL; FUNGAL CULTURE-PRELIMINARY {YEAST} INPATIENT [2169-9-15] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL INPATIENT [2169-9-14] URINE URINE CULTURE-FINAL Relevant Imaging: 1) CXray ([9-14]): No new areas of opacity are identified. There is continued opacity of the left retrocardiac region, which is stable in comparison to multiple prior studies. 2) CT Chest w/o contrast ([9-15]): (1) Left lower lobe atelectasis likley due to mucus obstruction of the left lower lobe bronchi with several areas of barium aspiration. These findings as well as multiple small consolidations suggest recurrent aspirations as a possible cause of the patient's pneumonia. 2) Cardiomegaly. Significant coronary artery calcifications, aortic valve and mitral annulus calcifications. 3) Multiple sub-cm mediastinal lymph nodes most likely reactive. 3)ECHO ([9-15]):The left atrium is normal in size. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([11-28]+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is a very small pericardial effusion. Compared with the prior study (images reviewed) of [2169-8-22], right ventricle is now smaller and more vigorous. LENI: IMPRESSION: No evidence of DVT involving the right lower extremity. Cardiology Report ECG Study Date of [2169-9-15] 9:20:12 AM Ectopic atrial rhythm. Right bundle-branch block. Compared to the previous tracing no significant change. OROPHARYNGEAL VIDEOFLUOROSCOPIC SWALLOWING EVALUATION EVALUATION: An oral and pharyngeal swallowing videofluoroscopy was performed today in collaboration with Radiology. Nectar-thick liquid, Honey thick liquid, pureed consistency barium, one ground cookie coated with barium and one half cookie coated with barium were administered. Results follow: ORAL PHASE: Bolus formation was mildly reduced with mildly prolonged mastication of the solid consistencies. Bolus control was moderately reduced with premature spillover to the pyriform sinuses and laryngeal vestibule before the swallow. Oral transport was also prolonged [12-29] mild tongue weakness and tongue pumping. The pt also appeared to have mildly reduced base of tongue retraction, but the residue on the posterior tongue may also have been the result of severe dry mouth. Oral transit times were mildly prolonged with a mild to moderate amount of oral residue after all consistencies. PHARYNGEAL PHASE: There was a mild to moderate delay in swallow initiation with all consistencies given. Palatal elevation and laryngeal elevation appeared wfl, however laryngeal valve closure was mildly reduced. The pt did achieve complete epiglottic deflection with all consistencies given. Pharyngeal transit was timely with adequate bolus propulsion, and no significant pharyngeal residue was seen immediately after any consistency. Pharyngoesophageal sphincter opening appeared wfl at the height of the swallow. ASPIRATION/PENETRATION: The pt penetrated the thin and nectar thick liquids before the swallow [12-29] the premature spillover and swallow delay. The pt penetrated to the level of the vocal cords, but had complete vocal cord closure before initiation of the swallow, preventing aspiration before the swallow. She cleared the majority of the penetration during the swallow, but the oral residue spilled to the valleculae and then over into the laryngeal vestibule / airway after the swallow. The aspiration was silent, or without coughing. Cued coughs were effective, but the pt reported she felt SOB after cued coughs. The aspiration after the swallow occurred with all liquids consistencies (thin, nectar and honey). The pt did not aspirate the purees or solids on this exam, but she did have significant residue on the base of her tongue that she could not consistently trigger a repeat swallow to clear. The risk for aspiration of this material was judged to be minimal, but there is a risk if her respiratory status declined over the course of PO intake. TREATMENT TECHNIQUES: A chin tuck was attempted to prevent the aspiration with the liquid consistencies. It reduced the penetration before the swallow, but increased the amount of the oral residue that then spilled into the pharynx / airway after the swallow. Cued coughs were effective, but resulted in SOB. Repeat swallows were most effective at clearing the oral residue, but she could not consistently trigger the repeat swallow. SUMMARY: The pt presents with a mild to moderate oral and pharyngeal dysphagia with more significant impairments compared to the video swallow completed here in [8-2]. She is now consistently aspirating all liquid consistencies after the swallow which cannot be prevented. The pt has a PEG tube in place, but has a strong desire to take POs for her quality of life. Solid consistencies were not aspirated today, but there is a mild to moderate amount of oral /base of tongue residue that sits in the valleculae after the swallow. When she is able to trigger a repeat swallow, this material is fully cleared, but she cannot always trigger the second swallow. This material did not build up over time and she was given several trials of multiple bites of puree and cracker during the video swallow today. There is however a very minimal risk for aspiration of this material after the swallow, although not seen today. Given her strong desire to take something PO, it is recommended she begin trials of solid food only (purees through soft consistency solids are safe) once discharged to rehab where she can be supervised by a speech-language pathologist. She should be cued to take a repeat swallow after each bite, but will not always be able to take the repeat swallow. It will be crucial that she takes the repeat swallow at the end of the trial before lying back down. The amount the pt will be able to take by mouth with be very limited, as it is very hard to take a large amount of solids without liquids. She should be monitored closely, as her PO intake may need to be adjusted if her overall status changes. RECOMMENDATIONS: 1. Suggest the pt continue to receive her primary means of nutrition, hydration and medication via the PEG tube in place. 2. When the pt is d/c'd to rehab, she can have trials of PO with speech language therapy only if: a) She takes purees, ground solids or soft consistency solids only b) NO liquids! c) She is cued to take a repeat dry swallow after every bite. She will not be abe to consistently take a 2nd swallow, but she must take a second swallow at the completion of the PO trial before lying down. d) Her CXRs and breath sounds can be monitored closely and regularly to monitor for any changes. 3. Pills via the PEG tube. 4. If there are any changes in her CXR or there are clinical signs of aspiration, PO intake will need to be stopped and the pt will need to return to an NPO status with tube feedings only. These recommendations were shared with the patient, the nurse and the medical team. Brief Hospital Course: Ms. [Known lastname ] is an 84 yo female with severe COPD, MAT, PVD s/p Left femoral-peroneal bypass, HTN, aspiration PNA who presented with worsening dyspnea and is currently s/p extubation ([9-17]) and PEG placement ([9-19]). . 1)Aspiration pneumonia: On the morning after admission, the patient had increasing respiratory distress on BiPAP, with an ABG of 7.34/61/67, and she was subsequently intubated. She is currently s/p extubation on [9-17]. A bronchoscopy on [2169-9-15] demonstrated a large amount of mucous and contrast/aspiration material that was suctioned out. Her BAL grew out MRSA. She was initially started on Vancomycin, Ceftriaxone, and Flagyl for aspiration pneumonia. Infectious disease was consulted and per their recommendations both Ceftriaxone and Flagyl were d/c'ed. She is currently day 11 of a 14 day course of her Vancomycin. Given her history of aspiration pneumonia a PEG tube was placed on [9-19] and is currently being used for feeding. Her NGT was removed (which she had in place prior to admission). A video swallow was performed on [9-25] recommending that the patient continue to receive her primary means of nutrition, hydration and medications via the PEG tube. She aspirates all liquid consistencies and she should be maintained on a solid diet. Patient remains afebrile during this hospital course. Ms. [Known lastname ] was started on a Prednisone taper, initially at 60mg, now on 40mg daily. Dose is being tapered by 5 mg Q3 days. She has also been receiving albuterol, Atrovent and Advair nebulizers q6H, q1H PRN. . 2)COPD exacerbation: COPD also likely cause of respiratory failure. She initially was on Ipratropium and Albuterol nebs on prior admission. Her Albuterol was changed to Xopenex given her tachycardia. She was also placed on Fluticasone MDI. Her oxygen saturation remained in the high 90's on RA. CARDIAC 3)CAD: Pt had mild elevation of cardiac enzymes on admission likely due to demand ischemia, no acute changes on EKG. She is currently on Plavix and Lipitor. ECHO demonstrated normal systolic function. Ms. [Known lastname ] was not placed on a beta blocker in the context of her Asthma & COPD. She also reports an Aspirin allergy and therefore was not started on ASA. . 4)Pump: Patient has history of CHF and was being treated as an outpatient with Lasix 40mg daily. ECHO during this admission demonstrated normal systolic function with an EF>65%. CXR suggested a combination of worsening heart failure and pneumonia. Her I/O's were closely monitored to make sure she was kept negative. She was diuresed appropriately with Lasix since she had clinical signs of fluid overloads. . 5)Rhythm: Patient has history of MAT. She had several episodes of SVT during her admission. She initially came to the CCU on Verapamil but was then started on IV Diltiazem and responded appropriately. She was then transitioned from IV to PO Cardizem 360mg daily. . 6)Lower extremity edema: She had pedal edema initially on admission. Since there was some asymmetry (L>R)an U/S was done to r/o a DVT, which was negative. Edema was likely secondary to fluid overload. She was diuresed with Lasix and responding appropriately. . 7)Normocytic Anemia: Guaiac positive on exam but lavage negative. Suspect chronic GI blood loss. High dose steroids may predispose to acute GIB. Hct was stable throughout her hospital stay. . 8)Renal insufficiency: BUN was elevated on admission likely due to volume depletion. Given guaiac positive stools, a GIB was also included in the differential, although unlikely. . 9)Resolving herpes zoster: Resolving infection but patient continued to have intolerable pain. She was started on standing Tylenol 650mg q4H and Neurontin for neuropathic pain. . 10)Insomnia: Per pt she takes Ambien daily at home. She was initially continued on Ambien but the team felt that she became extremely drowsy and sometimes not arousable. For this reason her Ambien was changed to Trazadone 50 mg QHS. . 11)FEN: PEG tube placed and was started on tube feeds and tolerated well. Did well with Promote with fiber, but got diarrhea from Nutren Pulmonary. . 12)Prophylaxis: Heparin SC, PPI [Hospital1 ] for high dose steroids and NG tube. pneumoboots. . 13)Code: Full Medications on Admission: Verapamil 120mg PO q6h Nexium 40mg qam Fexofenadine ([Doctor First Name ]) 60mg daily Montelukast (Singulair) 10mg PO daily Levalbuterol nebs q4h Esomeprazole (nexium) 40mg PO daily Ipratropium 0.02% nebs q4h Allopurinol 100mg daily Clopidogrel 75mg PO daily Furosemide 40mg daily Nitroglycerin Patch 0.6mg q12h, then off q12h Calcium250mg/Vitamin D Prednisone 20mg PO daily Insuling Humalog SS, NPH 10 qam Gabapentin 300mg tid Zolpidem 5mg PO qhs PRN Colace 100mg [Hospital1 ] PRN Bisacodyl 10mg PR daily PRN FLEETS enema PR daily PRN Nitropatch [Hospital1 ] Discharge Medications: 1. Montelukast 10 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device [Hospital1 ]: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 3. Gabapentin 300 mg Capsule [Hospital1 ]: One (1) Capsule PO BID (2 times a day). 4. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device [Hospital1 ]: One (1) Cap Inhalation DAILY (Daily). 5. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment [Hospital1 ]: One (1) Appl Rectal 1-5X QD () as needed for hemmorhoidal pain. 6. Levalbuterol HCl 0.63 mg/3 mL Solution [Hospital1 ]: One (1) Inhalation Q6H (every 6 hours). 7. Clopidogrel 75 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 9. Allopurinol 100 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 10. Acetaminophen 160 mg/5 mL Solution [Last Name (STitle) ]: [11-28] PO Q4H (every 4 hours) as needed for pain. 11. Insulin Glargine 100 unit/mL Solution [Month/Day (2) ]: Twenty (20) units Subcutaneous at bedtime: qhs - may increase for elevated blood sugars/taper for decreased blood sugars 12. Prednisone 20 mg Tablet [Month/Day (2) ]: Two (2) Tablet PO DAILY (Daily): Please taper by 5 mg Q3d to eventual goal of off prednisone. 13. Vancomycin in Dextrose 1 g/200 mL Piggyback [Month/Day (2) ]: One (1) dose Intravenous Q48H (every 48 hours) for 4 days: last day [2169-9-28]. 14. Diltiazem HCl 90 mg Tablet [Month/Day/Year ]: One (1) Tablet PO every six (6) hours. 15. Fexofenadine 60 mg Tablet [Month/Day/Year ]: One (1) Tablet PO twice a day. 16. CALCIUM 500+D 500-400 mg-unit Tablet, Chewable [Month/Day/Year ]: One (1) Tablet, Chewable PO twice a day. 17. Colace 100 mg Capsule [Month/Day/Year ]: One (1) Capsule PO twice a day. 18. Senna 8.6 mg Capsule [Month/Day/Year ]: One (1) Capsule PO once a day as needed for constipation. 19. Dulcolax 5 mg Tablet, Delayed Release (E.C.) [Month/Day/Year ]: [11-28] Tablet, Delayed Release (E.C.)s PO once a day as needed for constipation. 20. Nitroglycerin Transdermal 21. Fluticasone 220 mcg/Actuation Aerosol [Month/Day (2) ]: Two (2) puff Inhalation twice a day. Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Primary: Respiratory failure [12-29] aspiration with MRSA pneumonia Congestive Heart Failure with demand ischemia right leg swelling with no DVT normocytic anemia acute renal failure, resolved herpes zoster with neuralgia steroid induced hyperglycemia Discharge Condition: Stable, on room air and ready for discharge. Discharge Instructions: 1) Resume medications as indicated in discharge instructions. 2) Please weigh patient every morning, call your doctor if weight > 3 lbs and adhere to 2 gm sodium diet. 3) Please schedule follow-up with your primary care physician. 4) Based on studies done at [Hospital1 ], you are now restricted to a solid food diet. Please stay away from ALL liquids until cleared by speech and swallow at [Hospital1 ]. 5) If you experience any chest pain, pressure, dizziness or any other concerning symptoms, please return to the ED. Followup Instructions: Please follow-up with your PCP (Dr. [Last Name (STitle) ] within 1 week of discharge from rehab.	[ "507.0", "443.9", "403.90", "428.0", "280.0", "518.81", "V09.0", "584.9", "276.50", "585.9", "427.89", "053.9", "493.22", "482.41" ]	icd9cm	[ [ [] ] ]	[ "33.24", "44.32", "96.6", "96.71", "96.04", "99.04" ]	icd9pcs	[ [ [] ] ]	22841, 22920	15582, 19839	284, 345	23220, 23267	4555, 8167	23848, 23952	3808, 3830		20462, 22818	22941, 23199		19865, 20439			23291, 23825							3845, 4536																225, 246	8185, 15559							373, 2847													2869, 3552	3568, 3792
80,313	108,405	38866	Discharge summary	report	Admission Date: [2130-7-23] Discharge Date: [2130-7-31] Date of Birth: [2081-11-3] Sex: M Service: MEDICINE Allergies: lorazepam Attending:[First Name3 (LF) 11839] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: endotracheal intubation History of Present Illness: 48M w/ PMHx of Stage 4 NSCLC s/p thoracotomy in [2126] as well as chemo/radiation at [Company 2860] completed [2127] with known mets followed by Oncologist at [Hospital1 2025] as well as hx of post obstructive pneumonia and left lung collapse with left mainstem endobronchial tumor ([2128]), recently admitted to [Hospital1 18] with thoracic mets and mechanical compression of spinal cord s/p emobilization of met lesion ([6-20]) and s/p T3-6 laminectomy, T1-8 posterior fusion, T3-5 interbody fusion ([6-21]), PEG placement ([6-28]) presenting with acute dyspnea requiring ET intubation. Up until few days prior to admission, was walking around house with walker, teaching son to drive. Last 24 hrs, feeling more weak and more lethargic, also with AMS.Also had begun coughing more with thick secretions, difficulty coughing them up, gagging more and more. This morning, worse, so called EMS. Was hypoxic at home so was nasotracheally intubated in the field. No fevers, no nausea, no vomiting, loose stool potentially [12-29] lactulose, not requiring additional pain meds. In the ED, initial VS were: 99 125 115/72 20 100% (intubated with 500 x 20 5 peep 50%) Pt arrived via EMS from home with wife. Did not tolerate CPAP. Nasaltracheal intubation by EMS. Unsure of location. Hypoxic to 80s when first arrived. Signed DNR in chart but patient and family asked for resuscitation at this time Endotracheal intubation pursued with 20 etomidate, 120 succs and intubated with 7.5 ETT. Patient with reportedly good color change. Vanco/cefepime dosed. Examination notable for cachexia, diminished breath sounds on left, sunken left chest, power port (per wife) on left chest, and gtube site intact. There was no edema and cardiac exam simply sinus tach. CXR performed with whiteout on left (known). CT head and CTA chest ordered, and patient to complete before transfer to MICU. On transfer to MICU, patient's VS. 99 110 100/65 20 100% On arrival to the MICU, patient's VS. 97.2 108 116/63 17 100% (500 x20 Peep 5 FiO2 100%) Review of systems: (+) Per HPI (-) Further ROS not conducted as patient intubated, sedated. Past Medical History: PAST MEDICAL HISTORY: # Non-Small Cell Lung CA. LLL Mass. s/p thoracotomy at [Hospital6 ] in [2127-9-28]. s/p chemotherapy and radiation at [Hospital3 328], completed in [2127-11-28]. # Hyperlipidemia. # Episodic headaches. These are bifrontal. Imaging has been negative for metastatic disease. # History of hepatitis in childhood. He thinks that this was hepatitis B. # Right Hand Cellulitis, secondary to foreign body. PAST SURGICAL HISTORY: #Thoracotomy at [Hospital3 ] in [2127-9-28]. Social History: Lives at home in [Location (un) 3786] with wife and two children. Works as respiratory therapist at Mt Aubrun. Wife works as an administrative assistant at [Hospital1 18]. 25+ pack-year h/o smoking, quit with cancer diagnosis. Denies EtOH, drugs. Family History: No history of lung cancer in family. Physical Exam: T 37 HR 93 BP 102/48 RR 22 O2 sat 100% General: sedated, intubated HEENT: pupils equal adn reactive, sclearae anicteric, MMM Neck: supple, no LAD, no JVD Lungs: decreased breath sounds to left Abdomen:g-tube in place, no tenderness, soft and non-distended EXT:No c/c/e Neuro: sedated Pertinent Results: [2130-7-23] 12:34PM BLOOD WBC-29.1* RBC-3.97* Hgb-10.4* Hct-34.5* MCV-87 MCH-26.3* MCHC-30.2* RDW-16.3* Plt Ct-543* [2130-7-24] 03:32AM BLOOD Neuts-95.3* Lymphs-3.3* Monos-1.1* Eos-0.2 Baso-0 [2130-7-23] 12:34PM BLOOD PT-15.2* PTT-25.7 INR(PT)-1.4* [2130-7-24] 03:32AM BLOOD Glucose-117* UreaN-23* Creat-0.7 Na-142 K-4.5 Cl-110* HCO3-26 AnGap-11 [2130-7-27] 06:00AM BLOOD ALT-9 AST-21 AlkPhos-77 TotBili-0.4 [2130-7-24] 03:32AM BLOOD Albumin-2.9* Calcium-11.3* Phos-2.1# Mg-1.7 [2130-7-23] 6:58 pm BRONCHOALVEOLAR LAVAGE GRAM STAIN (Final [2130-7-24]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Preliminary): 10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora. STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML.. BETA STREPTOCOCCI, NOT GROUP A. 10,000-100,000 ORGANISMS/ML.. . [2130-7-23] CT Head IMPRESSION: Multiple metastatic lesions scattered throughout the brain. . [2130-7-23] CTA Chest IMPRESSION: 1. No evidence of pulmonary embolus. Some pulmonary arterial branches are slightly narrowed due to encasement by tumor. 2. Diffuse mediastinal and hilar confluent soft tissue density consistent with neoplastic infiltration. Accompanying complete left-sided lung collapse along with moderate size complex pleural effusion and pleural thickening. 3. Innumerable nodular pulmonary metastases on the right with superimposed ground glass opacities that could represent atypical infection or additional areas of lymphangitic spread Brief Hospital Course: 48M w/ PMHx of extensive metastatic NSCLC (stage IV) s/p thoracotomy ([2126]), chemoRT ([2127]), hx of post obstructive pna & left lung collapse with left mainstem endobronchial tumor ([2128]), met embolization and mechanical decompression of spinal cord due to cord compression ([2129]) presenting with acute dyspnea, found to be in respiratory distress requiring intubation. Patient had short stay in [Hospital Unit Name 153] briefly and after extubation, was transferred to oncology [Hospital1 ] for further management. Has had episodes of desaturation possibly related to accident removal of oxygen nasal cannula and anxiety. Started on XRT on [2130-7-27], 5 fractions planned, but since goals of care changed to comfort oriented, long term prognosis poor, completion of XRT deferred. DNR/DNI status discussed on [2130-7-27].On the night of [2130-7-28] pt became very dyspneac and agitated. He was given morphine and alprazolam for dyspnea with minimal relief and then thorazine, which did help patient. On [2130-7-29] pt was transitioned to CMO. He was treated with scheduled thorazine, morphine and alprazolam. He was non-arousable but remained comfortable. On [2130-7-30] at 20:50 patient expired. Medications on Admission: On transfer from [Hospital Unit Name 153]: 1. Azithromycin 250 mg PO/NG QDAILY 2. Acetaminophen 650 mg PO/NG Q6H:PRN pain 3. ALPRAZolam 0.75 mg PO/NG TID:PRN anxiety 4. Metoclopramide 10 mg PO/NG QID PRN nausea 5. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN 6. Morphine Sulfate 2-4 mg IV Q4H:PRN pain 7. Polyethylene Glycol 17 g PO/NG DAILY constipation 8. Piperacillin-Tazobactam 4.5 g IV Q8H 9. Dexamethasone 3 mg PO/NG DAILY 10. Pantoprazole 40 mg IV Q24H 11. Docusate Sodium (Liquid) 100 mg PO/NG [Hospital1 *] 12. Fentanyl Patch 125 mcg/h TP Q72H 13. Gabapentin 600 mg PO/NG Q8H 14. Heparin 5000 UNIT SC TID 15. Vancomycin 1250 mg IV Q 12H Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: Metastatic Lung Cancer Brain Metastasis Anxiety Shortness of Breath Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired	[ "162.5", "V44.1", "198.7", "518.84", "276.2", "196.1", "275.42", "799.4", "197.0", "338.3", "V49.86", "486", "V15.82", "198.5", "293.0", "286.9", "198.3" ]	icd9cm	[ [ [] ] ]	[ "96.71", "92.29", "96.04", "33.24", "96.6" ]	icd9pcs	[ [ [] ] ]	7227, 7236	5243, 6493	279, 304	7348, 7357	3681, 4348	7413, 7423	3323, 3361		7195, 7204	7257, 7327		6519, 7172			7381, 7390						2979, 3034	3376, 3662							4383, 5220							2421, 2496		232, 241								332, 2402													2540, 2956	3050, 3307
30,243	167,903	26202	Discharge summary	report	Admission Date: [2191-5-28] Discharge Date: [2191-5-30] Date of Birth: [2153-3-6] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1257] Chief Complaint: intoxication, SI Major Surgical or Invasive Procedure: None History of Present Illness: 38-year-old man with h/o polysubstance abuse, ADHD, past suicidal attempts, presented with "feeling like I'm dying," auditory hallucinations, SI - wanting to jump off bridge. His last drink was at 11 a.m. this morning. Has not been taking seroquel or depakote because drinking. Denies drug use. . In the ED, T 98.6, HR 134, BP 166/118, RR 18, 97%RA. Serum tox was negative except for EtOH level at 245. Patient was given haloperidol 5 mg IM x 1, thiamine, folic acid, diazepam 10 mg IV x 1. Psych has not seen patient yet. HR 99, BP 127/79, 16, 95%RA. Admitted to MICU for close monitoring. Past Medical History: 1. ADHD 2. learning disorder (dyslexia) 3. major depression 4. bipolar affective disorder 5. antisocial personality disorder 6. hx head trauma [1-31] a beating during court-mandated vocational program in TX 7. ethanol abuse - szs [1-31] ethanol withdrawal/DTs, per pt 8. ?heroin use . Psych hx: Bridgwater x2, "21" psych hospitalizations in [State 2690], >50 detoxes, last 2yrs ago. Suicide attempt [2186] - hanging. Social History: Etoh: + since [94], reportedly up to 2pints of vodka/d 2-3 days/wk Tobacco: 3ppd, smoking since age 13 Illicit Drug Use: cocaine/heroin, both IV. Last used cocaine [3-2], heroin [2-28]. Pt reports multiple detox programs. Marijuana once weekly, methamphetamine once weekly. Denied sexual activity. Lives in [Location ], lost job as cook/prep employee of 17 years. Stated he is a registered sex offender from an incident several years ago when intoxicated. Mother lives in [State 2690], father disabled. Family History: NC Physical Exam: General: middle-aged man, somnolent but arousable, refusing to answer questions, actively moving arms and legs repetitively when being observed but going back to sleep when exam was over, smelling of alcohol HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally from anterior CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [2191-5-28] 05:25PM PLT COUNT-268 NEUTS-43.8* LYMPHS-45.4* MONOS-6.2 EOS-2.9 BASOS-1.7 WBC-5.4 RBC-4.53* HGB-14.0 HCT-40.4 MCV-89 MCH-30.9 MCHC-34.6 RDW-13.7 ASA-NEG ETHANOL-245* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG VALPROATE-17* GLUCOSE-81 UREA N-9 CREAT-0.7 SODIUM-144 POTASSIUM-3.3 CHLORIDE-105 TOTAL CO2-24 ANION GAP-18 [2191-5-28] MRSA Nasal Swab (per ICU admission protocol): No growth Psychiatry Evaluation: Staff Psychiatry Consultation Note RFC: Asked by Dr. [Last Name (STitle) ] to assist in the assessment and management of suicidal ideation in the context of acute alcohol intoxication. Medical record reviewed, spoke with patient's mother [Telephone/Fax (1) 64932] & brother [Name (NI) ] [Telephone/Fax (1) 64933]. [Name2 (NI) 64934]ge left for uncle [Name (NI) 19529] [Telephone/Fax (1) 64935]. I personally evaluated the patient and discussed the a/p with Dr. [Last Name (STitle) ]. CC/HPI: Unemployed, 38 y/o man with h/o of treatment refractory alcohol dependence and past suicide attempt, who self-presented, with BAL 245, for management of alcohol w/d. At the time of presentation, he made suicidal statements, wanting to jump off a bridge. He received Haldol 5 mg IM, Fol, Thi, and Valium 10 mg x 2. According to the patient's mother and brother, he does have true suicidal intent and was making statements of planning to jump off a bridge as recently as yesterday pta. Things have gone markedly downhill after losing his job in [Month (only) 547], and two recent treatment programs have not helped ([Hospital1 1680] HRI, [Doctor Last Name ] Point). The structure of work has been the only thing helpful in containing his behavior, and he has become profoundly depressed over the past 1 month. The patient has been drinking upwards of [12-31] pints of vodka over the past several weeks. He describes hoplessness, poor sleep and food intake during that time with occ paranoia/social phobia. He has intermittently taken his medications not wanting to combine them with alcohol. He believes that he is ready to turn his life around and is declining further substance abuse help. Currently, he describes only feeling anxious w/o SI. His family, on the other hand, feels that his alcohol use has been refractory to all help, and they are significantly concerned for his safety. PPH: Per [Month/Day (2) ] and confirmed with family, ADHD, Learning Disorder (dyslexia), Major Depression, Bipolar Affective Disorder (no true mania per my evaluation), and Antisocial Personality d/o. Hospitalizations: Bridgwater x2 on Section 35. States he has had 21 psychiatric hospitalizations, many in [State 2690]. Last was 2 years ago in [Location (un) ]. States >50 detoxes, last was 1 month ago in [Doctor Last Name ] Point. Medication Trials: Prozac and Seroquel. Now on VA, Seroquel, and Zoloft, per patient. SA/SIB: suicide attempt [2186] in group home by hanging off [Location (un) ] balcony. leading to hospitalization. Patient confirms this. No weapons or violence. He adds that this occurred while intoxicated. Outpatient treaters: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 15582] ([Telephone/Fax (1) 17826]) and is also seen there by Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] for psychiatric medications; he last saw Dr. [Last Name (STitle) ] two weeks ago. PMH: Remote head trauma and one alcohol w/d seizure. MEDS: Seroquel, Depakote, and Zoloft as outpatient. ALL: NKDA SUB: Significant past history of alcohol dependence with vodka up to [12-31] pints per day. He has history of Section 35 and several ip/op treatments. h/o blacouts, ?DTs and w/d seizures. AA x 1 w/o sponsor. During 6 mos period of alcohol-free time, notes depressive symptoms w/o mania. Remote history of cocaine and inhalant use. SH: Lives alone in apartment in [Location (un) ]. No employment. No friends. Significant family support. Denies legal problems, although he is a registered sexual offender. FH: Per [Name (NI) ], Mother, maternal grandmother, and maternal uncle have alcohol dependence. Father's mother commit suicide in [Name (NI) 651]. A cousin on his father's side also was chronically hospitalized at [Hospital 64936] Hospital in [Location (un) 7349], though the diagnosis is not known. MSE: Notable pmr w/o tremor or hyperreflexia. Affect is blunted and minimally reactive. Mood is depressed. Speech is low and not pressured. Denies AH, VH, TH, OH. tp is logical, and there is no delusional, suicidal, or homicidal tc. Cognitively, he is awake, alert, and fully oriented. DOWB is notable for one error, however, he is able to complete Verbal trails w/o error. Luria sequence done w/o errors of omission or comission. Memory is [3-1] at 5 minutes. DATA: VS-HR 67-97, bp 130-160, rr 13-17, t 97.4 HCT 34.5 (40.4), VA 17, WBC WNL, TSH WNL, B12 WNL, Fol WNL, Stox NEG Assessment: 1. Mood Disorder NOS (311) - Substance-Induced Mood Disorder vs. Major Depressive Disorder, Recurrent, Severe, Without Psychotic Features. Binge drinking in the context of stress of losing his job. Patient with SI tied closely to his drinking. Patient has poor sleep, appetite, and hopelessness. Family feels that the patient has true suicidal intent in light of recent stress. He has limited social supports w/poor outpatient compliance. Active substance abuse and past suicide attempt place patient at high risk for intentional/accidental death. 2. Alcohol Dependence 3. Alcohol Withdrawal Plan: 1. Section 12, 1:1 observer, inpatient dual dx when cleared 2. Maintain on CIWA with Valium 10 mg PO q 1h until mildly intoxicated. Then PRN's per CIWA. He is at high risk for severe w/d symptoms given his level of tolerance. Do not give Valium for subjective complaints only (e.g. anxiety) 3. Seroquel 12.5-25 mg PO TID:PRN anxiety/insomnia. 4. Hold Depakote and Seroquel P contact with psychiatrist re: [Name (NI) 8372] Dx 5. [Doctor Last Name ] of BEST notified. They will evaluate. Addendum by [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 64937], MD on [2191-5-29] at 5:02 pm: Continue w/MVI, THi, Fol and make sure electrolytes WNL (K > 4, Mg goal of 2) Brief Hospital Course: 38-year-old man with h/o EtOH abuse and alcohol withdrawal seizures/DTs admitted with alcohol intoxication/suicidal ideation. # EtOH abuse: The patient presented with acute intoxication. He was admitted to the ICU for monitoring since he had an apparent history of DTs and withdrawal seizures. The patient received thiamine, and folate. He was assessed by psychiatry and felt to be unable to make appropriate medical decisions. He was transferred to the floor and held under section 12. He was loaded with diazepam and placed on a CIWA assessment score. Over his admission, the patient was intermittently requiring treatment with diazepam, but was otherwise stable. The patient was discharged to [Hospital 1680] Hospital for further rehabilitation and treatment. # SI/hallucinations: The patient initially presented with suicidal ideation and hallucinations which resolved as he sobered. Per the patient, he had not been taking his Depakote and Seroquel due to his recently increased drinking. He was placed on a one-on-one sitter and treated with Valium per CIWA. Psychiatry also recommended as needed use of Seroquel 25mg TID for anxiety. # Tobacco Abuse: The patient reported smoking a pack of cigarettes per day. He was started on a nicotine patch to aid in smoking cessation. Medications on Admission: Depakote Seroquel (pt not taking) Discharge Medications: 1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for anxiety/insomnia. 3. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 3 days. 5. Multivitamin Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Hospital 1680] Hospital - [Location (un) 538] Discharge Diagnosis: Ethanol abuse Depression Tobaccoabuse Bipolar affective disorder Antisocial personality disorder Hx head trauma Discharge Condition: The patient was stable. Discharge Instructions: You were admitted for evaluation and treatment of alcohol intoxication/abuse and suicidal thoughts. You were seen by our psychiatrist who feel you require further inpatient treatment. You are being discharged to [Hospital 1680] Hospital for further care. Followup Instructions: Please follow up with your PCP and outpatient counselor. PCP: [Name10 (NameIs) ],[Name11 (NameIs) ] [Name Initial (NameIs) ]. [Telephone/Fax (1) 17826] Completed by:[2191-5-30]	[ "296.80", "285.9", "296.33", "301.7", "314.01", "784.61", "303.01", "291.81", "305.1", "V62.84" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	10787, 10868	8984, 10282	332, 338	11024, 11050	2616, 8961	11359, 11559	1974, 1978		10366, 10764	10889, 11003		10308, 10343			11074, 11336							1993, 2597																275, 294								366, 959													981, 1416	1432, 1958
27,879	169,219	4275	Discharge summary	report	Admission Date: [2151-3-5] Discharge Date: [2151-3-7] Date of Birth: [2100-1-23] Sex: F Service: MEDICINE Allergies: Penicillins / Darvocet-N 100 / Aspirin / Amitriptyline / Wellbutrin Attending:[First Name3 (LF) 9454] Chief Complaint: cough Major Surgical or Invasive Procedure: None History of Present Illness: 51 y/o F COPD, Crohn's disease, AS s/p bioprosthetic aortic valve replacement who presents with worsening of chronic cough. Patient developed non-productive cough one week ago which continued to worsen. Patient describes associated fevers (according to patient 102), chills, fatigue, and mild nausea. Patient denies shortness of breath or chest pain. At home she wears 3 L of oxygen at night, and occasionally during the day - she has not had to increase her oxygen recently. Patient presented to [Company 191] today for an urgent care appointment to and was referred to the ED. . In the ED, initial vs were: T 98.4 P 93 BP 94/55 R 26 O2 sat 85%. BP ranged from 84-104/48-56. O2 sat 85% RA, patient was initially stable on 6L NC in the low 90s but dropped to 85% and consequently was started on non-rebreather. Patient was given NEBs, Solumedrol, Ceftriaxone, Levofloxacin, 1 L NS. Patient was admitted to ICU for further monitoring. . Patient reports her blood pressure has been low the past several weeks (SBP 90-100) and consequently has not been taking her atenolol. During this time she was experiencing significant diarrhea secondary to crohn's disease which mildy improved last week since starting Budesonide [2151-2-18]. Social History: - Tobacco: 1 pack a day past 34 years - Alcohol: Denies - Illicits: Denies Family History: Family History: No history of lung disease. Physical Exam: Vitals: T: 98.1 BP: 98/70 P: 72 R: 19 O2: 95% NRB General: Alert, oriented, no acute distress, on non-rebreather HEENT: Sclera anicteric, dry MM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Wheezes bilateral CV: Regular rate and rhythm, normal S1 + S2, systolic murmurs with click Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: CXR [2151-3-5]: IMPRESSION: Right middle lobe and left lower lobe opacity likely represent a combination of atelectasis and pneumonia. CXR [2151-3-6]: IMPRESSION: 1. Redemonstrated bibasilar airspace disease likely representing atelectasis. 2. Stable post-surgical changes. Brief Hospital Course: Assessment and Plan: 51 y/o F PMH COPD, Crohn's disease, AS s/p replacement who presents with chronic cough and hypoxia. # Pneumonia/COPD exacerbation: Patient with clinical history, symptoms & CXR supporting a pneumonia. CXR demonstrated a RML and LLL infiltrate. The patient was initially admitted to the ICU due to her oxygen requirement, but she improved with Prednisone, Azithromycin, and Ceftriaxone. She was maintained on standing Albuterol/Ipratropium nebulizers and O2 by NC (she requires 3L at home at baseline). She was transferred to the medicine floor within one hospital day and was discharged on a Prednisone taper, a 7 day course of Cefpodoxime & a 5 day course of Azithromycin. # Hypotension: Patient admitted with hypotension [2-16] diarrhea & insensible losses from infection, that resolved with IVF's. She demonstrated no positive SIRS criteria suggesting underlying sepsis. Two sets of cardiac enzymes were negative. When her hypotension resolved, her home antihypertensives were restarted without incident. # Microcytic anemia: Patient with a baseline Hct of 32 (baseline ranges from 25-32), likely secondary to iron deficiency from Crohn's disease. Patient's stools were guaiac negative during this admission. # Crohn's disease: Patient continued her home Budesonide and Sulfasalazine. A bowel regimen was held at the patient's request given tendency toward diarrhea. # HTN: Patient's home Lisinopril 5mg qPM & Atenolol 25mg PO daily were held in the context of hypotension & restarted when her hypotension resolved. # Chronic pain: Patient continue her outpatient medications Dilaudid and Lyrica. # Hypercholesterolemia: Patient continued her home Atorvastatin 80mg PO daily Medications on Admission: ATENOLOL - 25 mg Tablet - 1 Tablet(s) by mouth once daily Hold if systolic blood pressure < 100 - not been taking recently ATORVASTATIN [LIPITOR] - 80 mg Tablet - 1 Tablet(s) by mouth once a day FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg/Dose Disk with Device - 1 puff inhaled twice a day FOLIC ACID - 1 MG TABLET - ONE TABLET BY MOUTH EVERY DAY HYDROMORPHONE - 4 mg Tablet - 1 Tablet(s) by mouth three times daily as needed as needed for pain 3 tabs/day - 28 day supply is 84 tabs IBANDRONATE [BONIVA] - 150 mg Tablet - 1 Tablet(s) by mouth q month LISINOPRIL - 5 mg Tablet - 1 Tablet(s) by mouth daily in the evening OXYGEN 3 LITERS AT NIGHT AND WITH EXERTION - (Prescribed by Other Provider) - Dosage uncertain PANTOPRAZOLE - 40 mg Tablet, Delayed Release (E.C.) - 1 (One) Tablet, Delayed Release (E.C.)(s) by mouth twice a day Budesonide 6 mg qd PREGABALIN [LYRICA] - 75 mg Capsule - 3 Capsule(s) by mouth twice daily PROMETHAZINE - 25 mg Tablet - 1 Tablet(s) by mouth every 6 hours as needed for nausea SUCRALFATE - 1 gram Tablet - 1 Tablet(s) by mouth twice daily with meals SULFASALAZINE - 500 MG TABLET - 2 tablets by mouth three times a day TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule, w/Inhalation Device - 1 capsule inhaled Once daily at hs TIZANIDINE - 4 mg Tablet - 1 Tablet(s) by mouth every 8 hours as needed for as needed for muscle spasm do not combine with cyclobenzaprine (flexeril). Do not take before driving or operating machinery. TRAZODONE - 100 mg Tablet - [1-16] Tablet(s) by mouth at bedtime as needed for insomnia Medications - OTC ASPIRIN - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth daily CALCIUM - 500 mg Tablet - 1 Tablet(s) by mouth twice a day CYANOCOBALAMIN [VITAMIN B-12] - 100 mcg Tablet - 1 Tablet(s) by mouth daily FERROUS SULFATE [SLOW FE] - 160 mg (50 mg) Tablet Sustained Release - 1 Tablet(s) by mouth daily LIDOCAINE [LMX 4] - 4 % Cream - AAA ear at bedtime MULTIVITAMIN - Tablet - 1 Tablet(s) by mouth once a day ONE TOUCH II TEST - Strip - as directed twice a day Discharge Disposition: Home Discharge Diagnosis: Primary: Pneumonia, COPD exacerbation Secondary: Crohn's Disease Chronic pain Hypertension Hyperlipidemia Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: Ms. [Known lastname ], It was a pleasure taking care of you. You were admitted to the hospital for fever, cough, and shortness of breath. In the hospital, you were found to have a pneumonia and an exacerbation of your COPD. You were given antibiotics and steroids and your symptoms improved. You were discharged home with a short course of steroids and antibiotics. Medications: The following changes were made to your [Known lastname 4085] regimen, 1. Cefpodoxime: This is an antibiotic to treat your pneumonia. Please continue to take this [Known lastname 4085] as directed for the next 5 days. 2. Azithromycin: This is an antibiotic to treat your pneumonia. Please continue to take this [Known lastname 4085] as directed for the next 3 days. 3. Prednisone: This is a steroid used to treat your COPD exacerbation. Please continue to take this [Known lastname 4085] with the following tapered dose: 60 mg on [3-8] 40 mg on [2-25] 20 mg on [3-20] Followup Instructions: Please follow-up with your primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) ], in the next 1-2 weeks. Please call [Telephone/Fax (1) 250] to schedule an appointment.	[ "272.0", "305.1", "796.3", "338.29", "V42.2", "280.9", "486", "401.9", "491.21", "276.52", "555.9", "V46.2" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	6428, 6434	2597, 4309	332, 339	6584, 6584	2289, 2574	7734, 7939	1729, 1758			6455, 6563		4335, 6405			6729, 7711							1773, 2270																287, 294								367, 1605								6598, 6705						1621, 1697
5,877	172,786	28190	Discharge summary	report	Admission Date: [2103-9-27] Discharge Date: [2103-10-5] Date of Birth: [2040-3-21] Sex: F Service: SURGERY Allergies: Cephalexin Attending:[First Name3 (LF) 473] Chief Complaint: Obstructive Jaundice Major Surgical or Invasive Procedure: Whipple PPD Portal Vein Venography Open Cholecystectomy History of Present Illness: This is a 63-year-old otherwise healthy woman who has presented with obstructive jaundice. Brushings at that time of ERCP were positive for adenocarcinoma of the pancreas. CT angiography suggested the tumor to be resectable but did demonstrate pancreatic and biliary ductal dilatation. She presents for definitive resection. Social History: Works as a nurse [First Name (Titles) ] [Last Name (Titles) ] 3 years ago. Family History: Fam Hx of Pancreatic CA - cousin Father with throat CA - smoker Physical Exam: VS: HR 120, BP 150/76. Gen: NAD, AA+O x3 HEENT: anicteric (Jaundice until stent placement 1 weeks ago) CV: RRR, S1, S2 Pulm: WNL, no crackles or wheezes Abd: soft, obese, NT, ND. Lap sites C/D/I Inguinal: no Hernia Musc: WNL, full range of motion Lymph:m NO LAD Pertinent Results: [2103-9-28] 03:00AM BLOOD WBC-11.8* RBC-4.48 Hgb-13.4 Hct-37.1 MCV-83 MCH-30.0 MCHC-36.2* RDW-15.6* Plt Ct-121* [2103-9-28] 03:00AM BLOOD Plt Ct-121* [2103-9-28] 03:00AM BLOOD Glucose-159* UreaN-7 Creat-0.5 Na-139 K-4.1 Cl-106 HCO3-24 AnGap-13 [2103-9-27] 07:32PM BLOOD Na-139 K-3.9 [2103-9-27] 06:18PM BLOOD Glucose-176* Lactate-5.7* Na-138 K-4.1 Cl-114* [2103-9-27] 06:18PM BLOOD Hgb-13.3 calcHCT-40 [2103-10-3] 04:30PM ASCITES Amylase-17 Pathology Examination Name Birthdate Age Sex Pathology # [Hospital1 18] [Known lastname 68491],[Known firstname 2747] E [2040-3-21] 63 Female [-4/4372] [Numeric Identifier 68492] Report to: DR. [Last Name (STitle) ] [Last Name (NamePattern4) ] Gross Description by: DR. [Last Name (STitle) ]. MONDELBLATT/et SPECIMEN SUBMITTED: LYMPH NODE (COMMON HEPATIC ARTERY)-FS, LYMPH NODES (PORTA HEPATIC)-FS, PORTION OF PANCREAS, WHIPPLE, JEJUNUM. Procedure date Tissue received Report Date Diagnosed by [2103-9-27] [2103-9-28] [2103-10-5] DR. [Last Name (STitle) ] [Last Name (NamePattern4) ]/cma?????? Previous biopsies: [-4/4058] AMPULLARY. DIAGNOSIS: 1. Common hepatic artery and lymph node (A): One lymph node, no carcinoma seen. 2. Porta hepatis lymph nodes, one (B-C): 1. Bile duct with focal histiocytic aggregated, no carcinoma seen (B): 2. One lymph node, no carcinoma seen (C): 3. Pancreas (D-F): 1. Three lymph nodes, no carcinoma seen. 2. No pancreatic tissue is seen. 4. Whipple specimen (G-AD): Moderate to poorly differentiated adenocarcinoma, see synoptic report. 5. Jejunum (AE-AG): Segment of jejunum, no carcinoma seen. Pancreas (Exocrine): Resection Synopsis MACROSCOPIC Specimen Type: Pancreaticoduodenectomy, partial pancreatectomy. Tumor Site: Pancreatic head. Tumor Size Greatest dimension: 2 cm. Additional dimensions: 2 cm x 1 cm. Other organs/Tissues Received: None. MICROSCOPIC Histologic Type: Ductal adenocarcinoma. Histologic Grade: Moderately to poorly differentiated. EXTENT OF INVASION Primary Tumor: pT1: Tumor limited to the pancreas, 2 cm or less in greatest dimension Regional Lymph Nodes: pN1b: Metastasis in multiple regional lymph nodes. Lymph Nodes Number examined: 12. Number involved: 2. Distant metastasis: pMX: Cannot be assessed. Margins Margin(s) involved by invasive carcinoma: Uncinate process margin (non-peritonealized surface of the uncinate process). Pancreatic parenchymal margin. Venous/Lymphatic vessel invasion: Absent. Perineural invasion: Present. Brief Hospital Course: She was admitted to [Hospital1 18] on [2103-9-27] for a Whipple Procedure. This was complicated by a Portal Vein injury with an estimated 2000cc blood loss. She received 6 Units of PRBCs. She was admitted to the SICU post-operatively and remained intubated. She was stable post-op and extubated the next morning. Neuro: She was weaned and extubated on POD 1. She was transferred to the floor on POD 2 and was doing quite well. CV: She required neo for BP support overnight and was weaned off the next day. GI: She was NPO with an NGT. She was NPO until the NGT was removed on POD 4. She was started on sips on POD 4 and her diet was advanced per the pathway. She was tolerating a regular diet at time of discharge. Abd: Her JP amylase was 17 on POD 6 and this was removed. The staples were D/C'd prior to discharge. The incision was clean, dry, and intact. There was no redness or drainage. GU: She maintained a adequate Urine Output post-operatively. The Foley was D/C's on POD 3. Heme: Her HCT was monitored closely and she remained stable. Endo: She had post-op hyperglycemia with blood sugars in the 170-190'[Initials (NamePattern4) ] [Last Name (NamePattern4) ] was consulted and she was placed on Lantus 12 Units HS and Humalog sliding scale. Her sugars were well controlled on this new regimen. Pain: She was put on a PCA for pain control. She was switched to PO pain meds and had excellent pain control. Medications on Admission: Vicodin Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:120 Tablet(s) Refills:2 3. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for 1 months. Disp:50 Tablet(s) Refills:0 4. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:90 Tablet(s) Refills:2 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 6. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 7. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1) Subcutaneous three times a day: See sliding Scale. Dose at meal time. Disp:qs Refills:2 8. Lantus 100 unit/mL Solution Sig: Twelve (12) Units Subcutaneous at bedtime. Disp:qs Refills:2 9. Insulin Syringe Syringe Sig: One (1) Miscell. four times a day. Disp:QS Refills:2 10. Lancets Misc Sig: One (1) Miscell. four times a day. Disp:QS Refills:2 11. Insulin testing strips Sig: One (1) four times a day. Disp:qs Refills:2 Discharge Disposition: Home With Service Facility: [Hospital1 1474] VNA Discharge Diagnosis: Adenocarcinoma in Distal CBD Obstructive Acute on Chronic Pancreatitis Post-op Hyperglycemia Discharge Condition: Good Discharge Instructions: * Increasing pain * Fever (>101.5 F) * Inability to eat or persistent vomiting * Inability to pass gas or stool * Increasing shortness of breath * Chest pain Please resume all of your regular medications and take any new medications as ordered. Continue to ambulate several times per day. Continue to monitor your blood sugars and take the Lantus as Rx by [Last Name (un) ]. Followup Instructions: Please follow-up with Dr. [Last Name (STitle) 468] in [12-29] weeks. Call ([Telephone/Fax (1) 27730] to schedule an appointment. Please follow-up with your PCP regarding your blood glucose control. Completed by:[2103-10-5]	[ "196.2", "E849.7", "250.00", "577.1", "157.8", "E870.8", "998.2", "577.0" ]	icd9cm	[ [ [] ] ]	[ "38.93", "99.04", "39.32", "52.7" ]	icd9pcs	[ [ [] ] ]	6639, 6694	3874, 5305	290, 348	6831, 6838	1180, 3851	7266, 7508	818, 883		5363, 6616	6715, 6810		5331, 5340			6862, 7243							898, 1161																230, 252								376, 702														718, 802
14,904	140,807	16625+16626	Discharge summary	report+report	Admission Date: [2181-11-8] Discharge Date: [2181-11-12] Date of Birth: [2121-6-9] Sex: M Service: CICU HISTORY OF PRESENT ILLNESS: Mr. [Known lastname 47106] is a 60-year-old gentlemen with 60 plus pack year history of smoking, otherwise, no past medical history, who presented to [Hospital1 ] elevations in leads II, III and aVF. Patient reports that he his chest that woke him up accompanied by nausea and vomiting, but denied shortness of breath, diaphoresis. Patient reports that he was in his usual state of health until this episode. At the [Hospital1 ] Emergency Department, the patient was noted to be bradycardic to the 40s, blood pressure 97%. He was guaiac negative and started on nitroglycerin, morphine, aspirin, repro, heparin and received two doses of pain free at around 5 in the morning. That following morning, the patient was transferred to [Hospital6 1760] where he underwent a cardiac catheterization which showed a right atrial mean pressure of 9, right ventricular pressure of 27/11, pulmonary artery pressures of 27/16, wedge pressure of 13. His left anterior descending artery had a midsegment disease, left circumflex was nondominant, no aortic lesions. The right coronary artery was dominant with a distal 99% occlusion, which was stented with no reflow. The patient had persistent ST elevations following the catheterization in leads II, III and aVF. PAST MEDICAL HISTORY: Patient denies any diabetes, hypertension or coronary artery disease. ALLERGIES: No known drug allergies. MEDICATIONS AT HOME: None. SOCIAL HISTORY: Smokes currently, 50 plus pack year, two packs a day. Denies alcohol use. He is married, works for a landscaper and mortgage broker. FAMILY HISTORY: Mother with hypertension and father with possible coronary artery disease. PHYSICAL EXAMINATION: The patient, on presentation, had the following vital signs: Temperature 97.8. Blood pressure 108/54. Oxygen saturation 93-100% on room air. General: He was somnolent but in no acute distress. Head, eyes, ears, nose and throat: Jugular venous distention to the mandible. Cardiovascular: Regular rate and rhythm, normal S1, S2, 3/6 systolic ejection murmur at the left upper sternal border. Abdomen: Soft, nontender, nondistended, normal bowel sounds. Extremities: Warm, no edema, 2+ pulses, dorsalis pedis and posterior tibial. Lungs were clear to auscultation bilaterally. LABORATORY DATA FROM THE OUTSIDE HOSPITAL: White blood cell count 14.4, hematocrit 45.5. He had a sodium of 140, potassium of 5.1, chloride 100, BUN 18, creatinine 1, glucose 129, troponin of less than 0.2 and a CK-MB of 2.6. Electrocardiogram at the outside hospital showed ST elevations in II,III and aVF, ST depressions in V1 through V3 and bradycardia in the 40s. LABORATORY VALUES AT [Hospital6 ]: White blood cell count 13.5, hematocrit 39.4, platelet count 261,000. INR 1.2. PTT 47.1, CK of 1864, MB index of 9.0, troponin greater than 50. His Chem-7 showed sodium of 141, potassium 4.5, chloride 100, bicarbonate 23, BUN 16, creatinine 0.7, glucose 108. AST 178, ALT 42, alkaline phosphatase 40, T bilirubin 0.5, calcium 7.8, magnesium 1.6, phosphorus 2.1. The patient underwent echocardiogram which demonstrated the following: On the day of discharge, the patient had this transthoracic echocardiogram which showed left ventricular ejection fraction of 50-55%, mildly dilated left atrium, normal right atrium, normal ventricular size, mildly depressed left ventricular systolic function, right ventricular size and free wall motion normal, aortic root normal, aortic valve leaflets are mildly thickened, mitral valve leaflets mildly thickened, trivial mitral regurgitation and a left ventricular inflow pattern suggesting impaired relaxation. The tricuspid valve was normal with trivial regurgitation and there was no pericardial effusion. During his stay, the patient had a signal averaged electrocardiogram which was positive, however given his minimally impaired LV EF he was felt to be at relatively low risk for ventricular arrhythmias. In addition, the patient continued to have persistent ST elevations 1 mm to .5 a mm in the inferior leads despite the RCA stenting. HOSPITAL COURSE: 1. Cardiovascular: The patient underwent cardiac catheterization with a stent placed in the right coronary artery at the site of the 99% occlusion but with no reflow phenomenon. The patient was treated with aspirin, beta-blocker and 18 hours of Integrilin and an ACE inhibitor. He was pain free the following 24 hours after cardiac catheterization. However, subsequently patient developed what he called a chest soreness located across his chest that he said was significantly different from the pain he experienced the prior day. Electrocardiogram was unchanged. Initially the pain was thought possibly due to the coronary lesions, however, the patient, on hospital day number three, developed friction rub on physical examination and it was determined that his persistent pain was likely due to pericarditis. At that point, patient was treated with nonsteroidal anti- inflammatory drugs with complete relief of pain. He remained hemodynamically throughout and had no evidence of tamponade physiology. The patient's cardiac enzymes were peaked at 21. His CK peaked at 2103 on the 19th and had dropped to 489 on the 21st. CONDITION AT DISCHARGE: The patient was in good condition at discharge. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSES: 1. Coronary artery disease, 99% right coronary occlusion, status post stent without restoration of flow. 2. Mildly depressed left ventricular ejection fraction. 3. Pericarditis. 4. Hyperlipidemia with an LDL of 141. DISCHARGE MEDICATIONS: Patient had the following discharge medications: 1. Plavix 75 mg po q.d. for 12 months. 2. Lipitor 10 mg po q.d. 3. Lopressor 25 mg po b.i.d. 4. Lisinopril 5 mg po q.d. 5. Enteric coated aspirin 325 mg po q.d. FOLLOW-UP PLANS: The patient is to follow-up his cardiologist at [Hospital ] Hospital within two weeks of discharge and with his primary care physician within two weeks of discharge. [First Name4 (NamePattern1) 610] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3812] Dictated By:[First Name3 (LF) 33319] MEDQUIST36 D: [2181-11-12] 15:27 T: [2181-11-19] 19:11 JOB#: [Job Number 47107] Admission Date: [2181-11-8] Discharge Date: [2181-11-12] Date of Birth: [2121-6-9] Sex: M Service: CCU CHIEF COMPLAINT: Nausea, chest heaviness. HISTORY OF PRESENT ILLNESS: Patient is a 60 year-old male with 50 plus pack year history of smoking, otherwise no past medical history. He presented to [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] emergency and AVF on electrocardiogram. Patient reports he was sleeping the night prior to admission when the pain awoke him from sleep, described as a chest heaviness as if an animal was sitting on his chest accompanied by nausea and vomiting. He had no shortness of breath, no diaphoresis. He was in his otherwise usual state of health until this episode. At the [Hospital1 ] emergency department patient was found to be bradycardic to the 40s with a blood pressure in the 90s to 110s, O2 saturation 97 percent. He was guaiac negative and was started on nitroglycerin, morphine, aspirin, Reopro and Reteplase with 5 units intravenous times two given at around 3 o'clock in the morning. By about 5 in the morning he was pain-free. On the day of admission patient underwent cardiac catheterization at [Hospital1 1444] and was found to have the following hemodynamics: right atrial pressure mean of 9, right ventricular pressure of 27/11, pulmonary artery pressure 26/16, wedge of 16. Left sided catheterization showed LAD with mild segmental disease, left circumflex nondominant, no critical lesions, RCA which is dominant showed distal 99 percent occlusion which was stented. There was no reflow following stenting. The patient was given intracoronary nitroglycerin and diltiazem which resulted in TIMI 3 flow. However, there was persistence of ST elevation in the inferior leads and the patient was admitted to the Cardiac Care Unit for monitoring. PAST MEDICAL HISTORY: Is significant for 50 plus packing year smoking history. No history of diabetes mellitus, hypertension or coronary artery disease. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: None. SOCIAL HISTORY: Current smoker, about two packs per day, no alcohol use. Married and is currently an active landscaper. FAMILY HISTORY: Mother with hypertension, father with possible history of coronary artery disease per patient. PHYSICAL EXAMINATION: On admission temperature 97.8, blood pressure 108/54, heart rate in the 70s, O2 maturation 93 to 100 percent on room air. General: somewhat somnolent in no acute distress. Head, eyes, ears, nose and throat examination: jugular venous pulses difficult to assess as patient is lying down and unable to sit up due to recent catheterization. Cardiovascular examination: Regular rate and rhythm, normal S1, S2, II/VI systolic ejection left upper sternal border. Abdomen soft, nontender, nondistended, normal active bowel sounds. Extremities warm, no edema, 2+ dorsalis pedis, posterior tibialis pulses bilaterally. Lungs clear to auscultation bilaterally. LABORATORIES FROM ADMISSION: Sodium 141, potassium 4.5, chloride 110, bicarbonate 23, BUN 16, creatinine 0.7, glucose 108. White blood count 13.3, hematocrit 39.4, platelets 261, INR 1.2, PTT 47.1. Alk phos 40, AST 178, total bilirubin is 0.5, ALT 46. Calcium 7.8, phos 3.1, magnesium 1.6. CK 1864 with an MB of 167, MBI of 9, troponin greater than 50. Electrocardiogram showed ST elevations in 2,3 and AVF with ST depression in V1 through V3, bradycardia in the 40s. IMPRESSION: Patient is a 60 year-old male with past medical history of smoking who presents with acute inferior wall myocardial infarction likely due to critical RCA lesion, status post catheterization now with no reflow immediately after intervention with TIMI 3 flow after nitroglycerin and diltiazem. HOSPITAL COURSE: 1) Cardiovascular: Post catheterization patient was started on Plavix, aspirin, Lopressor, Captopril and had no further chest heaviness or shortness of breath. Patient underwent an echocardiogram on [11-12] the results of which are pending at this time. He was started on Captopril for afterload reduction. Patient was also noted to have some chest soreness on [2181-11-10] accompanied by a friction rub consistent with acute pericarditis. He was given Motrin for one day with relief of his pain and resolution of the pericardial friction rub by the following day. Patient was started on Lipitor 10 mg p.o. q.d. Echocardiogram revealed no pericardial effusion, EF 50-55% with inferior-posterior akinesis. Signal Averaged ECG was performed and was positive, however the patient's risk of life threatening ventricular arrhythmias was felt to be fairly low given his minimally depressed LV systolic function. Medical therapy with beta blockers and ACE inhibitors was initiated. 2) Heme: He was initially started on Reopro which was continued for 18 hours post catheterization with no significant bleeding. There was noted to be a small right groin hematoma at the catheterization site. However, there was no bruit and distal pulses were intact. DISCHARGE DIAGNOSIS: 1. Acute inferior myocardial infarction. 2. Acute pericarditis. DISCHARGE CONDITION: Good. Patient is feeling back to his usual state of health, no longer having any chest heaviness or soreness and has plans to follow up with his cardiologist, Dr. [Last Name (STitle) ], as an outpatient within the next week. DISCHARGE MEDICATIONS: Lipitor 10 mg p.o. q day, Lisinopril 5 mg p.o. q day, Lopressor 25 mg p.o. b.i.d., aspirin 325 mg p.o. q. day, Plavix 75 mg p.o. q day times one year [First Name4 (NamePattern1) 610] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3812] Dictated By:[Name8 (MD) 4630] MEDQUIST36 D: [2181-11-12] 08:38 T: [2181-11-20] 11:25 JOB#: [Job Number 36789]	[ "272.4", "414.01", "410.41", "423.9" ]	icd9cm	[ [ [] ] ]	[ "99.20", "36.06", "37.23", "88.56", "36.01", "88.52" ]	icd9pcs	[ [ [] ] ]				11637, 11868			8683, 8779	5523, 5744	11892, 12311	11540, 11615		8536, 8543	10258, 11519							1588, 1595										8802, 10240		5424, 5502		6002, 6582				6600, 6626								6655, 8315													8338, 8509	8560, 8666
55,337	164,768	37828	Discharge summary	report	Admission Date: [2169-10-31] Discharge Date: [2170-1-12] Date of Birth: [2118-7-8] Sex: F Service: SURGERY Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[First Name3 (LF) 695] Chief Complaint: End stage liver disease and hepatorenal syndrome Major Surgical or Invasive Procedure: [2169-11-7] EGD [2169-11-26] colonoscopy [2169-11-28] DCD Liver transplantation with portal vein to portal vein, roux-n-y hepaticojejunostomy, common hepatic artery (donor) to proper hepatic artery (recipient) [2169-11-28] DCD kidney tranplantation, left kidney to right iliac fossa [2169-11-28] splenectomy [2169-12-7] exploratory laparotomy, small bowel resection, enteroenterostomy x 2 [2169-12-21] open tracheostomy [2169-12-21] tube cholangiogram [2169-12-22] Ultrasound guided liver biopsy [2169-12-24] CT guided drainage of splenic bed fluid collection and aspiration of anterior abdominal wall collection [2169-12-25] right hepatic artery stent placement [2169-12-28] flexible bronchoscopy [2170-1-2] tube cholangiogram [2170-1-9]: post pyloric feeding tube replacement History of Present Illness: 51F with ESLD secondary to alcoholic cirrhosis with HRS requiring dialysis three times a week. Patient began experiencing symptoms in [2169-5-24], when she was admitted to OSH with jaundice, mild confusion, abdominal distention and abdominal pain. She was found to have significant ascites and hepatomegaly with splenomegaly. She was started on prednisone therapy and discharged. She was later readmitted with worsening jaundice and abdominal pain and found to have acute renal failure requiring dialysis. In [Month (only) 359] she was evaluated by Dr. [Last Name (STitle) 696] for liver-renal transplant (patient was refractory to prednisone tx). She last drank alcohol [2169-6-12]. She has been living at home and states she had no recent decompensation. She was admitted to an OSH 3 weeks ago for a fall (injured her right ankle) and was briefly at rehab. She denies recent fever, chills, vomiting. She describes mild nausea and poor appetite. She denies chest pain or shortness of breath. She describes occasional bright red blood in her stools related to hemorrhoids. Denies black stool or vomiting blood. Patient states she was called by the transplant team for direct admission to [Hospital1 18] for possible liver-renal transplant this admission. Her most recent MELD was 42 ([10-27] labs Tbili 27.6, INR 2.1, Cr 3.4). Additionally patient was told she needs an endoscopy to complete her transplant eval (per patient everything else completed) and a feeding tube was placed due to insufficient protein intake. Past Medical History: - ESLD [12-26] EtOH cirrhosis - hisory of alcohol hepatitis refractory to steroids. Diagnosed [2169-6-24], followed by Dr. [Last Name (STitle) 696] since [2169-8-24]. - HRS requiring HD Social History: Heavy EtOH use w/ last drink [5-/2169], actively involved in EtOH relapse prevention counseling. Patient was drinking 1 L of hard alcohol over 3 days for the past year (up until [Month (only) 205]). She denies any history of tobacco use or other substance use. She is not currently working, but was previously a human resources director. She lives at home with her husband and [Name2 (NI) ]. She has two children ages 21 and 18, who live near her. Family History: Her [Name2 (NI) ] are alive at ages 79 and 80 and in good health. She has four siblings, none of whom have any chronic illnesses. Physical Exam: Admission Exam VITAL SIGNS: T=96.6 BP=91/50 HR=76 RR=16 O2=100 RA . PHYSICAL EXAM GENERAL: Severly jaundiced. Pleasant, NAD. HEENT: + scleral icterus. Normocephalic, atraumatic. No conjunctival pallor. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No thyromegaly. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or [Last Name (un) 549]. LUNGS: CTAB, good air movement biaterally. ABDOMEN: Round, distended, soft. No fluid wave. No hepatomegaly. Unable to appreciate spleenomegaly. EXTREMITIES: + 3 pedal edema. SKIN: Severly jaundiced. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. [11-25]+ reflexes, equal BL. Normal coordination. Gait assessment deferred. PSYCH: Listens and responds to questions appropriately, pleasant. Pertinent Results: AT time of Admission: [2169-10-31] WBC-11.6* RBC-2.84* Hgb-8.6* Hct-26.9* MCV-95 MCH-30.2 MCHC-31.9 RDW-20.0* Plt Ct-131* PT-24.1* INR(PT)-2.3* Fibrino-147* Glucose-111* UreaN-5* Creat-2.1# Na-137 K-3.4 Cl-97 HCO3-28 AnGap-15 ALT-18 AST-75 AlkPhos-142* TotBili-23.1* Albumin-2.5* Calcium-8.5 Phos-3.4 Mg-2.0 At time of discharge: [2170-1-12] WBC-11.2* RBC-2.87* Hgb-8.6* Hct-27.3* MCV-95 MCH-29.9 MCHC-31.4 RDW-18.2* Plt Ct-316 PT-10.6 PTT-21.5* INR(PT)-0.9 Glucose-129* UreaN-12 Creat-0.5 Na-133 K-4.4 Cl-94* HCO3-29 AnGap-14 ALT-23 AST-27 AlkPhos-604* TotBili-0.5 Calcium-9.1 Phos-3.9 Mg-1.8 tacroFK-10.5 [2170-1-9] TSH-8.9* T4-7.5 T3-61* Brief Hospital Course: 51 year old female with ESLD secondary to alcohol cirrhosis complicated by HRS requiring hemodialysis. She was admitted with MELD 42 in hopes of liver-kidney transplant. 1. END STAGE LIVER DISEASE [12-26] ETOH CIRRHOSIS: MELD score based on [10-27] labs was 42. She was currently stable and fully oriented with no clinically symptoms of acute liver decompensation. Patient has been evaluated by the transplant team as an outpatient who recommended admission for possible tranplant based on elevated MELD score. 2. Hepatorenal Syndrome: Creatinine on [2169-10-27] 3.4. Requires dialysis three times a week. Received dialysis today. Patient is candidate for dual liver-renal transplant and followed by Dr. [Last Name (STitle) 970]. She received hemodialysis and was followed in consult by the transplant surgery team until the time of her combined liver/kidney transplant with splenectomy on [2169-11-28] She was taken to the OR with Dr [Last Name (STitle) ] and Dr [Last Name (STitle) ] for the liver portion of the transplant and received an Orthotopic deceased donor liver transplant, portal vein to portal vein anastomosis, Roux-en-Y hepaticojejunostomy over a 5-French feeding tube, common hepatic artery(donor) to proper hepatic artery(recipient) end-to-end), and splenectomy. Intra-op she received 9 liters of crystalloid, 18 units fresh frozen plasma, 12 units of packed red cells, 5 units of platelets, 4 units of cryo and 4680 mL of Cell [Doctor Last Name ]. The kidney was then placed in the right iliac fossa, no ureteral stent was used per op report and none seen on follow up KUB a few days later. The patient was transferred to the SICU where she underwent a prolonged ICU stay. ********** MICU course: Patient was hypotensive and required pressors. Was receiving CVVH, once that stopped and some fluid, albumin, blood was repleted and midodrine was given, she was able successfully to come off of pressors. Afterwards, patient was able to tolerate HD, off of pressors. Patient had Dobhoff placed; it was coiled so was replaced. Patient was nauseous frequently, so tubefeeds were held intermittently, and antiemetics were provided. PPN was given temporarily. Patient had a leukocytosis, so Infectious Disease team was consulted. Patient was pan-cultured(no infection identified), and she was started on broad-spectrum antibiotics as prophylaxis. ******** The following is the [Hospital 228] hospital course after her combined liver and kidney transplant with splenectomy on [2169-12-1]. The hospital course will follow in the systems format. . Neurological: She remained intubated and sedated for many days post-operatively. As she was weaned from the propofol gtt she was started on prn versed. After her tracheostomy she was placed on clonidine and prn ativan for brief periods of anxiety. She is now alert and oriented x 3 and has good pain control on po pain medication. . Cardiovascular: Her post-operative course was complicated by atrial fibrillation with rapid ventricular response. She initially required an amiodarone gtt and intermittent IV lopressor. This was due to atrial stretch from large fluid shifts as she was beginning to diurese. Once her heart rate was well controlled and she converted to a normal sinus rhythm her amiodarone and lopressor were converted to PO. The lopressor was titrated up to her current dose of 100mg tid. She does occasionally go into a-flutter but remains with good rate control. . Pulmonary: She was extubated after her liver and kidney transplant but had to be taken back to the operating room for a leaking jejunojejunostomy. After her anastomosis repair she required large volume IVF resuscitation and was extremely hard to wean from the ventilator. Once she was hemodynamically stable she was able to tolerate aggressive diuresis to help with vent weaning. Ultimately she failed multiple spontaneous breathing trials and underwent an open tracheostomy on [2169-12-21]. She did still require some pressure support after her tracheostomy but was finally able to be weaned to trach mask. A flexible bronchoscopy was obtained as there was concern for tracheobroncheomalacia but this showed a normal dynamic airway with mild broncheomalacia in the bronchus intermedius. She was subsequently able to be weaned to trach mask. Speech therapy evaluated her and she was able to tolerate a passy-muir valve. Her initial trach was replaced with a #6-0 fenestrated noncuffed trach. She remains stable with saturations in the high 90s. . Gastrointestinal: ESLD secondary to alcoholic cirrhosis complicated by hepatorenal syndrome. Underwent a successful combined liver and kidney transplant with a splenectomy on [2169-12-1]. Her liver began functioning immediately. On POD [3-29] she began to develop an increasing leukocytosis. A CT scan was obtained and this showed extraluminal air near her jejunojejunostomy. She went back to the operating room for an exploratory lapartomy where she was found to have a perforation of the small bowel near her anastomosis so she underwent a small bowel resection and a redo of her jejunojejunostomy. Post-operatively she has done quite well. Her liver has continued to function well. The only abnormality in her LFTs was a slowing increasing alkaline phosphatase which peaked at 869 on [2170-1-1]. To workup her increasing alkaline phosphatase she had two cholangiograms obtained through her roux tube that showed a patent biliary anastomosis with no stricture (performed on [2169-12-21] and [2170-1-2]). A liver biopsy performed on [2169-12-22] showed no signs of rejection. A CTA of her torso obtained on [2169-12-22] showed a stenosis of her right hepatic artery and a fluid collection in her splenic bed as well as a fluid collection in her anterior abdominal wall. On [2169-12-24] she underwent a percutaneous drainage of the splenic bed abscess with pigtail catheter placement and also underwent an aspiration of her anterior abdominal wall collection. On [2169-12-25] she underwent arteriogram and stent placement into the stenosis of her right hepatic artery. A liver duplex obtained on [1-1] and showed normal flow within her vasculature. She was started on Aspirin and plavix for her hepatic artery stent. Even after her right hepatic artery stent she continued to have a slow elevation of her ALP so she was started on Ursodiol. Her ALP is now in a slow decline. Her transaminases and bilirubin have remained stable in the normal range. Her abdominal incision did have three areas that exhibited drainage and had to be opened; these areas were out laterally on the right on left and also at the middle of the chevron incision. A wound vac dressing has been applied and the wounds are closing and developing good granulation tissue. The bases of the wounds required bedside debridement but have since been healing nicely. . Genitourinary: After her second operation she was approximately 20kg over her dry weight. Once she stablized hemodynamically she was aggressively diuresed with lasix and acetazolamide. Once her weight stablized at the 77-79kg range and she showed no signs of edema on her physical examination her lasix was discontinued. There were two times when her urine output did drop to about 10cc per hour where she received 2 500cc normal saline boluses. This was thought to be due to overdiuresis and intravascular volume depletion. Her weights have been stable off the lasix and her kidney continues to function normally with a serum creatinine of 0.5. A renal transplant duplex showed no hydronephrosis with normal vasculature. . Fluids/Electrolytes/Nutrition: She has a post-pyloric dobhoff tube and is now tolerating her tube feeds at 30cc per hour. A bedside swallow study was performed and she passed wonderfully. She was immediately written for a regular diet and has been doing quite well. Her appetite is slowly returning back to normal but she still requires supplemental enteral nutrition. She did develop high volume diarrhea which is now slowing down in volume. A sample was sent for C.diff which returned back negative x 3. . Hematological: She did require multiple transfusions of blood products in the peri-operative period. Her hematocrit has remained stable in the range of 24-28. She did receive blood transfusions on 2 different occasions the most recent one being on [2169-12-30] of 1 unit of packed RBCs. Her INR is normal. She is receiving subcutaneous heparin for DVT prophylaxis. . Endocrine: Her TSH was noted to be 11 so she was started on levothryoxine. A repeat check of her TSH has shown that it has normalized. Her blood sugars have been well controlled on an insulin sliding scale. . Infectious: After her kidney and liver transplant she began to exhibit a leukocytosis. A CT obtained at that time showed a perforation near her jejunojejunostomy site. Her WBC ultimately rose to a high of 53K on [2169-12-8]. Her urine culutre from [12-8] revealed growth of Burkholderia cepacia. Sputum from [12-9] and a BAL from [12-13] both revealed growth of Burkholderia cepacia as well. A wound culture from [12-11] revealed growth of both VRE and Klebsiella. A repeat wound culture on [12-20] revealed persistent VRE. The splenic bed abscess that was drained revealed growth of VRE as well. She did complete a lengthy and appropriate course of Linezolid (to treat the VRE), Meropenem (for the Burkholderia and Klebsiella), and Flagyl (empiric coverage). She has remained afebrile since completing her course of antibiotics and repeat cultures have all been negative. . Immunosuppresion/Prophylaxis: Her tacrolimus is currently being dosed daily by her level. She is continuing on her prednisone taper. Due to complaints of nausea her cellcept dose was decreased to 500mg [Hospital1 ], down from 1000mg [Hospital1 ]. She continues on fluconazole and valcyte for prophylaxis. Her PCP prophylaxis is in the form of monthly doses of pentamadine. . Once the patient was transferred to the regular surgical floor after 40 days in the ICU she made excellent progress. The trach was decannulated and capped which she tolerated without evidence of respiratory distress. She remained afebrile and was off all antibiotics except prophylactic transplant meds. Her tube feeds were continued and the dobhoff had to be replaced. She was tolerating the tubes feeds but had some diarrhea. Tube feeds have been changed to reflect improved renal function. Her PO intake remains compromised and she should be encouraged on diet and supplements and not drink plain water. Alk phos has been persistently elevated but other LFTs are stable and WNL. Renal function omproved with excellent urine output and baseline creatinine of 0.5 The patient received Haemophilus, Meningococcal and Pneumovax prior to discharge s/p splenectomy. Final trach removal can be performed at [Hospital1 ] [Hospital1 8]. Levothyroxine dose which was started in the ICU was increased on [1-10] and the patient should have follow up thyroid function testsweek of [2-12]. Medications on Admission: - Clotrimazole [Mycelex] 10mg Troche dissolve in mouth 5x day - Ergocalciferol (Vitamin D2) 50,000 unit Capsule 1 Capsule(s) by mouth weekly - Folic Acid 1mg Tablet daily - K Phos Di & Mono-Sod Phos Mono 250mg Tablet TID - Lactulose 10 gram/15 mL Solution 30 ml by mouth twice daily - Midodrine 10mg Tablet twice daily (Prescribed by Other - Norfloxacin [Noroxin] 400mg Tablet mouth daily - Omeprazole [Prilosec] 20mg Capsule, Delayed Release(E.C.) - Rifaximin [Xifaxan] 200mg Tablet twice daily - Vit B Cmplx 3-FA-Vit C-Biotin [Nephro-Vite Rx] 1 mg-60 mg-300 mcg mouth daily - Multivitamin - Thiamine HCl 100mg Tablet by mouth daily Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection TID (3 times a day). 2. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale Subcutaneous every six (6) hours. 5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for anxiety. 8. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 10. Prednisone 5 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily): Through [1-16] the reduce to 10 mg daily and follow transplant clinic taper per attached sheet. 11. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QTUES (every Tuesday): Taper dose per transplant clinic recommendations. 13. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily): This dose was increased on [1-10]. 14. Ursodiol 300 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 15. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): Hold for SBP < 110 or HR < 60. 16. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 17. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO twice a day. 18. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Two (2) ml Injection Q8H (every 8 hours) as needed for nausea. 19. Pentamidine 300 mg Recon Soln Sig: One (1) INH Inhalation once a month: Last dose received [2170-1-9]. Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: alcoholic cirrhosis, hepatorenal syndrome now s/p combined liver/kidney transplant [2169-11-28] hypothyroid malnutrition Hepatic artery stenosis with stent placement Post transplant DM Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Bedbound. Discharge Instructions: Please call the transplant clinic at [Telephone/Fax (1) 673] for fever, chills, nausea, vomiting, diarrhea, constipation, inability to take or keep down food, fluids or medications. Monitor the incision for redness, drainage or bleeding. The abdominal incision is currently being treated with a VAC which will be evaluated at her clinic appointment with Dr [Last Name (STitle) ] on [1-17] Labwork every Monday and Thursday with results to the transplant clinic, please fax results to [Telephone/Fax (1) 697] Trach may be removed at your facility upon admission Followup Instructions: f/u with [Last Name (un) ] next week [1-17] at 9AM (BEFORE her appts here at 10:30 and 11:20. Please make sure patient brings glucometer and all supplies with her to [Last Name (un) ] visits [Last Name (LF) ],[First Name3 (LF) 156] TRANSPLANT SOCIAL WORK Date/Time:[2170-1-17] 10:30 [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707], MD, PHD[MD Number(3) 708]:[Telephone/Fax (1) 673] Date/Time:[2170-1-17] 11:20 [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707], MD, PHD[MD Number(3) 708]:[Telephone/Fax (1) 673] Date/Time:[2170-1-25] 9:20 **Please see attached form for full appointment schedule* [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707] MD, [MD Number(3) 709] Completed by:[2170-1-12**]	[ "518.5", "787.91", "276.52", "427.31", "585.6", "997.4", "789.59", "571.2", "572.4", "263.9", "041.3", "998.32", "456.8", "244.9", "998.59", "572.8", "997.79", "303.93", "V09.80", "572.3", "447.1", "427.32", "567.22", "E878.0" ]	icd9cm	[ [ [] ] ]	[ "45.91", "31.1", "54.91", "39.95", "00.40", "87.54", "00.93", "96.72", "41.5", "45.62", "45.25", "50.59", "33.21", "39.50", "00.45", "55.69", "50.11", "39.90", "96.6" ]	icd9pcs	[ [ [] ] ]	18805, 18884	5139, 16310	339, 1175	19122, 19122	4458, 5116	19853, 20707	3468, 3603		16994, 18782	18905, 19101		16336, 16971			19252, 19830							3618, 4439																251, 301								1203, 2749								19136, 19228					2771, 2975	2991, 3452
64,057	135,043	33713	Discharge summary	report	Admission Date: [2173-3-11] Discharge Date: [2173-3-26] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 30] Chief Complaint: Slurred speech Major Surgical or Invasive Procedure: [2173-3-18]: Mid-line placed R arm History of Present Illness: 87yoF with multiple medical problems including atrial fibrillation on Coumadin, dCHF (EF >70%), DM, CRI (Stage III) who presented to OSH with slurred speech, found to have right occipital and right cerebellar infarcts with hemorrhagic transformation of both infarcts. The pt had normal speech on [3-10] at 3 a.m. when she spoke to her husband when he got up to the bathroom. When her husband woke her at 8 a.m., her speech was slurred, as if she were drunk. EMS was called and she was taken to [Location (un) 16843]. . At [Hospital 16843] Hospital, she was judged as somnolent. Laboratory data was significant for WBC 11.6, INR 1.36, creatinine 1.35, A1c 6.9, cholesterol 160, triglycerides 107 and LDL 102, digoxin 1.1. Chest x-ray with mild pulmonary edema, BNP 316. TSH described as normal range. EKG showed t-wave inversion laterally and in leads II and III with flat cardiac enzymes. . Given concern for CVA, an aspirin was given, Neurology consulted, and MRI planned for the afternoon of [3-11], Coumadin was restarted. Of note, Digoxin level was 1.1 and she was noted to be in afib with adequate rate control. BNP increased to 838 on [3-11]. She was hypertensive and was treated with metoprolol and increased amlodipine. At about 14:30 on [3-11] she was noted to be unresponsive per nursing notes. Stat non-contrast head CT was ordered and Coumadin held at ~ 5:30 p.m. She was found to have the right occipital and right cerebellar infarcts with hemorrhagic transformation and the patient was transferred to [Hospital1 18] for further managment. Past Medical History: - Atrial fibrillation - Coronary artery disease - Chronic renal insufficiency - Diastolic congestive heart failure (EF >55%) - Diabetes - Hypertension - Glaucoma Social History: Husband [Name (NI) 8096], daughter [Name (NI) ], [First Name3 (LF) ] [Name (NI) 333]. Lives with [Doctor Last Name 8096] and [Doctor Last Name 333]. Aids twice weekly for help with her husband at home. Mrs. [Known lastname 67299] was independent in self-care and ambulation prior to hospitalization. Non-smoking. No alcohol. Family History: Non-contributory Physical Exam: VS: Tc 97.3; Tm 98.9; BP 140/37; HR 58; RR 16; Sat 96% RA Gen: AAOx3, able to answer questions with some difficulty communicating; still dyarthric; NAD HEENT: NC/AT, sclerae anicteric; dry MM, OP clear Neck: JVP ~ 8 cm H2O; no JVD; supple, trachea midline CV: Regular rate, irregular, III/VI systolic murmer RUSB, II/VI holosystolic murmur LLSB Resp: scant bibasilar crackles; decreased breath sound R base; no IWOB; speaking in full sentences GI: Soft, NTTP; no rebound; non-tympanic; +BS Ext: WWP, no c/c/e; feet cool, palpable DP pulses (L>R) Neuro: AAOx3; EOMI, PERRL, face symmetric, tongue midline; dysarthric; 5/5 strength in upper and lower extremities; LT intact distally; no extinction Pertinent Results: Admission Labs: [2173-3-11] 11:11PM BLOOD WBC-11.9* RBC-4.89 Hgb-14.2 Hct-43.2 MCV-88 MCH-28.9 MCHC-32.8 RDW-14.1 Plt Ct-294 [2173-3-11] 11:11PM BLOOD PT-17.4* PTT-23.4 INR(PT)-1.6* [2173-3-11] 11:11PM BLOOD Glucose-127* UreaN-27* Creat-1.4* Na-141 K-4.1 Cl-99 HCO3-30 AnGap-16 [2173-3-11] 11:11PM BLOOD Calcium-9.3 Phos-3.1 Mg-2.2 [2173-3-19] 05:34PM BLOOD Type-ART pO2-49* pCO2-41 pH-7.54* calTCO2-36* Base XS-10 Discharge Labs: [2173-3-26] 11:11PM BLOOD WBC-9.8 RBC-4.50 Hgb-13.0 Hct-39.5 MCV-88 MCH-28.9 MCHC-32.8 RDW-14.2 Plt Ct-296 [2173-3-26] 11:11PM BLOOD PT-19.1* PTT-25.2 INR(PT)-1.7* [2173-3-26] 11:11PM BLOOD Glucose-121* UreaN-50* Creat-2.1* Na-141 K-4.7 Cl-95 HCO3-34 AnGap-17 [2173-3-26] 11:11PM BLOOD Calcium-9.2 Phos-4.7 Mg-2.6 Micro: URINE CULTURE (Final [2173-3-13]): NO GROWTH. URINE CULTURE (Final [2173-3-19]): NO GROWTH. Blood Culture, Routine (Final [2173-3-25]): NO GROWTH x2 CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [2173-3-23]): Feces negative for C.difficile toxin A & B by EIA. Studies: CT head [3-12]: No interval change from [2173-3-11] of a right occipital and cerebellar infarction with associated hemorrhagic components. . CXR PA/LAT [3-13]: There are bilateral pleural effusions, which are moderate in size, right side worse than left. Left retrocardiac opacity is again seen. There is also prominence of the pulmonary interstitial markings, which is stable. Calcification in thoracic aorta is present. . . CTA Chest [3-16]: 1. No pulmonary embolism or aortic dissection. 2. Prominent central pulmonary arteries are suggestive of pulmonary hypertension. 3. Marked coronary artery disease and atherosclerotic plaques along the aorta. 4. Moderate bilateral pleural effusions, right worse than left, with adjacent atelectasis. 5. Ground-glass opacities compatible with fluid overload, but also suspicious for superimposed infection. . Portable CXR [3-19]: Large right and small-to-moderate left pleural effusion has worsened. This intensifies the severity of edema in the right lung and may account for apparent upper lobe consolidation but followup is recommended to exclude right upper lobe pneumonia. Large heart is substantially obscured by leural fluid, but no better than it was on [3-16]. Mediastinal veins and the hila are still dilated. No pneumothorax. . AP/Lat CXR [3-23]: Improvement of pleural effusion and marked pulmonary congestion on this followup examination. Both lung fields can now be identified and do not show any acute local infiltrates. . Cards: [3-12] ECG: Atrial fibrillation. Left ventricular hypertrophy with secondary repolarization abnormalities. Q waves in the anteroseptal leads could be due to left ventricular hypertrophy, although old anteroseptal myocardial infarction cannot be excluded. No previous tracing available for comparison. [3-20] ECG: Atrial fibrillation. Prior anteroseptal myocardial infarction of indeterminate age. Inferior and lateral ST-T wave changes may be due to myocardial infarction or left ventricular hypertrophy. Compared to the previous tracing of [2173-3-15] the findings are similar. . [2173-3-12] TTE: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Left ventricular systolic function is hyperdynamic (EF>75%). There is a mild resting left ventricular outflow tract obstruction. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is mild functional mitral stenosis (mean gradient 4mmHg) due to mitral annular calcification. 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 an anterior space which most likely represents a prominent fat pad. Brief Hospital Course: 87yoF with multiple medical problems including atrial fibrillation on Coumadin, dCHF, DM, CRI who presented to OSH with slurred speech, found to have right PCA embolic stroke with hemorrhagic transformation. The [Hospital ] hospital course was complicated by worsening dCHF, persistent hypoxia and R >>> L pleural effusions. Clinical status improved with aggresive diuresis. . #) CVA The patient underwent CT head for her slurred speech and was found to have the right occipital and right cerebellar infarcts with small hemorrhagic transformation of both infarcts. The infarcts are believed to be cardioembolic secondary to atrial fibrillation, as her INR was found to be sub-therapeutic at 1.36 at [Hospital 16843] Hospital where she first presented [3-10]. Given concern for CVA, an aspirin was given, Neurology consulted, and MRI planned for the afternoon of [3-11], Coumadin was restarted. At about 14:30 on [3-11] she was noted to be unresponsive per nursing notes. Stat NCHCT was ordered and Coumadin held at ~ 5:30 p.m. She was found to have the right occipital and right cerebellar infarcts with hemorrhagic transformation and the patient was transferred to [Hospital1 18] for further managment. . On arrival to the [Hospital1 18] Neuro ICU, Coumadin was held and ASA 325mg was started until serial CT heads [3-11] and [3-12] showed no interval change in the hemorrhagic conversions of both infarcts. TTE was obtained on HOD2 to determine a source of the embolic CVA. No thrombus or source of embolus was commented on. The patient was determined to be neurologically stable and Coumadin was re-started with an ASA 325mg bridge. Per neurology recs no heparin gtt was initiated due to concern for bleeding. Her ASA was discontinued on HOD8 after her INR was between [2-18] for > 24hrs. Coumadin was held from [3-20] to [3-25] due to elevated INR and poor nutritional status. Coumadin was restarted on [3-25] (0.5mg) and [3-26] (2mg), and INR on discharge was 1.7. - Recommend Speech therapy, OT, PT - last INR 1.7, recommend rechecking on [2173-3-28] and continue warfarin as appropriate for a goal INR of 2 to 3. Note: due to diminished nutritional status her INR remained elevated at 2.5-2.9 for several days despite holding her coumadin. . #) dCHF Exacerbation Since arrival at [Hospital1 18] the pt had progressively worsening hypoxia, and CXR on HOD3 showed pulmonary edema and moderate R>L layering pleural effusions. The patient was given Lasix 20mg IV x 5 (HOD4-6, and HOD9) for little effect. The patient's fluid balance remained positive during this time (200 to 400cc per day). Repeat CXR on HOD6 showed continued cardiomegaly, pulmonary vascular congestion, R>L pleural effusions, and left retrocardiac opacification. A CTA was also obtained on HOD6 that showed no PE, but did show evidence of pulmonary HTN, marked CAD, moderate R>L pleural effusions, fluid overload and likely superimposed infection. A BNP was sent on HOD7 that returned 10,676. . By HOD8, the patient's O2 saturation had dropped to 90-92% on 6L NC and she was transferred to the Medicine Team. The patient underwent aggressive diuresis with lasix 100mg IV two to three times daily with net negative fluid balances (-1000 to -2000cc). Therapeutic thoracentesis was considered, but given her INR and improving O2 sats it was deferred. Repeat CXR on HOD13 showed reduced effusions, and her supplemental O2 was weaned off. The patient was not reporting dyspnea at time of discharge. - Recommend titrating the pt's lasix dose from 60mg PO based on symptoms and signs of CHF. Recommend goal negative -500cc to 1L. - monitor volume status, electrolytes and renal function . #) Leukocytosis Due to worsening hypoxia, a CXR was taken on HOD3 that showed evidence of CHF with possible superimposed infection. Serial ABGs on HOD5 showed 7.46/43/41 -> 7.43/46/62 -> 7.46/43/46, and the patient was started empirically on Levofloxacin and Cefepime for concern of HAP vs. aspiration. On HOD6 CTA of the thorax showed possible infection in the setting of massive fluid overload. Of note, the patient's WBC increased to 12.0 (HOD8) -> 11.8 (HOD9) while on Levo/Cefepime. The patient was transferred to the Medicine Service and it was decided to stop antibiotics given no evidence of active pulmonary infection. The pt finished a 5 day course of her emperic coverage, and the Levo/Cefepime was discontinued on HOD9. Repeat CXR on HOD13, in the setting of reduced effusions and better visualization of the lung fields, did not show signs of infection. Urine ctx from HOD2 and HOD7 returned no growth. Blood ctx's from HOD8 were negative. . #) AFib On arrival to the [Hospital1 18] Neuro ICU, Coumadin was held and ASA 325mg was started (due to concern of the ICH). Initial INR was 1.6. TTE was obtained on HOD2 to determine a source of the embolic CVA. No thrombus or source of embolus was commented on, and was presumably not seen. The patient was determined to be neurologically stable and Coumadin was re-started and ASA was discontinued on HOD7 (INR now 1.3). Of note, the pt was adequately rate controlled throughout the admission on metoprolol. Her digoxin was discontinued secondary to bradycardia. Coumadin was held from [3-20] to [3-25] due to elevated INR (2.5 to 2.9) and poor nutritional status. Coumadin was restarted on [3-25] (0.5mg) and [3-26] (2mg). At the time of discharge, the pt's INR was 1.7, and her coumadin dose was 2mg daily. - last INR 1.7, recommend rechecking on [2173-3-28] and continue warfarin as appropriate for a goal INR of 2 to 3 - titrate metoprolol as needed fro rate control . #)Acute Renal Failure The patient was admitted with a Cr of 1.3, which trended up with diuresis to 1.9 by HOD10. Of note, the pt received IV contrast for her CTA on HOD6, which may have contributed to her ARF. Despite rising creatinine, diuresis was continued due to her dCHF flare and worsening hypoxia. FeUrea on HOD7 was found to be 15%. By HOD12 her Cr fell to 1.8 and stabilized. On HOD14, 5mg Lisinopril was added to optimize BP control and CHF regimen, and Cr increased to 2.0 on HOD15. On HOD16 her Cr increased to 2.1, and the lisinopril was discontinued. During the course of her admission, medications were renally dosed appropriately. There were no indications for renal replacement therapy throughout the hospital course. - Recommend checking creatinine [2173-3-27]; Creatinine at time of discharge was 2.1; her lisinopril was stopped at that time. . #) Nutrition The pt was evaluated by Speech & Swallow on HOD2 and recommended NPO status. She was upgraded to pureed solids and nectar thick solids by HOD4, and to ground solids by HOD11. Initially the pt was taking poor POs, with gradual improvement over the course of the admission. By HOD14 she was taking approximately 400cc of PO fluid per day. The family declined PEG tube placement. - recommend repeat speech and swallow assessment at rehab . #) HTN While in the Neuro ICU, the pt's blood pressure was strictly controlled with a nicardipine drip and IV hydralizine for SBPs 120-150. Her metoprolol was also continued at admission. Upon transfer to the floor, she was controlled with PO metoprolol and PO amlodipine. SBPs were kept below 160 with IV hydralizine prn. Spironolactone was added on HOD13, and increased on HOD14 to 50mg daily. Given the pt's stable Cr by HOD14, 5mg of PO lisinopril were begun to optimize BP control, but then discontinued on HOD16 due to worsening Creatinine. -- consider adding additional BP medications when patient creatinine stable and no further active diuresis is needed. . #. Code Status: Spoke with patient and HCP (daughter- [Name (NI) ]) and confirmed to be Full Code. Although the patient and HCP stated that she did not want long term intubation . #.CONTACT: HCP: [Name (NI) ] [Name (NI) 67299] [Telephone/Fax (1) 78008] Medications on Admission: Medications on Transfer: - Drisdol 50,000 U PO every Sunday - Digoxin 0.125 QD at 13:00 - Lasix 20 mg IV QD - Lopressor 25 mg PO Q12H - Lumigan 0.03 % both eyes QHS - Norvasc 10 mg - Oxygen 2L by nasal cannula - baseline - Timoptic 0.25% both eyes QAM - Tylenol 650 mg Q4H PRN pain or fever Home Medications also included: - Coumadin 3 mg PO QD - Asacol 2400 mg PO BID - Calium - Glyburide - Iron sulfate - Levothyroxine 75 mg PO QD - Pilocarpine 4 % both eyes QHS Discharge Medications: 1. timolol maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic QAM (once a day (in the morning)). 2. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. pilocarpine HCl 4 % Drops Sig: One (1) Drop Ophthalmic QHS (once a day (at bedtime)). 4. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 5. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. insulin lispro 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR (AS DIRECTED): Please follow sliding scale. 7. spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for Wheezing. 9. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for Wheezing. 10. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: [1-17] Tablet Extended Release 24 hr PO once a day. 11. docusate sodium 50 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 13. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 14. warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: Goal INR 2 to 3. 15. Lasix 20 mg Tablet Sig: Three (3) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Hospital3 68789] ([Last Name (un) 16844]) - [Location (un) 1157] Discharge Diagnosis: Primary Diagnosis: - Right cerebellar/occipital cardioembolic CVA with hemorrhagic transformation - Acute diastolic heart failure with large pleural effusion - Bradycardia - Dysphagia and malnutrition Secondary: - Atrial fibrillation - CKD stage IV - Diabetes mellitus type II - Hypothyroidism - Hypertension - Hyperlipidemia - Osteoarthritis - Osteoporosis Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. [Known lastname 67299], It was a pleasure taking care of you while you were in the hospital. You were transferred to our hospital after you developed an infarct (stroke) in two regions of your brain from an emboli (blood clot) from your heart. These infarcts began to bleed, and your home blood thinner was held until serial head CT scans showed stabilization of the hemorrhage. You were restarted on your home warfarin at this point to decrease the risk of future stroke. You also had worsening heart function on this admission, and subsequently developed hypoxia (low blood oxygen level) due to fluid accumulation in you lungs. You were given furosemide (a diuretic) to help you clear the excess fluid from your body. By the end of the second week of your hospitalization, repeat chest X-ray showed substantial improvement in the amount of fluid in and around your lungs, and you no longer required supplemental oxygen. Your hypoxia subsequently resolved. Also during this hospitalization, you were given a 5 day course of broad spectrum antibiotics (levofloxacin and cefepime) to cover a possible superimposed infection. After completion of your antibiotics, there were no signs or symptoms of infection. You should follow-up with Neurology and your primary care provider regarding your strokes and heart failure. An appointment for neurology has been set, and details can be found below. Please see ophthamology within 2 months of discharge regarding the changes to your eye medications. Significant changes have been made to your medication regimen while you were in the hospital. The following changes have been made: 1) Your Coumadin (Warfarin) dose is currently 2mg by mouth daily, your extended care facility should adjust your Warfarin for the appropriate INR (goal of 2 to 3), and you should continue to take your Warfarin as directed by them 2) Your Lasix (Furosemide) was INCREASED to 60mg by mouth daily, your extended care facility will reduce this amount over time, and you should continue to take your Furosemide as directed by them 3) Your home Glyburide was STOPPED, you should follow-up with your primary care provider regarding this medication 4) Timolol eye drops (0.25%) were ADDED to your regimen, one drop in each eye in the mornings; please follow-up with your ophthamologist regarding this medication 5) Latanoprost eye drops (0.005%) were ADDED to your regimen, one drop in each eye in the evening; please follow-up with your opththamologist regarding this medication 6) Simvastatin 10mg by mouth daily was ADDED to your regimen 7) Spironolactone 50mg by mouth daily was ADDED to your regimen 8) Metoprolol XL (12.5mg) by mouth daily was ADDED to your regimen 11) Amlodipine (10mg) by mouth daily was ADDED to your regimen 12) Albuterol (0.083%) and Ipratropium (0.02%) nebulizers were ADDED to your regimen; please take as needed every 6 hours for wheezing or shortness of breath 13) Docusate 100mg by mouth was ADDED for constipation as needed, and can be taken up to twice a day 14) Senna 1 tablet by mouth was ADDED for constipation as needed, and may be taken up to twice a day The following medications were STOPPED, and you should follow-up with your primary care provider regarding continuation of these medications: 1) Asacol STOPPED 2) Cyclobenzaprine STOPPED 3) Alprazolam STOPPED Please continue to take your over-the-counter vitamins as instructed by your extended care facility and your primary care physician, [Name10 (NameIs) 19566] your iron supplementation, and your calcium supplementation. A list of your new medication list will be provided with this document. Followup Instructions: Department: NEUROLOGY When: WEDNESDAY [2173-4-7] at 2:00 PM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 640] [Last Name (NamePattern4) 3445], MD [Telephone/Fax (1) 2574] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 858] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Please follow-up with your primary care provider [Name Initial (PRE) 176] 1 week after discharge from your rehabilitation facility. Please follow-up with ophthamology within 2 months of discharge. Completed by:[2173-3-27]	[ "427.31", "414.01", "428.33", "585.4", "416.8", "784.51", "272.4", "427.89", "518.0", "584.9", "434.11", "V58.61", "733.00", "787.20", "244.9", "799.02", "250.00", "263.9", "403.90", "432.9", "428.0" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	17247, 17351	7390, 15357	264, 304	17754, 17754	3244, 3244	21600, 22186	2494, 2512		15873, 17224	17372, 17372		15383, 15383			17932, 21577		3696, 7367					2527, 3225																210, 226								332, 1919					3260, 3680	17391, 17733		17769, 17908				15408, 15850	1941, 2105	2121, 2478
43,782	101,748	39711	Discharge summary	report	Admission Date: [2100-8-18] Discharge Date: [2100-8-23] Date of Birth: [2057-1-23] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1] Chief Complaint: Multinodular goiter Major Surgical or Invasive Procedure: Total thyroidectomy History of Present Illness: The patient is a 43 year old woman who has had a history of hypothyroidism,here for total thyroidectomy for MNG.She had an increasing thyroid swelling since a couple of years,and showed up at Dr[Name (NI) 10946] clinic. The goiter went basically from her chin down to her sternum. She was diagnosed with MNG and was planned for a total thyroidectomy. Past Medical History: hypothyroidism Social History: She works as a hotel manager. Prior smoker and quit in [2098]. Drinks alcohol rarely per hospital records. Denies illicit drug use. Family History: No history of thyroid disease, diabetes, heart disease, or COPD. Father's side of family has had uterine cancer and other cancers of unknown etilogy. Physical Exam: General: Alert and oriented x3, Obese female with large neck swelling, no distress, appears comfortable. Eyes: Anicteric sclerae. Extraocular movements normal. ENT: Normal external appearance. Oropharynx is without lesions. Neck: incision with steri strips clean dry intact,no erythema, positive edema. Cardiovascular: Regular, borderline tachycardic, [1-16] SM at LUSB. Respiratory: Normal to inspection, percussion, and auscultation. GI: Normal bowel sounds. Abdomen not distended or tender. No hepatomegaly. Neurologic: Normal deep tendon reflexes. No tremor. No spasms. Vulvar exam: erythematous vulva with redness extending out to inner thigh. underlying skin - moist with concern for wheeping from the wound. No vaginal discharge noted. Extremities:[12-12]+ pitting edema present bilaterally, warm, no clubbing. Pertinent Results: [2100-8-18] 08:50PM BLOOD WBC-12.7* RBC-2.75* Hgb-8.8* Hct-26.6* MCV-97 MCH-31.9 MCHC-33.0 RDW-13.5 Plt Ct-213 [2100-8-18] 08:50PM BLOOD PT-13.7* PTT-30.2 INR(PT)-1.2* [2100-8-18] 08:50PM BLOOD Plt Ct-213 [2100-8-18] 08:50PM BLOOD Glucose-154* UreaN-10 Creat-0.6 Na-140 K-4.0 Cl-108 HCO3-22 AnGap-14 [2100-8-18] 08:50PM BLOOD Calcium-8.2* Phos-4.6* Mg-1.6 [2100-8-18] 09:49PM BLOOD Lactate-0.9 [2100-8-18] 09:49PM BLOOD Type-ART Temp-35.9 Rates-14/ Tidal V-500 PEEP-5 FiO2-40 pO2-149* pCO2-44 pH-7.38 calTCO2-27 Base XS-0 -ASSIST/CON Intubat-INTUBATED [2100-8-19] 03:52AM BLOOD WBC-11.6* RBC-2.46* Hgb-7.9* Hct-25.4* MCV-103* MCH-32.0 MCHC-31.0 RDW-14.1 Plt Ct-193 [2100-8-19] 05:54AM BLOOD WBC-13.4* RBC-2.88* Hgb-9.1* Hct-27.4* MCV-95# MCH-31.6 MCHC-33.2 RDW-14.2 Plt Ct-228 [2100-8-19] 03:52AM BLOOD Plt Ct-193 [2100-8-19] 05:54AM BLOOD PT-13.0 INR(PT)-1.1 [2100-8-19] 05:54AM BLOOD Plt Ct-228 [2100-8-19] 03:52AM BLOOD Glucose-686* UreaN-8 Creat-0.4 Na-110* K-3.4 Cl-88* HCO3-17* AnGap-8 [2100-8-19] 05:54AM BLOOD Glucose-139* UreaN-11 Creat-0.5 Na-139 K-4.0 Cl-107 HCO3-21* AnGap-15 [2100-8-19] 01:50PM BLOOD CK(CPK)-375* [2100-8-19] 08:16PM BLOOD CK(CPK)-448* [2100-8-20] 04:03AM BLOOD CK(CPK)-482* [2100-8-19] 01:50PM BLOOD CK-MB-9 cTropnT-<0.01 [2100-8-19] 08:16PM BLOOD CK-MB-9 cTropnT-<0.01 [2100-8-20] 04:03AM BLOOD CK-MB-9 cTropnT-<0.01 [2100-8-19] 05:54AM BLOOD Calcium-7.4* Phos-5.1* Mg-2.3 [2100-8-19] 08:16PM BLOOD Calcium-7.7* [2100-8-19] 03:52AM BLOOD PTH-12* [2100-8-19] 05:54AM BLOOD PTH-14* [2100-8-19] 05:53AM BLOOD Type-ART pO2-113* pCO2-45 pH-7.38 calTCO2-28 Base XS-1 [2100-8-19] 04:28AM BLOOD freeCa-1.11* [2100-8-19] 05:53AM BLOOD freeCa-1.06* [2100-8-20] 04:03AM BLOOD WBC-10.3 RBC-2.37* Hgb-7.5* Hct-22.7* MCV-96 MCH-31.6 MCHC-33.1 RDW-14.2 Plt Ct-122* [2100-8-20] 03:41PM BLOOD Hct-24.0* [2100-8-20] 04:03AM BLOOD Glucose-93 UreaN-8 Creat-0.5 Na-137 K-3.8 Cl-104 HCO3-20* AnGap-17 [2100-8-20] 03:41PM BLOOD Calcium-8.0* Brief Hospital Course: 43 year old female with diagnosis of a massive goiter is status post total thyroidectomy on [2100-8-18]. Intraoperatively patient was intubated and transferred to the intensive care unit for observation as there were concerns that the patient may not be able to maintain her airway due to preoperatively concerns that the thyroid was compressing the airway. Over the night of her operation she became hypotensive with systolic blood pressure to the 80s and she was started on Dopamine drip this was ultimately thought to be related to hypocalcemia. She was infused with 250 ml of albumin to which her systolic blood pressure responded and she was successfully weaned off dopamine drip and was extubated on [2100-8-19] and on room air. On [2100-8-20] she was transferred out of the intensive care unit to the surgical inpatient unit.Of note, she was noted to have extensive vulvar irritation and erythema while in the intensive care unit and Gynecology were consulted and provided recommendations. On [2100-8-21] she her oxygen saturation was in the mid 90s on Room air during the morning,and then triggered at noon time for O2 Sat of 85% Room air. Patient had no dyspnea and was asymptomatic. She was placed on 1 to 4 liters via nasal cannula to maintain her O2 sats. However patient continued to have an O2 Sat 90% on 3 liters nasal cannula. Therefore a chest xray was done which was negative for pneumonia and chest scan was done and was negative for pulmonary embolism. She was diuresed with Lasix intravenously. She continued to have low grade temperature 99 up to 100.2, an electrocardiogram and continued to be tachycardic, although denied dyspnea or chest pain. On [9-28] she continued to have decrease Oxygen saturation, mid 90's on 40-50% shovel mask. She received Lasix 20 mg intravenous and diuresed well. Overnight she was ordered for blood transfusion for a hematocrit of 22 which was stopped due to a rise in temperature from 99.2 to 100.2. She was expectorating green and brown sputum and a sputum culture was obtained. She has some intermittent productive sputum but otherwise is dry and per the patient this is usually worse during the night. A sputum culture and repeat chest Xray PA/Lat was done to rule out pneumonia. The patient continued to have no dyspnea, no respiratory distress and the oxygen was subsequently weaned to 40% and her O2 sats 92% to 94%room air. She was started empirically on Levofloxacillin but has no evidence of lower respiratory tract infection. The pulmonary team were consulted for etiology of hypoxia and recommendations. The patient will follow-up with Pulmonology Outpatient for a bubble study. The patient has no nausea or emesis and diet was advanced from clears to regular which was tolerated well. Her pain was well controlled with oral analgesia. She is ambulating independently with a steady gait. The neck incision with steri strips is clean, dry and intact without erythema, there is edema in the neck. She will follow-up with Dr. [Last Name (STitle) ] on [2100-8-26] for her postoperative visit. She will be discharged home on Levothyroxine, Calcium carbonate and Calcitriol. She will follow up with primary care provider and gynecology in [12-12] week. Medications on Admission: 1. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily) Discharge Medications: 1. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Calcium Carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). Disp:60 Tablet, Chewable(s) Refills:2 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 4. Calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:20 Capsule(s) Refills:2 5. Aluminum-Calcium Packet Sig: One (1) Packet Topical TID (3 times a day) as needed for vulvar pruritis. Disp:20 Packet(s) Refills:0 6. Silver Sulfadiazine 1 % Cream Sig: One (1) Appl Topical TID (3 times a day) as needed for vulvar pruritis. Disp:2 tubes Refills:0 Discharge Disposition: Home Discharge Diagnosis: Multinodular goiter Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the General Surgery Inpatient Unit and underwent a total thyroidectomy.Your tissue was sent to pathology and you should have your results in 1 week. Please monitor your neck incision for any drainage, swelling or redness. Please seek immediate attention if you develop shortness of breath or increase neck swelling. Please notify Dr. [Last Name (STitle) ] office if you have any questions or concerns. You have steri strips on your neck incision, please keep clean and dry. These steri-strips will fall off on their own, please do not remove them. You may shower but avoid swimming or bathing. Please take Tylenol for pain as directed. Please do not drink alcohol or drive while taking this medication as it may cause drowsiness. Do not take more than 4000 mg of acetaminophen (Tylenol) in a 24 hour period. Please monitor for signs and symptoms of hypothyroidism: watch for numbness or tingling around mouth or legs, confusion, muscle spasm,or changes in level of conciousness, these could be signs of low calcium which can happen after thyroid surgery. Please monitor for signs and symptoms of Hyperthyroidism: Anxiety, irritability, trouble sleeping Weakness (in particular of the upper arms and thighs, making it difficult to lift heavy items or climb stairs), Tremors (of the hands, Perspiring more than normal, difficulty tolerating hot weather Rapid or irregular heartbeats, Fatigue,Weight loss in spite of a normal or increased appetite, Frequent bowel movements. If you experience any of these signs or symptoms please contact Dr. [Last Name (STitle) ] office [Telephone/Fax (1) 9]. Your follow-up appointment with Dr. [Last Name (STitle) ] is scheduled for Thursday [2100-8-26] at 11:00 A.M. You will be given a prescription for Ciprofloxacin to treat your respiratory infection, please take 500mg twice a day for 2 weeks, please take all antibiotics as prescribed. Please follow-up with the Pulmonary Clinic ([Telephone/Fax (1) 3554] as an Outpatient for a Bubble Study. Please resume your home medication. Please schedule an appointment with your primary care provider for monitoring of your thyroid level. You will be given a prescription for Calcium Carbonate(Tums)and Calcitriol please take as directed. Followup Instructions: Your follow-up appointment with Dr. [Last Name (STitle) ] is scheduled for Thursday [2100-8-26] at 11:00 A.M.([Telephone/Fax (1) 84720] [Street Address(2) ]., [Location (un) ] Division: General Surgery Please schedule an appointment with Pulmonary Clinc for Bubble study [Telephone/Fax (1) 612] Please schedule follow-up appointment with primary care provider [Last Name (NamePattern4) ].[Last Name (STitle) ] in 2 weeks. Please schedule follow-up appointment with Gynecology in 1 week. Completed by:[2100-8-24]	[ "244.9", "799.02", "780.62", "458.29", "275.41", "278.00", "241.1", "616.9" ]	icd9cm	[ [ [] ] ]	[ "06.4", "86.11", "06.95" ]	icd9pcs	[ [ [] ] ]	8168, 8174	4070, 7329	331, 353	8238, 8238	1972, 4047	10681, 11231	947, 1098		7448, 8145	8195, 8217		7355, 7425			8389, 10658							1113, 1953																272, 293								381, 737								8253, 8365					759, 775	791, 931
26,704	137,002	52414	Discharge summary	report	Admission Date: [2127-12-21] Discharge Date: [2127-12-31] Service: MEDICINE Allergies: Penicillins / Sulfonamides / Morphine Attending:[First Name3 (LF) 465] Chief Complaint: Femur fracture s/p fall Major Surgical or Invasive Procedure: ORIF for left inter/sub troc. fracture Intubation Central Line placement History of Present Illness: 86 year-old male who presented to the ED s/p mechanical fall with left hip Fx. Was at his daughters house walking from bathroom and fell as he walked through the door. Landed on left Hip. No LOC, no CP , No SOB. + Headstrike against the floor. Underwent uncomplciated ORIF on [12-23]. Extubated in PACU without complciation. While on floor, found to be in respiratory distress with SaO2 85% on NRB. ABG done showed 7.09/94/91 with a lactate of 1.8. He was intubated and transferred to MICU for management of hypercarbic respiratory failure. He was tachycardic and had a negative CTA on [12-24]. He steadily improved with normal ABGs by MICU day #1 and was extubated on [12-25] with room air O2 sats 95%. The patient has fluctuating MS and sundowns frequently at night. He does not report pain but, according to his family, this is easily assessed by watching his face. He has been covered with very small doses of Dilauded (0.25mg) which, according to the patient and his family, has well controlled his pain. He is being transferred to the floor for further inpatient medical care. Past Medical History: R TKR in [2117] L TKR in [2127-4-27] (c/b post-op confusion and AF-RVR) [11-30] to OR for L hip repair CAD s/p CABG times two with sternal ostia as a complication. PM Right inguinal hernia repair Pilonidal cyst I&D. Parkinson's with [Last Name (un) 309] Body Dementia c/b Visual Hallucinations. Social History: Social Hx: The patient lives with his wife in a 1 story apartment. He has difficulty walking [1-29] leg stiffness due to Parkinsons. His wife takes care of him. He is able to eat and dress by himself. His daughter lives down the street. He quit smoking in [2094]. He has occassional sips of wine. Family History: Noncontributory. Physical Exam: Vitals: 99.8 137/73 89 17 96% RA General: Intubated HEENT: PERRL, no scleral icterus noted, ETT Neck: supple Pulmonary: Lungs CTA bilaterally anteriorlaterally without R/R/W Cardiac: Irregularly irregular rhythm, S1, S2, [2-2] HSM heard best at apex. Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 1+ radial, DP and PT pulses b/l. neuro: CN II-XII intact Pertinent Results: [2127-12-21] 09:46PM URINE HOURS-RANDOM [2127-12-21] 09:46PM URINE GR HOLD-HOLD [2127-12-21] 09:46PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.014 [2127-12-21] 09:46PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2127-12-21] 09:46PM URINE RBC-[2-29]* WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-<1 [2127-12-21] 02:10PM GLUCOSE-109* UREA N-34* CREAT-1.3* SODIUM-140 POTASSIUM-5.1 CHLORIDE-106 TOTAL CO2-22 ANION GAP-17 [2127-12-21] 02:10PM CK(CPK)-24* [2127-12-21] 02:10PM CK-MB-NotDone cTropnT-<0.01 [2127-12-21] 02:10PM CALCIUM-9.3 PHOSPHATE-3.0 MAGNESIUM-2.0 [2127-12-21] 02:10PM DIGOXIN-1.1 [2127-12-21] 02:10PM WBC-7.1 RBC-3.76* HGB-9.8# HCT-30.4 MCV-81# MCH-26.0# MCHC-32.1 RDW-17.3* [2127-12-21] 02:10PM NEUTS-65.3 LYMPHS-27.4 MONOS-3.9 EOS-2.3 BASOS-1.2 [2127-12-21] 02:10PM HYPOCHROM-2+ ANISOCYT-1+ MICROCYT-1+ [2127-12-21] 02:10PM PLT COUNT-150 [2127-12-21] 02:10PM PT-22.0* PTT-38.5* INR(PT)-3.5 . ECHO [12-24] 1. The left atrium is mildly dilated. The right atrium is markedly dilated. 2. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is difficult to assess but is probably low normal. Overall left ventricular systolic function (EF) cannot be reliably assessed. 3. The right ventricular cavity is dilated. Right ventricular systolic function appears depressed. 4. The aortic root is mildly dilated. The ascending aorta is mildly dilated. 5. The aortic valve leaflets (3) are mildly thickened. Mild (1+) aortic regurgitation is seen. 6. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. 7. At least moderate [2+] tricuspid regurgitation is seen. . EKG: AF with VR 130's and evidence of right hrt strain . Radiologic Data: 1. Hip xray ([12-20])- Comminuted fracture, left proximal femur with intertrochanteric and subtrochanteric components. Moderately severe to severe diffuse osteopenia. . 2. Head CT ([12-20])- no acute intracranial findings -prelim. . 3. C-spine CT ([12-20])- no fractures or prevertebral soft tissue swelling. DJD of spine, but relatively normal vertebral body alignment. . 4. CXR([12-24]) - Status post sternotomy. Cardiomegaly and probable COPD. A right-sided single lead pacemaker with lead tip over right ventricle. No change from preop. . 5. CTA [12-24] MPRESSION: 1. No evidence of pulmonary embolism. 2. Bilateral lower lobe atelectasis with small effusion. 3. Patchy ground glass opacities in bilateral lungs, probably representing pulmonary edema. 4. Marked enlargement of right atrium, IVC and hepatic veins, representing right-sided heart failure. 5. Small low-density area in the left lobe of the liver, which cannot be further characterized on this chest CT. 6. Low-density areas in the right kidney, which is only partially imaged. . 6. CXR for NG placement [12-26] (wet read). Some evidence of atalectasis and fluid in lungs. ? R sided opacity mid-lung. . 7. CXR [12-26] There is a nasogastric tube whose distal tip and side port are not included on the study and are below the inferior margin of the film. However, they are likely below the gastroesophageal junction and within the stomach. There is a single lead right-sided pacemaker and a left-sided IJ central line, which are unchanged in position. Median sternotomy wires are seen. There is cardiomegaly. There is again seen an opacity at the left base most consistent with subsegmental atelectasis as seen on the recent chest CT. There is no evidence for overt pulmonary edema or focal infiltrate. . 8. Elbow x rays [12-28] FINDINGS: Three views of the right elbow are limited secondary to difficulty in positioning the patient. No true lateral radiograph has been provided, thus assessment for joint effusion cannot be performed. There are several densities seen in the joint space suspicious for loose bodies. One density is seen just volar to the distal humerus and a second density is seen adjacent to the radial head. Smaller densities are seen within the adiocapitellar joint, which may represent chondrocalcinosis. No clear fracture is identified. Dedicated films with a true lateral radiograph would be helpful to exclude occult fracture. . [12-31] CXR, official read pending but no gross evidence of opacity (wet read) Brief Hospital Course: The patient is a 86 yo male with AF on Coumadin, CAD s/p CABG, s/p ORIF for left hip fracture [2127-12-24] after a fall on [2127-12-21]. . #. Hip Fracture s/p fall: In the ED, CTA was negative for PE, and showed some pulm edema, RLL opacity read as likely atelectasis. The patient was followed by ortho throughout his hospitalization. He was kept non-weight bearing and went for ORIF of his fracture on [12-23]. The operation went well and he was transeferred to the floor. The patient was transfered to the MICU on [12-24] after his post-op course was complicated by hypercarbic respiratory failure (ABG 7.09/94/91), thought to be secondary to obstruction vs. aspiration vs. sedation on meds. Also on arrival to the MICU gross blood was seen from NGT but this quickly changed to billious output over the day. He was started on Levo/Flagyl and intubated. His hypercarbic respiratory failure resolved within a day, and he was extubated without event. He was subsequently transferred to the floor and followed by ortho and PT who were pleased with his progress despite some persistent edema in the surgical leg and oozing at the wound site. Ortho recommended Cefazolin 1gm IV Q8H for 1 week course and this was switched to PO Keflex to be completed at rehab. He will need ongoing PT and rehabilitation of his recently fractured hip. . #. Elbow pain: The patient developled elbow pain after transfer to the floor. Concern was for previously undiagnosed fracture from his fall. Elbow films were negative for fracture and ortho considered this a frozen elbow. PT worked with him and he had marked improvement in ROM and pain prior to discharge. . #. Cardiovascular: He has a PMH significant for CAD s/p CABG times two with sternal ostia as a complication which was stable without active ischemia. Surveillance cardiac enzymes from [12-24] were negative. Throughout hospitalization he was intermittently in AF with RVR, as in the past. His beta blocker and digoxin were continued, and anticoagulation was accomplished with Heparin gtt until the patient was therapeutic on Coumadin. He is being discharged on his home dose of 5mg Warfarin daily PO. Pt currently off ACE and statin and this can be addressed with his PCP. [Name10 (NameIs) ] also has an aspirin allergy, so his health care providers may consider plavix as outpatient once his fracture heals. . # Labile WBC count: Four days prior to discharge the patient's WBC began to trend upwards in the absence of fever. Work-up revealed negative urinalysis, although CXR showed RLL opacity read as likely atelectasis. His Levo/Flagyl was continued for 5 days and then discontinued in the absence of symptoms (had been started [12-24] for presumed aspiration pneumonia). He was treated with lasix for fluid overload daily at 20mg (home dose 10mg) and will continue on this 20mg dose upon discharge. On the day of discharge, WBC count was elevated at 14. CXR was done and negative for PNA. U/A was sent and negative. He did not have diarrhea. Urine cultures are pending at time of discharge. . #Anemia - Baseline low 30s per old records. This is probably anemia of chronic disease with superimposed iron defficiency anemia. Has been worked up as outpatient by PCP. [Name10 (NameIs) ] was guaiac positive on [12-29]. This was communicated to his PCP and he can have an outpatient colonoscopy at a later date. Otherwise, his HCT was stable throughout admission. . #[Last Name (un) 309] Body Dementia: No antipsychotics. Followed as outpatient for this by a specialist. He was pleasantly demented but able to converse well throughout admission. . #Depression: Restart Zoloft down NG. . #Prophylaxis: PPI, bowel regimen, hep gtt throughout admission . #FEN: NG tube was placed after extubation with tubefeeds for several days. Pt passed a speech and swallow eval on [12-29] with recommended soft diet with nectar thickened liquids. . #Access: PIVs, Left IJ was in place s/p transfer to unit and discontinued one day prior to discharge. . #Communication: With pt and family. He has a PCP at the [Name9 (PRE) 42986] Clinic: Dr. [Last Name (STitle) 108319] [Telephone/Fax (1) 108320] . #Code Status: Full . #Dispo: to rehab . Medications on Admission: Coumadin 5mg q.day; Lopressor 25mg po bid; Lanoxin 0.125 q.day; Allopurinol 100 q.day; Zoloft 100mg po qd, Protonix 40mg po qd, lasix 10mg po qd Discharge Medications: 1. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 7. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO DAILY (Daily). 11. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO Q 8H (Every 8 Hours). 12. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Potassium & Sodium Phosphates [Telephone/Fax (3) 4228] mg Packet Sig: Two (2) Packet PO BID (2 times a day). 14. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 15. Lasix 20 mg Tablet Sig: 0.5 Tablet PO once a day. 16. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a day for 7 days. Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Femur fracture s/p fall Hypercarbic respiratory failure CAD AF Anemia Dementia Discharge Condition: Stable Discharge Instructions: Please take all meds as prescribed. Seek medical attention immediately if you experience new symptoms including leg pain, shortness of breath, bleeding, lightheadedness, fainting, falls, etc. Please follow up as per below Followup Instructions: Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1941], [Name Initial (NameIs) ].D. Phone:[Telephone/Fax (1) 1942] Date/Time:[2128-1-26] 8:30 Have your staples removed in 2 weeks per Ortho Follow-up with your PCP as soon as possible (or with rehab MD) [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 472]	[ "331.82", "V43.65", "276.0", "458.9", "E937.9", "V45.81", "427.31", "311", "518.5", "294.10", "280.9", "E885.9", "V45.01", "719.42", "820.21" ]	icd9cm	[ [ [] ] ]	[ "96.71", "96.6", "96.04", "38.91", "38.93", "99.04", "79.35" ]	icd9pcs	[ [ [] ] ]	12996, 13066	7186, 11433	270, 345	13189, 13198	2627, 7163	13470, 13885	2143, 2162		11628, 12973	13087, 13168		11459, 11605			13222, 13447							2177, 2608																207, 232								373, 1469													1491, 1804	1820, 2127
41,729	119,305	35721	Discharge summary	report	Admission Date: [2172-2-10] Discharge Date: [2172-3-2] Date of Birth: [2116-8-16] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1384] Chief Complaint: Coffee ground emesis Major Surgical or Invasive Procedure: [2172-2-12] cholecystectomy with closure of cholecystoduodenal fistula for duodenal ulcer with cholecystoduodenal fistula. History of Present Illness: 55 year-old male with a h/o EtOH and Hep C cirrhosis, [Month/Day/Year 7344] abuse and ?CAD and seizure d/o who presented to OSH on [2-9] with several episodes of coffee ground emesis. He apparently went to Center for Addictive Behavior to be detoxed from heroin on [1-29]. Approx 3:30am on the 15th, pt woke up and had a loose stool but did not see the color. At approx 730am, he vomitted black material. He then went to the OSH ED where he had coffee ground material in his stomach with some pinkish liquid which did not clear. He also had black positive stool. He then stated he had had some abd cramping during the day [2-8]. During the day [2-9] at OSH, he stated he was nauseous and dizzy. . He got an EGD at OSH in evening [2-9] which showed 2 duodenal ulcers which were clean based. One was noted as having a crater in the center c/w perforation or fistula. Had gastric but not esophageal varices. CT and KUB both showed no free air but CT showed gas in biliary tree and KUB showed ? emphysematous cholecystitis. Of note, pt states he has been using NSAIDs for L knee pain for the last several months. He recieved 6 units FFP and 3 units PRBCS a OSH as well as kayexalate for hyperkalemia. On morning of transfer, Hct 27.8, INR 1.8, Tbili 3.5. Apparently, on admission, Hct 38 but dropped after fluid resuscitation to 24. On admission, INR 1.99 at OSH. . On arrival to the ICU, the pt has dry mouth, headache, L knee pain and abd pain [8-3] which he has had for several days. Last BM was black and was 24 hrs ago. Denies nausea, vomitting, fevers, CP, SOB, diarrhea. States he has had dark urine over past several days at rehab. Past Medical History: Hep C/ EtOH cirrhosis- per OSH, no known h/o ascites, SBP. Has h/o hepatic encephalopathy. States had GIB 6 mo ago with dark stools but was d/c'd from OSH without EGD w/ ?dx [Doctor First Name 329]-[Doctor Last Name ] tear. Gastric varices at OSH on EGD, no esophageal varices. States recieved a partial course of interferon but d/c'd [1-27] psych side effects. - poly substance abuse- last used heroin but detoxed at Center for Addictive Behavior [1-29]. H/o benzodiazepine abuse per OSH record. - HTN- formerly was on clonidine - ?CAD- states tx for possible MI approx 7 yrs ago at [Hospital 189] Hospital - OA of L Knee- s/p injury [5-1]. was taking NSAIDs prior to admission. h/o arthroscopy [10-1] which showed avascular necrosis - bilat middle cerebral artery aneurysm- on MRI/ MRA at OSH. Pt noted in records to have refused intervention in past - depression and anxiety- h/o SI - ETOH abuse with h/o withdrawl - seizure D/O- reports last seizure 6 mo ago. On neurontin but per pt should be on other meds as well. Does not know names thereof. - chronic headaches - "breathing problems" [1-27] deviated septum (per [Hospital ] hosp record) - ulnar nerve entrapment, L carpal tunnel syndrome -bipolar d/o -h/o drug overdoses Social History: Homeless living prior to admission at OSH at rehab and prior to that at shelter and with girlfriend. [Name (NI) ] abuser- last used Heroin IV on a daily basis in early [Month (only) 956] prior to entering detox. States last used EtOH 1 yr ago. Apparently used heavily in his 20's. Smokes cigarettes [12-27] ppd. Family History: Positive for substance abuse in 2 sisters. [Name (NI) ] FH of liver disease. Aunt with lung Ca in her 50s. Mother with HTN. On FH of heart disease Physical Exam: Vitals: T: BP: HR: RR: O2Sat: GEN: no acute distress, states in pain but falling asleep during exam HEENT: PERRL, sclera icteric, no epistaxis or rhinorrhea, dry mucous membrane COR: RRR, no M/G/R, normal S1 S2, PULM: Lungs CTAB, no W/R/R ABD: NT, softly distended, +BS, no masses EXT: No C/C/E, 2+ DP bilat NEURO: alert, oriented x2. Unsure of date and day of week. CN II ?????? XII grossly intact. Moves all 4 extremities. slight resting tremor. No asterixis. SKIN: no cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: CXR [2172-2-10] HISTORY: Transferred from outside hospital, to evaluate for central catheter. FINDINGS: No previous images. No evidence of acute cardiopulmonary disease. Right subclavian catheter extends to the mid portion of the SVC. The study and the report were reviewed by the staff radiologist. CT Abd/Pelvis [2172-2-11] CT ABDOMEN: There are trace bilateral pleural effusions. Absence of intravenous contrast limits evaluation of the abdominal parenchymal organs and vasculature. There is CT evidence of anemia. Liver is nodular in contour, and slightly shrunken, consistent with reported history of cirrhosis. There is an ill-defined hypodensity in segment IV (2, 19), which is incompletely characterized without IV contrast. There is pneumobilia, as well as air within the gallbladder lumen. Gallbladder is also filled partially with oral contrast, which appears to have entered the gallbladder via a fistulous connection from the second portion of the duodenum. In this region, the duodenum is markedly thickened, with prominent peri-duodenal inflammatory stranding. Air and oral contrast material is also seen in the distal common bile duct. There is soft tissue prominence in the region of the ampulla, though no definite nodule or mass is seen, and this prominence may be post-procedural related to recent EUS. There are prominent porta hepatis, and peripancreatic lymph nodes, but the non-contrast appearance of the pancreas itself is unremarkable. Pancreatic duct is not dilated. There are no pancreatic calcifications. Prominent varices are seen throughout the left upper abdomen. Spleen is mildly enlarged. Non-contrast appearance of the kidneys is unremarkable. Adrenal glands are normal in size bilaterally. There is no free intraperitoneal air. CT PELVIS: Pelvic loops of large and small bowel are unremarkable. Genitourinary structures are unremarkable. Urinary bladder is decompressed with a Foley catheter balloon in place. There is no free pelvic fluid or abnormal pelvic or inguinal lymphadenopathy. There is no osseous lesion suspicious for malignancy. Mild lumbar spine degenerative changes are noted. IMPRESSION: 1. Pneumobilia, and air and oral contrast material within the gallbladder lumen, concerning for fistulous connection between the adjacent ulcerated second portion of the duodenum seen on recent EGD. 2. Cirrhotic liver, with incompletely characterized hypodensity in segment IV, prominent periportal lymph nodes, and numerous large splenorenal varices in the left upper quadrant. 3. Trace bilateral pleural effusions. Labs at discharge: (Drawn [2172-2-28]) WBC-4.1 RBC-3.52* Hgb-11.1* Hct-33.1* MCV-94 MCH-31.5 MCHC-33.5 RDW-16.7* Plt Ct-116* PT-23.5* PTT-46.9* INR(PT)-2.3* BLOOD Glucose-145* UreaN-8 Creat-0.6 Na-136 K-3.3 Cl-97 HCO3-36* AnGap-6* ALT-27 AST-75* AlkPhos-254* TotBili-1.4 Albumin-2.2* Calcium-7.3* Phos-3.2 Mg-1.6 Brief Hospital Course: This is a 55 year-old male with a history of ETOH/ Hep C cirrhosis, [Year/Month/Day 7344] abuse who presented from OSH with coffee ground emesis, and found to have duodenal ulcers and pneumobilia. Upper endoscopy at OSH revealed two duodenal ulcers, one which had appeared to be perforated or fistulized. Hepatology was consulted and recommended pantoprazole IV drip and octreotide. The octreotide was discontinued after one day. He was given dilaudid for pain. Ciprofloxacin and metronidazole were started. Surgery was consulted and recommended repeat abdominal CT. CT revealed pneumobilia, with air and oral contrast in gallbladder and CBD, which was thought to be most commmon with fistulous connection between the duodenal ulcer and gallbladder. He was transferred to the surical service on his third hospital day. On [2-10], he was given vitamin K 10mg IV X1 on [2-12], in preparation for surgery, given his INR was 1.9. He underwent cholecystectomy with closure of cholecystoduodenal fistula for duodenal ulcer with cholecystoduodenal fistula. Surgeon was Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 816]. Please see operative note for complete details. Operative findings included cirrhotic liver with some ascites and the gallbladder was quite inflamed as was the entire porta. Per the OP note, "dissection was quite difficult and bloody given the patient's inflammation and cirrhosis. We were able to get around the fistula and the fistula was transected revealing a hole in the duodenum of approximately 1 cm." 4 silk sutures were used to close the duodenal hole. Details of the sutures were then used to fix the omentum down over this as a patch. An NG and JP drain were placed. Postop, he was sent to the SICU for management. JP drainage was sanguinous.He was transfused with blood products to keep hemodynamics stable. Hematocrits stabilized. LFTS increased though, but later trended down. Daily [Hospital1 ] Lactulose enemas were started on pod 1 as he was NPO and on bowel rest. TPN was started. IV methadone (10mg q 12 hours) was started to assist with pain control as well as iv dilaudid and ativan prn for agitation given h/o substance abuse. Last EtOH use was approx 1 yr ago. Heroin use IV earlier this month. He did not have signs/symptoms of withdrawl on admission though he was given ativan for anxiety. He was given multivitamins, thiamine, and folic acid. He became increasingly confused/disoriented with O2 desats with PCA use. PCA was held and dose decreased with improvement. On [2-14], he was transferred to the med-[Doctor First Name ] unit where NPO status and NG continued. NG was removed on [2-18]. Sips were started on [2-20]. The volume of JP drainage decreased to ~ 110cc/day and became more consistent with ascites fluid. He continued to have waxing/[Doctor Last Name 688] delerium. Lactulose enemas [Hospital1 ] continued and Rifaximin was started on [2-19]. Methadone wean was started and weaned off by [2-21]. Ativan and dilaudid doses were decreased with ativan later discontinued but restarted due to anxiety issues. He continued to have a 1:1 sitter to prevent removal of the NG/IV until [2-21]. LFTS trended down and cbc/lytes remained stable on TPN. He became much more clear and the sitter was able to be stopped The JP drainage decreased and the drain was removed on [2-24] as output was 110cc of straw colored fluid for the previous 24 hours. Prolene stitch placed to LRQ due to excessive drainage through dressings. Stitch to be removed as an outpatient. A picc line was inserted in the left arm. This site became swollen and an US was done to evaluate for DVT. This US revealed a thrombosed left basilic vein with PICC line in place. No thrombus in the deep veins of the left arm or in the central veins were noted. TPN continued thru [2-21] then was d/c'd on [2-21] as well as the Picc line as he tolerated diet advancement. PT was consulted and recommended using a cane for safety. He was cleared for discharge with outpatient continued PT to work on safety, strength and balance. He is ambulating independently with the cane, but required reminders to use the cane as he would forget to use. Antibiotics were stopped on [2-24] (flagyl, ampicillin and cipro). He remained afebrile. The patient has a history of seizure disorder, but not history of seizures while withdrawing in past. He was managed on oral neurontin at home. Neurontin was switched to IV keppra and then to PO which is his discharge medication. No seizures were noted during this hospital stay. Lasix, spironolactone and inderal were restarted at the end of the hospitalization for cirrhosis management. Pathology report Gallbladder, cholecystectomy: A. Chronic cholecystitis. See note. B. Cholelithiasis, pigmented type. Medications on Admission: Home medications: Lactulose 2 TBSP daily Ibuprofen 800mg PRN pain Inderal 20mg [Hospital1 ] Aldactone 50 [Hospital1 ] Lasix 20 daily Neurontin 100 [Hospital1 ] Mirtazepine 45 PO qhs Celexa 20 daily Prilosec- states should be on it but can't afford it. . Medications on transfer: Neurontin 100 PO BID Lactulose 20gm PO TID Levofloxacin 500 PO daily Metronidazole 500 IV TID Mirtazepine 45 PO QHS Octreotide 500mcg IV gtt Pantoprazole 80 IV gtt Dilaudid 1mg IV q 4 prn Lorazepam 1mg PO Q 4HR PRN Discharge Medications: 1. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Mirtazapine 30 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime). 5. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 8. Lactulose 10 gram/15 mL Solution Sig: Thirty (30) ML PO BID (2 times a day). 9. Propranolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Spironolactone 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [First Name5 (NamePattern1) 2048] [Last Name (NamePattern1) 81258] House Discharge Diagnosis: HCV cirrhosis h/o [Last Name (NamePattern1) 7344] abuse Depression cholecystoduodenal fistula encephalopathy Discharge Condition: stable Discharge Instructions: Please call Dr.[Name (NI) 1381] office [Telephone/Fax (1) 673] if fever, chills, nauea, vomiting, jaundice, increased abdominal distension/abdominal pain, incision redness/drainage or confusion Followup Instructions: [First Name11 (Name Pattern1) 819] [Last Name (NamePattern4) 820], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2172-3-12] 8:30 AM Completed by:[2172-3-2]	[ "070.54", "304.01", "532.50", "V60.0", "789.59", "574.10", "401.9", "715.36", "571.2", "E935.9", "996.74", "305.03", "437.3", "733.42", "284.1", "453.8", "305.60", "345.90" ]	icd9cm	[ [ [] ] ]	[ "51.93", "51.22", "99.15" ]	icd9pcs	[ [ [] ] ]	13822, 13929	7422, 12274	334, 463	14086, 14095	4510, 7081	14346, 14522	3805, 3957		12831, 13799	13950, 14065		12300, 12300			14119, 14323							3972, 4491				12318, 12566												274, 296				7100, 7399				491, 2157												12591, 12808	2180, 3448	3464, 3789
7,884	185,731	12869	Discharge summary	report	Admission Date: [2160-11-27] Discharge Date: [2160-12-27] Date of Birth: [2100-10-31] Sex: M Service: MEDICINE Allergies: Metoprolol / Ibuprofen / Aspirin Attending:[First Name3 (LF) 4282] Chief Complaint: leg thigh pain Major Surgical or Invasive Procedure: Radiation therapy Blood transfusions History of Present Illness: 60 year old male with metastatic non-small cell lung cancer (on weekly Navelbine), membranous nephropathy, schizophrenia, and COPD who presents with complaints of left thigh pain and fatigue. PET scan performed today revealed progression of his disease as well as a lytic lesion in the left femur. Additionally he has had a decline of his renal function of the past month and creatinine is up to 2.7. He is admitted for evaluation and management of renal failure,pain, and his new lytic bone disease. Past Medical History: Non-small-cell lung cancer, metastatic Arterial embolic disease s/p right SFA stent in [June 2159] CAD s/p 2 vessel CABG at [Hospital1 112] in [Month (only) 205] 97 HTN COPD CHF; EF 35-40% Hypercholesterolemia Primary polydipsia BPH s/p TURP Schizophrenia, Paranoia Nephrotic Syndrome [2-29] membranous GN Social History: No current tobacco. He did smoke for 30 years, but quit five months ago. No current ETPH; he quit 12 years ago. He previously was in the real estate business with his brother. [Name (NI) ] is Lebanese by heritage. He has two children who are 31 and 29 years of age and he is married and lives [Location (un) 6409], [Location (un) 86]. Family History: Mother died at age 60 of cancer (unknown type) Physical Exam: VS: T 96.6 BP 164/84 HR 92 RR 22 98%RA GEN: chronically-ill appearing, NAD HEENT: MMM, OP clear, anicteric, PERRL NECK: Supple, no LAD, no masses CV: RRR no m/r/g LUNGS: bilateral diffuse rhonchi and wheeze ABD: soft, NT, ND, +BS, no HSM EXT: no edema, left thigh w/o palpable mass, mild TTP SKIN: no rash NEURO: A/A, anxious, Ox3, strength intact throughout, CN II-XII intact Pertinent Results: 133 / 97 / 69 gluc 248 4.7 / 23 / 2.7 . Ca: 9.7 Mg: 2.4 P: 3.3 . WBC 6.8 HCT 29.2 PLT 328 N:89.7 L:5.9 M:3.8 E:0.4 Bas:0.1 . PT: 10.8 PTT: 29.3 INR: 0.9 . PET Scan: Multiple new FDG-avid mediastinal, hilar, liver, and soft tissue lesions consistent with progression of disease. Lytic lesion in the proximal left femur with evidence of cortical breakthrough placing the patient at high risk for pathologic fracture. Interval resolution of two right upper lobe spiculated opacities and non-visualization of two right lower lobe nodules. . L thigh xray: Large lytic intratrochanteric lesion (33mm in diamater). No pathologic fracture Brief Hospital Course: 60 year old male with progressive metastatic lung cancer and membranous nephropathy who presents with left thigh pain in the setting of a new left femur lytic lesion. . 1. Left lytic femoral bone lesion/fracture: Pt was found to have a lytic lesion in the intertrochanteric left femur on admission. Radiation oncology was consulted the following day and recommended radiation. Orthopedics was also consulted the following day and at the time it was felt that given the pt's comorbities that surgery to stabilize the weight-bearing bone would be risky and recovery would be difficult. The patient and his family decided to defer surgery and proceed with radiation therapy. The patient was immediately placed on non-weight-bearing for his left lower extremity; the patient started with his activity restricted to bedrest and as he did well, he graduated to out of bed with walker and assist per orthopedic recommendations. Physical therapy also worked with the patient. . Unfortunately, the patient sustained a traumatic pathologic fracture while in the hospital when he fell. Pt was then found to have low blood pressure, and was transferred to the intensive care unit. He was placed on vasopressors, and treated for a presumed penumonia. He was found to have a perifracture hematoma and was transfused 4 units of PRBCs. His plavix was held. His blood pressure stabilized and he was transferred back to the oncology floor. . After a long discussion involving the primary oncology team and orthopedics, given the risks of operating, the family decided to defer surgery for now and complete radiation therapy. Mortality from surgery was estimated to be 40-50%. Radiation therapy was resumed. Patient continued to work with physical therapy. Pt received palidronate on [2159-12-12]. Repeat xray films of hip, femur and knee revealed minimal change since time of fracture. Pt will be discharged to [Hospital1 ] for rehabilitation. . 2. Chronic renal failure: Pt has history of membranous nephropathy associated with malignancy. Although his creatinine was elevated, his urine protein/Cr actually improved to his previous results. Nephrology was consulted and recommended holding his home diuretics (bumetanide, HCTTZ) but continuing with ACEI/[Last Name (un) ] and prednisone with bactrim for PCP [Name Initial (PRE) 1102]. His creatinine improved. His HCTZ and bumetanide were re-added as his BP rose. However, he again became hypotensive to 70's and all antihypertensives were held. Creatinine was followed carefully with these additions and remained at his baseline. . 3. Hospital-acquired pneumonia, RLL: His sputum culture grew Pseudomonas aeroginosa. He was treated with a 2 week course of Zosyn. After completing his course patient was intermittiently hypotensive and tachycardic. There was concern for sepsis and cultures were sent. Sputum grew out sparse gram negative rods and patient was started on 2 week course of ceftazidime because of concern for partially treated pseudomonal pneumonia (sensitivities to Zosyn were borderline). CT chest was completed that showed worsening of his lung cancer, scarring secondary to radiation and areas of persistent pneumonia. Out of concern for fungal source, pulmonary was consulted. Patient's blood pressures stabilized and pulmonary felt there was no indication to bronch patient. His blood pressure stabilized, and He was sent out to complete a two-week course of IV ceftazidime. . 4. COPD: Pt appears to have wheezing at baseline. He was treated with ipatropium and albuterol nebulizers. Albuterol nebulizers were changed to levalbuterol nebulizers given the patient's baseline tachycardia. During his stay at ICU, he was given a steroid burst which was tapered back to his home dose of prednisone. . 5. Hypertension: After returning from the ICU, pt was noted to have high blood pressure. He was placed back on his complete home regimen of ACEI, [Last Name (un) ], HCTZ, and bumetanide. Beta blockers were avoided given his poor respiratory status and past records noting inability to tolerate beta blockers. However blood pressure again became tenuous requiring boluses with IV fluids. Therefore all antihypertensives were held. At time of discharge, blood pressure ranged from 90-130 systolic. . 6. Hyperglycemia: This is likely due to steroids and olanzapine. His home glipizide was held and he was placed on a Humalog insulin sliding scale while in the hospital. . 7. CHF: Pt was maintained on home regimen of ACEI/[Last Name (un) ], HCTZ, and Bumetanide. He was maintained on a low sodium diet, but all antihypertensives were held as blood pressure was low. . 8. CAD: Pt was continued on his home regimen of statin, ACEI/[Last Name (un) ]. Plavix was held after his perifracture hematoma. He is allergic to ASA. BP meds held. . 9. Schizophrenia and Paranoia: Pt was continued on his outpatient regimen of olanzapine, lorazepam, and fluphenazine. His outpatient psychiatrist Dr. [Last Name (STitle) 10166] was contact[Name (NI) ]. [Name2 (NI) ] changes were made to his regimen and patient did not have any auditory hallucinations while in house. Medications on Admission: Advair 250/50 1 puff [Hospital1 ] Albuterol QID prn Atrovent prn Bactrim DS 3x/week Bumex 1mg [Hospital1 ] Diovan 240 Daily Duoneb prn Fluphenazine 10 qam and 15mg qpm Glypizide SR 2.5 Daily HCTZ 25 Daily Levothyroxine 25 Daily Lisinopril 5 Daily Lorazepam 2mg TID Plavix 75 Daily Pravachol 20 Daily Prednisone 20 Daily Senna Vicodin prn Trazodone prn Zyprexa 10 qam and 20q qpm Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 2. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 5. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 9. Olanzapine 10 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 10. Olanzapine 10 mg Tablet Sig: Two (2) Tablet PO QPM (once a day (in the evening)). 11. Fluphenazine HCl 10 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 12. Fluphenazine HCl 10 mg Tablet Sig: 1.5 Tablets PO QPM (once a day (in the evening)). 13. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 14. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 15. Levalbuterol HCl 0.63 mg/3 mL Solution Sig: One (1) ML Inhalation q4 hr prn () as needed for wheezing. 16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 18. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 19. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO 3X PER WEEK (). 20. Insulin Please see attached insulin sliding scale 21. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 22. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). 23. Ceftazidime-Dextrose (Iso-osm) 1 gram/50 mL Piggyback Sig: One (1) Intravenous Q12H (every 12 hours) for 10 days. Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Primary: Non small cell lung cancer, pathologic intertrochanteric fracture of the left hip, Pneumonia Secondary: Membranous nephropathy , Chronic renal failure, Chronic obstructive pulmonary disease, Hypertension, Coronary artery disease, Congestive heart failure, Schizophrenia Discharge Condition: Stable Discharge Instructions: You were admitted for left thigh pain. You were found to have a bone lesion there and have unfortunately fractured your bone at that site. You have been treated with radiation and pain medications. Physical therapy has worked with you. Repeat xrays of your hip and thigh show minimal change since time of injury. . You had low blood pressure after you had fractured your leg. You were taken to the intensive care unit and were treated with medications to help support your blood pressure and blood transfusions. Your blood pressure is now normal. . Please take your medications as prescribed. . If you feel lightheaded, short of breath, chest pain, or worsening pain, please call your primary care physician or oncologist or go to the Emergency Department. Followup Instructions: Please keep the following appointments: Provider: [Name10 (NameIs) ] [Name8 (MD) 490], MD, PHD[MD Number(3) 708]:[0-0-] Date/Time:[2161-1-1] 4:00 Provider: [Name10 (NameIs) ] Phone:[Telephone/Fax (1) 128] Date/Time:[2161-2-4] 10:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4450], M.D. Phone:[Telephone/Fax (1) 4451] Date/Time:[2161-2-4] 11:20	[ "412", "401.9", "V45.81", "244.9", "482.1", "428.0", "197.7", "295.30", "733.14", "276.0", "285.1", "428.22", "162.8", "198.5", "785.0", "458.29", "250.00", "496", "582.1", "272.0" ]	icd9cm	[ [ [] ] ]	[ "92.24", "99.04" ]	icd9pcs	[ [ [] ] ]	10485, 10564	2747, 7930	311, 350	10887, 10896	2078, 2724	11705, 12126	1611, 1659		8367, 10462	10585, 10866		7956, 8344			10920, 11682							1674, 2059																257, 273								378, 881													903, 1227	1243, 1595
5,991	194,029	27027	Discharge summary	report	Admission Date: [2183-12-13] Discharge Date: [2183-12-17] Date of Birth: [2111-11-6] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2181] Chief Complaint: UGI bleed Major Surgical or Invasive Procedure: EGD with injection of epi and cautery to duodenal bleed History of Present Illness: 72 yo M otherwise healthy, presented with dark stools x1 day. The pt had started taking 600mg of ibuprofen twice daily for musculoskeletal shoulder pain. On the day prior to admission, the pt states that there were some dark stools, which became progressivel more profuse over the course of the day. He also noted lightheadedness, no syncope. He came to the ED for further w/u. NG lavage showed red blood and clot that persisted without clearing despite 500ml; he had maroon-colored stools. The hct was 30.2 on admission. He was taken for EGD which showed a single bleeding ulcer in the duodenum which was treated with epi and cautery. The pt received transfusions, 2U on consecutive 2 days, remained stable after cautery and bumped appropriately. Past Medical History: None Social History: Pt lives with his wife. [Name (NI) ] smoked for about 15 years but quit 40 yrs ago. He drinks a 1-2 beers/day and occasionally a scotch at night. Family History: Sister with GI bleed, otherwise healthy siblings, no fhx of cad. Physical Exam: VS: Tm 98.2 Tc 98.9 p63(60-87) bp 120/64(114-124/51-61) rr 15([1-25]) spo2 97-99% RA I/O 2700/1600 gen: well appearing male, sitting in chair, NAD heent: anicteric sclera, MMM, op clear CV: RRR, no m/r/g chest: CTA ABD: soft, nt/nd, NABS ext: no c/c/e Pertinent Results: [2183-12-12] 11:30PM PT-13.1 PTT-22.3 INR(PT)-1.2 [2183-12-12] 11:30PM PLT COUNT-277 [2183-12-12] 11:30PM NEUTS-77.4* LYMPHS-17.6* MONOS-2.8 EOS-1.9 BASOS-0.3 [2183-12-12] 11:30PM WBC-10.0 RBC-3.40* HGB-10.6* HCT-30.2* MCV-89 MCH-31.1 MCHC-35.0 RDW-12.0 [2183-12-12] 11:30PM LIPASE-28 [2183-12-12] 11:30PM ALT(SGPT)-15 AST(SGOT)-20 ALK PHOS-42 AMYLASE-69 [2183-12-12] 11:30PM GLUCOSE-185* UREA N-51* CREAT-1.0 SODIUM-139 POTASSIUM-4.8 CHLORIDE-106 TOTAL CO2-24 ANION GAP-14 [2183-12-12] 11:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2183-12-12] 11:50PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.021 [2183-12-13] 04:48AM HCT-27.8* [2183-12-13] 06:40AM PT-13.0 PTT-25.4 INR(PT)-1.1 [2183-12-13] 06:40AM PLT COUNT-276 [2183-12-13] 06:40AM WBC-9.6 RBC-2.99* HGB-9.5* HCT-26.8* MCV-90 MCH-31.7 MCHC-35.3* RDW-13.3 [2183-12-13] 06:40AM CALCIUM-8.4 PHOSPHATE-4.0 MAGNESIUM-2.1 [2183-12-13] 06:40AM GLUCOSE-98 UREA N-45* CREAT-1.0 SODIUM-142 POTASSIUM-4.2 CHLORIDE-108 TOTAL CO2-24 ANION GAP-14 [2183-12-13] 11:37AM HCT-29.7* [2183-12-13] 04:45PM HCT-30.3* Brief Hospital Course: 72 yo M otherwise healthy presented with UGIB in setting of NSAID use, underwent EGD cautery to bleeding duodenal ulcer, without recurrent bleeding, stable hct. . 1. UGIB: The pt was found to have a hct of 30.2 on admission. Given his history he was aggressively volume repleted in the ED with drop in hct to 26.8, he was transfused and taken for urgent EGD. The EGD showed a bleeding duodenal ulcer which was able to be treated with successful hemostasis with cautery, epi injection. The pt was monitored x 48 hours without recurrent bleeding, stable hct. He appeared clinically very well. Serum H. Pylori was found to be positive. The plan was to f/u as outpt with the pt's pcp at the JP [Hospital ] hospital for H. Pylori eradication treatment. The vital importance of this treatment was emphasized to the pt who indicated that he understood. PPI was continued during the hospital stay and prescribed at discharge. . 2. PPx: pt ambulates, PPI 3. Access: 2 18 guage PIV's RA and LA were continued for 48 hours, then pt was discharged. 4. Comm: with pt Medications on Admission: ASA 81mg Ibuprofen prn Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO BID (2 times a day). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: blood loss anemia bleeding duodenal ulcer Discharge Condition: hct stable x 48 hours Discharge Instructions: If you notice any recurrent symptoms of blood in stool, or dark black stools, please go to the emergency room. . Please note the following changes in your medications: 1. you should stop taking the aspirin and ibuprofen for now. If you have any joint pain, you should take tylenol only. 2. You should take pantoprazole as directed . Followup Instructions: 1. Please follow up with your primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 66440] within 1-2 weeks. Make sure that you discuss treatment for H. Pylori positive, which contributed to your ulcer. You will definitely need this to be treated, because it increases your risek of bleeding. . 2. You will follow up with the gastroenterologist for a repeat EGD as you have discussed with the GI physician. [Name10 (NameIs) ] have written insructions and the bowel prep for your appointment on [1-26]. With questions, please call ([Telephone/Fax (1) 66441].	[ "285.1", "790.6", "532.40", "535.60", "E935.9", "E849.8" ]	icd9cm	[ [ [] ] ]	[ "44.43", "99.04" ]	icd9pcs	[ [ [] ] ]	4331, 4337	2996, 4056	327, 384	4423, 4447	1734, 2973	4828, 5428	1375, 1441		4129, 4308	4358, 4402		4082, 4106			4471, 4805							1456, 1715																278, 289								412, 1162													1184, 1190	1206, 1359
32,437	195,982	33421	Discharge summary	report	Admission Date: [2182-3-3] Discharge Date: [2182-3-16] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1674] Chief Complaint: This is a [Age over 90 ] year old male transferred from outside hospital with c/o abdominal pain, nausea and vomiting. On ultrasound patient found to have stones/sludge in a distended gall bladder. Major Surgical or Invasive Procedure: ERCP with sphincterotomy History of Present Illness: Patient was initially on the surgical service and was then transferred to the medicine service. In brief, this is a [Age over 90 ] yo M with Afib, CKD presented to surgical service with acute cholangitis, underwent urgent ERCP on [3-4], with succesful removal of stone & pus and sphincterotomy. Originally, 2 weeks prior, he was admitted to an outside hospital with abdominal pain. The pain resolved and he was discharged. He was readmitted with RUQ/Epigastrum pain over one day with nausea and vomiting and transferred to [Hospital1 18]. After his sphincterotomy and stone removal, he finished a 6 day course of Zosyn and has been afebrile with negative blood cultures and no leukocytosis. . On admission, his Cr was 2.5; this was in the setting of being hypotensive and infected and he was initially admitted to the SICU. Since then, his Cr has continued to rise, which Renal has attributed to ATN. On transfer to the medicine service, he was on the cusp of dialysis (with a Cr of 8.9), but without uremic symptoms. He was willing to start dialysis. Past Medical History: MI/CAD COPD GERD/PUD h/o Afib CHF Social History: Married lives with [Age over 90 ] year old wife. Family History: NC Physical Exam: PE: On txfer to med service vitals: Tc 96.6 118/64 86 24 96-99%RA FS well controlled tele: Afib gen: overweight, NAD, tired looking, pleasant, lying in bed heent: moist mucosa, +scleral icterus neck: no JVD heart: irregulur, 2/6 systolic murmur LSB but distant lungs: crackles b/l 1/3way, with exp wheeze abd: soft, distended, +bs, epigastric tenderness without rebound/guarding extr: 1+ le edema LE bruises Pertinent Results: Imaging Studies: [2182-3-7] CXR Residual coarse reticular interstitial opacities are probably due to chronic interstitial lung disease. [2182-3-6] Renal Ultrasound IMPRESSION: No evidence of hydronephrosis. . [3-8]: ECHO: 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 hypokinesis of the inferior and inferolateral walls. There is mild hypokinesis of the remaining segments (LVEF = 35-40 %). The right ventricular cavity is mildly dilated with free wall hypokinesis. The aortic root is moderately dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets are moderately thickened. There is severe aortic valve stenosis (area <0.8cm2). Mild (1+) aortic regurgitation is seen. The mitral leaflets are mildly thickened. Mild to moderate ([1-23]+) mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Severe aortic stenosis. Mild symmetric left ventricular hypertrophy with mild regional and global left ventricular systolic dysfunction. Right ventricular cavity enlargement with free wall hypokinesisl. Mild-moderate mitral regurgitation . [2182-3-3] 08:00PM BLOOD WBC-6.6 RBC-4.38* Hgb-13.1* Hct-40.1 MCV-91 MCH-29.9 MCHC-32.7 RDW-13.5 Plt Ct-202 [2182-3-5] 02:30AM BLOOD WBC-8.4 RBC-4.18* Hgb-12.6* Hct-38.6* MCV-92 MCH-30.2 MCHC-32.7 RDW-13.8 Plt Ct-178 [2182-3-9] 04:54AM BLOOD WBC-5.7 RBC-3.68* Hgb-10.8* Hct-32.6* MCV-89 MCH-29.4 MCHC-33.1 RDW-14.8 Plt Ct-261 [2182-3-14] 05:05AM BLOOD WBC-5.7 RBC-3.84* Hgb-11.4* Hct-34.8* MCV-91 MCH-29.8 MCHC-32.9 RDW-15.2 Plt Ct-291 [2182-3-16] 06:15AM BLOOD WBC-5.0 RBC-3.41* Hgb-10.8* Hct-30.9* MCV-91 MCH-31.6 MCHC-35.0 RDW-15.2 Plt Ct-287 [2182-3-3] 08:00PM BLOOD Neuts-77.4* Lymphs-17.1* Monos-4.5 Eos-0.8 Baso-0.3 [2182-3-7] 05:02AM BLOOD Neuts-70.6* Lymphs-19.5 Monos-6.4 Eos-3.1 Baso-0.3 . [2182-3-3] 08:00PM BLOOD Glucose-132* UreaN-46* Creat-2.5* Na-144 K-4.0 Cl-104 HCO3-29 AnGap-15 [2182-3-5] 02:30AM BLOOD Glucose-91 UreaN-38* Creat-2.6* Na-148* K-3.5 Cl-111* HCO3-27 AnGap-14 [2182-3-6] 05:48AM BLOOD Glucose-88 UreaN-43* Creat-3.4* Na-142 K-3.9 Cl-104 HCO3-30 AnGap-12 [2182-3-7] 05:02AM BLOOD Glucose-92 UreaN-57* Creat-4.9# Na-141 K-4.0 Cl-103 HCO3-29 AnGap-13 [2182-3-8] 05:19AM BLOOD Glucose-93 UreaN-68 Creat-6.3# Na-139 K-3.8 Cl-99 HCO3-26 AnGap-18 [2182-3-9] 04:54AM BLOOD Glucose-85 UreaN-74 Creat-7.1* Na-139 K-4.0 Cl-99 HCO3-24 AnGap-20 [2182-3-10] 05:50AM BLOOD Glucose-89 UreaN-80* Creat-8.2# Na-138 K-3.9 Cl-101 HCO3-23 AnGap-18 [2182-3-11] 06:00AM BLOOD Glucose-81 UreaN-84 Creat-8.5* Na-140 K-4.2 Cl-101 HCO3-21* AnGap-22* [2182-3-12] 05:25AM BLOOD Glucose-94 UreaN-86* Creat-9.0* Na-143 K-4.0 Cl-105 HCO3-24 AnGap-18 [2182-3-13] 06:00AM BLOOD Glucose-93 UreaN-85* Creat-8.9* Na-144 K-3.9 Cl-106 HCO3-24 AnGap-18 [2182-3-14] 05:05AM BLOOD Glucose-90 UreaN-83* Creat-8.3* Na-143 K-4.0 Cl-105 HCO3-23 AnGap-19 [2182-3-15] 05:25AM BLOOD Glucose-80 UreaN-77* Creat-7.9* Na-143 K-4.1 Cl-105 HCO3-23 AnGap-19 [2182-3-16] 06:15AM BLOOD Glucose-89 UreaN-79* Creat-7.5* Na-141 K-4.2 Cl-105 HCO3-24 AnGap-16 . [2182-3-3] 08:00PM BLOOD ALT-119* AST-138* AlkPhos-519* Amylase-285* TotBili-2.0* [2182-3-4] 01:51PM BLOOD ALT-245* AST-283* AlkPhos-561* Amylase-296* TotBili-4.4* [2182-3-7] 05:02AM BLOOD ALT-199* AST-131* LD(LDH)-160 AlkPhos-564* Amylase-48 TotBili-6.3* [2182-3-9] 04:54AM BLOOD ALT-110* AST-50* AlkPhos-370* Amylase-69 TotBili-2.5* [2182-3-12] 05:25AM BLOOD ALT-145* AST-107* AlkPhos-370* TotBili-1.4 . [2182-3-10] 05:50AM BLOOD Albumin-2.9* Calcium-8.5 Phos-4.9* Mg-2.2 [2182-3-16] 06:15AM BLOOD Calcium-8.7 Phos-5.5* Mg-2.2 Brief Hospital Course: This is a [Age over 90 ] year old male who was admitted with a second bout of abdominal pain in a 2 week period with stones/sludge by ultrasound and rising lft's. He was admitted to SICU and an ERCP was done on [3-4] showing cholangitis (pus in CBD post stone extraction), choledocholithiasis, and mild pancreatitis. During the ERCP, he had a sphincterotomy to remove the stones. Hospital course complicated with following issues; 1. Gallstone pancreatitis - lipase and LFT's peaked from [Date range (1) 77547]. total bili peaked 8.3 om [3-6] now 1.4 on [2182-3-12]. His abdominal pain resolved. He finished a 1 week course of zosyn for his infection and did not have any fevers or leucocytosis for the remainder of his hospital stay. A copy of his ERCP report is included for PCP. [Name10 (NameIs) 77548] was discussed with the patient but he declined this option. 2. Renal insufficiency - The patient's baseline creatinine ~2.5. Since admission bun/cre steadily rose to a max of with bun 90 and creatinine of 8.9 on [3-12]. Renal was consult and felt that his story was consistent with ATN (non-oliguric). Dialysis was discussed and the patient was OK with having short term dialysis. He did not have any uremic symptoms and fortunately, his ATN started to resolve. His urine output continued to be in the 1.2-1.5L range until discharge. His Cr had dropped to 7.5 on discharge. On [3-18], his VNA will check his Chem 7 and fax the results to Dr.[Name (NI) 11632] office. In the event that his Creatinine starts to rise, Dr. [Last Name (STitle) 25064] (Renal fellow) at [Hospital1 18] can be contact[Name (NI) ] - I provided her pager number to Dr.[Name (NI) 11632] secretary as well as my cellular phone number. In addition, Nephrology followup will need to be arranged close to Mr. [Known lastname 77549] home (~1.5 hours from [Hospital1 18]) within the next 2 weeks. If this cannot be arranged, then he can be seen at the [Hospital 10701] clinic at [Hospital1 18]. 3. CAD - The patient's telemetry monitoring demonstrated atrial fibrillation alternating sinus bradycardia with pauses. Not on coumadin baseline because of a history of GI bleed. His ASA was held after the sphincterotomy and restarted 10 days post ERCP (discussed with ERCP team). 4. The patient was seen by PT, who recommended short term rehab. He preferred to go home with PT and VNA. Medications on Admission: NG TD 0.6 24', advair diskus 250/50, zantac 40 QD, lasix 40'QD, ASA 81', duoneb, amiodarone 200 mg daily, nitro patch daily, Coreg 3.125 [Hospital1 ] Discharge Medications: 1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 2. Zantac 150 mg Capsule Sig: One (1) Capsule PO twice a day. 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [1-23] Puffs Inhalation Q 8H (Every 8 Hours). 5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Chem 7 Sig: One (1) once a day: Please fax Chem 7 to Dr. [Name (NI) 77550] @ [Telephone/Fax (1) 77551]. Disp:0 0 Refills:0 Discharge Disposition: Home With Service Facility: Care Network VNA Discharge Diagnosis: Choledocholithiasis Bacteremia Acute Tubular Necrosis Discharge Condition: AAO x 3 Afebrile Urinating Creatinine trending down Discharge Instructions: You were admitted for an infection in your gall bladder. You had a procedure called an ERCP to remove an infected gall stone and were treated with antibiotics. In addition, you had kidney failure, which has started to improve. You will need to be followed up by your primary care doctor and a kidney doctor. [First Name (Titles) ] [Last Name (Titles) 7712], your labs will be drawn by your visiting RN who will fax the results to your PCP (Dr.[Name (NI) 11632] office). Dr. [Last Name (STitle) 1968] will help to arrange for Nephrology follow up. . Please call your primary care doctor or come back to the ED with any concerning symptoms such as chest pains, nausea, confusion. Followup Instructions: You will need to follow up with Dr. [Last Name (STitle) 1968]. Please call for an appointment in the next week. Your lab results from Monday will be faxed to Dr.[Name (NI) 11632] office. I have sent your hospital course to Dr. [Last Name (STitle) 1968]. He will also arrange for a follow up with a Nephrologist close to your house. If this is not possible, you can be seen by the [Hospital 10701] clinic at [Hospital1 18]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [MD Number(2) 1677] Completed by:[2182-3-16]	[ "585.9", "398.91", "574.51", "412", "V12.71", "427.31", "576.1", "038.9", "427.89", "995.92", "V15.82", "496", "584.5", "577.0", "414.01", "396.2" ]	icd9cm	[ [ [] ] ]	[ "51.85", "51.88" ]	icd9pcs	[ [ [] ] ]	9368, 9415	6087, 8517	464, 491	9513, 9567	2180, 2180	10309, 10905	1729, 1733		8721, 9345	9436, 9492		8543, 8698			9591, 10286							1748, 2161																222, 426								519, 1586													1608, 1643	1659, 1713			2198, 6064
963	159,921	11152	Discharge summary	report	Admission Date: [2195-4-24] Discharge Date: [2195-4-30] Date of Birth: [2134-3-12] Sex: F Service: [Hospital Unit Name 196] HISTORY OF PRESENT ILLNESS: The patient is a 61 year old female with a history of coronary artery disease status post myocardial infarction in [2188], status post left anterior descending stent placement, type 2 diabetes mellitus, hypercholesterolemia, and hypertension, who presents to [Hospital1 1444] via [Hospital1 26200], where the patient was hospitalized for rule out myocardial infarction after presenting with substernal chest pain, as if an elephant was sitting on her chest. EKG at that time showed T wave flattening in the lateral leads. The patient was ruled out by enzymes times three and underwent Stress Echocardiogram at [Hospital1 190] on the day of admission which revealed ischemic ST changes and new reversible defects with failure of the inferior and posterior walls to augment. The patient was admitted to [Hospital1 69] [Hospital Unit Name 196] Service for catheterization and possible intervention. On admission, she denied chest pain, shortness of breath, nausea or vomiting. PAST MEDICAL HISTORY: 1. Coronary artery disease status post myocardial infarction in [2188] with a stent to the left anterior descending. 2. Diabetes mellitus. 3. Hypercholesterolemia. 4. Hypertension. 5. Gastroesophageal reflux disease. 6. Osteoporosis. 7. Fibromyalgia. 8. Right sided cerebrovascular accident in [2194-9-22]. MEDICATIONS ON ADMISSION: 1. Glucophage. 2. Glucotrol. 3. Lopressor. 4. Aspirin. 5. Diltiazem. 6. Accupril. 7. Plavix. PHYSICAL EXAMINATION: On admission, vital signs were afebrile; blood pressure 117/76; breathing at 14; pulse 82; O2 saturation 98% on room air. In general, she is in no apparent distress, alert and cooperative. Cardiovascular: Regular rate and rhythm, normal S1, S2. No murmurs, rubs or gallops. Lungs are clear to auscultation bilaterally. Extremities with no cyanosis, clubbing or edema noted. Abdomen is soft. There are positive bowel sounds throughout. She has no tenderness or distention. LABORATORY: On admission, white count 7.1, hematocrit 36.3, platelets 236. Sodium 140, potassium 3.9, chloride 102, bicarbonate 26, BUN 12, creatinine 0.8. Glucose 153. Stress echocardiogram on [4-24], showed ischemic changes in the inferior posterior wall, failure to augment, ST depressions inferolaterally. ALLERGIES: The patient's allergies include codeine, shellfish, intravenous contrast dye, iodine, [Location (un) 2452] extract, Darvon, Ciprofloxacin and penicillin. SOCIAL HISTORY: No alcohol and no tobacco use. HOSPITAL COURSE: The patient was admitted to the [Hospital Unit Name 196] service on [2195-4-24]. She underwent cardiac catheterization on [2195-4-27]. The patient's cardiac catheterization demonstrated normal coronary arteries, mild diastolic dysfunction with normal systolic ventricular function. The patient, post-procedure, developed a large hematoma in her right groin. Her hematocrit dropped from 39 to 31, and remained stable between 30 to 33. A CT scan on [4-28], showed a right anterior abdominal wall hematoma extending superiorly from the right groin. The patient's serial hematocrits were stable as previously noted, other than the abdominal groin pain, and the patient was asymptomatic. She did not describe any chest pain, shortness of breath, lightheadedness, palpitations, coldness, numbness or tingling in her right lower extremity. She had good pulses. The hematoma subsequently resorbed, and the patient was transferred back to the [Hospital Unit Name 196] Floor for further management from the Cardiac Care Unit. While on the [Hospital Unit Name 196] Floor, the patient's cough progressively worsened. This coughing was reduced after the patient's Prinivil was discontinued. Cozaar was started at that time and the patient's cough essentially resolved. On the last hospital day, the patient developed symptoms of a urinary tract infection. Urinalysis and urine culture are pending at this time. The patient is being discharged home on [2195-4-30]. DISCHARGE MEDICATIONS: 1. Protonix 40 mg p.o. q. day. 2. Losartan 50 mg p.o. q. day. 3. Colace 100 mg p.o. twice a day. 4. Glucophage 500 mg p.o. twice a day. 5. Glipizide 10 mg p.o. q. day. 6. Lopressor 25 mg p.o. twice a day. 7. Plavix 75 mg p.o. q. day. 8. Aspirin 325 mg p.o. q. day. 9. Diltiazem 180 mg p.o. q. day. 10. Macrodantin 100 mg p.o. twice a day times three days. DISCHARGE DIAGNOSES: 1. Coronary artery disease status post myocardial infarction in [2188] with a stent to the left anterior descending. 2. Diabetes mellitus. 3. Hypercholesterolemia. 4. Hypertension. 5. Gastroesophageal reflux disease. 6. Osteoporosis. 7. Fibromyalgia. 8. Right sided cerebrovascular accident in [2194-9-22]. 9. Right groin hematoma which is resolving. 10. Urinary tract infection, which is under treatment with Macrodantin. DISCHARGE INSTRUCTIONS: 1. The patient will follow-up with her Cardiologist, Dr. [Last Name (STitle) 35910] in two weeks' time. [Doctor First Name 900] [Name8 (MD) 901], M.D. [MD Number(1) 2144] Dictated By:[Last Name (NamePattern1) 5476] MEDQUIST36 D: [2195-4-30] 09:33 T: [2195-4-30] 10:29 JOB#: [Job Number 35911]	[ "250.00", "530.81", "272.0", "599.0", "V45.82", "786.50", "998.12", "401.9", "412" ]	icd9cm	[ [ [] ] ]	[ "88.53", "37.22", "88.55" ]	icd9pcs	[ [ [] ] ]								4630, 5072	4243, 4609			1565, 1666	2725, 4220		5096, 5463															1689, 2658																190, 1193													1215, 1539	2675, 2707
78,473	186,925	19054	Discharge summary	report	Admission Date: [2119-9-20] Discharge Date: [2119-9-29] Date of Birth: [2068-10-14] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 695] Chief Complaint: Hepatocellular carcinoma Major Surgical or Invasive Procedure: [2119-9-20] liver transplant History of Present Illness: 50-year-old man with HBV cirrhosis s/p segment V resection for a 3.7 x3.5 cm hepatocellular carcinoma lesion in [2118-4-26] now presents for transplant. Pt most recent MELD score is 31. His hepatitis B is suppressed on adefovir 10 mg daily. He currently feels well and has been active with all of his usual activities. He has not had any abdominal pain, nausea, vomiting, fevers, chills, cough, or change in urination or bowel habits. He denies, weight loss or gain, any recent hospitalizations, illness, travel or sick contact. he denies any history of abd swelling (ascites) or tapping. He denies any history of vomiting blood or blood in his BM. He is due for a repeat CT scan and nuclear bone scan today. He also requires a repeat echo as it is more than 1 year since his last echocardiogram. He had complained of occasional hematuria at his last visit and this was confirmed on urinalysis in [8-3]. Analysis showed no white blood cells or bacteria in his urine. He proceeded to have a cystoscopy, which was normal. There have never been any renal problems identified on his multiple prior abdominal scans. HBV antibody and antigen levels are pending. In [Month (only) 205] HBV antigen was + but antibody neg. Past Medical History: HBV related cirrhosis PSH: tympanic membrane grafting Social History: Cantonese Married with two children ages 17 and 9 works as a floor sander Family History: mother on HD Father deceased from "lung problems" Physical Exam: 97.6 133/91 111 20 97% RA NAD, sitting in bed AOX3 HEENT: PERRL, EOMI CNII-XII grossly intact, no masses no enlarged lymphs felt CV: RRR Pul: CTAB Abd: soft non tender non distended Ext: no edema skin: not jaundice, no icterus neuro: grossly intact, good strength, CN intact, good balance, understanding situation Labs:[2119-9-20] 12:55p 143/4/100/29/14/1<142 ALT: 15, AST: 22 tbili 0.7 Abl: 4.6 HBS pending HBS pending ADDED CHEM 1:10PM 140/3.7/103/27/13/1.1<105 Ca: 9.8 Mg: 2.2 P: 3.6 ALT: 10 AP: 72 Tbili: 0.9 Alb: 4.3 AST: 15 LDH: WBC: 8.2>47.2<200 Other Blood Chemistry: HBsAg: pending HBs-Ab: pending PT: 13.1 PTT: 28.6 INR: 1.1 Fibrinogen: 341 Pertinent Results: [2119-9-20] 12:55PM BLOOD WBC-8.2# RBC-5.09 Hgb-16.2 Hct-47.2 MCV-93 MCH-31.9 MCHC-34.4 RDW-12.5 Plt Ct-200 [2119-9-29] 05:02AM BLOOD WBC-13.6* RBC-3.51* Hgb-11.4* Hct-33.6* MCV-96 MCH-32.4* MCHC-33.9 RDW-14.2 Plt Ct-325 [2119-9-29] 05:02AM BLOOD PT-12.5 PTT-19.3* INR(PT)-1.1 [2119-9-29] 05:02AM BLOOD Glucose-73 UreaN-14 Creat-1.0 Na-139 K-4.2 Cl-102 HCO3-28 AnGap-13 [2119-9-20] 12:55PM BLOOD ALT-10 AST-15 AlkPhos-72 TotBili-0.9 [2119-9-21] 11:57AM BLOOD ALT-1900* AST-2770* AlkPhos-74 TotBili-1.0 DirBili-0.5* IndBili-0.5 [2119-9-29] 05:02AM BLOOD ALT-242* AST-35 AlkPhos-151* TotBili-0.6 [2119-9-29] 05:02AM BLOOD Calcium-9.0 Phos-3.5 Mg-1.8 [2119-9-29] 05:02AM BLOOD tacroFK-9.8 Brief Hospital Course: On [2119-9-20], he underwent orthotopic liver transplant, piggyback method for end-stage liver disease with hepatocellular cancer due to hepatitis B. Surgeon was Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 816]. Please refer to operative note for details. He received cellcept preop and solumedrol intraop. HBIG was given intraop. Two [Doctor Last Name 406] drains were placed. Postop, he was transferred to the SICU for management. He was extubated on postop day 1 and did well from a respiratory stand point. He was hemodynamically stable. LFTs increased initially as expected. Duplex U/S of the liver showed patent portal vein, hepatic veins, and hepatic artery. Low resistive indices were noted in the hepatic artery and left and right branches of the hepatic artery. A repeat ultrasound in 24 hours was performed noting patent portal vein, hepatic vein, and hepatic artery, and their branches. The resistive indices increased to the normal range in relation to the hepatic artery and its branches. LFTs trended down. Daily HBSAg and antibody titers were monitored each day. A total of 5 days of HBIG was given. Antibody titers were greater than 450. He was transferred out of the SICU to the med-[Doctor First Name ] unit. Vital signs remained stable. LFTs trended down. Diet was advanced. The incision appeared intact with scant serosanguinous drainage initially then dry. The Drains appeared bilious. On [9-26], an ERCP was done showing common bile duct narrowing with contrast extravasation at the level of the anastomosis. The intrahepatic bile ducts were slightly prominent. A pigtail stent was placed in the CBD. Postop ERCP he remained stable. Drainage became serosanguinous. These drains were removed on [9-24] and [9-29]. On [9-27], CT of the Abd/pelvis was done to assess for bilioma. A small amount of fluid and air in the porta hepatitis was noted. No organized fluid collection was seen. A 3-mm right middle lobe lung nodule, not significantly changed from [2118-10-19] was noted. Three month CT follow up recommended given the history of malignancy. Given bile leak and prior initial duplex with low resistive indices, a repeat liver duplex was done on [9-28] to assess the hepatic artery. This demonstrated normal hepatic vasculature and no fluid collections. He was ambulatory initally with assist then independently. Minimal pain medication was used. He tolerated oral dilaudid without problems. Solumedrol was tapered per protocol. He did experience some hyperglycemia necessitating long acting and short acting sliding scale insulin. [Last Name (un) ] was consulted and assisted with management. Insulin teaching went well and he was able to self inject. Solumedrol was tapered to prednisone. Cellcept was well tolerated. Prograf was initiated on [9-21] with dose adjustment per trough levels. He was sent home on 4mg [Hospital1 ]. Medication teaching went well. On postop day 8, he was discharged to home with VNA services coordinated. Medications on Admission: Hepsera (Adefovir)10mg qd Discharge Medications: 1. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 2. Prednisone 5 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily): follow tapering scale schedule. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Capsule(s) 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Entecavir 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:20 Tablet(s) Refills:0 8. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Hepatitis B Immune Globulin you will receive this injection when you follow up in the transplant clinic 11. Tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO Q12H (every 12 hours). 12. Insulin Glargine 100 unit/mL Solution Sig: Thirty Six (36) Subcutaneous at bedtime. 13. Insulin Lispro 100 unit/mL Solution Sig: follow sliding scale Subcutaneous four times a day. 14. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:12 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: HBV HCC hyperglycemia related to steroids bile leak Discharge Condition: good Discharge Instructions: please call the Transplant Office [Telephone/Fax (1) 673] if fever, chills, nausea, vomiting, inability to take any of your medications, increased abdominal pain, jaundice, incision redness/drainage, or blood sugars persisently over 200s or less than 80. check blood sugars prior to meals and bedtime. Give insulin as directed on insulin scale. Lab work every Monday and Thursday at [Last Name (NamePattern1) 439] Lab [Location (un) 86] [Month (only) 116] shower No heavy lifting No driving while taking pain medications Followup Instructions: Provider: [First Name11 (Name Pattern1) 819] [Last Name (NamePattern4) 820], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2119-10-5] 9:00 Provider: [Name10 (NameIs) ],[Name11 (NameIs) 156] TRANSPLANT SOCIAL WORK Date/Time:[2119-10-5] 10:00 Provider: [First Name11 (Name Pattern1) 819] [Last Name (NamePattern4) 820], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2119-10-12] 9:30 [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707] MD, [MD Number(3) 709] Completed by:[2119-10-4]	[ "249.00", "576.8", "070.32", "V58.67", "782.3", "155.0", "458.29", "568.0", "790.01", "572.8", "997.4", "E878.0", "E932.0", "571.5" ]	icd9cm	[ [ [] ] ]	[ "50.59", "51.85", "51.87", "00.93", "54.59" ]	icd9pcs	[ [ [] ] ]	7761, 7818	3319, 6363	340, 375	7914, 7921	2573, 3296	8506, 9085	1826, 1877		6440, 7738	7839, 7893		6389, 6417			7945, 8483							1892, 2554																275, 302								403, 1641													1663, 1718	1734, 1810
28,939	129,505	45723	Discharge summary	report	Admission Date: [2154-5-19] Discharge Date: [2154-5-27] Date of Birth: [2085-3-29] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1481] Chief Complaint: chest pain, shortness of breath Major Surgical or Invasive Procedure: Endogastroduodenoscopy with pyloric dilatation History of Present Illness: ms [Known lastname ] is a 69 yo female s/p recent minimally invasive esophagectomy ([2154-5-3]) for esophageal cancer. She presented to the ED on [5-19] with complaint of progressively worsening chest pain and shortness of breath for the four hours prior to arrival. Of note, She had had a CT scan of her chest on [5-13] showing significant bilateral pleural effusions and bilateral lower lobe atelectasis/ collapse. Flexible bronchoscopy was performed on [5-15], during which there was noted to be "frankly aspirated bile" Past Medical History: Diabetes Mellitus hypertension hyperlipidemia COPD Esophageal Cancer s/p minimally invasive esophagectomy Breast Cancer s/p Right mastectomy Social History: She has been a nonsmoker for the past year, having started at the age of 14 and smoked up to one pack per day. She drinks an occasional alcoholic beverage, but they are so rare she cannot remember when her last one was. Family History: Her family history is negative for breast or ovarian cancer. She had a maternal uncle with [Name2 (NI) 499] cancer and a maternal grandmother with some type of cancer that spread; she is unsure whether this could have been ovarian. There has been no prostate or pancreatic cancers. Physical Exam: at time of admission: temp 101.4 HR 114 BP 119/69 O2 sat: 90% 1.5L Gen: awake alert, mildly uncomfortable ENT: neck surgical incision healing well, without erythema Card: Regular rhythm, tachycardic Chest: diminished breath sounds at the based bilaterally, bibasilar crackles Abdomen: Soft non-tender non-distended. Port site incision healing without erythema or drainage. Feeding Jejunostomy in place Extremities: warm and well-perfused. Pertinent Results: [2154-5-19] 11:38AM PT-13.7* PTT-31.3 INR(PT)-1.2* [2154-5-19] 11:38AM NEUTS-91.6* LYMPHS-3.7* MONOS-3.6 EOS-1.1 BASOS-0.1 [2154-5-19] 11:38AM WBC-18.9* RBC-3.77* HGB-11.0* HCT-34.2* MCV-91 MCH-29.2 MCHC-32.2 RDW-15.2 [2154-5-19] 12:30PM cTropnT-<0.01 [2154-5-19] 12:30PM CK(CPK)-26 [2154-5-19] 12:30PM CK-MB-NotDone [2154-5-19] 12:30PM GLUCOSE-198* UREA N-15 CREAT-0.7 SODIUM-132* POTASSIUM-5.1 CHLORIDE-92* TOTAL CO2-26 ANION GAP-19 [2154-5-19] 05:50PM URINE RBC-<1 WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0-2 TRANS EPI-0-2 [2154-5-19] 05:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG Brief Hospital Course: Ms [Known lastname 805] presented to the ED and was evaluated for her chest pain and shortness of breath. Given her presentation of pleuritic chest pain, fever, shortness of breath, recent history of aspiration, and negative cardiac enzymes it was felt that she was most likely suffering from aspiration pneumonia. She was admitted to the SICU for continuous cardio pulmonary monitoring, and IV antibiotics. After several days of antibiotics she defervesced and her white count began to drop. Given her improvement, she was transferred out of the SICU and to the floor where she continued to receive IV Vancomycin and Zosyn. She did well on the floor except for one episode of Atrial fibrillation that occurred as a result of a missed beta blocker dosage (held per protocol because of low systolic blood pressure). She was evaluated at the bedside and EKG confirmed A-fib and she was given appropriate doses of her beta blocker and fluid. During the entire episode, she never endorsed chest pain, dizziness, or palpitations. The event lead to a trigger being called. Because she remained mildly tachycardic, she was transferred to a higher level of care for observation and converted to Sinus rhythm overnight. In the morning she was transferred back to the floor and continued to improve, working with physical therapy and beginning to take in some regular diet in addition to her tube feeds. The primary team scheduled a EGD for further evaluation of her aspiration and patency of her esophagectomy anastomosis. The EGD showed widely patent esophago-gastric anastomosis, large amount of retained food in stomach and a normal appearing pylorus that was dilated to 18mm. Since the EGD, Ms. [Known lastname 805] has been afebrile, voiding, ambulating, tolerating oral intake as well as receiving tube feeds. Medications on Admission: advair lopressor 25 Lansoprazole 30 Fentanyl colace albuterol ativan Discharge Medications: 1. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback [Known lastname ]: One (1) Intravenous Q8H (every 8 hours). Disp:18 6 day supply Refills:0 2. Vancomycin in Dextrose 1 gram/200 mL Piggyback [Known lastname ]: One (1) Intravenous Q 12H (Every 12 Hours). Disp:12 6 day supply Refills:0 3. Metoclopramide 5 mg/5 mL Solution [Known lastname ]: One (1) mg PO every six (6) hours: take 10mg (10 mL of solution PO or via G tube). Disp:800 ml Refills:0 4. Fentanyl 50 mcg/hr Patch 72 hr [Known lastname ]: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). Disp:3 Patch 72 hr(s) Refills:0 5. Outpatient Lab Work Please draw a chem 7, vancomycin trough on [5-30] and deliver results to Dr. [Last Name (STitle) ] [Telephone/Fax (1) 25782] and Dr. 6. heparin Heparin Flush-100u Heparin 5 mL SASH and PRN for a total of 6 days 7. Normal saline Normal saline 5 mL SASH and PRN for a total of 6 days 8. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device [Telephone/Fax (1) ]: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). Disp:1 Disk with Device(s) Refills:2 9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). Disp:30 Tablet,Rapid Dissolve, DR(s) Refills:2 10. Albuterol 90 mcg/Actuation Aerosol [Last Name (STitle) ]: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. Disp:1 1 Refills:0 11. Metoprolol Tartrate 25 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 12. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [Last Name (STitle) ]: 5-10 MLs PO Q6H (every 6 hours) as needed for Pain. Disp:1 250 ML(s) Refills:0 Discharge Disposition: Home With Service Facility: Physician [Name9 (PRE) ] [Name9 (PRE) ] Discharge Diagnosis: 1.) aspiration pneumonia 2.) gastric distension Discharge Condition: hemodynamically stable, tolerating some oral intake, tolerating Tube feeds, ambulating Discharge Instructions: Please return to the Emergency Room for evaluation if you experience increasing shortness of breath or difficulty breathing, vomiting that does not stop or any other symptoms that are concerning to you Followup Instructions: Call Dr.[Name (NI) 1482] office for follow up in 2 weeks ([Telephone/Fax (1) 8818]. You should also make an appointment with your primary care provider for management of your atrial fibrillation. Completed by:[2154-5-27]	[ "250.00", "401.9", "V10.03", "427.31", "507.0", "496", "511.9", "V10.3" ]	icd9cm	[ [ [] ] ]	[ "96.6", "44.22" ]	icd9pcs	[ [ [] ] ]	6629, 6707	2877, 4704	346, 395	6798, 6887	2152, 2854	7137, 7373	1388, 1676		4823, 6606	6728, 6777		4730, 4800			6911, 7114							1691, 2133																275, 308								423, 969													991, 1134	1150, 1372
12,982	130,282	52511+59431	Discharge summary	report+addendum	Admission Date: [2165-10-18] Discharge Date: [2165-11-2] Date of Birth: [2097-6-5] Sex: M Service: HISTORY OF THE PRESENT ILLNESS: This 68-year-old white male has a history of coronary artery disease. He is status post CABG times two with left [Female First Name (un) 899] in [2147] and status post PTCA and stenting to the left circumflex. He has had several weeks of chest pain at rest which is relieved promptly with sublingual nitroglycerin. He had a Persantine exercise tolerance test on [2165-10-11] without symptoms or EKG changes which showed an LVEF of 30-35%, moderate to severe ischemic dilatation, severe partially reversible inferior wall defect, and mild reversible inferolateral defect and akinesis of the septum. He underwent a cardiac catheterization at [Hospital1 18] on [2165-10-18] which revealed that the LV had 1+ MR and a LVEF of 35%. The LAD had an ostial 90% lesion. The left circumflex was a codominant vessel with mild paroxysmal disease from 60% left main lesion. The left main had a diffuse 60% lesion with moderate calcifications. The RCA was a codominant vessel which was 100% occluded proximally. The saphenous vein graft to the RCA was proximally occluded. The LIMA to the LAD was patent without critical lesions. His left subclavian artery had an ostial 80% lesion. His right subclavian artery had a 90% lesion at the origin. He had a stent of his left subclavian on that same day. He was now admitted for redo CABG. He had an echocardiogram in [9-11] which revealed an EF of 50%, 2+ MR and trivial TR. PAST MEDICAL HISTORY: 1. Status post CABG times two with LIMA to LAD and saphenous vein graft to the RCA in [2147]. 2. Status post aortobifemoral in [2147]. 3. History of hypertension. 4. History of hypercholesterolemia. 5. Status post CVA in [7-11] of the right MCA with residual left hand paresis and left-sided weakness. 6. History of frequent falls. 7. History of chronic renal insufficiency with a creatinine of 1.3. 8. History of celiac sprue. 9. History of iron-deficiency anemia. 10. History of remote seizure disorder. 11. History of gout. 12. History of an aortic atheroma. 13. Status post bilateral carotid endarterectomies in [3-9]. 14. Status post renal artery stents in [2159]. ADMISSION MEDICATIONS: 1. Ecotrin 325 mg p.o. q.d. 2. Allopurinol 100 mg p.o. q.d. 3. Protonix 40 mg p.o. q.d. 4. Iron OTC 65 mg p.o. q.d. 5. Imdur 30 mg p.o. q.d. 6. Atenolol 25 mg p.o. q.d. 7. Lipitor 40 mg p.o. q.d. 8. Plavix was started on the day of this procedure. ALLERGIES: The patient has no known drug allergies. FAMILY HISTORY: Unremarkable. SOCIAL HISTORY: He has a 50 pack year smoking history and quit five years ago. He does not drink alcohol. He lives with his wife. REVIEW OF SYSTEMS: Left hemiparesis and left leg weakness. He walks with a cane. PHYSICAL EXAMINATION ON ADMISSION: General: The patient is an elderly white male in no apparent distress. Vital signs: Stable, afebrile. HEENT: Normocephalic, atraumatic. The extraocular movements were intact. The oropharynx was benign with upper and lower dentures. Neck: Supple, full range of motion. No lymphadenopathy or thyromegaly. Carotids 2+ and equal bilaterally with bilateral bruits. Lungs: Occasional wheezes bilaterally. Cardiovascular: Regular rate and rhythm without rubs, murmurs, or gallops, normal S1, S2. Abdomen: Soft, nontender with positive bowel sounds. No masses or hepatosplenomegaly. He had well-healed surgical incisions. Extremities: Without clubbing or cyanosis. The right leg had a well-healed surgical incision. His radials were 2+ bilaterally, brachial 1+ bilaterally. The femoral had a sheath on the left and 1+ on the right. PT 1+ bilaterally. DP 1+ bilaterally. Neurologic: Alert and oriented times three. Paretic left hand. The left arm had 5/5 strength. The left leg had 4/5 strength. HOSPITAL COURSE: The patient was admitted to Cardiology. Dr. [Last Name (STitle) 1537] was consulted. He had a carotid ultrasound which showed significant narrowing of the bilateral carotid arteries. The right had a 60-69% stenosis and the left had a 70-79% stenosis. He did have some chest pain while he was here. His creatinine went up to 2.3 post catheterization and then came down again to 2. On [2165-10-24], he underwent an off-pump CABG times one with a saphenous vein graft to the OM via a left thoracotomy. He was transferred to the Surgical Intensive Care Unit in stable condition. He was extubated on postoperative day number one. His creatinine was 2.3 on postoperative day number one. He had his chest tubes out on postoperative day number two. He was somewhat agitated and had pain. On postoperative day number four, he underwent angiography to be completely revascularized and he had a successful DES placed in the OM1. He tolerated the procedure well. He was hydrated, treated with Mucomyst and returned to the CRSU. He continued to have intermittent agitation and went back to the Catheterization Laboratory on postoperative day number six and had a PTCRA and [Name Prefix (Prefixes) ] [Last Name (Prefixes) 5175] in the left main and LAD. He was again treated with Mucomyst and restarted on Plavix and went directly to the floor where he continued to progress. His creatinine did increase to 2.3 and another was pending prior to discharge to rehabilitation. On postoperative day number nine, he is planned to be discharged to East Point Rehabilitation in stable condition. LABORATORY DATA ON DISCHARGE: White count 11.1, hematocrit 28.3, platelets 234,000. Sodium 140, potassium 4.3, chloride 106, C02 25, BUN 42, creatinine 2.3, blood sugar 97. DISCHARGE MEDICATIONS: 1. Lopressor 75 mg p.o. b.i.d. 2. Aspirin 325 mg p.o. q.d. 3. Tylenol one to two p.o. q. four to six hours p.r.n. pain. 4. Plavix 75 mg p.o. q.d. 5. Colace 100 mg p.o. b.i.d. 6. Levofloxacin 250 mg p.o. q. 24 hours for seven days. 7. Allopurinol 100 mg p.o. q.d. 8. Lipitor 40 mg p.o. q.d. 9. Imdur 60 mg p.o. b.i.d. 10. Hydralazine 25 mg p.o. q. six hours. 11. Nystatin swish and swallow 5 cc p.o. q.i.d. 12. Protonix 40 mg p.o. q.d. FOLLOW-UP: The patient will be followed by Dr. [Last Name (STitle) ] in two to three weeks and by Dr. [Last Name (STitle) 1537] in four weeks. [First Name11 (Name Pattern1) 275] [Last Name (NamePattern4) 1539], M.D. [MD Number(1) 1540] Dictated By:[Last Name (NamePattern1) 6516] MEDQUIST36 D: [2165-11-1] 06:46 T: [2165-11-1] 18:50 JOB#: [Job Number 108457] Name: [Known lastname ], [Known firstname ] Unit No: [Numeric Identifier 17732] Admission Date: [2165-10-18] Discharge Date: [2165-11-9] Date of Birth: [2097-6-5] Sex: M Service: Cardiothoracic Surgery Overnight the patient complained of fatigue and insomnia, and had a nosebleed on the morning of the 26th. Blood pressure was 90/60 in sinus rhythm at 79, satting 99% on room air. He was alert and oriented. His left thoracotomy site was clean, dry, and intact. He had positive bowel sounds and benign abdominal examination. He had decreased breath sounds at his left base, but his lungs were clear. His creatinine rose to 2.8. The decision was made between his nosebleed and his creatinine to hold his transfer out. On the 27th, which was postoperative day #11, his creatinine rose to 3.0. He is ambulating well with assistance, and he was much clearer mentally. He was satting 95% in sinus rhythm in the 80s with a blood pressure of 153/60s. K was 4.2 with a corresponding BUN of 41 down from 44. He had decreased breath sounds in both bases. Otherwise, his lungs were clear. His heart was regular, rate, and rhythm. He has trace pedal edema. Incision was clean, dry, and intact. He had a tiny open in his left knee from saphenectomy site incision, but no erythema and no purulent drainage. It was agreed that he was not ready for discharge given his rise in creatinine and renal consult was discussed with a plan to allow him to continue to ambulate. He was also screened by the Nutrition team. On postoperative day 12, he had no evidence overnight. That morning his creatinine rose from 3 to 3.1. His examination was otherwise unremarkable, and it was expected that his creatinine bump was due to the iodine contrast after having two cardiac catheterizations. Urinalysis was sent off. Renal agreed to see the patient in the afternoon. Chest x-ray was ordered. His hematocrit dropped to 23.7 and he was transfused 2 units of packed red blood cells. On the 28th, he was seen by Renal, who recognized the probable contrast induced nephropathy. Please refer to their consult note. On the 29th, he continued to be monitored. His hematocrit rose to 28 after the 2 units of transfusion. His creatinine dropped to 2.9. His scans showed no hydronephrosis, mass, or stones, but resistive indices in his right kidney. His left kidney was not examined. He continued to be monitored for his acute renal failure and was seen by the Renal staff. On postoperative day 13, he continued to receive aggressive pulmonary toilet and had to be encouraged to do his spirometry. He received another unit of packed red blood cells on postoperative day #13, and remained on [Hospital Ward Name ] 2 to be monitored. On the 30th, he was seen again by Case Management and was noted that he no longer qualified for rehab bed. He was re-evaluated by Physical Therapy to determine if this was so and whether or not he could be safely discharged to home with VNA services. His hematocrit on the [**] dropped to 2.6. His breathing was improved. He seemed overall to feel much better. He was satting 95% on room air. His hematocrit rose to 32 with a white count of 8 and continued on his Plavix. His K was 4.5. His renal function continued to improve. He also received a GI consult for anemia and possible hemolysis. Please refer to the consult note. On postoperative day 14, his renal failure continued to improve. His sternum was stable. His lungs are clear. On the 31st, his creatinine rose slightly from 2.6 to 2.7. His baseline creatinine was noted to be 1.5 to 2.0. He continued to have his GI workup. On the 31st, he had some left upper extremity weakness, but was alert and oriented and had decreased breath sounds at both bases. His incisions were clean, dry, and intact. He had no melena over that 48 hour period, which had provoked a GI consult. He was to have an upper GI series during the day. His aspirin was decreased to 81 mg. He completed a 14 day course of Levaquin and was ambulating on his own with a walker, and the plan was to discharge him home since his GI issues were resolved. DISCHARGE STATUS: On the [2-9], he was discharged home with VNA services. DISCHARGE INSTRUCTIONS: Make a follow-up appointment with Dr. [Last Name (STitle) 17733], his primary care physician. [Name10 (NameIs) ] see Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1426] of Cardiology in [2-11] weeks and make an appointment for his postoperative visit with Dr. [Last Name (STitle) ] in four weeks. DISCHARGE DIAGNOSES: Were noted in his discharge summary dictated on [11-1]. Of note, his postoperative stenting of his left anterior descending artery and left subclavian. DISCHARGE MEDICATIONS: Also listed, although are repeated here for completeness. 1. Tylenol 650 mg p.o. prn q.4h. 2. Plavix 75 mg p.o. q.d. 3. Lipitor 40 mg p.o. q.d. 4. Imdur 30 mg p.o. b.i.d. 5. Metoprolol 50 mg p.o. b.i.d. 6. Aspirin 81 mg p.o. q.d. 7. Allopurinol 100 mg p.o. q.d. 8. Protonix 40 mg p.o. q.d. 9. Keflex 250 mg p.o. q.i.d. x7 days. [First Name11 (Name Pattern1) 63] [Last Name (NamePattern4) 1508], M.D. [MD Number(1) 1509] Dictated By:[Last Name (NamePattern1) 981] MEDQUIST36 D: [2165-12-24] 11:00 T: [2165-12-27] 10:57 JOB#: [Job Number 17734**]	[ "584.9", "401.9", "414.02", "272.0", "424.0", "414.01", "411.1", "486", "V45.82" ]	icd9cm	[ [ [] ] ]	[ "99.20", "39.90", "88.53", "36.11", "39.50", "88.56", "37.22", "37.23", "36.01", "36.07" ]	icd9pcs	[ [ [] ] ]							2684, 2699	11328, 11486	11510, 12119				3987, 5609		10969, 11306	2355, 2666																	5624, 5769			2853, 2937																	2952, 3969						1632, 2332	2716, 2833
53,931	111,439	47358	Discharge summary	report	Admission Date: [2183-11-27] Discharge Date: [2183-12-3] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 8487] Chief Complaint: gait instability Major Surgical or Invasive Procedure: none History of Present Illness: Dr [Known lastname 3271] is a 84y/o M with recently dx right frontal glioblastoma who presented to Dr[Name (NI) 6767] onc clinic today with increased giat instability. The patient was had worsening weakness and psychomotor slowing since monday. He presented to clinic on monday and recieved a avastin infusion with some improvement in symptoms. Starting [11-25] his Decadron was decreased from 8mg to 4mg daily. Since monday he has had intermittant diarrhea. Per family he did recieve abx around brain bx on [2183-11-5]. This am he had difficulty swallowing his pills. Pt reports hiccups partially controled with ativan. Dr [Known lastname 3271] also has swelling of his R eye lid and new lesions on his chin noted today. No trauma noted. He denies F/C/S, HA, visual changes. No cough, sorethroat, sob, abd pain, N/V. No urinary symptoms. In clinic VS, T 99.8, BP 90/60, p 72, R 18. PT noted to have magnetic gait and abulia on neuro exam. He was sent for further evaluation including MRI of the brain. Past Medical History: Onc Hx: -In end of [2183-9-29] presented with imbalance, short-term [Last Name ] problem, flat affect, and urinary urgency. -[2183-11-3] MRI showed Large heterogeneous infiltrative mass in the right frontal lobe, extending into the left anterior corpus callosum -a stereotaxic brain biopsy by [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], M.D., Ph.D. on [2183-11-5] confirming Glioblastoma -started temozolomide chemo-irradiation on [2183-11-18]. -started C1D1 bevacizumab on [2183-11-24] - pt opted not to persume debulking PMHx: presumed small renal cell ca followed by Dr [Last Name (STitle) 261] melanoma of his left eye s/p enucleation in [2181] retinal detachment in OD. cataractsurgery in right eye hypertension typical values of 150/80. Social History: He is a physician, [Name10 (NameIs) ] Chief of Medicine; married with adult children (a cardiologist and a psychiatrist). He drinks 2 glasses of wine per night; he does not smoke cigarettes or use illicit drugs. Family History: noncontributory Physical Exam: PE: VS: T95.4, BP 147/93, R 16, P 75, 95%RA, wt 129lb GEN: elderly man apearing frail HEENT: erythematous scalp. Left eye is prostetic. R pupil post surgical and non-responsive. EOMI impaired superior rightward gaze in left eye. Retina exam, optic disk not clearly visualized. Throat erythematous dry MM. multiple 1cm brown ulceration on chin. Slight R periorbital swelling. neck: supple CV: RRR, no m/r/g nl S1 and S2 lungs: CTA BL abd: ND, NT +BS, no HSM ext: no edema neuro: Pt speech is slow but appropriate, however not responding to all questions. Eye exam as above. Left facial droop. weakness in L SCM. no tongue deviation. Strength 5/5 on right, [5-3] diffusely on Left. DTR 3+ LUE, 2+ RUE. 2+ DTRs in [Name2 (NI) ]. normal babinski. Pt to weak to safely access gait. Pertinent Results: [2183-11-27] 02:45PM PLT COUNT-244 [2183-11-27] 02:45PM NEUTS-92.6* LYMPHS-3.3* MONOS-3.9 EOS-0.1 BASOS-0.1 [2183-11-27] 02:45PM WBC-17.2* RBC-4.89 HGB-15.1 HCT-42.8 MCV-88 MCH-31.0 MCHC-35.4* RDW-13.1 [2183-11-27] 02:45PM OSMOLAL-277 [2183-11-27] 02:45PM ALT(SGPT)-104* AST(SGOT)-27 ALK PHOS-67 TOT BILI-0.7 [2183-11-27] 02:45PM UREA N-37* CREAT-1.1 SODIUM-129* POTASSIUM-4.8 CHLORIDE-88* TOTAL CO2-25 ANION GAP-21* [2183-11-27] 02:45PM GLUCOSE-151* . [2183-11-27]: MRI head: 1. Infiltrative right frontal mass lesion consistent with glioblastoma multiforme as suggested in the history. 2. New areas of slow diffusion in the posterior [Doctor Last Name 534] of the right lateral ventricle and in the subarachnoid space along the falx of the right vertex (which appears to be associated with enhancement) may represent tumor seeding, however, these findings are concerning for infection and clinical correlation is recommended. . [2183-11-28]: EEG: This is an abnormal portable EEG due to the slow and disorganized background and the multifocal intermittent slowing. The first abnormality suggests a mild encephalopathy, whereas the second one suggests multifocal subcortical dysfunction. There were no epileptiform features seen. Note is incidentally made of occasional PVC's. . [2183-11-28] CXR: Since [2183-11-25], lungs remain clear. The cardiomediastinal silhouette and hilar contours are normal. There is no pleural effusion. . [11-29] CT head: No interval change from [2183-11-24], with a large right frontal lobe necrotic mass, extending into the corpus callosum with associated vasogenic edema. Brief Hospital Course: Dr [Known lastname 3271] is a 84 y/o with a h/o of suspected renal cell ca, L eye melenoma s/p enucleation, recent dx of GBM s/p temozolomide chemo-irradiation on [2183-11-18], bevacizumab on [2183-11-24] presents with giat instability, dyspahagia, diarrhea, left sided weakness. . #. Glioblastoma: Presenting with evidence of frontal lobe dysfunction, magnetic gait and slowed speech. In additiona diffuse left weakness concerning for worsening brain edema. Edema may be worsening in setting of recent decrease in decadron. s/p recent becacizumab making hemmorhage likely although [11-24] ct without evidence of bleed. MRI brain prelim showed no hemmorhage, edema similar to previous imaging. He was put on increased ICP precautions, head bed > 30 degrees, ppx zofran, autoreg bp, serum na goal > 130. He received decadron IV 10mgx1 and 4mg [Hospital1 ], later increased to 4mg q6h. He MS continued to deteriate. An EEG was obtained which did not show any seizure activity but had evidence of encephalopathy. The encephalopathy could be radiation induced vs herpes vs [3-1] hyponatremia. Despite high dose acyclovir and correction of his hyponatremia Dr.[Known lastname 87904] MS deteriorated to the point that he could no longer protect his airway. When reversible causes of his altered MS had all but been corrected, it was determined that he should be made comfortable. However, upon [Location (un) 1131] his article entitled "The Role of the Physician in the Preservation of Life", vital signs were monitored, physical exams were performed and labs were measured in a tribute to this great teacher of the art of medicine. On [2183-12-3], Dr. [Known lastname 3271] expired. . #. Hyponatremia: differential includes SIADH or hypovolemic hyponatremia [3-1] poor po intake. Urine lytes consistant with SIADH. He was placed on fluid restriction. Started on hypertonic saline, transfered to [Hospital Unit Name 153] for worsening hyponatremia. As above, correction of his sodium did not correct his mental status and Dr. [Known lastname 3271] expired on [2183-12-3]. Medications on Admission: Dexamethasone 4mg Tablet [Hospital1 ] (recently decreased from TID) Fluoxetine 10mg PO daily Keppra 750mg [Hospital1 ] Lisinpril 5mg daily lorazepam 1mg q6h prn anxiety/hiccups pantoprazole 40mg daily prochlorperazine 5mg prn nausa ambien 6.25mg hs prn Temodar 125mg PO daily Cyanocobalamin 1000mcg PO daily Allergies: NKDA Discharge Medications: Patient expired. Discharge Disposition: Expired Discharge Diagnosis: Glioblastoma Multiforme. Patient expired. Discharge Condition: Patient expired. Discharge Instructions: Patient expired. Followup Instructions: Patient expired. Completed by:[2183-12-6]	[ "285.9", "V10.82", "054.9", "253.6", "348.30", "427.31", "V45.78", "191.1", "348.8", "V85.1", "427.32", "189.0" ]	icd9cm	[ [ [] ] ]	[ "38.93", "92.29", "96.6" ]	icd9pcs	[ [ [] ] ]	7506, 7515	4954, 7081	280, 286	7600, 7618	3254, 4763	7683, 7730	2415, 2433		7465, 7483	7536, 7579		7107, 7442			7642, 7660							2448, 3235																224, 242								314, 1342		4772, 4931											1364, 2165	2181, 2399
15,322	118,891	45550	Discharge summary	report	Admission Date: [2149-2-6] Discharge Date: [2149-2-12] Date of Birth: [2069-2-27] Sex: M Service: NEUROLOGY Allergies: Lopressor / Gadolinium-Containing Agents / Erythromycin Base Attending:[First Name3 (LF) 2569] Chief Complaint: garbled speech Major Surgical or Invasive Procedure: None History of Present Illness: 79 yo man with hx of stroke in past ([5-26], L anterior corona radiata), admitted to [Hospital1 ] [8-26] for transient aphasia (TIA, no TPA), as well as hx DM, CAD, high chol, AAA, prostate CA last PSA 19, PD, Dementia, who p/w acute change in speech noticed at 9am after last known well time 8:30am. The patient had been living at NH ([Hospital 100] Rehab) since last admission to medicine service [12-29] for falls and mental status change; he had apparently been in USOH at NH without speech, language or comprehension problems at 8:30 AM. At 9AM physical therapist went to work with him and he was apparently speaking in garbled, incomprehensible language. There was no apparent weakness noted. He was brought to [Hospital1 18] by ambulance as a "code stroke" and arrived at 10:30AM; intial finger stick BG was >300, for which the patient received insulin. He was noted to be speaking very few words, with very little comprehension (considered to have some global aphasia). There was also an apparent right visual field cut. NIHSS score was 6 (aphasia, field cut, unable to answer questions about loc). He had a head CT which only showed an old stroke L corona radiata without hemorrhage. He received IV TPA. Within one hour when next seen he had a language production which was garbled once again, with persistently poor comprehension and repetition, considered to be more of a Wernicke's type aphasia. 1-2 hours after that, his repetition had improved. Past Medical History: -recent admission to medicine for "confusion" and falls, went to [Hospital 100] Rehab after this ([12-30]) -stroke [5-26] treated at [Hospital1 2025] (L anterior corona radiata) -TIA (aphasia) [8-26] - [Hospital1 18] -AAA s/p repair -Prostate Ca with last PSA 19 in [10-28], not treated -High chol -DM -CAD -PD with dementia -Hyperthyroidism and associated hypercalcemia -Hyperparathyroidism, hypercalcemia -Gastric Varices [5-26] and hx GIB s/p colonoscopy within past 3 yrs -COPD Social History: Retired sales, lives at [Hospital ] Rehab recently, no tob/etoh, drugs Family History: Non-contributory Physical Exam: MS [First Name (Titles) ] [Last Name (Titles) 3003] to TPA MS: awake, alert, interactive but unable to following commands efficiently, only following simple midline and appendicular commands withvisual cues Speech sparse w/ paraphasic errors, cannot name, repeat, or comprehend No evidence fo neglect [Last Name (Titles) ] (1hr post TPA; please see Dr.[Name (NI) 28511] note for pre-TPA exam) Afeb 175/75 HR 80 RR 18 97% RA General appearance: well appearing, trying to speak but not making sense, thin white elderly male Heart: regular rate and rhythm Lungs: clear to auscultation bilaterally. Abdomen: soft, nontender +bs GU: foley in place with blood in tubing Extremities: warm, well-perfused Mental Status: The patient is alert and attempts to respond to questions but speech is slightly slurred and language is frequently garbled with about 50% real words and 50% errors (both semantic and phonemic). He could name some simple items (watch) and could follow simple commands "point to the ceiling," "raise your hand" and "open your eyes," but not "point to the exit." He said "[Last Name (LF) 46536], [First Name3 (LF) ] day" for "today is a [First Name3 (LF) ] day" and said gibberish when asked to repeat "in the dining room on the table." Read "baseball maysball" for "baseball player," and could not read sentences. Cranial Nerves: Visual acuity is intact. The visual field on the right may be impaired to confrontation (assessed with blink to threat). Eye movements are normal spontaneously, with no nystagmus, though he did not follow directions to follow moving finger. Pupils react equally to light, both directly and consensually. Sensation was difficult to assess due to comprehension problems. Facial movements are normal and symmetrical. Hearing is intact to voice. The palate elevates in the midline. The tongue protrudes in the midline and is of normal appearance. Motor System: Appearance, tone, power are normal in all 4 limbs, including shoulder abductors, and extensors and flexors of the arms, wrists, fingers, hips, knees, feet and toes. There is no tremor, drift, or abnormal movements. Reflexes: The tendon reflexes are present, symmetric and normal. The plantar reflexes are flexor on the left, extensor on the right. Sensory: The patient does not seem to have DSS when asked to raise the hand being touched (raises both) but could not comprehend more detailed sensory testing. W/d to any stimuli bilat ue/le. Coordination: There is no ataxia. The finger/nose test is normal. Gait: Gait could not be assessed. Pertinent Results: [2149-2-6] 11:16PM CK(CPK)-42 [2149-2-6] 11:16PM CK-MB-NotDone [2149-2-6] 11:16PM HCT-34.0* [2149-2-6] 06:06PM URINE COLOR-Yellow APPEAR-Cloudy SP [Last Name (un) 155]-1.014 [2149-2-6] 06:06PM URINE BLOOD-LG NITRITE-POS PROTEIN-30 GLUCOSE-TR KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [2149-2-6] 04:30PM CK(CPK)-33* [2149-2-6] 04:30PM CK-MB-NotDone [2149-2-6] 04:30PM WBC-13.9* RBC-4.92 HGB-12.6* HCT-38.2* MCV-78* MCH-25.7* MCHC-33.1 RDW-15.7* [2149-2-6] 04:30PM NEUTS-86.5* LYMPHS-9.4* MONOS-3.3 EOS-0.4 BASOS-0.3 [2149-2-6] 04:30PM MICROCYT-2+ [2149-2-6] 04:30PM PLT COUNT-335 [2149-2-6] 12:25PM WBC-16.2# RBC-4.53 HGB-11.9* HCT-35.2* MCV-78* MCH-26.4* MCHC-33.9 RDW-16.0* [2149-2-6] 12:25PM NEUTS-87.0* BANDS-0 LYMPHS-8.4* MONOS-3.1 EOS-0.8 BASOS-0.8 [2149-2-6] 12:25PM PLT SMR-NORMAL PLT COUNT-301 [2149-2-6] 10:05AM GLUCOSE-327* UREA N-21* CREAT-1.2 SODIUM-136 POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-22 ANION GAP-15 [2149-2-6] 10:05AM WBC-7.3 RBC-4.42* HGB-11.6* HCT-34.5* MCV-78* MCH-26.2* MCHC-33.5 RDW-15.8* [2149-2-6] 10:05AM PLT COUNT-281# [2149-2-6] 10:05AM PT-11.7 PTT-20.1* INR(PT)-1.0 * * * Head CT [2149-2-6] NON-CONTRAST HEAD CT SCAN: There is no evidence of acute intracranial hemorrhage or shift of the normally midline structures. The ventricles and sulci are prominent, consistent with involutional change. There is hypodensity of the cerebral periventricular white matter, consistent with chronic microvascular infarction. A chronic infarct is again noted in the region of the left internal capsule. The [Doctor Last Name 352]-white matter differentiation appears preserved. The visualized paranasal sinuses and mastoid air cells are clear. There are calcifications of the cavernous internal carotid arteries bilaterally. IMPRESSION: No evidence of acute intracranial hemorrhage. Unchanged appearance of the brain compared to [2148-12-25]. * * * [2-6] CT C-spine INDICATIONS: Assess for metal foreign body. Coronal and lateral radiographs of the cervical spine were obtained. Comparison is made to a scout from a CT of the head from [2146-9-14] (prior to brain MRI from later the same day). Two metallic fragments overly the lateral aspect of the left cervical spine, anterior to the facet at C5. An additional metallic density overlies the right lung apex on the AP view. * * * [2-6] Chest X-ray AP SEMI-ERECT RADIOGRAPH OF THE CHEST: No significant interval change is noted. Again seen is a tortuous aorta. The heart size is within normal limits. The hilar regions appear unremarkable. There is no evidence for consolidations. No pleural effusions are seen. IMPRESSION: No evidence for pneumonia. * * * [2-6] EKG Sinus rhythm Normal ECG Since previous tracing, atrial premature complexes and sinus tachycardia absent * * * [2149-2-7] ECHO - Conclusions: 1. The left atrium is mildly dilated. 2. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function difficult to assess but is probably normal (LVEF>55%). 3. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. 4. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. 5. Compared with the findings of the prior study of [2146-9-15], there has been no significant change. * * * [2149-2-7] HEAD CT (follow-up) FINDINGS: There is no evidence of acute intracranial hemorrhage. Otherwise, study appears unchanged compared to yesterday's. There is no shift of normally midline structures. Again seen is hypodensity of the cerebral periventricular white matter, consistent with chronic microvascular infarction or ischemia. Again seen is hypodensity in the left putamen consistent with old infarct. [Doctor Last Name ]-white matter differentiation appears preserved. IMPRESSION: No evidence of acute intracranial hemorrhage or change from prior study. * * * [2149-2-7] CT ABDOMEN/PELVIS IMPRESSION: 1. Wall thickening in the rectum and sigmoid colon, suggesting proctocolitis of an infectious or inflammatory origin. The distribution is atypical for ischemia. 2. Diverticulosis. 3. Cholelithiasis. 4. Left lower lobe pulmonary nodule. 5. Ill-defined 2.3 cm low density lesion in the posterior right lobe of the liver. An abdominal ultrasound is recommended for further assessment of this finding. 6. Enlargement of the prostate gland. * * * [2149-2-8] Abdomen, a single supine view is compared to previous [Month/Day/Year 29765] of [2148-11-18]. There is no evidence of intestinal obstruction or toxic megacolon. Oral contrast is seen in the ascending, transverse and proximal portion of the descending colon. IMPRESSION: No evidence of intestinal obstruction. Brief Hospital Course: NEURO - By the second day of admission Mr. [Known lastname 97154] no longer exhibited deficits in productive or receptive language, and was able to register, name, and repeat without difficulty. He displayed some lapses in short term memory and perseveration, but apparently has a baseline history of possible dementia. There were no further episodes of aphasia, and follow-up CT was unchanged. There was never evidence of an acute infarct on CT scan. MRI could not be obtained due to shrapnel in the patient's body. The pt was continued on atorvastatin and ASA. FEN - Tolerated po intake without difficulty. Calcium ranged from 8.1 to 9.6, and on discharge was 9. Phosphorus ranged from 1.2 to 3.0, and on discharge was 2.3. PULM - No respiratory difficulties during this admission. CT of the abdomen and pelvis revealed a left lower lobe pulmonary nodule. CV - Hypotensive in the ICU to 80's/40's and tachycardic to 120's, treated with IV fluids. This occurred in the setting of a urinary tract infection (described below). At the time of discharge heart rate and blood pressure were within normal limits. EKG was normal as well. ENDO - Hemoglobin A1C was 7.9. The patient was maintained on insulin sliding scale and glyburide. The pt may be restarted on his metformin 1000 mg po bid after discharge when his creatinine normalizes back down to 1-1.2. GI - Continue to have loose stools, likely related to C. diff infection diagnosed prior to admission. Initially had significant abdominal pain, requiring treatment with morphine, but this resolved by the third day of admission. Non-contrast CT of the abdomen and pelvis revealed wall thickening of the rectum and colon, suggesting proctocolitis, diverticulosis, cholelithiasis, an ill-defined 2.3 cm density in the posterior right lobe of the liver. Decision was made between the primary team, GI, and the pts PCP [Last Name (NamePattern4) ]. [Last Name (STitle) 67935] that EGD/colonoscopy was not necessary. Of note, the pt was also having mild discomfort related to his hemorrhoids this admission. ID - Mr. [Known lastname 97154] continued treatment with flagyl for the c.diff infection that was diagnosed prior to admission. The pt is to continue his course of flagyl for 1 week after discontinuation of the pts Zosyn. Repeat c. diff testing was negative. He was diagnosed with an Enterococcus/Klebsiella UTI on [2-6] and began treatment with Zosyn. At the time of discharge he was on day [5-7]. RENAL/GU - An enlarged prostate was demonstrated on CT pelvis. After his diagnosis of UTI, the Foley catheter was removed, but Mr. [Known lastname 97154] was unable to urinate within 8 hours. An 18F coude catheter was replaced without incident, with good urine output after that. The pt had a slight rise in creatinine at the time of discharge (BL Cr 1-1.2) up to 1.4, likely due to dehydration in the setting of bowel prep (as the pt possibly going for colonoscopy--later deferred as discussed above). [Name (NI) 1623] The pt developed a metabolic acidosis on the day after admission (non-gap). His bicarb was decreased at 16 at the time of discharge, likely due to [Doctor First Name 48] as well as diarrhea during his bowel prep. The pts electrolytes should be followed at least 3 times weekly until his bicarb and creatinine resolve. The pt will need mild IV hydration as needed. Medications on Admission: Advair Tamsulosin Glyburide Paxil Protonix Zyprexa 2.5 qd ASA 81 Lisinopril 5 Lactulose prn constipation Metformin Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: Two (2) Capsule, Sust. Release 24HR PO HS (at bedtime). 3. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 6. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO HS (at bedtime). 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 12. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 15 days. 13. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment Sig: One (1) Appl Rectal TID (3 times a day). 14. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal QD () for 5 days. 15. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Zosyn 4.5 g Recon Soln Sig: 4.5 gram Intravenous every eight (8) hours for 8 days. 17. Advair Diskus 100-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation twice a day. 18. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1) unit Subcutaneous as directed: For FS of: 151-200 give 2 units, 201-250 give 4 units, 251-300 give 6 units, 301-350 give 8 units, 351-400 give 10 units, >400 call HO. 19. Lactulose 10 g/15 mL Solution Sig: Fifteen (15) cc PO every eight (8) hours as needed for constipation. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - [Location (un) 550] Discharge Diagnosis: Aphasia Urinary tract infection Discharge Condition: Good Discharge Instructions: Please attend all follow-up appointments and take all medications as directed Followup Instructions: Follow up with Dr. [First Name8 (NamePattern2) 2530] [Name (STitle) ] in the [Hospital1 18] stroke clinic [First Name8 (NamePattern2) ] [Name8 (MD) 162] MD [MD Number(2) 2575]	[ "250.00", "784.5", "414.01", "785.6", "041.04", "593.9", "496", "458.9", "600.00", "294.8", "599.0", "784.3", "276.2", "562.10", "780.93", "242.91", "275.42", "041.3", "573.8", "441.4", "599.7" ]	icd9cm	[ [ [] ] ]	[ "99.10" ]	icd9pcs	[ [ [] ] ]	15478, 15563	10062, 13469	336, 343	15639, 15646	5149, 10039	15772, 16004	2509, 2527		13635, 15455	15584, 15618		13495, 13612			15670, 15749							2542, 3262																282, 298								371, 1862	3920, 5130							3277, 3904					1884, 2400	2416, 2493
45,812	175,775	33899	Discharge summary	report	Admission Date: [2199-8-14] Discharge Date: [2199-8-21] Date of Birth: [2121-2-14] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins Attending:[First Name3 (LF) 2969] Chief Complaint: carcinoid tumor resection Major Surgical or Invasive Procedure: right hemiclamshell thoracotomy/ right pneumonectomy SVC reconstruction - CP bypass intubation with ICU monitoring central venous lines arterial lines x 2 chest tube NG tube History of Present Illness: 78F, non-smoker and history of carcinoid s/p right upper lobectomy p/w worsening sympotoms of cough and chest discomfort for two years. Hilar mass discovered by imaging mass on CXR this past spring. CT and mediastinioscopy confirming presence of mediastinal mass, encasing and narrowing right pulmonary artery, compressing SVC. Plan for completion of pneumonectomy and resection of this mass. Cardiac surgery also involved for institution of cardiopulmonary bypass, division of the aorta, and resection of the SVC with reconstruction of the SVC. . now w/ mediastinal mass, which narrows the right pulmonary artery to 7 mm and also compresses and narrows the SVC to 2 mm. Past Medical History: hyperlipidemia, bronchial carcinoid s/p right lobectomy, fibroids s/p hysterectomy, breast ca (DCIS) s/p mastectomy and tamoxifen x 5 years Social History: Patient does drink alcohol ([1-7]) per day. Denies tobacco or recreational drug use. Lives at home with husband Family History: Noncontributory Physical Exam: On admission Vitals: VSS HEENT: NCAT, EOMi, MMM Neck: Supple, no lymphadenopathy Pulm: CTA, no egophony, no dullness to percussion Cardio: RRR Abd: soft, NT, ND, act BS Ext: no C,C,E, palpable pulses bilaterally On discharge VS: 98.7 98.7 81 118/64 18 93RA Gen: NADS, AAOx3 Cardio: RRR Pulm: rales at bases bilaterally, clear bs otherwise, no egophony Abd: soft, NT, ND, act BS Wound: clean, dry, intact Ext: no C/C/E Pertinent Results: Path intraoperatively - [8-14] Right lung, lobectomy (C-S): Carcinoid tumor extensively involving hilar area with infiltration of bronchial wall and replacement of nodes (2). Extending to pulmonary arterial margin(G); tumor adjacent to and superficially infiltrating cardiac muscle. [2199-8-14] WBC-13.7# RBC-2.74# Hgb-8.7# Hct-24.3# Plt Ct-149* [2199-8-15] WBC-16.7# RBC-3.47 Hgb-10.9* Hct-30.2* Plt Ct-191 [2199-8-16] WBC-15.8* RBC-3.28* Hgb-10.5* Hct-28. Plt Ct-204 [2199-8-19] WBC-11.4* RBC-3.08* Hgb-9.5* Hct-27.3* Plt Ct-272 [2199-8-14] Glucose-147* UreaN-17 Creat-0.7 Na-141 K-4.1 Cl-111* HCO3-26 [2199-8-15] Glucose-139* UreaN-19 Creat-0.8 Na-138 K-4.4 Cl-110* HCO3-24 [2199-8-18] Glucose-106* UreaN-30* Creat-0.6 Na-142 K-3.7 Cl-106 HCO3-29 [2199-8-21] Glucose-92 UreaN-26* Creat-0.6 Na-140 K-4.1 Cl-102 HCO3-28 [2199-8-17] Type-ART pO2-103 pCO2-41 pH-7.44 calTCO2-29 Base XS-3 [2199-8-20] CXR: FINDINGS: In comparison with the study of [8-19], there is little overall change. Almost complete opacification of the right hemithorax is seen with several scattered air-fluid levels projected over the area of the right lung apex. These most likely represent regions of loculation. Small unchanged left-sided pleural effusion. Scoliosis persists and there is little change in the subcutaneous emphysema. The left chest tube remains in place with small pneumothorax in the apical region. Brief Hospital Course: Patient was admitted to our surgical service on [2199-8-14] and taken to OR by Dr. [Last Name (STitle) ] and Dr. [Last Name (STitle) 78336]. Patient tolerated procedure and there were no intraoperative complications. Please see dicated operative report for more details. Postoperatively patinet taken to cardiac ICU for further monitoring. She remained intubated and chest tube left to waterseal. Started on fentanyl and propofol drips for sedation while being intubated and neo to maintain pressor support. Patient was transfused 1u pRBC later that evening for Hct 26.3. Post-transfusion Hct stable at 31. On POD1, patient was weaned from intubation and extubated successfully. She was also weaned from neo and started on lopressor. Patient monitored closely with marginal urine output. Her intraoperative antibiotics were held given rise in BUN/Cr. Fentanyl was weaned off and morphine used to provide for pain control. To assist with breathing, she was gently diuresed with lasix and patient's urine responded well. On POD2, patient's CT removed without complications. CXR confirmed clear lung fields without any effusions or infiltrates. Patient's diet advanced to clears later that evening. On POD3, patient was transferred out of cardio ICU to thoracic surgical floors for further postoperative recovery. She was advanced to regular diet and medications transitioned to oral form. her femoral arterial line was removed. During remainder of hospital stay, we continued with gentle diuresis, keeping track of daily body weights. She was placed on restriced intake to accomdate negative fluid balance. Daily electrolytes checked and repleted as necessary. Physical therapy consulted to help with conditioning. She will be discharged to rehab postop day 8. She is doing well, tolerating regular food, on all oral medications and stable. Medications on Admission: albuterol, atenolol, lipitor, captopril, advair, hctz, combivent, protonix, vitamin c, asa, calcium, vit b6, vit b12, mvi Discharge Medications: 1. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 6. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [12-5] Puffs Inhalation Q6H (every 6 hours). 7. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 10. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 13. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 14. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 16. Regular Insulin Sliding Scale Fingerstick QACHSInsulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Humalog Humalog Humalog Humalog 61-119 mg/dL 0 Units 0 Units 0 Units 0 Units 120-140 mg/dL 2 Units 2 Units 2 Units 2 Units 141-199 mg/dL 4 Units 4 Units 4 Units 4 Units 200-239 mg/dL 6 Units 6 Units 6 Units 6 Units 240-280 mg/dL 8 Units 8 Units 8 Units 8 Units 17. Captopril 25 mg Tablet Sig: One (1) Tablet PO twice a day: Hold SBP < 100. 18. Multivitamin Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Hospital1 ] House Rehabilitation & Nursing Center - [Location (un) 5087] Discharge Diagnosis: Mediastinal tumor, carcinoid, status post right upper lobectomy [2175] Hyperlipidemia Hypertension Breast CA status post left mastectomy in [2189] Bladder Suspension in [2196] Hysterectomy in [2168] Discharge Condition: Deconditioned Discharge Instructions: Call Dr.[Doctor Last Name 4738] office [Telephone/Fax (1) 4741] if experience: -Fever > 101 or chills -Increased shortness of breath, cough or sputum production -Chest pain -Incision develops drainage: steri-strips remove in 10 days or sooner if start to peel off. You may shower: No tub bathing or swimming for 6 weeks. No lifting > 10 pounds for 10 weeks No driving for 1 month. Followup Instructions: Provider: [First Name11 (Name Pattern1) 2389] [Last Name (NamePattern1) 2390], MD Phone:[Telephone/Fax (1) 4741] Date/Time:[2199-9-5] 11:30am on the [Hospital Ward Name 516] [Hospital Ward Name 23] Clinical Center, [Location (un) 24]. Chest X-Ray 45 minutes before your appointment on the [Location (un) 861] Radiology Department.	[ "459.2", "272.4", "198.89", "196.1", "511.9", "788.5", "164.8", "401.9", "197.0", "V10.3" ]	icd9cm	[ [ [] ] ]	[ "32.59", "39.61", "34.3", "38.45" ]	icd9pcs	[ [ [] ] ]	7422, 7530	3445, 5297	304, 480	7789, 7805	1968, 3422	8243, 8609	1497, 1514		5469, 7399	7551, 7768		5323, 5446			7829, 8220							1529, 1949																239, 266								508, 1185													1207, 1348	1364, 1481
41,890	151,796	47479	Discharge summary	report	Admission Date: [2142-6-9] Discharge Date: [2142-6-13] Date of Birth: [2060-7-12] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 4309] Chief Complaint: Chief Complaint: shortness of breath Reason for MICU transfer: hypoxia Major Surgical or Invasive Procedure: None History of Present Illness: 81F w/hx osteoporosis, recurrent [First Name3 (LF) ] UTIs, HTN, parkinsonian features and depression with recent admission for pna/uti requiring ICU admission now p/w new oxygen requirement in rehab earlier today. The patient reports 2-3 days of progressive shortness of breath such that today she was unable to read. She reports subjective fevers (unrecorded) and chills in addition to an associated productive cough of white/green sputum. Her symptoms are worse in comparison to her recent admission for pneumonia. She denies abdominal pain, nausea, vomiting, chest pain, palpitations. [Hospital 100] Rehab called EMS who found her with O2 sats in the low 80s which improved to the mid 90s on a NRB. Of note the patient was admitted in early [Month (only) 116] for pneumonia and urinary tract infection requiring ICU stay. She initialy presented with hypoxia and leukocytosis with bibasilar opacities. She was treated originally with CTX/azithro/Flagyl switched to Vanc/Cefepime and ultimately discharged on an 8 day course of levofloxacin. Her urinalysis was concerning for a UTI but culture data was ultimately unremarkable and [Month (only) ] swab negative. Her course was complicated by abdominal pain and LLQ abdominal pain initially concerning for diverticulitis. She was empricially started on flagyl and CT abdomen revealed no evidence of intrabdominal process. In the ED, initial VS were: 100 103 168/70 24 92% 15L Non-Rebreather. Initial exam revealed a tachypneic female, alert x [12-25]. She was able to report her own symptoms but was very short of breath. Labs demonstrated a lactate 1.7, troponin <0.01, creatinine 0.6, BNP 1588 and WBC of 20.5 A chest xray demonstrated bilateral opacities superimposed on known lung scars concerning for a pneumonia. She was given vancomycin and levofloxacin. Attempts at weaning her oxygen were not tolerated with desaturations to the low 80s. She appeared comfortable on 15L NRB therefore Bipap was not pursued. She confirmed her code status was DNR/I. She had 2 PIV. Vitals on transfer were: 105 150s/80s, 24-26, 94% on NRB and afebrile. On arrival to the MICU, the patient complained of some shortness of breath but improved from prior to coming in. VS: 98.5, 123/96, 90, 17, 93% on 5LNC Past Medical History: Left Arm Fracture S/P Bone Graft ([2099]) Recurrent UTIs ([Year (4 digits) ] x multiple, E coli, Proteus) Hypertension Anemia of Chronic Disease Multinodular Goiter with Right Dominant Nodule, normal TSH/T4. Recurrent C. difficile infection Osteoporosis Radial Fracture [2134] Pubic Rami Fracture [2134] Hx delirium w/paranoia [2134] (sx responded to risperdol) Concern for depression Parkinsonian features Hx dilated hepatic ducts (refused MR evaluation/further workup) Hx FDG-avid pulmonary nodules Incidental Left Adnexal Cyst Social History: -etoh: negative -illicits: negative -tobacco: negative -housing: Lives at [Hospital 100] Rehab. Never married, no children. Only brother is deceased. -[First Name8 (NamePattern2) ] [Known lastname 62417] ([Street Address(2) ] in [Location (un) 5089]), her cousin, is the next-of-[Doctor First Name ]. -wheelchair bound Family History: Per records: Her brother died from heart disease. No known cancers. Physical Exam: ADMISSION Vitals: 98.5, 123/96, 90, 17, 93% on 5LNC General: Alert, oriented, cachectic elder woman in no acute distress HEENT: Sclera anicteric, dry MM, poor dentition, 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: foley with clear/dark yellow urine Ext: warm, well perfused, 1+ pulses, no edema Neuro: slighlty dysarthric but CNII-XII intact, grossly normal sensation, resting tremor of tongue, moves toes on bl lower extremities, moves upper extremities freely DISCHARGE EXAM: Afebrile, normotensive, normocardic, 94-96% on 3L Lungs: Good air excursion, generally clear with scattered rhonchi Pertinent Results: Admission [2142-6-9] 07:15PM BLOOD WBC-20.5# RBC-3.60 Hgb-11.3* Hct-35.1* MCV-98 MCH-31.5 MCHC-32.2 RDW-13.8 Plt Ct-314 [2142-6-9] 07:15PM BLOOD Neuts-95.8* Lymphs-1.9* Monos-1.7* Eos-0.5 Baso-0.2 [2142-6-9] 07:15PM BLOOD Glucose-154* UreaN-29* Creat-0.6 Na-142 K-4.3 Cl-106 HCO3-25 AnGap-15 [2142-6-9] 07:15PM BLOOD cTropnT-0.01 [2142-6-9] 07:15PM BLOOD proBNP-1588* [2142-6-9] 07:15PM BLOOD Albumin-PND Calcium-8.8 Phos-3.3 Mg-2.0 [2142-6-9] 07:26PM BLOOD Lactate-1.7 . Microbiology: BCX- NGTD UCX- negative SPUTUM- contaminated Studies CXR [2142-6-9] FINDINGS: Single portable view of the chest is compared to previous exam from [2142-5-1]. When compared to prior, there has been partial resolution of the bilateral parenchymal opacities seen on prior. There is however persistent left basilar opacity. Both could be due to atelectasis, aspiration or infection is also possible. Blunting of the right lateral costophrenic angle is suggestive of an effusion. Cardiac silhouette is difficult to assess given differences in positioning and technique, but likely has not changed. IMPRESSION: Interval improvement in the appearance of the lungs with some persistent left basilar opacity, potentially atelectasis versus aspiration/infection and small probable right pleural effusion. CXR [6-13]: FINDINGS: As compared to the previous radiograph, there is an increase in extent of a pre-existing small pleural effusion and a newly occurred small right pleural effusion. Subsequently, areas of atelectasis are seen at the lung bases. In addition, the pre-existing left basal opacity with air bronchograms persists. The presence of aspiration pneumonia cannot be excluded. Borderline size of the cardiac silhouette, no pulmonary edema. Brief Hospital Course: Ms [Known lastname 62417] is an 81F w/hx osteoporosis, recurrent [Known lastname ] UTIs, HTN, parkinsonian features and depression with recent admission for pna/uti requiring ICU admission now p/w new oxygen requirement, subjective fever, and cough found to have pneumonia. She was initially stabilized in the ICU given NRB requirement, but this was weaned and the patient's care was continued on the floor. On the floor, the patient had intermittent desaturations due to mucus plugging that required intermittent suctioning. 1. Pneumonia: The patient presented with fevers, leukocytosis, productive cough and CXR with bilateral opacities. Patient coming from nursing home with recent hospitalization, so initially treated as healthcare associated PNA with Vancomycin and Cefepime, however, patient's respiratory status improved rapidly and she remained HD stable and afebrile. On HD# 2, abx narrowed to PO levofloxacin (day 1 [6-9]). Her last day of levofloxacin will be on [6-17]. The patient continued to have intermittent desaturations on the floor due to mucus plugging and her inability to clear secretions. She has a weak cough, due to deconditioning and malnutrition. She will need MACU level care for pulmonary toilet and suctioning. The patient is at a continuous increased risk of aspiration and plugging due to her overall health. 2. Chronic Pain: Pt w/known pelvic fracture 5y ago and osteoporosis. We continued her oxycodone, Tylenol, and Gabapentin. 3. Chronic Constipation: Continued Miralax and senna. 4. Severe Malnutrition: Due to eating disorder, psych NOS. Encourage eating and supplement TID. 5. Code Status: Wheelchair bound at baseline. DNR/DNI Medications on Admission: 1. oxycodone 5 mg Tablet 0.5 Tablet PO Q8H (every 8 hours) prn pain 2. gabapentin 100 mg Capsule One (1) Capsule PO qPM. [on hold per rehab documentation] 3. senna 8.6 mg Tablet Sig: 1-2 Tablets PO DAILY (Daily). 4. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO bid pain 5. Vitamin D2 50,000 unit Capsule Sig: One (1) Capsule PO qwk 6. benzocaine 10 % Gel Sig: One (1) application Mucous membrane [Hospital1 ] 7. calcium carbonate 500 mg calcium (1,250 mg) Tablet qhs 8. Miralax 17 gram/dose Powder qdaily Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN pain 2. Calcium Carbonate 500 mg PO DAILY 3. Gabapentin 100 mg PO HS 4. OxycoDONE (Immediate Release) 2.5 mg PO BID Give at 0800, 1200 5. Polyethylene Glycol 17 g PO DAILY 6. Senna 1 TAB PO DAILY 7. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB 8. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheezing, dyspnea 9. Levofloxacin 500 mg PO DAILY Day 1 [6-11]. Last day [6-17] 10. benzocaine NF 10 % Mucous Membrane [Hospital1 ] Spray for [12-25] second. Peak effect is attained 15-30 seconds following the spray. Do not leave spray at patient bedside 11. Vitamin D 50,000 UNIT PO 1X/WEEK (SA) Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Community-Acquired Pneumonia Mucus Plugging Anxiety Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hospital with shortness of breath, low oxygen saturation, and were found to have a pneumonia. Initially, you were monitored in the ICU, but then your oxygen was weaned down and we took care of you on the medicine floor. We have you on an antibiotic called Levofloxacin which you will continue for 7 days. You will be discharged to the [Hospital1 100] MACU where they can perform O2 monitoring, chest PT, and suctioning of your secretions. Followup Instructions: Your facility will setup follow-up for you.	[ "285.9", "401.9", "486", "733.00", "307.50", "262", "564.00", "241.1" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	9305, 9371	6380, 8072	377, 384	9467, 9467	4569, 6357	10137, 10184	3645, 3715		8635, 9282	9392, 9446		8098, 8612			9645, 10114							3730, 4417					4433, 4550											282, 339								412, 2694								9482, 9621					2716, 3268	3284, 3629
30,890	126,522	31677	Discharge summary	report	Admission Date: [2194-7-31] Discharge Date: [2194-8-17] Date of Birth: [2121-12-27] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4963] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Pericardiacentesis History of Present Illness: Patient is a 72 yo F who was initially admitted to the surgical service on [7-31] with the chief complaint of dyspnea. Echo was performed and found pericardial effusion with tamponade physiology prompting an admission to [Hospital ] hospital. Additionally at the outside hospital a CT was done at [Doctor First Name ] that showed aortitis. The patient was then transferred to [Hospital1 18] for further work up and evaluation. Patient was transferred to CT surgery service with rheumatology consult that recommended an MRI/A for signs of vasculitis of the chest. This showed aoritis that was confirmed on repeat CT chest. Additionally a number of additional labs were ordered that showed normal compliment levels, elevated CRP, normal [Doctor First Name ]/ANCA, normal SPEP. Pericardiocentesis and drain was placed on [8-4]. Evaluation of the pericardial fluid revealed MSSA bacteria and leukocytosis with monocytic predominance. For which ID was consulted ( of note patient had an Ecoli UTI and was treated with cipro from [Date range (1) 74440]). They recommended brucella serologies (negative), RPR and other serologies that have been negative. Vancomycin was started for broad spectrum (prior to culture data being known). Opthomology consulted on the patient and found no retinal disease. Temporal artery biopsy was taken on [8-8]. Additionally the patient was started on doxycycline for treatment given positive IgM for mycoplasma. On the 20th the renal function began to worsen and nephrology consult was obtained on [8-9] with differential being vasculitis or medication side effect primarily. Past Medical History: CVA with residual left sided weakness [2194-4-14] Osteopenia Psoriasis Diabetes type 2 HTN Social History: Lives in [Location ] with son. Denies tobacco, EtOH, illicits. Family History: No history of autoimmune diseases, gout. Physical Exam: Vitals: T97-98.1, BP 112-132/60-62, HR65-70, RR18, 96% on RA Pulsus: 8-10mmHg GEN: pleasant, elderly woman in NAD HEENT: EOMI (difficult to assess upgaze), patient with baseline left facial droop, scar on right parotid area NECK: No LAD, no carotid bruits LUNGS: decreased BS at left lung base, some basilar crackles CVA: RRR, I/VI SEM ABD: +BS, soft, ND, NT EXT: no edema, no weakness in UE, LE, multiple scaly plaques Pertinent Results: Renal US [2194-8-9]: No hydronephrosis or perinephric fluid collection CXR [2194-8-10] The heart is enlarged, tortuosity of the aorta is present. There is a new onset of diffuse interstitial markings with bilateral pleural effusions consistent with cardiac failure. CXR [2194-8-16] - IMPRESSION: Improving CHF. [2194-8-8] - Temporal Artery Biopsy - Arterial vascular segment, no diagnostic abnormalities recognized. ECHO - [2194-8-12] - Conclusions: Overall left ventricular systolic function is normal (LVEF 70%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets appear structurally normal with good leaflet excursion. The mitral valve leaflets are mildly thickened. There is a small 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. No right atrial or right ventricular diastolic collapse is seen. Compared with the prior study (images reviewed) of [2194-8-8], the pericardial effusion is slightly smaller. [2194-7-31] WBC-12.6* RBC-4.82 Hgb-11.9* Hct-37.4 MCV-78* MCH-24.7* MCHC-31.8 RDW-15.9* Plt Ct-544* Neuts-74.9* Lymphs-19.6 Monos-3.6 Eos-1.6 Baso-0.4 PT-12.6 PTT-32.0 INR(PT)-1.1 ESR-35* Glucose-140* UreaN-14 Creat-0.7 Na-140 K-3.8 Cl-101 HCO3-29 AnGap-14 [2194-8-5] ESR-31* [2194-8-9] Glucose-77 UreaN-27* Creat-2.7* Na-140 K-4.1 Cl-103 HCO3-25 AnGap-16 [2194-8-14] Glucose-99 UreaN-33* Creat-2.0* Na-141 K-4.0 Cl-107 HCO3-27 AnGap-11 [2194-7-31] ALT-20 AST-16 LD(LDH)-128 AlkPhos-267* Amylase-21 TotBili-0.4 [2194-7-31] TSH-2.6 [2194-8-5] ANCA-NEGATIVE B [2194-8-14] CRP-63.0* [2194-8-5] [Doctor First Name ]-NEGATIVE [2194-8-5] CRP-252.0* [2194-7-31] CRP-40.9* [2194-8-5] SPEP-NO SPECIFIc protein [2194-8-5] C3-122 C4-24 [2194-8-11] ANGIOTENSIN 1 - CONVERTING [Last Name (un) ]-neg [2194-8-5] BRUCELLA ANTIBODY, IGG, IGM-neg [2194-8-5] MYCOPLASMA PNEUMONIAE ANTIBODY IGM-pos [2194-8-13] EBV IGG pos, IGM neg [2194-8-17] 04:10AM BLOOD Glucose-88 UreaN-23* Creat-1.7* Na-140 K-3.6 Cl-102 HCO3-29 AnGap-13 [2194-8-16] 05:10AM BLOOD AlkPhos-222* [2194-8-15] 04:45PM BLOOD GGT-149* [2194-8-15] 05:30AM BLOOD CRP-45.9* Brief Hospital Course: 72 yo F with history of pericardial effusion s/p pericardiocentesis on [8-4], aortitis, diabetes and new renal failure transferred from surgery for further management. #. Pericardial effusion - Unclear etiology. Low voltage on EKG. Fluid from pericardiocentesis showed reactive fluid but negative for malignant cells. +MSSA treated with IV vancomycin for 5 days. Antibiotics d/c'd as positive culture felt to be contaminant given sparse growth and the patient's very stable clinical picture. Patient also was myoplasma + which was also felt to be a false positive. Was treated with 2 days of doxcycline that was also d/c'd. Repeat ECHO showed only small pericardial effusion that was smaller with each repeat scan. Histo, Legionella, and current EBV infxn negative. No Bence [Doctor Last Name ] proteins in urine. Cryptococcus negative. - Pleural Fluid, smear negative for TB, culture still pending - Lyme Ab was negative #. Aortitis - found by CT chest. ANCA, C3/C4, [Doctor First Name ], ACA, RPR, TB smear all negative. Temporal biopsy negative for diagnostic abnormalities. No role for steroids felt to be warranted. CRP 252 at peak, 46 later in hospital course. #. Acute renal failure - Patient with acute rise in Cr from 0.7 on [8-6] to 2.4-2.7. It was 1.7 on discharge. No evidence of hydronephrosis or mass on renal ultrasound. No improvement with IVFs, in fact, worsened volume overload. FeNa was <1%. Likely the combined result of contrast, cardiac cath and vancomycin, slowly improving. Renal followed the patient while here and aided in management. UPEP also tested and negative. Patient will need repeat chem-7 within a week of discharge. #. s/p R CVA w/ resolving L hemiparesis [4-/2194]-The patient had possible episode of TIA while in hospital on [8-10], with possible paresthesia but no neurological residual deficits. She was continued on aspirin. #. Urinary Tract Infection - Had an E.coli pansensitive UTI, treated with 5 days of Cipro # Volume overload- Patient autodiuresed but did have residual lower extremity edema on discharge. Her CXR showed small bilateral pleural effusions and interstitial pattern. BNP was checked day prior to discharge and was 2449. She was given lasix. On discharge, ambulatory O2 sat was in the mid 90 %. #. DM- was on a RISS initially but fingersticks were well controlled. #. HTN- patient was continued on atenolol which was started at a lower dose but uptitrated back up to 50mg daily before discharged # Elevated alkaline phosphatase-AP peaked at 519, last value 222. GGT was 149. This will need to be further worked up as an outpatient. #. FEN- Cardiac heart healthy diet. Electrolytes repleted prn. #. PPx- Heparin Sc, senna, colace #. Code: Full code Medications on Admission: Atenolol 50mg Qday Glucophage 125mg [Hospital1 ] Prevacid 30mg qday Celebrex 100mg qday Lipitor 10mg qday ASA 325 mg qday Timolol eye drops Discharge Medications: 1. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. Disp:1 bottle Refills:0 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 6. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home With Service Facility: Home Health and Hospice Care Discharge Diagnosis: Pericardial Effusion Aortitis Osteopenia Psoriasis Diabetes Type 2 Hypertension Discharge Condition: Stable Discharge Instructions: You have been diagnosed with a preicardial effusion, or fluid around your heart. You have had the fluid drained and a repeat Echocardiogram of your heart shows that there is now less fluid surrounding your heart. All tests so far have been negative that would indicate why you have this fluid. You will need to follow-up as an outpatient to obtain all of the final results of these tests. While you were in the hospital you experienced renal failure. Your kidneys are now improving. Please call your physican or return to the emergency department if you develop any fevers, chills, sbortness of breath, chest pain, or lightheadedness. Followup Instructions: 1. Please follow-up with your primary care physican in 1 week. You will need to have your kidney function checked. 2. We recommend that you have another CT scan of your chest and abdomen to reevaluate your aortitis in about a month. You must have your renal function checked before having this test. If your kidney function is not back to normal, we recommend that you have an MRI without contrast for this evaluation. We also recommend that you have an outpatient mammogram. 3. You need to have a repeat ECHOCARDIOGRAM within 1 week after leaving the hospital. Please call ([Telephone/Fax (1) 19380] to schedule an apppointment. 4. You also need to follow up with DR. [Last Name (STitle) ], the cardiac surgeon who saw you in the hospital. Please call [Telephone/Fax (1) 170] to schedule an appointment in [11-19] weeks. Please have your follow-up echo before meeting with Dr. [Last Name (STitle) 914]. 5. After you receive your MRI, you need to follow up with rheumatology. They can be reached at ([Telephone/Fax (1) 68766]. 6. Please follow up with your PCP [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 13013]([Telephone/Fax (1) 74441] within the next week for a CBC and chem-7.	[ "447.6", "696.1", "451.84", "733.90", "401.9", "438.89", "250.00", "599.0", "272.4", "715.36", "584.9", "423.9", "428.0", "285.9" ]	icd9cm	[ [ [] ] ]	[ "38.21", "37.0" ]	icd9pcs	[ [ [] ] ]	8606, 8665	5120, 7874	324, 344	8789, 8798	2742, 5097	9484, 10760	2243, 2286		8068, 8583	8686, 8768		7900, 8045			8822, 9461							2301, 2723																277, 286								372, 2023													2045, 2141	2157, 2227
43,557	199,376	48101	Discharge summary	report	Admission Date: [2135-9-1] Discharge Date: [2135-9-9] Date of Birth: [2076-7-22] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 974] Chief Complaint: s/p Bicycle crash Major Surgical or Invasive Procedure: None History of Present Illness: 59F helmeted rider of a bicycle vs auto. Brief Hospital Course: 59F bicyclist with following injuries: -1-10th and lateral 3-8th rib fractures. non-displaced medial lt clavicular fxr. rt 12th rib fxr, age indeterminate -grade II splenic lac w/ subcapsular and extracapsular hematoma and blood tracking into pelvis. -grade I-II anterolisthesis of L5 on S1 with bilateral pars defects. -likely focal fatty infiltration along falciform ligament rather than hepatic contusion. Admitted to Trauma-SICU. Serial hematocrits with abdominal exams were followed and the patient remained stable and without need for surgical intervention. Chronic pain consultation for pain management recommended Toradol, Lidoderm patches in addition to oral and intravenous narcotics. Hand/Plastic Surgery was consulted for 5th metacarpal fx., and pt. was placed in ulnar gutter splint with follow-up as outpatient in 2 weeks. Orthopedic spine surgery was consulted and the patient was not managed operatively. Her C-spine was cleared clinically and radiographically. Physical therapy was consulted and the patient was recommended to be discharged home. The patient experienced shortness of breath. Chest CTA revealed multiple left rib fractures, presumably causing splinting of the left chest with a moderately large new left pleural effusion and partial collapse of the left lower lobe and new smaller right pleural effusion with atelectasis. The patient's pain medication regimen was optimized, and she was discharged tolerating a regular diet and ambulating. Medications on Admission: Wellbutrin SR 300mg QAM, Niaspan Discharge Medications: 1. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Disp:90 Tablet(s) Refills:0 2. Niacin 500 mg Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO BID (2 times a day) as needed for hypercholestermia. 3. Bupropion HCl 150 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO QAM (once a day (in the morning)). 4. Polyethylene Glycol 3350 100 % Powder Sig: 17 Grams PO DAILY (Daily) as needed for constipation. 5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Apply to left chest wall. Remove old patch first. Disp:30 Adhesive Patch, Medicated(s) Refills:1 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. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). Disp:60 Tablet Sustained Release(s) Refills:0 8. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for breakthrough pain. Disp:60 Tablet(s) Refills:0 11. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML's PO twice a day as needed for constipation. Discharge Disposition: Home With Service Facility: [Hospital1 ] Family & [Hospital1 1926] Services Discharge Diagnosis: s/p Bicycle crash Multiple left rib fractures Grade II splenic laceration Nondisplaced fracture 4th metacarpal Discharge Condition: Hemodynamically stable, tolerating a regular diet, pain adequately controlled. Discharge Instructions: Return to the Emergency room if you develop fevers, chills, become dizzy or lightheaded, productive cough, shortness of breath, chest pain, nausea, vomiting, diarrhea and/or any other symptoms that are concerning to you. DO NOT participate in contact sports of any kind or other activity that may cause injury to your abdominal region because of your spleen injury. It is important that you continue to cough, deep breathe and use the incentive spiormeter 10x every hour that you are awake. Take the pain medication as prescribed. Continue with stool softners and laxatives while you are on the narcotics to avoid constipation. Followup Instructions: Follow up in 2 weeks in Hand clinic, call [Telephone/Fax (1) 3009] for an appointment. Follow up in 2 weeks with Dr. [Last Name (STitle) ], Trauma surgery for evaluation of your spleen injuries and rib fractures. Call [Telephone/Fax (1) 6429] for an appointment. Follow up with your primary care doctor in 2 weeks, call for an appointment.	[ "733.90", "338.11", "860.2", "807.08", "865.00", "810.00", "861.21", "287.5", "919.0", "E826.1", "272.0", "815.00", "737.30" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	3417, 3503	428, 1908	329, 335	3658, 3738		4418, 4774			1991, 3394	3524, 3637		1934, 1968			3762, 4395																							272, 291								363, 405
20,718	117,983	24986	Discharge summary	report	Admission Date: [2101-9-23] Discharge Date: [2101-10-4] Date of Birth: [2081-3-16] Sex: M Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 11415] Chief Complaint: Status-post MVC vs. tree Major Surgical or Invasive Procedure: ORIF Right femur fracture [2101-9-23] ORIF Right calcaneus fracture History of Present Illness: Pt. is a 20 yo man; driver in MVC vs. tree at 40-50mph. +LOC 1-2min. Air bag was deployed and there was significant damage to the front-end of car. He was not ejected; was extricated by bystanders at the scene. Tx to [Hospital1 18] by airflight from [Location (un) 1475]. Past Medical History: none Social History: + EtOH, no tob, no IVDU Family History: noncontributory Physical Exam: In ER, per trauma surgery initial note: 90/palp improved to 120/56, P88, R18, T98.6, O295%RA HEENT: small head abrasion, PERRLA4-5mm Chest: b/l BS, small L chest abrasion CVS: RRR, nlS1S2 Abd: soft, -FAST exam Ext: RLE splint in place. + R thigh swelling. Right DP pulse palpable. Moves all other extremities spontaneously Rectal: Nl tone, trace guaiac + GU: no blood at meatus. Foley passed easily Spine: no TTP CTLS splne Pertinent Results: [2101-9-23] 02:40AM URINE RBC-[4-2]* WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0-2 RENAL EPI-0-2 BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2101-9-23] 03:40AM PT-14.7* PTT-28.6 INR(PT)-1.4 [2101-9-23] 03:40AM FIBRINOGE-192 [2101-9-23] 03:40AM WBC-25.4* RBC-4.72 HGB-14.6 HCT-40.6 PLT COUNT-285 [2101-9-23] 03:40AM PT-14.7* PTT-28.6 INR(PT)-1.4 [2101-9-23] 03:40AM ASA-NEG ETHANOL-249* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2101-9-23] 03:40AM AMYLASE-67 [2101-9-23] 03:40AM GLUCOSE-115* UREA N-12 CREAT-0.8 SODIUM-137 POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-20* ANION GAP-19 [2101-9-23] 05:31PM CALCIUM-8.2* MAGNESIUM-1.4* Brief Hospital Course: [9-23]: Pt admitted to TSICU. Injuries: -pulmonary contusions -R femur fx -R calcaneus fx -grade 2 splenic laceration 5cm w/ encapsulated hematoma -blood in pelvis Pt. developed blood-loss anemia. Hct was monitored. Received 2u PRBCs. Begun on Ancef IV [9-24]: -ORIF R femur -received addnl 4u PRBC and 6u FFP [9-25]: -developed fever. W/u negative. Remained on Ancef. -evaluated by neurosurgery due to anteriolisthesis of C2 on C3 seen on C-spine CT. -f/u flex/ex films neg and c-spine was cleared, c-collar was removed. [9-26]: -b/l LE CT done to evaluate for rotational deformity of R femur s/p ORIF. -abx were stopped [9-30]: -Pt taken to OR for correction of rotation of IM nail in femur and ORIF of right calcaneous. -Lovenox restarted post-operatively. [10-4]: -bivalve cast placed and pt was discharged in stable condition. Will follow up with Dr. [Last Name (STitle) 1005] in clinic in two weeks. Medications on Admission: none Discharge Medications: 1. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain for 2 weeks. Disp:40 Tablet(s) Refills:0 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 2 weeks: continue to take as long as you are taking the percocet to prevent constipation. Disp:28 Capsule(s) Refills:0 3. Enoxaparin Sodium 40 mg/0.4mL Syringe Sig: One (1) syringe Subcutaneous DAILY (Daily) for 4 weeks. Disp:28 syringe Refills:0 4. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO Q12H (every 12 hours) for 1 weeks. Disp:14 Tablet Sustained Release 12HR(s) Refills:0 Discharge Disposition: Home With Service Facility: Gentiva Discharge Diagnosis: Right mid-shaft comminuted femur fracture, status-post ORIF Right calcaneal fracture, status-post ORIF Discharge Condition: stable Discharge Instructions: --take all medications as prescribed --keep all followup appointments watch incision sites for redness/drainage and call your doctor with any concerns. Go to the ER if you experience fevers, chills, chest pain, or shortness of breath. Physical Therapy: Non-weightbearing RLE Treatments Frequency: sutures will be removed at your first post-operative visit. Followup Instructions: Follow-up with Dr. [Last Name (STitle) 1005]. Please call [Telephone/Fax (1) 8746] for an appointment. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2235] MD, [MD Number(3) 11417] Completed by:[2101-10-4]	[ "865.03", "821.01", "996.4", "825.0", "865.01", "E816.0", "868.03", "780.6", "861.21", "285.1" ]	icd9cm	[ [ [] ] ]	[ "79.37", "99.07", "99.04", "79.07", "79.35", "78.55" ]	icd9pcs	[ [ [] ] ]	3812, 3850	2138, 3082	345, 419	3997, 4006	1292, 2115	4412, 4685	814, 831		3137, 3789	3871, 3976		3108, 3114			4030, 4266							846, 1273	4284, 4306	4328, 4389														281, 307								447, 729													751, 757	773, 798
32,635	115,613	31386	Discharge summary	report	Admission Date: [2128-8-17] Discharge Date: [2128-8-27] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3223] Chief Complaint: s/p Fall Major Surgical or Invasive Procedure: None History of Present Illness: 86 year male who was at home when he stood to walk across room and experienced acute dizziness associated with palpitations and right sided rib pain and then stumbled and fell. No reported LOC, he was able to call 911 for assistance. He was transported to an area hospital where upon CT imaging of his head wasfound to have a left frontal/parietal subarrachnoid bleed with intraparenchymal hematoma. He was then transferred via [Location (un) ] to [Hospital1 18] for further work-up and management. Past Medical History: CAD History MI Pacemaker s/p CABG s/p bovine aortic valve replacement TIA Atrial fibrillation Hypertension Bilateral knee replacements Kidney stones Social History: Lives at home alone, recently wife deceased. Supportive son who lives in [Name (NI) 6607]. Rare alcohol, rare tobacco. Family History: Non-contributory Physical Exam: Upon admission: PHYSICAL EXAM - O: T: 96.8 137/49 58 16 O2sat 100% on 2L Gen: NAD. HEENT: Pupils: PERRLA EOMs full Neck: on hard collar; non-tender Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: PERRLA 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. No dysarthria. Pertinent Results: On admission: . [2128-8-17] 09:40PM POTASSIUM-5.4* [2128-8-17] 08:15PM GLUCOSE-141* UREA N-60* CREAT-2.7* SODIUM-136 POTASSIUM-5.8* CHLORIDE-102 TOTAL CO2-22 ANION GAP-18 [2128-8-17] 08:15PM CALCIUM-10.9* PHOSPHATE-4.2 MAGNESIUM-2.1 [2128-8-17] 08:15PM WBC-9.3 RBC-2.91* HGB-9.1* HCT-26.6* MCV-92 MCH-31.1 MCHC-34.0 RDW-16.1* [2128-8-17] NEUTS-86.5* BANDS-0 LYMPHS-8.2* MONOS-4.6 EOS-0.5 BASOS-0.1 [2128-8-17] 08:15PM PLT SMR-NORMAL PLT COUNT-158 [2128-8-17] 08:15PM BLOOD PT-31.5* PTT-35.3* INR(PT)-3.3* . Diagnostics: CT HEAD [2128-8-17]: IMPRESSION: 1. Focal subarachnoid hemorrhage in the left frontal, parietal lobe sulci. Caudalmost hemorrhagic focus may represent small intraparenchymal hemorrhage. 2. Generalized atrophy, with symmetrically prominent extra-axial CSF spaces, which may represent chronic subdural hematomas. . CAROTID STUDY ([2128-8-19]): FINDINGS: Scattered areas of heterogeneous calcific plaque involving the common carotid arteries and extending into the ICA and ECA bilaterally. Peak systolic velocities on the right are 50, 86 and 75 cm from the proximal, mid and distal ICA. Similar values on the left are 140, 119 and 97 cm per second. Peak systolic velocities involving the right CCA and ECA are 62 and 116 cm respectively and similar values on the left are 77 and 67 cm respectively. There is antegrade flow involving both vertebral arteries. The ICA to CCA ratios are normal. IMPRESSION: 1. No significant right ICA stenosis (graded as less than 40%). 2. 40-59% left ICA stenosis. . ECHO ([2128-8-19]): Results Measurements Normal Range Left Atrium - Long Axis Dimension: 4.3 cm <= 4.0 cm Left Atrium - Four Chamber Length: 7.4 cm <= 5.2 cm Left Atrium - Peak Pulm Vein S: 0.2 m/s Left Atrium - Peak Pulm Vein D: 0.5 m/s Right Atrium - Four Chamber Length: 7.1 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: 1.3 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.2 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 6.0 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 4.1 cm Left Ventricle - Fractional Shortening: 0.32 >= 0.29 Left Ventricle - Ejection Fraction: 50% to 55% >= 55% Aorta - Sinus Level: 2.7 cm <= 3.6 cm Aorta - Ascending: 3.1 cm <= 3.4 cm Aortic Valve - Peak Velocity: 3.6 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: 51 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 27 mm Hg Mitral Valve - Peak Velocity: 2.1 m/sec Mitral Valve - Mean Gradient: 5 mm Hg Mitral Valve - Pressure Half Time: 86 ms Mitral Valve - MVA (P [1-20] T): 2.6 cm2 Mitral Valve - E Wave: 2.0 m/sec Mitral Valve - E Wave deceleration time: 316 ms 140-250 ms TR Gradient (+ RA = PASP): 41 mm Hg <= 25 mm Hg Findings: LEFT ATRIUM: Dilated LA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA. LEFT VENTRICLE: Mild symmetric LVH. Moderately dilated LV cavity. Low normal LVEF. [Intrinsic LV systolic function likely depressed given the severity of valvular regurgitation.] RIGHT VENTRICLE: Dilated RV cavity. Normal RV systolic function. [Intrinsic RV systolic function likely more depressed given the severity of TR]. Paradoxic septal motion consistent with conduction abnormality/ventricular pacing. AORTA: Normal aortic diameter at sinus level. Nl ascending aorta diameter. AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). Normal AVR gradient. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. Mild thickening of mitral valve chordae. Eccentric MR jet. [Month/Day (2) ] (2+) MR. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. [Month/Day (2) ] to severe [3+] TR. [Month/Day (2) ] PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: No pericardial effusion. CONCLUSIONS: The left atrium is dilated. The right atrium is markedly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is low normal (LVEF 50-55%). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] The right ventricular cavity is dilated. Right ventricular systolic function is normal. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] A bioprosthetic aortic valve prosthesis is present. The transaortic gradient is normal for this prosthesis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. An eccentric, [Month/Day (2) 1192] (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. [Month/Day (2) ] to severe [3+] tricuspid regurgitation is seen. There is [Month/Day (2) 1192] pulmonary artery systolic hypertension. There is no pericardial effusion. . Right upper extremity doppler ([2128-8-19]): IMPRESSION: Deep vein thrombosis in one of the two right brachial veins and clot identified in the right basilic and cephalic veins. . ECG: [2128-8-17] 20:05:02 Ventricular paced rhythm with capture. No previous tracing available for comparison. Intervals Axes Rate PR QRS QT/QTc P QRS T 61 0 178 462/463 0 -72 96 . ECG: [2128-8-18] 12:19:30 Ventricular paced rhythm. Compared to tracing of [2128-8-17] there is no significant diagnostic change. Intervals Axes Rate PR QRS QT/QTc P QRS T 60 0 176 482/482 0 -71 94 . CT head ([2128-8-22]): IMPRESSION: Unchanged appearance of blood products in the left frontal and parietal lobe sulci, most consistent with subarachnoid hemorrhage, although caudal-most focus again demonstrates features, which may be consistent with small intraparenchymal hemorrhage. Brief Hospital Course: He was admitted to the Trauma service. Neurosurgery was consulted given his subarachnoid hemorrhage. His injuries were nonoperative. He was loaded with Dilantin and will need to remain on this for a total of 10 days. Serial head CT scans were obtained and were stable. He will require follow up with Dr. [Last Name (STitle) ], Neurosurgery in [4-23] weeks for repeat head imaging. He was noted to have a significant cardiac history and recently had a pacemaker placed about 1 year ago. His pacer was interrogated by electrophysiology service who have recommended an EP study at some point to investigate ventricular arrythmias. He was on Coumadin for Afib and TIA's prior to this hospitalization; prescribed by his primary cardiologist, Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] ([Telephone/Fax (1) 73951]). His Coumadin was withheld initially and was restarted on [8-26] per request of his cardiologist. His goal INR is [2-21]; his INR today ([8-27]) is 2.2. He also underwent a dedicated carotid study which showed <40% right ICA stenosis and 40-59% left ICA stenosis. An ECHO was also performed which showed EF 55%; [Month/Year (2) 1192] MR [First Name (Titles) ] [Last Name (Titles) 1192] to severe TR. His primary cardiologist (Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] in [Hospital1 ], MA) was contact[Name (NI) ] regarding his history and Coumadin. He had been started on Coumadin for chronic AF, bovine aortic valve and h/o TIA's. His Coumadin was eventually restarted once cleared by Neurosurgery. Because of his traumatic brain injury there were several episodes of psychotic behavior; he was initially placed on 1:1 sitters; Haldol was also recommended by Psychiatry who were consulted. He did eventually become less agitated and more cooperative with his care; the sitters were removed. He was evaluated by Physical and Occupational therapy and it was recommended that he go to a rehab facility after acute hospital stay. Medications on Admission: lasix, prilosec, norvasc, celexa, coumadin, zestril, lopressor, aspirin, aldactone, uroxatral Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold for HR <60; SBP <110. 4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): hold for SBP<110. 5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): hold fpr SBP< 110. 6. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) for 4 days. 7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily): Goal INR [2-21]; adjust dose per INR. 9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day: hold for loose stools. 10. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime: hold for loose stools. 11. Haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold for increased sedation. 12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Location (un) 6594] Discharge Diagnosis: s/p Fall Left frontal & parietal subarachnoid hemorrhages Discharge Condition: Good Followup Instructions: Please follow-up with Dr. [Last Name (STitle) ], Neurosurgery in [4-23] weeks. Please call [Telephone/Fax (1) 1669] to make an appointment. Inform the office that you will need a repeat head CT scan for this appointment. Follow up with your primary care doctor and your cardiologist after discharge from rehab. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 520] MD, [MD Number(3) 3226] Completed by:[2128-8-27]	[ "401.9", "E849.7", "V45.01", "427.31", "V58.61", "V13.01", "V45.81", "V43.3", "414.00", "285.9", "305.1", "V43.65", "852.01", "E888.9", "453.8", "424.0" ]	icd9cm	[ [ [] ] ]	[ "99.04" ]	icd9pcs	[ [ [] ] ]	10752, 10803	7494, 9535	270, 277	10905, 10912	1662, 1662	10935, 11418	1144, 1162		9679, 10729	10824, 10884		9561, 9656										1177, 1179																222, 232								305, 814							1676, 7471	1457, 1643					836, 986	1002, 1128
58,193	133,164	12879	Discharge summary	report	Admission Date: [2106-10-27] Discharge Date: [2106-11-6] Date of Birth: [2047-1-25] Sex: F Service: MEDICINE Allergies: Penicillins / Keflex / Erythromycin Attending:[First Name3 (LF) 3531] Chief Complaint: Abdominal Pain, Diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: This is a 59 year old female with history of multiple abdominal surgeries including gastric bypass and reversal who was transferred from [Hospital3 ] in the context of hypotension and acute kidney injury with a radiographic finding of pneumatosis ileum. The patient initially presented to [Hospital1 3325] on [2106-10-18] with abdominal pain, nausea, and recent diarrhea. The patient reports in the week prior to her presentation at [Hospital1 46] she was having many (>10) bowel movements per day but that this diarrhea had stopped in the last day or so before she went to [Hospital1 46]. Of note, the patient reports multiple similar bouts of diarrhea and abdominal complaints during the past six months that could be quite severe and then completely resolved. Previous work-up has been unrevealing. At [Hospital 26580] Hospital the patient underwent a CT abdomen that revealed possible pneumatosis of the small bowel (possible focal air in the mesentery adjoining the ileum) though it was a poor quality scan. She was treated with bowel rest, IV hydration, and ciprofloxacin/metronidazole. Over the last day or so prior to transfer the patient deteriorated with SBPs decreasing from 110s-120s to the 90s and Cr rising from 0.7 to 1.6. She also developed chills and a vesicular rash. Antibiotics were broadened to tigecycline/metronidazole and she was transferred to [Hospital1 18]. On arrival to [Hospital1 18], the patient was complaining of abdominal pain. Other review of systems was negative. Past Medical History: -Obesity -Fibromyalgia -Substance abuse (EtOH and narcotics) -Hypertension -Hyperlipidemia -Bipolar affective disorder? -Chronic pain -s/p C-section -s/p hysterectomy -s/p multiple exploratory laparotomy -s/p gastric bypass and reversal done at here at [Hospital1 ] in the early [2086]'s -s/p hiatal hernia repair -s/p choleycystectomy Social History: Lives in adult [Doctor Last Name ] care secondary to long struggle with substance abuse issues. Her daughter [Name (NI) 2110] is involved. tobacco: former smoker, quit 17 years ago EtOH: alcoholic, sober x 4-5 months Drugs: has history of illicit drug use, although none recently Family History: Adopted. Has 2 children Physical Exam: VITAL SIGNS: T 96.9, BP 100/43, HR 74, RR 18, O2 Sat 96%/RA, weight 110 kg, blood sugar 113 GENERAL: Middle-aged woman in NAD. DERM: Grouped pustulovesicles on left dorsal hand and bilateral dorsal feet. HEENT: NC/AT. Anicteric sclerae. No conjunctival injection or exudate. Moist oral mucosa. No oral lesions. Oropharynx clear. (NECK: Supple. No cervical or supraclavicular lymphadenopathy.) CHEST: Normal respiratory effort. Diminished breath sounds at right base. No wheezes, rales, or rhonchi. CV: RRR. Quiet heart sounds. Normal s1, s2. No M/G/R. ABD: Normal bowel sounds. Protuberant. Non-distended. Tender to palpation in right abdomen, with guarding but not rebound. No masses. EXT: Radial, DP pulses 2+ bilaterally. No C/C/E. NEURO: Mental status: Alert, oriented to hospital and year but not month. Grossly inattentive. Cannot spell world forward. Cranial nerves. PERRL. EOMI, with no nystagmus. Facial movement normal. Palatal elevation symmetric. Tongue protrudes in midline. Motor: +Asterixis. Normal bulk and tone. Strength limited by pain in right biceps and right iliopsoas. Strength otherwise [4-20] throughout. Sensory: Intact to light touch distally in all extremities. Reflexes: Toes downgoign bilaterally. Pertinent Results: =================== LABORATORY RESULTS =================== On Admission: WBC-5.4 RBC-3.29* Hgb-10.0* Hct-30.8* MCV-94 RDW-13.4 Plt Ct-122* ---Neuts-79.3* Lymphs-15.2* Monos-5.1 Eos-0.3 Baso-0.1 PT-17.3* PTT-27.8 INR(PT)-1.6* ALT-36 AST-34 LD(LDH)-149 AlkPhos-61 Amylase-26 TotBili-0.2 Glucose-91 UreaN-20 Creat-3.2* Na-144 K-3.3 Cl-114* HCO3-18* Albumin-3.1* Calcium-6.7* Phos-4.8* Mg-2.3 Lactate-0.9 Fibrino-456* On Discharge: WBC-3.2* RBC-3.24* Hgb-10.0* Hct-30.6* MCV-94 RDW-13.8 Plt Ct-145* Glucose-115* UreaN-15 Creat-0.6 Na-143 K-3.9 Cl-111* HCO3-27 Other Important Results: HBsAg-NEGATIVE HBsAb-NEGATIVE IgM HBc-NEGATIVE HCV Ab-NEGATIVE TSH-0.47 ANCA-NEGATIVE [Initials (NamePattern4) ] [Last Name (NamePattern4) ]-NEGATIVE C3-80* C4-15 CRP-35.6* ESR-25* Urine Studies: Urinalysis: Blood-TR Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR Color-Straw Appear-Clear Sp [Last Name (un) ]-1.004 RBC-1 WBC-4 Bacteri-FEW Yeast-NONE Epi-0 RenalEp-<1 Eos-NEGATIVE Creat-33 Na-52 TotProt-17 Prot/Cr-0.5* ============== MICROBIOLOGY ============== blood Cultures 2: No growth Urine Cultures 2: No growth Stool Cultures including yersinia, shigella, salmonella, campylobacter and E Coli 0157:H7: NEGATIVE Stool for C diff Toxin: NEGATIVE Stool DFA for Giardia or crytosporidium: NEGATIVE =============== OTHER STUDIES =============== OSH Studies (as reported): CT abdomen/pelvis [2106-10-18]: In addition to the wall thickening in the distal small bowel and terminal ileum, there is pneumatosis in the mid small bowel and a few small associated areas of microperforation. Thyroid U/S [2106-10-21]: Multinodular goiter with a dominant nodule in the left mid to lower lobe. Repotedly, this dominant nodule has been previously biopsied but the camparison films are no longer available to evaluate for a change in the nodule. KUB [2106-10-21]: No evidence of small bowel obstruction. Contrast within the colon. NOnspecific linear areas of contrast in the lower abdomen/pelvis. CT abdomen w/o contrast [2106-10-25]: Grossly limited study. Chest Radiograph [2106-10-28]: FINDINGS: As compared to the previous radiograph, the lung volumes have slightly increased potentially reflecting improved ventilation. The appearance of the pre-existing right basal opacity is more suggestive of an atelectasis than of pneumonia. A similar opacity is also seen at the left lung base. Unchanged size of the cardiac silhouette. No pulmonary edema. No larger pleural effusions. KUB [2106-10-29]: FINDINGS: The tip and the side port of nasogastric tube are below the gastroesophageal junction within the fundus of the stomach. There is contrast material seen throughout the colon, without signs of bowel obstruction. Portable Abdomen Radiograph [2106-11-6]: One supine view of the abdomen was submitted for review. Barium has progress through the colon, now is also present in the descending colon and sigmoid colon. Before, it was only seen in the ascending colon and transverse colon. Surgical clips project in the right upper quadrant. Degenerative changes are in the lumbar spine. There is no evidence of bowel obstruction. Brief Hospital Course: Ms. [Known lastname 39599] is a 59 year-old female who was transferred to the [Hospital1 18] [Hospital Unit Name 153] from [Hospital3 3583] with abdominal pain, possible pneumotosis of the small bowel, hypotension to the 90s, and acute kidney injury. 1. NAUSEA/VOMITING/ABDOMINAL PAIN/DIARRHEA/CONSTIPATION: The patient reports intermittent prolonged periods of diarrhea the most recent resolved just before she went into [Hospital3 3583]. These are associated with abdominal pain and diarrhea. As of the patient's presentation to the outside hospital she actually had minimal bowel movements and remained constipated through much of her outside hospital course and the beginning of her stay at [Hospital1 18]. Because of her abdominal pain and question of pneumatosis of the ileum she had been started on empiric therapy with ciprofloxacin/metronidazole that had been broadened to tigecycline/metronidazole by her time of presentation here. She had also been kept on bowel rest, but due to her lack of peritonela signs she was not surgically managed. At presentation here she was seen by surgery who remained with relatively low concern for an acute surgical abdomen but did think she had a significant enteritis and thus tigecylcine was continued. Gastroenterology evaluated her as well and thought an inflammatory bowel disease versus an infectious etiology was most likely and recommended checking inflammatory markers, which were elevated. Over the course of the patient's hospitalization her stool cultures all returned negative and her symptoms began to improve with less pain and nausea so that she could be advanced to a full diet. Her abdomen remained non-surgical, though general surgery did follow her throughout her course. Unfortunately, due to a large amount of retained barium from her outside hospital scan, which proved refractory to attempts to clear it with mineral oil, aggressive bowel regimen including docusate, senna, and lactulose, and eventually a GoLytely prep she was unable to be reimaged with CT prior to discharge. Multiple KUB's failed to show extraluminal air. As she had drastically improved regarding her abdominal pain and had no clinical sigsn of periotonitis or fever even after antibiotics were stopped (on [11-4]) she was discharged to continue her work-up as an outpatient. Likely the patient should have a full inflammatory bowel disease work up including colonoscopy and upper endoscopy after she has had time to clear her barium. At the time of discharge, however, she only had very minor abdominal pain and was tolerating a full diet without concern. 2. Acute Kidney Injury: The patient had worsening renal function during her OSH course with Cr increasing from <1 to 3.2 on presentation to [Hospital1 18]. She was seen by nephrology who looked at her sediment and thought most likely etiology was acute interstitial nephritis with most likely causative [Doctor Last Name 360] being ciprofloxacin, which had been restarted at time of transfer, though pantoprazole was another possible offender. Ciprofloxacin was discontinued on [10-28] and pantoprazole was changed to famotidine. Patient's creatinine improved to 2.8 on [10-29] and returned to [Location 213] over the following days. She never became anuric. 3. HYPOTENSION: The patient was relatively hypotensive at presentation with SBP's in the 90's. These resolved back to the 110's with multiple fluid boluses shortly after her presentation to the MICU. She never required pressors. 3. ALTERED MENTAL STATUS/ ASTERIXIS: At presentation to the hospital the patient had mental status changes primarily somnolence and inability to hold position. These were thought most likely due to polypharmatcy in the context of the multiple anti-psychotics and narcotics the patient received at the OSH. During her MICU course the patient frequently requested narcotic pain medications asking for several medications by name. On the night prior to transfer out of the MICU she became extremely sedated and difficult to arouse. She was unresponsive to voice commands and light touch, but grimaced with sternal rub. A stat ABG was obtained which showed some hypercarbic respiratory acidosis, and physical exam revealed reactive but pinpoint pupils bilaterally. Narcan was pushed, and patient was immediately aroused and agitated. Security was called as she had medications in her purse. Subsequently, her pain medications were kept at a minimum; with her only receiving approximately 1-2 mg of PO hydromorphone Q6hrs. She frequently would ask for increases in these doses or decreasing intervals, which were refused secondary to her unimpressive discomfort on exam and the fact her pain did not seem to affect her functioning. 4. DIGIT RASHES: At presentationg the patient had vesicular lesions on the backs of her hands and feet and given her presentationg with kidney injury there was concern these were vasculitic. Given history of IVDU hepatitis seriologies were sent given concern for PAN along with complement levels and ANCA were sent. Hepatitis serologies were all negative and other labs were unimpressive for an autoimmune vasculitis. Dermatology was consulted who thought the rash was due to dihydrotic eczema and started a hydrating ointment along with clobetasol cream. This led to resolution of the vesicularl lesions though she did continue to have dry and cracking skin on her extremities. 5. PSYCH: The patient presented on an impressive list of psychotropic medications with multiple anti-depressants and mood stabilizers. These were held initially secondary to her altered mental status and hypotension but then were partially restarted. Clonidine was restarted due to her anxiety and hypertension and then trazodone was restarted for sleep. After confirming her outside doses citalopram and buproprion were also restarted though her quetiapine was held on the advice of psychiatry who were unconvinced the patient had bipolar disorder and thought it best to minimize medications in the acute setting. The patient received SC heparin for DVT prophylaxis. She received pantoprazole then famotidine for DVT prophylaxis while NPO. She was full code. Medications on Admission: Ciprofloxacin 400 mg IV Q12H Flagyl 500 mg Q8H Protonix IV daily Atorvastatin 40 mg PO daily Bupropion 200 mg Q12H Citalopram 20 mg daily Clonidine 0.2 mg TID Neurontin 300 mg TID Promethazine 25 mg TID Quetiapoine 200 mg PO TID Trazodone 200 mg PO QHS Enoxaparin 40 mg SC daily Benadryl PRN Reglan PRN Morphine 3 mg IV Q3H PRN Tylenol Oxycodone Ranitidine PRN Discharge Medications: 1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 3. Trazodone 100 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for insomnia. 4. Bupropion HCl 200 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day. 5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO once a day. 6. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO three times a day. 7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO three times a day. 8. Dilaudid 2 mg Tablet Sig: 0.5-1 Tablet PO every six (6) hours as needed for pain for 5 days. Disp:15 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: Ileitis, presumed infectious without clear organism identified Eczema Acute Kidney Injury, like secondary to acute interstitial nephritis Discharge Condition: Stable, able to take and tolerating food by mouth, ambulating. Discharge Instructions: You were admitted to the outside hospital because of abdominal pain and diarrhea. You were then transferred to [Hospital3 ] because your blood pressure was low and your kidney function declined. We gave you fluids and your blood pressure returned to normal. We stopped a medication that was likely harmful to your kidneys and their function improved. Regarding your abdominal pain there was concern based on outside hospital imaging that your intestines had perforated, which can lead to a severe infection. Therefore, you were treated with antibiotics and followed by surgeons. The surgeons were eventually very reassured by your exam that you did not have an acute surgical process in your abdomen and were comfortable with you going home and following up with your primary care doctor. Overall, you received antibiotics and your symptoms improved then continued to improve once you were off antibiotics. We feel comfortable you do not have an acutely dangerous process in your abdomen. We were not able to rule out several abnormalities including the possibility you could have an inflammatory bowel disease. You should follow up with a gastroenterologist (your primary care doctor can refer you) to complete the work up for these types of conditions. Finally, in the hospital you had an outbreak of a rash. The dermatologists saw this and thought it was most consistent with eczema. You improved with steroid creams. Your medications have not been changed. Please continue to take your medications as previously prescribed. You were given a prescription for pain medication if you continue to have pain for the next few days. Use this only as needed. Please call your doctor or come to the ED if you have fevers, night sweats, inability to eat or drink due to nausea, bloody or black tarry stools, progressive abdominal pain, or any other concerning changes in your health. Followup Instructions: ?????? PCP: [Last Name (NamePattern4) ]. [First Name11 (Name Pattern1) 39600] [Initial (NamePattern1) ] [Last Name (NamePattern4) ], Wednesday [11-10] at 9:30 AM at [Hospital3 ], [Street Address(2) 39601], [Location (un) ], [Numeric Identifier 39453]; [Telephone/Fax (1) 31010]; ?????? Psychiatry: Dr. [Last Name (STitle) 39602] on [2106-11-26] at Bayview Associates at 11:45 AM.	[ "458.9", "729.1", "790.92", "569.89", "304.93", "692.9", "E931.9", "296.80", "303.93", "580.89", "284.1", "E849.8", "272.4", "009.0", "278.00", "401.9", "518.0" ]	icd9cm	[ [ [] ] ]	[ "38.93" ]	icd9pcs	[ [ [] ] ]	14458, 14464	7102, 13336	322, 329	14665, 14730	3883, 3942	16677, 17110	2590, 2616		13748, 14435	14485, 14644		13362, 13725			14754, 16654							2631, 3373											4312, 7079					258, 284								357, 1901							3956, 4298	3388, 3864					1923, 2268	2284, 2574
77,987	118,001	38208	Discharge summary	report	Admission Date: [2117-7-27] Discharge Date: [2117-8-23] Date of Birth: [2047-3-17] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Doctor First Name 3290] Chief Complaint: Diarrhea Major Surgical or Invasive Procedure: Colonoscopy EGD Octreotide Scan History of Present Illness: Mr. [Known lastname 85187] is a 70 year old with a history of chronic diarrhea who presented to [Hospital1 18] with positive blood cultures and arterial clots. He had presented the day prior to admission to Dr. [Last Name (STitle) ] who in his workuop obtained blood cultures and an MRI enterography to assess for intestinal lymphangiectasia. He had blood cultures drawn for a temperature of 101 in the office. On the day of admission Dr. [Last Name (STitle) ] was notified that blood cultures grew GPCs and also his MR enterography showed thrombus in his proximal celiac artery, distal SMA, chronic or subacute infarct of left upper renal pole, small splenic infarct. He was referred to the ED. . In the ED, initial vs were: T99.8 P105 BP135/110 R16 O2 sat99% RA. He vomitted once and was given 4mg IV zofran. He was given 1gm IV vancomycin and 2L normal saline. Rectal exam showed yellow, guaiac positive stools. He was started on a heparin gtt without a bolus. Lactate was 2.3. . Currently, the patient is complaining of heartburn. He has had this problem off and on for the past 3 years. He describes a burning sensation in his larynx without radiation. He states it occasionally causes him to vomit and he did vomit once in the ED. He has 3 bowel movements which are loose stools. He reports that when this started 3 years ago he had up to 8 bowel movements per day. He denies abdominal pain or cramping, melena, hematochezia. He has had 3 EGDs and multiple colonoscopies per his report. He has been on prilosec and zantac in the past but is not taking these currently. He reports a fever while on the plane to come here. He has had a 20lb weight loss in the past year. In the past two weeks, he has been started on Peptamen as well as a low-fat diet. . He reports a fever while on the plane to the US. He reporedly had a MR enterography which was [Doctor First Name ](+) Per HPI (-) Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. No constipation or abdominal pain. No recent change or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: R Kidney Tumor treated with partial nephrectomy 2 years ago S/P Retinal Detachment and cataract surgery bilaterally Inguinal Hernia Repair Appendectomy 4 years ago ? cardiac arrhythmia which he states he was told was insignificant Social History: Notable for a former heavy smoker with 90 pack years, stopped approximately three years ago, distant alcohol intake and significant travel history. Family History: non-contributory Physical Exam: On admission: Vitals: T: 100.3 BP:120/62 P:97 R:24 SpO2: 95% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric Neck: supple Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Irregular, SEM Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: Left leg is warm, well perfused, 2+ DP, Right leg is slightly colder, pulses are present on doppler. Clubbing in fingertips. Pertinent Results: On admission: [2117-7-26] 12:20PM BLOOD WBC-20.0* RBC-4.24* Hgb-13.4* Hct-40.2 MCV-95 MCH-31.6 MCHC-33.4 RDW-13.9 Plt Ct-143* [2117-7-26] 12:20PM BLOOD Neuts-89.1* Lymphs-5.5* Monos-5.2 Eos-0 Baso-0.2 [2117-7-26] 12:20PM BLOOD PT-10.8 PTT-24.8 INR(PT)-0.9 [2117-7-27] 11:30AM BLOOD Glucose-212* UreaN-27* Creat-0.6 Na-129* K-3.2* Cl-95* HCO3-25 AnGap-12 [2117-7-26] 12:20PM BLOOD ALT-27 AST-36 CK(CPK)-57 AlkPhos-54 TotBili-0.3 [2117-7-26] 12:20PM BLOOD TotProt-3.8* Albumin-2.2* Globuln-1.6* Mg-1.9 Cholest-168 [2117-7-28] 03:21AM BLOOD calTIBC-146* VitB12-1357* Folate-12.8 Ferritn-224 TRF-112* . Upon discharge: . Chem10: 138 107 44 (TPN) / 91 4.8 25 0.9 CBC: WBC 8.9 H/H: 8.1/23.8 Plts 332 INR 1.2 Alb 2.1 . Radiology: MR ENTEROGRAPHY ([Numeric Identifier 46893]&[Numeric Identifier 46894]) SBFT Study Date of [2117-7-27] 7:08 AM IMPRESSION: 1. Filling defects in the proximal celiac artery and distal branch of the superior mesenteric artery compatible with thrombus/embolus. 2. Probably subacute infarction of the superior pole of the left kidney with delayed rim of capsular enhancement. As imaging was not targetted towards assessment of renal arterial vasculature, arterial clot is not definitely identified. Nonetheless, this is presumably also from embolic disease. 3. Splenic infarct.Given the multiple arterial thrombi/emboli, recommend echocardiogram to evaluate for potential cardiac valvular disease or right-to-left shunting. 4. Hyperenhancement and jejunal bowel wall thickening. These findings may reflect hypoperfusion secondary to previously described mesenteric vascular filling defects. No discrete mass is identified. 5. Circumferential narrowing within the mid transverse colon but without discrete mass identified. This may reflect spasm, although neoplasm cannot be excluded. Recommend evaluation with colonoscopy if not recently performed. 6. Liver cysts. Left renal cyst. Portable TEE (Complete) Done [2117-7-29] at 11:30:24 AM FINAL IMPRESSION: Large vegetation on the aortic valve. Mild aortic regurgitation. Globally normal systolic function. CHEST (PA & LAT) Study Date of [2117-7-29] 8:46 PM IMPRESSION: Scattered, patchy consolidations throughout the left lung consistent with possible septic emboli. CT scan of the chest with IV contrast is recommended. CTA CHEST/ABD/PELVIS W&W/O C & RECONS Study Date of [2117-7-30] 3:28 PM IMPRESSION: 1. Filling defects in the proximal celiac artery and distal branch of the superior mesenteric artery compatible with thrombus/embolus, unchanged from the MR enterography of [2117-7-27]. 2. Probable subacute infarction of the superior pole of the left kidney. 3. Small splenic infarct. 4. Hyperenhancement and jejunal bowel wall thickening; these findings are concerning for hypoperfusion secondary to mesenteric vascular filling defects. 5. Hypodense lesion within the caudate lobe of the liver likely represents a liver cyst. 6. Two bladder calculi at the right uretrovesical junction. 7. Multiple areas of ground-glass opacification within the upper and lower lobes of lungs, corresponding to areas of opacification seen on the chest x-ray of [2117-7-29] are noted. These may represent infectious process versus minimal pulmonary edema; however, there is no definite evidence of septic emboli. . [8-20] CXR: REASON FOR EXAMINATION: Followup of the patient with known endocarditis. PA and lateral upright chest radiograph was compared to [8-18], [2117]. Bilateral pleural effusion, partially loculated, is unchanged, moderate, left more than right. The evaluation of the cardiac silhouette is difficult due to obscuration of the cardiac borders bilaterally by pleural effusion. Upper lungs are essentially clear. No pneumothorax is present. The right PICC line tip can be seen till the level of low SVC at least. . [8-15] MRI Abdomen: No hypervascular tumors; no evidence of neuroendocrine tumor Brief Hospital Course: Mr. [Known lastname 85187] is a 70 yoM, Greek-speaking only, who initially presented for work-up of chronic diarrhea (protein losing enteropathy, possible lymphangectasia), who was incidentally found to have MSSA endocarditis with arterial thrombus to mesentery; also with PICC line LUE DVT, bil. pleural effusions; recently started on TPN . #Endocarditis: The patient presented to the [Hospital ] clinic with a fever, at which blood cultures were drawn, and were shown to contain GPCs in clusters and pairs. A TEE was performed which showed a large vegetation on the aortic valve with mild aortic regurgitation. MRE showed emboli to the proximal celiac and distal SMA. Blood cultures grew MSSA and the patient is on Nafcillin 2g q4h to complete a 6 week course; last day of antibiotics is [2117-9-7]. He has ID follow-up and will need weekly labs checked (CBC with diff, LFTs, BUN/Cr) and faxed to the [Hospital ] clinic; follow-up appts are schedule with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 6137]. The patient should have a repeat Echo and blood cultures at the end of therapy to be certain he has cleared the infection. . #Pleural Effusions: Due to the patient's protein-losing enteropathy, he has chronically low albumin. Today, albumin is 2.1. He has had problems in the past with pulmonary edema and was on Lasix 40 mg qd at home in [Country 5881]. He had at least 1 admission in [Country 5881] with Pulmonary Edema. On [8-18], the patient had complaints of SOB and was placed on 2L nc. CXR showed bil. pleural effusions. Lasix was started and since the 11th, the patient has maintained stable weight. He was discharged on a regimen of PO Lasix 120 mg qam, and 80 mg q6pm. He may need either up or down titration of this regimen depending on his diuresis. He has also required regular potassium repletion during active diuresis. He was discharged on 20 mEq [Hospital1 ] of PO potassium. . #LUE DVT: The patient was found to have a PICC line associated thrombus in his L UE on [8-6] so the PICC line was removed and a new PICC was placed on the Right. The patient continued to complain of swelling in his L arm, and on [8-16] a repeat UE doppler showed extension of the thrombus into the axillary vein. Hematology recommended anticoagulation therapy for 3 months. The patient was initially on a heparin drip but was transitioned to lovenox and coumadin. On the day of discharge, the patient was still subtherapeutic on coumadin with an INR of 1.2. He was discharged on 7.5 mg coumadin qday as well as lovenox 70 mg [Hospital1 ]. He will need regular follow-up with [Hospital3 ] to reach a therapeutic INR. . #Aterial Thrombus: The patient was discovered to have filling defects in the proximal celiac artery and distal branch of the superior mesenteric artery compatible with thrombus/embolus via MR on [2117-7-27]. . #Atrial Tachycardia: While in the ICU and the beginning of his stay on the floor, the patient was noted to have a murmur (likely aortic vegetation), as well as bursts of tachycardia up into the 150s, which one night required the usage of PO and IV Metoprolol. Cardiology was consulted, and after examining the EKGs felt that the patient's tachycardia was likely atrial tachycardia vs sinus tachycardia with very frequent PAC, and recommended starting him on PO Metopolol. The patient responded well to Metoprolol Tartrate 25 mg PO/NG TID, and did not have any further bursts of tachycardia during his stay. . #Diarrhea: The patient has had chronic diarrhea for the past [3-11] years. He was recently started on a low-fat diet and a medium chain triglycerides, which are a large part of the Peptamen formulation, and found some improvement in his diarrhea, which was therefore thought to be evidence consistent with intestinal lymphangiectasia. Per the GI team, the patient is thought to have a protein-losing enteropathy. The patient has been having approximately 3 episodes of diarrhea a day, which has been fairly stable since his admission to the hospital. A colonoscopy and enterography were concerning for TI and IC valve ulcers, but the gross appearance of the proximal transverse lumen and jejunal were unremarkable. CMV staining of the GI tissue returned negative. Per GI the patient was started on TPN. He was discharged on TPN, cycled at night, as well as Peptamen supplementation. He has a GI follow-up appointment scheduled with Dr. [Last Name (STitle) ]. . #Anemia: On admission, patient's HCT was 35.6. His Hct stabilized during his hospitalization at 23-24. The patient was iron deficient by labs, with low TIBC and low ferritin. The patient did not tolerate PO iron, however, and declined a blood transfusion though he would likely benefit from either of these strategies. . #Thrombocytopenia: On admission, the patient's plt count was 103. It reached a nadir during his stay at 73; Heme/Onc was consulted, and they felt that his thrombocytopenia was likely due to consumption and infection, particularly as it normalized to ~200 at the time of his discharge following treatment of his endocarditis and nutrition via TPN. Flow cytometry was performed per Heme/Onc request, which returned normal. . #GERD: Patient started on a PPI, no complains of GERD symptoms in hospital.. . #Depression: Per pt's son, the patient had increasing depression during this hospitalization. On [8-22], the patient was started on 20 mg qday of Celexa. He was also started on 1 mg PO Ativan qhs prn for anxiety/insomnia, which seemed to give the patient great relief. . The patient was anticoagulated with heparin drip/pneumoboots/lovenox or coumadin for DVT prophylaxis. He remained full code throughout this admission. He had a PCP appointment on the day of discharge to help manage the ongoing diruesis as well as the patient's anticoagulation therpay. Medications on Admission: Chlordiazepoxide-Clidinium (Librax) 5/2.5mg daily Lasix 40mg PO daily Spironolactone 25mg PO daily Peptamen supplement Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). [Month/Year (2) ]:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). [Month/Year (2) ]:90 Tablet(s) Refills:2 3. Nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: Two (2) grams Intravenous Q4H (every 4 hours) for 15 days: Please continue to take until [2117-9-7]. [Month/Day/Year ]:90 doses Refills:0 4. Medium Chain Triglycerides 7.7 kcal/mL Oil Sig: Fifteen (15) ML PO TID (3 times a day): Pt may take up to 4-5 times per day as tolerated. [Month/Day/Year ]:30 cans Refills:2 5. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) 70mg dose Subcutaneous Q12H (every 12 hours): Until stopped by PCP. [Name Initial (NameIs) ]:30 70mg dose Refills:1 6. Coumadin 2.5 mg Tablet Sig: Three (3) Tablet PO once a day: Please follow the coumadin regimen prescribed by your new PCP. . [Name Initial (NameIs) ]:90 Tablet(s) Refills:2 7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [Name Initial (NameIs) ]:30 Tablet(s) Refills:2 8. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. [Name Initial (NameIs) ]:30 Tablet(s) Refills:0 9. Lasix 40 mg Tablet Sig: 2-3 Tablets PO twice a day: Please take 3 tabs (120 mg) each morning and 2 tabs (80mg) each evening . [Name Initial (NameIs) ]:150 Tablet(s) Refills:2 10. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO twice a day. [Name Initial (NameIs) ]:120 Tablet Sustained Release(s) Refills:2 11. Outpatient Lab Work You will need weekly labs drawn including LFTs, Cr/BUN, and CBC with diff. These should be faxed to Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 6137] (Infectious Diseases) at [Telephone/Fax (1) 1419] (phone # is [Telephone/Fax (1) 457]). 12. Outpatient Lab Work In addition, your TPN will be followed by [First Name8 (NamePattern2) ] [First Name4 (NamePattern1) 553] [Last Name (NamePattern1) ], RN. For her, weekly labs including CBC/diff and CMP should be faxed to [Telephone/Fax (1) 18738]. She will help to manage your TPN regimen. 13. Outpatient Lab Work You will need to have routine INR's drawn and managed by your PCP, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] and the [Hospital3 ]. Discharge Disposition: Home With Service Facility: Home Solutions Infusion Therapy Discharge Diagnosis: Primary Diagnosis: - Chronic Diarrhea - Endocarditis - Mesenteric Arterial Thrombi - LUE DVT - Protein losing enteropathy . Secondary Diagnoses: - Sinus Tachycardia with PAC - Chronic diarrhea Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname 85187], . It was a pleasure taking care of you at the [Hospital1 771]. You were admitted to the hospital after it was discovered on imaging of your abdomen that you had clots in the arteries that supply your intestinal tract; in addition, you had bacteria growing in your blood (known as MSSA). . We then imaged your heart with ultrasound, and saw that you had a bacterial vegetation on one of your heart valves - the aortic valve. We started treating you with IV antibiotics, which you will continue until [9-7]. . In addition, we consulted the GI doctors who performed a colonoscopy and an enteroscopy. These procedures showed that you have ulcers in your colon. Biopsies showed esophagitis, ileitis, and focal inflammation in your colon - possibly as result of the blood clots or as a result of a chronic process that accounts for your ongoing protein-losing diarrhea. We have temporarily started you on IV nutrition, known as TPN, that will be continued after you are discharged from the hospital. . Finally, your hospital course was complicated by a blood clot in your left arm that was associated with the PICC line (IV) that you had placed. For this, you have been started on anticoagulation and will need to complete 3 months of anticoagulation therapy. You will receive lovenox shots twice per day until your INR is therapeutic on coumadin. . In the hospital, we STOPPED the following of your home medications: Please STOP taking the following medications: - Chlordiazepoxide-Clidinium (Librax) 5/2.5mg daily - Spironolactone 25mg PO daily . We STARTED the following medications: Nafcillin 2 g IV every four hours until [9-7] Pantoprazole 40 mg DAILY Metoprolol Tartrate 25 mg THREE TIMES A DAY Coumadin 7.5 mg per day; Your PCP will help manage your anticoagulation; you will need labs drawn (INR) until your regimen is stabilized Lovenox 70 mg TWICE DAILY; 1 shot every 12 hours Ativan 1 mg at bedtime as needed for anxiety/insomnia Celexa 20 mg per day; this medication may need to be further titrated by your PCP We started you on TPN -> the prescription is included in your discharge papers Peptamen (Medium Chain Triglycerides); you should take [3-12] cans per day as tolerated to help supplement your nutrition Lasix (120 mg in the AM, 80 mg at night) Potassium 20 mEq, twice per day . You have many follow-up appointments scheduled. The exact times and locations are below. . Your first appointment is with your new PCP, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. He will help to manage your anticoagulation and your ongoing diuresis. . You also have appointments with the Infectious Disease physicians. They will help to manage your antibiotic therapy. You will need weekly labs drawn including LFTs, Cr/BUN, and CBC with diff. These should be faxed to Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 6137] at [Telephone/Fax (1) 1419] (phone # is [Telephone/Fax (1) 457]). . In addition, your TPN will be followed by [First Name8 (NamePattern2) ] [First Name4 (NamePattern1) 553] [Last Name (NamePattern1) ]. For her, weekly labs including CBC/diff and CMP should be faxed to [Telephone/Fax (1) 18738]. She will help to manage your TPN regimen. . Finally, when you complete your antibiotic course, please have your doctor check a blood culture to make sure that you have been cleared of your infection. You will also need a repeat Echocardiogram. Followup Instructions: Your appointments are listed below: You have a new primary care doctor, Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], to help manage your coumadin (INR) levels as well as your diuresis with Lasix. You have the following appointment: Department: [Hospital3 249] When: MONDAY [2117-8-23] at 3:00 PM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 250] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage . Department: INFECTIOUS DISEASE When: MONDAY [2117-8-30] at 10:30 AM With: [First Name4 (NamePattern1) 2482] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 457] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Hospital 1422] Campus: WEST Best Parking: [Hospital Ward Name ] Garage . Department: DIVISION OF GI When: FRIDAY [2117-9-3] at 7:40 AM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 463] Building: Ra [Hospital Unit Name 1825] ([Hospital Ward Name 1826]/[Hospital Ward Name 1827] Complex) [Location (un) ] Campus: EAST Best Parking: Main Garage . Department: INFECTIOUS DISEASE When: MONDAY [2117-9-20] at 10:30 AM With: [First Name4 (NamePattern1) 2482] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 457] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Hospital 1422] Campus: WEST Best Parking: [Hospital Ward Name ] Garage . When you return to [Country 5881], please make appointments to see your Primary Care doctor, Dr. [Last Name (STitle) 85188], as well as a cardiologist, as well as an infectious disease physician.	[ "427.89", "263.9", "996.74", "530.19", "276.1", "457.1", "530.81", "E879.8", "557.0", "421.0", "287.5", "787.91", "511.9", "558.9", "579.8", "569.82", "311", "041.11" ]	icd9cm	[ [ [] ] ]	[ "45.25", "99.15", "45.16", "88.72", "38.93" ]	icd9pcs	[ [ [] ] ]	16145, 16207	7550, 13420	325, 359	16444, 16444	3553, 3553	20131, 21946	3009, 3027		13591, 16122	16228, 16228		13446, 13568			16595, 20108							3042, 3042			16373, 16423													277, 287							4196, 7527	387, 2573						16247, 16352	3567, 4180	16459, 16571					2595, 2827	2843, 2993
10,150	100,131	26443	Discharge summary	report	Admission Date: [2144-3-7] Discharge Date: [2144-3-16] Service: MEDICINE Allergies: Codeine Attending:[First Name3 (LF) 2145] Chief Complaint: transfer from OSH in [State 108] with R hip IT fx. Major Surgical or Invasive Procedure: R hip ORIF History of Present Illness: HPI: [Age over 90 ]F with hx dementia, CAD, CHF EF 40%, chronic afib, lives with 24 hour caretaker. Was brought into OSH for neck pain and inability to hold her head up as well as confusion, found to have transverse C2 dens fracture, which has been immobilized with [Location (un) 5622] collar. Pt fell 3 weeks prior to admission, but home aide stated that there were no injuries from fall. Noted to have CHF exacerbation --> resolving with diuresis and now is reportedly stable on [3-20] liters NC (uses no O2 at home). In-house at OSH, had a fall and unfortunately suffered right intertrochanteric fracture. Pt has family in [Hospital1 1559] and had pt med flighted from [State 108] to [Hospital1 18]. Family connection to [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. Reportedly, her C2 fracture is stable and the surgeons there only wanted to immobilize it until her hip could be addressed. . Pt had a cardiology consult in [State 108], she had a CHF exacerbation with a BNP of 15,000. Her Toprol XL was increased from 37.5 to 50 mg PO qd with a plan to increase to 100 mg po QD. She was started on digoixin. Her lasix was increased. . Of note, transfer paperwork notes that the pt was seen by PCP in [Name9 (PRE) 108] for exertional CP and SOB relieved by NTG in [Month (only) 1096] [2143]. At that time her Imdur was increased from 30 to 60 mg PO qd. . Before her hospitalization she had been increasingly agitated and had been started on Risperdal, which was recently d/c'd after she became increasingly confused. . Labs at OSH: [3-6]: INR 1.1, Na 146, K 3.8, Cl 106, HCO3 33, BUN 29, Cr 1.0, Ca 8.7 Dig 1.0, [3-2] Blood Cx: NGTD . Studies: [3-2] EKG: afib at 98bpm RAD, LVH, QTc 526, bad baseline [3-4] CT Head mod-severe atrophy, no bleed [3-5] R hip/pelvis, comminuted IT fx R hip [3-5] CT cervical spine: transverse fx through base of dens. No displacement. Transverse lucency through the spinous process at C3 (chronic) Transverse lucency through spinous process at C3 (chronic). [3-3] CXR: Mild CHF, patchy infiltrate base of right lung, small bilateral pleural effusions. . Past Medical History: PMH: CHF EF 40%, [2-20] echo: inf hypokinesis CAD, hx MI, s/p PCI of LAD, LCx and RCA with stents [2136] at [Hospital1 ] afib hypercholesterolemia COPD HTN severe AS ([2-20] echo 59 mmHg peak gradient, valve area 0.6 cmsq) mod-severe MR mild MS [First Name (Titles) ] [Last Name (Titles) ] Dementia (Mild Alzheimer's vs vascular) per transfer paperwork, however pt's family states that before this hospitalization pt was living independently with live in help. Hiatal hernia s/p repair hx GIB from AVM associated with elevated INR [4-18] s/p ccy s/p TAH macular degeneration kyphoscoliosis DJD/OA Social History: Social Hx: widowed, with 4 children. Lived independently with 24 hour aides. No EtOH or tob. Transferring physician: [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) 24606] [Last Name (NamePattern1) 79] cell [Telephone/Fax (1) 65356] (is on-call this weekend) [Hospital 32303] Medical Center in [Hospital 65357], [State 108] [Telephone/Fax (1) 65358]. [Name (NI) ] son: [Name (NI) ] [Name (NI) 122] [Telephone/Fax (1) 65359] is her HCP, he lives in [Name (NI) 108] and is coming to MA [3-7]. Pts daughter ([Name (NI) 19948] [Last Name (NamePattern1) ]) lives in [Name (NI) 1559] and her phone number is [Telephone/Fax (1) 65360]. . [Hospital1 1559] PCP: [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1683] ([Hospital1 ]) [Hospital1 1559] Cardiologist: Dr. [Last Name (STitle) 65361] ([Hospital1 ]) Physical Exam: PE: VS: T 98.6 HR 64 R 20 BP 88/54 95%2L Gen: NAD, laying in bed in Aspen collar HEENT: slight droop L eyelid, PERRL, MMM, O/P clear Neck: in Aspen collar Chest: crackles at bases, clear at apices CV: [Last Name (un) 3526] [Last Name (un) 3526] rate and rhythm, 3/6 SEM at RUSB rad to carotids, 3/6 systolic murmur at apex Abd: soft, NT, ND +BS Ext: pain with palpation R hip, lim ROM. no edema, 2+ DP pulses bilaterally Neuro: alert, oriented to person only, moves all 4. Brief Hospital Course: [Age over 90 ] yo F with h/o dementia, CAD, diastolic CHF (EF 55%), severe AS, chronic afib, transferred from OSH with R hip fracture and possible C2 fracture for operative management of hip. She was stable on the floor on her initial arrival. Given her CHF and AS, she was a high risk surgical candidate, but the family decided to go ahead with the operation. Postoperatively she was in the MICU briefly for hypotension but was extubated without difficulty, weaned off pressors after rehydration and transferred back to the floor. Perioperatively, she developed a UTI and a LIJ clot, which were both treated. Postoperatively, she also developed delirium, and was less verbal than she was previously. She failed a speech and swallow evaluation, but the medical team was optomistic that she would improve. In the meantime, multiple attempts at NGT placement were unsuccessful. While on the floor, [3-14]-30, patient showed signs of inability to clear her secretions. On [3-15], she had an episode of hypoxia. CXR at that time revealed fluid overload, and she seemed to improve with lasix. Overnight that night, 1/2 blood culture bottles were positive for S.aureus and Vancomycin was started. [3-16], she continued to do poorly, and again was hypoxic. CXR this time revealed dry lungs, but likely aspiriation PNA or LUL. Despite aggressive suctioning and broadening of antibiotic coverage, Mrs. [Known lastname 65362] continued to deteriorate and ultimately died approx 4:25 PM on [3-16]. . # COde - DNR/DNI verified with son who is HCP. . # Communication: son [Name (NI) ] [Name (NI) 122] [Telephone/Fax (1) 65359] (HCP; daughter ([Name (NI) 19948] [Name (NI) ] [Telephone/Fax (1) 65360]). [Hospital1 1559] PCP: [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1683] ([Hospital1 ]); [Hospital1 1559] Cardiologist: Dr. [Last Name (STitle) 65361] ([Hospital1 ]). Previously at [Hospital 32303] Medical Center in [Last Name (LF) 65357], [First Name3 (LF) 108] [Telephone/Fax (1) 65358]. . Medications on Admission: Meds on transfer: Lipitor 40 mg PO qd Digoxin 0.125 mg qD Lasix 80 mg IV BID Atrovent neb QID Imdur 30 mg PO qd Levalbuterol neb QID Losartan 12.5 mg PO BID Toprol XL 50 mg PO qd coumadin 2 mg PO alternating with 3 mg PO qd (held) Tylenol prn Discharge Disposition: Expired Discharge Diagnosis: Hip fracture s/p ORIF LIJ clot UTI Aspiration PNA Perioperative delirium Discharge Condition: Death Discharge Instructions: None. Followup Instructions: None. [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 2158]	[ "507.0", "496", "997.3", "427.31", "820.21", "E885.9", "401.9", "414.01", "424.1", "599.0", "272.0", "428.32", "293.0", "285.1" ]	icd9cm	[ [ [] ] ]	[ "79.35", "99.15" ]	icd9pcs	[ [ [] ] ]	7065, 7074	4637, 6770	270, 282	7190, 7197		7251, 7351				7095, 7169		6796, 6796			7221, 7228							4132, 4614																175, 232								310, 2496													2518, 3146	3162, 4117		6814, 7042
8,675	191,144	26286	Discharge summary	report	Admission Date: [2165-12-16] Discharge Date: [2165-12-20] Date of Birth: [2098-4-13] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3948] Chief Complaint: Dyspnea/COPD Major Surgical or Invasive Procedure: [2165-12-17]: Flexible bronchoscopy [2165-12-18]: Rigid bronchoscopy with black Dumon bronchoscope; tumor debridement; Argon plasma coagulation; therapeutic aspiration of secretions History of Present Illness: This is a 67-year-old M with a history of progressive NSCLC s/p RML and RLL lobectomy through open thoracotomy in [1-/2163] also with hx of R hemicolectomy in [6-/2163] for presumed metastases now presenting to OSH with worsening SOB x 1 month. On CT at OSH was found with worsening progression and spread of cancer to L hilum with occlusion/stenosis of central branches of L bronchus and occlusion of L lower pulmonary vein and severe L pulmonary AA stenosis. There was also evidence of pericardial involvement. Pt on home O2 2L NC. On transfer to [Hospital1 18] by med flight, patient went into rapid a-fib to the 150s which converted back to sinus rhythm after 2 rounds of 20mg IV cardizem and 0.25 IV dig x 2. Past Medical History: 1. Lung cancer s/p right lower lobectomy s/p chemo 2. COPD 3. h/o tularemia [2138] (hospitalized) 4. h/o babesiosis- 5 yrs ago (hospitalzed) 5. chronic/recurrent right sided pnas 2-4 episodes in last year 6. GERD 7. Eye surgery Social History: 75 pk-yr smoker (1.5 ppd x 50 years), quit on [2162-12-31]. Heavy EtOH >10 yrs ago. Denied exposure to toxins. Retired road crew. Lives with friend in [Hospital3 4298]. Has sister close by. Not married. No children. Family History: Sister w/ CAD, CABG, DM. Brother passed away suddently at age 43, thinks he had MI. Father w/ "[Name2 (NI) ]-induced cancer." Physical Exam: PHYSICAL EXAM: VS: Temp 98.5, HR 97, BP 142/92, RR 17, O2 96% on 4L NC GEN: WNL, NAD, A&O HEENT: No lymphadenopathy CV: RRR, no M/R/G, no JVD, distant heart sounds RESP: Significant wheezing in upper airways bilaterally with decreased breath sounds over L side diffusely, also diffuse rales/ronchi on right ABD: Soft, NT/ND, no masses or hernia, no hepatosplenomegaly SKIN: Diffuse hyperpigmented lesions 1-2cm diameter EXT: No clubbing, cyanosis, edema Pertinent Results: [2165-12-16] 09:40PM BLOOD WBC-8.9 RBC-5.00# Hgb-15.8# Hct-44.3# MCV-89 MCH-31.7 MCHC-35.8* RDW-13.6 Plt Ct-390# [2165-12-17] 02:26AM BLOOD WBC-13.0* RBC-4.56* Hgb-14.4 Hct-40.7 MCV-89 MCH-31.7 MCHC-35.5* RDW-13.6 Plt Ct-372 [2165-12-18] 03:18AM BLOOD WBC-14.4* RBC-4.06* Hgb-12.8* Hct-36.7* MCV-90 MCH-31.5 MCHC-34.8 RDW-13.7 Plt Ct-322 [2165-12-19] 02:23AM BLOOD WBC-13.6* RBC-4.08* Hgb-13.0* Hct-36.4* MCV-89 MCH-31.8 MCHC-35.6* RDW-13.6 Plt Ct-328 [2165-12-16] 09:40PM BLOOD PT-13.0 PTT-27.1 INR(PT)-1.1 [2165-12-17] 02:26AM BLOOD PT-15.6* PTT-36.4* INR(PT)-1.4* [2165-12-16] 09:40PM BLOOD Glucose-159* UreaN-19 Creat-1.0 Na-136 K-4.7 Cl-101 HCO3-23 AnGap-17 [2165-12-17] 02:26AM BLOOD Glucose-152* UreaN-20 Creat-0.9 Na-137 K-4.7 Cl-103 HCO3-23 AnGap-16 [2165-12-18] 03:18AM BLOOD Glucose-113* UreaN-18 Creat-0.8 Na-134 K-4.6 Cl-102 HCO3-28 AnGap-9 [2165-12-19] 02:23AM BLOOD Glucose-139* UreaN-17 Creat-0.9 Na-137 K-4.5 Cl-101 HCO3-28 AnGap-13 [2165-12-17] 02:26AM BLOOD Calcium-10.4* Phos-2.6* Mg-1.9 [2165-12-18] 03:18AM BLOOD Calcium-9.7 Phos-2.8 Mg-2.2 [2165-12-19] 02:23AM BLOOD Calcium-10.3* Phos-2.4* Mg-2.2 [2165-12-16] 09:40PM BLOOD CK(CPK)-35* [2165-12-16] 09:40PM BLOOD cTropnT-<0.01 [2165-12-17] 02:26AM BLOOD cTropnT-<0.01 [2165-12-17] CT CHEST W/CONTRAST: 1. Left hilar mass invading the right main bronchus just proximal to the upper lobe orifice, surrounds and invades the left lower lobe and lingular bronchi and surrounds the mid left descending pulmonary artery, extending medially along the left superior pulmonary vein. No evidence of mediastinal invasion. 2. New 4-mm upper lobe nodule is suspicious for metastasis. [2165-12-17] Chest Xray: Since the prior radiograph, a large infrahilar mass has developed in the left lung. This is associated with inferior displacement of the left hilum and apparent obstruction of the airways with distal mucoid impaction. Peripheral to this area in the region of the lingula, there is a large 6.2 cm diameter opacity that could be due to additional mass or area of post-obstructive atelectasis. Post-thoracotomy changes are again demonstrated in the right hemithorax, and there is either a small right pleural effusion or pleural thickening present. Periphery of left lower lung and lateral ribs have been excluded from the radiograph, but will be fully evaluated on the patient's separately dictated chest CT from the same date. Brief Hospital Course: Patient was admitted to the ICU on the Interventional Pulmonology/Thoracic Surgery service on [2165-12-16]. He was kept on [2-19] liters of oxygen and nebulizer treatment overnight. On [2165-12-17], chest xray was obtained, showing a large infrahilar mass that developed in the left lung along with a large opacity peripherally that could be due to additional mass or area of post-obstructive atelectasis. Subsequent chest CT was obtained, confirming a left hilar mass invading the left main stem bronchus. Metoprolol IV was also started. Flexible bronchoscopy revealed a viable stump in the bronchus intermedius with distal left main stem endobronchial lesion causing significant airway compromise (75% occlusion) and tumor infiltration in the left upper lobe. Postop, he had episode of stridor and was given racemic epinephrine and oxygen with improvement. On [2165-12-18], patient went back to the OR for a rigid bronchoscopy with black Dumon bronchoscope and did therapeutic aspiration of secretions along with tumor debridement using Argon plasma coagulation with successful recanalization of the distal left main stem and left upper lobe. He tolerated the procedure well. On [2164-12-18], patient was stable enough to be transferred to the floor. He was able to ambulate, void on his own, and tolerate regular diet. On [2164-12-19], he was discharged with VNA services for hospice care. Medications on Admission: ASA 325 mg daily Albuterol/Atrovent nebs 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. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:60 Tablet(s) Refills:2 3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). Disp:1 Disk with Device(s) Refills:2 5. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). Disp:60 Cap(s) Refills:2 6. Prednisone 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): Take 2 tabs daily from [12-21] to [12-23]; then take 1 tab daily from [12-24] to [12-26]. Disp:9 Tablet(s) Refills:0 7. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:120 Tablet(s) Refills:2 8. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for anxiety. Disp:60 Tablet(s) Refills:0 9. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig: Three (3) ML Inhalation q4-6 PRN (). Disp:QS ML(s) Refills:2 10. Continue home oxygen Discharge Disposition: Home With Service Facility: [Location (un) ] nursing association Discharge Diagnosis: Distal left main stem endobronchial tumor History of squamous cell carcinoma status post bilobectomy Discharge Condition: Stable Discharge Instructions: Call your hospice care coordinator or Dr.[Name (NI) 14679] office at [Telephone/Fax (1) 7769] if: * If you are vomiting and cannot keep in fluids or your medications. * If you have shaking chills, fever greater than 101.5 (F) degrees or 38 (C) degrees, increased redness, swelling or discharge from incision, chest pain, shortness of breath, or anything else that is troubling you. * Any serious change in your symptoms, or any new symptoms that concern you. --- * Please resume all regular home medications and take any new meds as ordered. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. * Continue using your home oxygen of 2L as previously presribed. Followup Instructions: 1. Call Dr.[Name (NI) 14679] office at [Telephone/Fax (1) 7769] to [Telephone/Fax (1) ] a follow-up appointment. 2. Talk with your VNA nurse [First Name (Titles) ] [Last Name (Titles) ] an appointment with the hospice care coordinator. Completed by:[2165-12-24]	[ "530.81", "496", "197.0", "V10.83", "275.42", "427.31" ]	icd9cm	[ [ [] ] ]	[ "33.23", "96.56", "32.29", "33.22" ]	icd9pcs	[ [ [] ] ]	7667, 7738	4915, 6337	337, 529	7883, 7892	2421, 4892	8877, 9165	1800, 1932		6428, 7644	7759, 7862		6363, 6405			7916, 8854							1962, 2402																284, 299								557, 1288													1310, 1543	1559, 1784
5,254	103,168	26110	Discharge summary	report	Admission Date: [2131-5-10] Discharge Date: [2131-5-12] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2297] Chief Complaint: Fever Major Surgical or Invasive Procedure: Central Venous Line History of Present Illness: 85 y/o female with a h/o CAD, CVA, AF/sick sinus syndrome s/p pacer placement, T2DM, hyperlipidemia, and COPD who presented to the ED with fever. Pt was transferred from [Hospital 100] Rehab where she is a resident when she spiked a temp to 101 and subsequently sent to [Hospital1 18] ED for further evaluation. Of note, she is s/p recent left BKA c/b MRSA wound infection treated with vancomycin, ceftriaxone, and Flagyl. In the ED, she was given cefepime and clindamycin for broader coverage. Past Medical History: CAD s/p stenting of MI [2124] history of left CVA1/[2129] manafested with left hemiparesis history of cardiac arrythmia, sick sinus syndrome, AF ,s/p paacemaker history of DM2, diet controlled hsitory of GI bleed while on anticoagulation for renal thrombus history of hyperllpdemia history of COPD history of aortic valve stenosis history of Left ventricular diastolic dysfunction history of asscending aortic aneurysem history of pulmonary hypertension history of urosepsis [2128] history of dysphasia history of hyperlipdemia postoperative hypovolemia with low urinary output-fluid resustated postoperative blood loss anemia-transfused posopterative electrolyte imbalance-corrected Social History: nursing home resident since [2129] post CVA Family History: NC Physical Exam: Vitals - T 102.4, BP 108/57, HR 85, RR 17, O2 sat 94% 7L FM General - elderly female, no acute distress HEENT - mild anisocoria; R>L pupil, both reactive; OP clr, MMM, no LAD CV - RRR; [3-20] crescendo-decrescendo murmur @ LUSB Chest - coarse crackles with expiratory wheezes throughout Abdomen - NABS, soft, NT/ND Extremities - L lower extremity surgically absent; AKA stump with ~3-5 mm skin defect with minimal surrounding erythema, minimal whitish drainage Pertinent Results: [2131-5-10] 07:52PM GLUCOSE-189* UREA N-13 CREAT-0.6 SODIUM-142 POTASSIUM-4.1 CHLORIDE-110* TOTAL CO2-24 ANION GAP-12 [2131-5-10] 07:52PM CK(CPK)-34 [2131-5-10] 07:52PM CK-MB-NotDone cTropnT-0.07* [2131-5-10] 07:52PM CALCIUM-8.5 PHOSPHATE-3.8 MAGNESIUM-1.8 [2131-5-10] 07:52PM WBC-7.7 RBC-3.16* HGB-10.6* HCT-31.8* MCV-101* MCH-33.6* MCHC-33.4 RDW-15.7* [2131-5-10] 07:52PM PLT COUNT-157 [2131-5-10] 04:20PM PO2-89 PCO2-43 PH-7.37 TOTAL CO2-26 BASE XS-0 [2131-5-10] 03:47PM TYPE-ART PO2-46* PCO2-46* PH-7.37 TOTAL CO2-28 BASE XS-0 INTUBATED-NOT INTUBA [2131-5-10] 01:00PM URINE COLOR-Amber APPEAR-Hazy SP [Last Name (un) 155]-1.030 [2131-5-10] 01:00PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM [2131-5-10] 01:00PM URINE RBC-0-2 WBC-[12-4]* BACTERIA-MOD YEAST-NONE EPI-[3-19] [2131-5-10] 11:52AM TYPE-[Last Name (un) ] COMMENTS-NOT SPECIF [2131-5-10] 11:52AM GLUCOSE-108* LACTATE-1.2 NA+-143 K+-5.1 CL--109 [2131-5-10] 11:48AM GLUCOSE-113* UREA N-10 CREAT-0.7 SODIUM-145 POTASSIUM-4.7 CHLORIDE-111* TOTAL CO2-29 ANION GAP-10 [2131-5-10] 11:48AM estGFR-Using this [2131-5-10] 11:48AM CALCIUM-8.7 PHOSPHATE-3.7# MAGNESIUM-2.0 [2131-5-10] 11:48AM WBC-6.9 RBC-3.51* HGB-11.7* HCT-35.8# MCV-102# MCH-33.4* MCHC-32.8 RDW-15.9* [2131-5-10] 11:48AM PLT COUNT-176 [2131-5-10] 11:48AM PT-12.5 PTT-25.5 INR(PT)-1.1 Echo [2131-5-11]: EF 70-75%, 3+TR 2+MR, 2+AR, mod AS, mod pulm HTN. CXR [2131-5-10]: 1. Left internal jugular central venous catheter likely terminating within the brachiocephalic confluence. No definite pneumothorax identified; however, left apex was not included on current radiograph. 2. Grossly unchanged appearance to bilateral pleural effusions and basilar atelectasis. More dense opacity within the retrocardiac region also likely represents atelectasis; however, underlying consolidation cannot be excluded. Brief Hospital Course: 85 F s/p recent left AKA on [2131-3-23], transferred from [Hospital 100] Rehab with fever and hypotension. Felt to be related to possibly multiple sources including AKA stump (cellulitis vs abscess vs osteo), C Diff colitis, UTI; also possible early pneumonia with retrocardiac opacity on CXR). Pt initially covered broadly with vanco/cefepime/metronidazole without good effect. Hemodynamics continued to decline as well as respiratory status with increasing CO2 retention despite non-invasive positive pressure ventilation. Pressors initially started with moderate effect, however, pt's mental status began to decline despite improved mean arterial pressures. Family meeting was held given continued decline, and pt was made comfort measures only by son. Pt expired at 19:49 [2131-5-12] and family was informed. Autopsy was declined. Medications on Admission: Acetaminophen 650 TID Aspirin 325 Ceftriaxone 1 gm QD Iron 325 QD Gabapentin 300 QHS Heparin 5000 SQ TID Lactobacillus [Hospital1 ] Toprol XL 37.5 QD Flagyl 500 PO Q8h Mirtazapine 30 PO QHS Protonix 40 PO QD Senna 2 QHS Simvastatin 40 QHS Vancomycin 750 IV QD Discharge Medications: na Discharge Disposition: Expired Discharge Diagnosis: Sepsis Hypotension Probable C diff colitis Probable nosocomial pneumonia Probable stump cellulitis Congestive heart failure Atrial fibrillation with sick sinus syndrome Hypoxic respiratory distress Hypercarbic respiratory failure Discharge Condition: expired	[ "414.01", "438.20", "E878.5", "272.0", "008.45", "995.91", "250.70", "424.1", "496", "038.9", "997.62", "518.81", "443.81", "427.5", "428.0", "427.31", "486", "682.6" ]	icd9cm	[ [ [] ] ]	[ "38.93" ]	icd9pcs	[ [ [] ] ]	5370, 5379	4172, 5028	268, 289	5652, 5662	2127, 4149		1622, 1626		5343, 5347	5400, 5631		5054, 5320										1641, 2108																223, 230								317, 821													843, 1541	1557, 1606
24,287	144,219	13597	Discharge summary	report	Admission Date: [2150-9-24] Discharge Date: [2150-10-4] Date of Birth: [2087-6-17] Sex: M Service: Green Surgery PRINCIPAL DIAGNOSIS: Severe ischemic colitis. PHYSICAL EXAMINATION: The patient is a well-developed, well-nourished male in no apparent distress at the time of discharge. HEENT - Mucous membranes are moist. There is no evidence of oral ulcers. The sclerae was anicteric. Cranial nerves II through XII were intact. There was no cervical lymphadenopathy. His chest was clear to auscultation bilaterally. There were no rales or rhonchi. Cardiac - Regular rate and rhythm, no murmurs. His abdomen revealed Steri-Strips intact with ostomy pink and viable with bag, positive gas. His abdomen was soft, nontender and nondistended with no palpable masses noted. LABORATORY DATA: On [2150-9-26], complete blood count revealed white count 8.3, 27.5 hematocrit, and platelets 129. Chemistry on [2150-9-29] revealed sodium 137, potassium 3.6, chloride 97, bicarbonate 28, BUN 6, creatinine 0.7, and glucose 125. Sigmoidoscopy which was performed on [2150-9-24] showed granularity, friability, erythema, and congestion in the descending colon compatible with severe ischemic colitis for biopsy. HOSPITAL COURSE: Mr. [Known firstname ] [Known lastname 41045] is a 63-year-old male with past medical history of severe peripheral vascular disease and diabetes mellitus who presented to the Emergency Department with acute onset of bloody diarrhea and left-sided abdominal pain with consequent sigmoidoscopy diagnosis of ischemic colitis per biopsy. The patient underwent an uncomplicated left hemicolectomy from left transverse to sigmoid colon. Immediately postoperatively, the patient was sent to the Post Anesthesia Care Unit for close monitoring. On postoperative day one, the patient was extubated in the Post Anesthesia Care Unit and continually observed. Immediately postoperatively, the patient presented with tachycardia and numerous premature ventricular contractions. Ischemic origin of premature ventricular contractions were promptly ruled out, and after pain was adequately controlled, premature ventricular contractions resolved. The patient also presented with significant hypertension which was controlled with perioperative beta blocker. Throughout the hospital stay, the patient's diabetes and corresponding hyperglycemia were controlled by the [Hospital 8392] Clinic fellow. Otherwise, the patient's postoperative course was unremarkable with diet being advanced appropriately with return of bowel function. The decision was made to discharge the patient after the patient was able to tolerate solids by mouth and showed good ostomy output. CONDITION AT DISCHARGE: Stable. DISCHARGE STATUS: To home with ostomy care. DISCHARGE DIAGNOSIS: Status post left hemicolectomy. DISCHARGE MEDICATIONS: None. FOLLOW-UP: The patient was instructed to follow-up with Dr. [Last Name (STitle) 41046] in two to four weeks in surgery clinic. [Name6 (MD) 41047] [Name8 (MD) 1955], M.D. [MD Number(1) 41048] Dictated By:[Name6 (MD) 41049] MEDQUIST36 D: [2150-11-2] 13:53 T: [2150-11-2] 18:20 JOB#: [Job Number 41050]	[ "557.0", "250.60", "443.9", "536.3", "401.9", "357.2", "707.14", "250.50", "362.01" ]	icd9cm	[ [ [] ] ]	[ "45.25", "45.75", "46.10" ]	icd9pcs	[ [ [] ] ]									2899, 3281	2842, 2875			1274, 2751																	216, 1256		2766, 2821
30,303	140,765	5557	Discharge summary	report	Admission Date: [2171-9-19] Discharge Date: [2171-9-24] Date of Birth: [2093-4-30] Sex: F Service: ORTHOPAEDICS Allergies: Morphine / Oxycodone Attending:[First Name3 (LF) 64] Chief Complaint: Right knee pain, Hypotension Major Surgical or Invasive Procedure: Revision of Right total knee replacement History of Present Illness: This is a 78 y/o F with history of failed R knee revision c/b infection requiring multiple I&D and long antibiotic course. She underwent attempted fusion of the right knee today. EBL approx 400cc. Received 2.3L LR in OR & total 4L in PACU. Her initial post-op BP was 76/50, came up to 104/68 with fluid bolus. Several hours later her SBP was in the 80s, she was given one more bolus, SBPs remained in the 80s and then found to be 68-79 at 10pm, so she was given 100mcg of phenylepherine. This initially brought her pressure up to 106/70 but within 20 minutes she was back down to 79/45. One more bolus of phenylepherine was started, she was given a 500cc bolus of LR and one unit of PRBCs and 1g IV Vancomycin. Urine output was 5-15cc/hr for 8hrs post-op. Her post-op HCT was 33.7 and she was noted to have drainage out of her hemovac. HCT was re-checked 5 hours later and it was 25.9. To tamponade a possible bleed her hemovac was clamped. Her knee dressing was then noted to be blood stained. She remained alert and oriented, pain controlled with a dilaudid PCA pump and she was transferred to the ICU for management of hypotension and low urine output. . ROS: The patient denies any fevers, chills, weight change, nausea, vomiting, abdominal pain, diarrhea, constipation, melena, hematochezia, chest pain, shortness of breath, orthopnea, PND, lower extremity oedema, cough, urinary frequency, urgency, dysuria, lightheadedness, gait unsteadiness, focal weakness, vision changes, headache, rash or skin changes. Pt recovered well from ICU, with increased UOP w/ 1000+ml/day and BP maintained at SBP120-140. On the floor pt did not have any problems and the course was uncomplicated. Pt knee looked OK from surgical perspective. She had many surgical I+D and antibx spacer on that knee, was extremely scarred down. Her knee always looks reddish/ecchymosis, even prior to surgery d/t extensive soft tissue trauma. Her inflammatory markers were essentially neg. The cultures from OR was neg. Pt was given 3days of vancomycin postop. Pt will be continued to be oozy from the incision site. This has always been the case from prior surgery. She also requires multiple transfusion at baseline. The procedure was well tolerated and there were no complications. Please see the separately dictated operative report for details regarding the surgery. The patient was weaned off of the PCA onto oral pain medications. The Foley catheter was removed without incident. The surgical dressing was also removed, and the surgical incision was found to be clean, dry, and intact with baseline redness nor purulent drainage. During the hospital course the patient was seen daily by physical therapy. Labs were checked both post-operatively and throughout the hospital course and repleted accordingly. The patient was tolerating regular diet and otherwise feeling well. Prior to discharge the patient was afebrile with stable vital signs. Hematocrit was stable and 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 service or rehabilitation in a stable condition. Past Medical History: Right total knee replacement ([2169])but did not gain full ROM so underwent a patellectomy and lateral release [2171-5-8]. This was then complicated by infection with MRSA and MRSA bacteremia. The knee prosthesis was removed on [2171-5-26] and an antibiotic spacer was placed. She was treated with a 6 week course of vancomycin. The spacer was felt to be causing irritation and tenting on the skin and thus it was removed with debridement of devitalized tissue and VAC application on [2171-6-14]. On [2171-7-5], she was returned with dehiscence of right knee incision. Multiple debridements were subsequently performed with growth primarily of Enterobacter as well as one culture positive of VRE and one of CNS. She was treated with Meropenem and Daptomycin and ultimately was changed to oral Cipro for the Enterobacter and continued on Daptomycin for the VRE/CNS. CAD s/p MI x 2 (25 years ago) Colon Cancer ([2162]) s/p 5-FU and partial colectomy Anemia Urge incontinence HTN Cervical cancer Tonsilectomy Appendectomy, Rectosigmoidectomy Wrist ORIF ([2166]) & right prosthetic knee infection as above. . Social History: Recently widowed over the past year and lost her son. Lives alone at home. She does not currently smoke, quit 30 years ago, [6-8] year history of 3 packs/week. She does not drink coffee. No ETOH. No IVDU. Family History: [Name (NI) ] father died in his 90s of an MI, and the patient's mother died of unknown causes. Physical Exam: Vitals: T: BP: HR: RR: O2Sat: GEN: NAD HEENT: EOMI, PERRL, sclera anicteric OP Clear NECK: No JVD, no cervical lymphadenopathy, trachea midline CV: RRR PULM: Lungs CTAB ABD: Soft, NT, ND, +BS. EXT: Right knee dressing with blood, hemovac in place but clotted. Able to move toes on LLE and RLE, strength 4.5 in Right foot. DP Pulses 1+ bilaterally. NEURO: alert, oriented to person, place, and time. CN II ?????? XII grossly intact. Moves all 4 extremities. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. [Name (NI) ] WOUND: mininal-mod serosang drainage (expected, and we suspect that this will go on for another 5-7 days; pt had so many surgeries on that knee, that she sustained extensive soft tissue trauma. It will look bit red and that has been her baseline even prior to surgery. The cultures from OR were essentially neg. Her incision will take long to heal d/t extensive scarring and the sutures should NOT be removed until 4 weeks. Likely, she will have her follow-up before than and might be evaluated and left in longer. Pertinent Results: [2171-9-19] 03:01PM PLT COUNT-180 [2171-9-19] 03:01PM WBC-5.4 RBC-4.00* HGB-10.9* HCT-33.7* MCV-84 MCH-27.3 MCHC-32.5 RDW-13.5 [2171-9-19] 03:01PM estGFR-Using this [2171-9-19] 03:01PM GLUCOSE-177* UREA N-17 CREAT-0.8 SODIUM-139 POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-26 ANION GAP-12 [2171-9-19] 07:48PM HCT-25.9* [2171-9-22] 05:50AM BLOOD WBC-3.9* RBC-2.97* Hgb-8.6* Hct-24.7* MCV-83 MCH-29.0 MCHC-34.8 RDW-14.8 Plt Ct-76* [2171-9-21] 05:30PM BLOOD WBC-6.8 RBC-3.59* Hgb-10.5* Hct-30.0* MCV-83 MCH-29.3 MCHC-35.1* RDW-14.8 Plt Ct-78* [2171-9-20] 01:39AM BLOOD Neuts-86.9* Lymphs-7.1* Monos-5.9 Eos-0.1 Baso-0.1 [2171-9-20] 09:40AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-OCCASIONAL Macrocy-OCCASIONAL Microcy-1+ Polychr-OCCASIONAL Ovalocy-1+ Stipple-OCCASIONAL [2171-9-22] 05:50AM BLOOD Plt Ct-76* [2171-9-21] 05:10AM BLOOD Glucose-109* UreaN-19 Creat-0.8 Na-136 K-4.0 Cl-106 HCO3-26 AnGap-8 [2171-9-20] 09:40AM BLOOD Glucose-138* UreaN-23* Creat-0.9 Na-137 K-4.2 Cl-105 HCO3-24 AnGap-12 Brief Hospital Course: #Hypotension: Likely [3-2] volume loss in surgery and blood loss in joint. Also possible early sepsis given her history of infection and instrumentation recently. On transfer to MICU, patient with clot in JP drain but bandages were soaked. Patient recieved 4 U PRBC and 10 L of IVF. On the 2nd day, her Hct remained in the 25-28 range. Given distant CAD (MI >20 yrs ago) it was decided that we would not transfuse unless Hct < 21 or unless actively bleeding.Low UOP for 8hrs in PACU did not seem to respond to bolus. Concern for ATN given hypotension. Creatinine 0.6 at baseline before surgery. # Infection: Abx were started on [2171-9-20]: Vancomycin (MRSA and CNR history) and Cefepime (GNR history, with sensitivities), given fever to 100.4 on day 2 of MICU stay. Tissue cultures later showed GPC in pairs and clusters. #Anemia: Patient has chronic anemic, now superimposed acute anemia 2/2 blood loss s/p surgery. After 4 U Hct was flat. -Transfuse <21 or active bleeding # Thrombocytopenia: Platelets trending down to 65 today although started at 114 and received 10 L IVF yesterday. Likely dilutional. Heparin and lovenox were held for now. #s/p Knee fixation: Drain was clamped for concern of bleeding and then clotted. Dressings were soaked on day 1 but dry by day 2 in MICU. Had pain but can move toes and flex ankle - has diffuse pain. Patient used dilaudid pca for pain control ?????? although she has hallucinations on morphine. Monitored for sedation as pt with halucinations with morphine. #h/o CAD s/p MI x 2 (25 years ago) Held BB for hypotension, consider restarting when hemodynamically stable # FEN: Regular diet . # PPx: Pneumoboots on one leg. Did not restart lovenox while bleeding, but high risk given for PE should try to restart as soon as cilincally stable. . During the hospital course the patient was seen daily by physical therapy. Labs were checked both post-operatively and throughout the hospital course and repleted accordingly. The patient was tolerating regular diet and otherwise feeling well. Prior to discharge the patient was afebrile with stable vital signs. Hematocrit was stable and 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 service or rehabilitation in a stable condition. [Date Range ] FLOOR COURSE: Pt recovered well from ICU, with increased UOP w/ 1000+ml/day and BP maintained at SBP120-140. On the floor pt did not have any problems and the course was uncomplicated. Pt knee looked OK from surgical perspective. She had many surgical I+D and antibx spacer on that knee, was extremely scarred down. Her knee always looks reddish/ecchymotic, even prior to surgery d/t extensive soft tissue trauma. Her inflammatory markers were essentially neg. The cultures from OR was neg. Pt was given 3days of vancomycin postop. Pt will continued to be oozy from the incision site. This has always been the case from prior surgery. She also requires multiple transfusion at baseline. The procedure was well tolerated and there were no complications. Please see the separately dictated operative report for details regarding the surgery. The patient was weaned off of the PCA onto oral pain medications. The Foley catheter was removed without incident. The surgical dressing was also removed, and the surgical incision was found to be clean, dry, and intact with baseline redness nor purulent drainage. During the hospital course the patient was seen daily by physical therapy. Labs were checked both post-operatively and throughout the hospital course and repleted accordingly. The patient was tolerating regular diet and otherwise feeling well. Prior to discharge the patient was afebrile with stable vital signs. Hematocrit was stable and 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 service or rehabilitation in a stable condition. Medications on Admission: Metoprolol XR 25 po qday Amlodipine 5mg po q day Aspirin 81mg po qday Vitamin D Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO Q 8H (Every 8 Hours). 3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 8. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 9. Lovenox 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous once a day for 3 weeks. 10. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 11. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 13. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital ] - [Location (un) ] Discharge Diagnosis: infected R TKA s/p multiple washouts and antibx spacers. Discharge Condition: stable Discharge Instructions: should experience: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers >101.5, shaking chills, redness or drainage at 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 your 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 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 can 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 continued to be non-draining. Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment, by your PCP or at rehab. 7. Please call your surgeons/doctors office to [Name5 (PTitle) ] or confirm your follow-up appointment. 8. Please DO NOT take any NSAIDs (i.e. celebrex, ibuprofen, advil, motrin, etc). ANTICOAGULATION: Please take lovenox injections (40mg) once a day x 3 weeks and then take aspirin 325 mg twice a day x 3 weeks. [Month (only) 116] discontinue all blood thinners 6 weeks post-operatively. Please call [First Name9 (NamePattern2) 22369] [Doctor Last Name ] at [Telephone/Fax (1) 22370] with any questions. WOUND CARE: Keep your incision clean and dry. Okay to shower after when there is no drainage but do not tub-bath or submerge your incision. Please place a dry sterile dressing to the wound each day if there is drainage, 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 4 weeks. If you are going to rehab, then rehab can remove staples at 4 weeks after surgery. ACTIVITY: TDWB, no ROM of R knee; No strenuous exercise or heavy lifting until follow up appointment, at least. VNA (after home): Home PT/OT, dressing changes as instructed, and wound checks, staple removal in 4 weeks after surgery. Physical Therapy: TDWB on R leg; knee immobilizer when ambulating. Treatments Frequency: should experience: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers >101.5, shaking chills, redness or drainage at 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 your 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 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 can 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 continued to be non-draining. Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment, by your PCP or at rehab. 7. Please call your surgeons/doctors office to [Name5 (PTitle) ] or confirm your follow-up appointment. 8. Please DO NOT take any NSAIDs (i.e. celebrex, ibuprofen, advil, motrin, etc). ANTICOAGULATION: Please take lovenox injections (40mg) once a day x 3 weeks and then take aspirin 325 mg twice a day x 3 weeks. [Month (only) 116] discontinue all blood thinners 6 weeks post-operatively. Please call [First Name9 (NamePattern2) 22369] [Doctor Last Name ] at [Telephone/Fax (1) 22370] with any questions. WOUND CARE: Keep your incision clean and dry. Okay to shower after when there is no drainage but do not tub-bath or submerge your incision. Please place a dry sterile dressing to the wound each day if there is drainage, 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 4 weeks. If you are going to rehab, then rehab can remove staples at 4 weeks after surgery. ACTIVITY: TDWB, no ROM of R knee; No strenuous exercise or heavy lifting until follow up appointment, at least. Knee immobilizer when ambulating. VNA (after home): Home PT/OT, dressing changes as instructed, and wound checks, staple removal in 4 weeks after surgery. Followup Instructions: Provider: [First Name8 (NamePattern2) 4599] [Last Name (NamePattern1) 9856], [MD Number(3) 3261]:[Telephone/Fax (1) 1228] Date/Time:[2171-10-18] 10:20	[ "414.01", "038.9", "736.6", "285.1", "276.2", "788.31", "287.5", "E878.8", "V10.05", "V10.41", "401.9", "998.59", "412", "998.0", "998.11", "584.9", "995.92" ]	icd9cm	[ [ [] ] ]	[ "99.04", "81.22" ]	icd9pcs	[ [ [] ] ]	12538, 12603	7225, 11269	312, 354	12704, 12713	6157, 7202	17738, 17912	4963, 5063		11399, 12515	12624, 12683		11295, 11376			12737, 14474							5078, 6138	15182, 15231	15253, 16990														244, 274					17002, 17715			382, 3557													3579, 4717	4733, 4947
1,339	109,444	50585	Discharge summary	report	Admission Date: [2138-9-22] Discharge Date: [2138-9-30] Date of Birth: [2071-3-16] Sex: F Service: MEDICINE Allergies: Heparin Agents / Percocet Attending:[First Name3 (LF) 358] Chief Complaint: Chief complaint:Respiratory distress Major Surgical or Invasive Procedure: Intubation and mechanical ventilation History of Present Illness: 67F with extensive cardiac history and COPD with post-intubation tracheal stenosis, s/p tracheal decannulation and tracheocutaneous fistula. Discharged from ENT service [9-20] after tracheocutaneous fistula closure; her hospital course was complicated by respiratory failure requiring intubation, MRSA bacteremia/RLL PNA completed a course of vancomycin, discharged home with BiPap at night on a course of bactrim. Has history of pseudomonas PNA. Overnight on evening of admission had acute SOB after getting up OOB to use bathroom. Reports feeling very anxious, put on CPAP, able to sleep for an our, awoke again with severe SOB and presented to OSH ED. Reports jaw pain is her anginal equivalent but did not experience this during the episode. No chest pain. Has been coughing, producing white sputum, though no more than prior to last discharge. Subjective fevers this afternoon. No chills. Slight right hip pain although not new. On 2L 02 at home, able to ambulate and climb stairs without difficulty. No note of LE swelling or recent weight gain. Initially presented to [Hospital 2725] hospital, found to have RLL PNA on CXR and new leukocytosis, transfered to [Hospital1 18] ED. In our ED, tried off BiPap, desatted to 80s on NRB. Got CTX, azithromycin lasix and 500NS at OSH at [Location (un) ] was flown here. In our ED, initial VS 98.5 HR 80s BP 95/44 20 98% BiPAP, given 1 dose of levaquin. Past Medical History: -Coronary artery disease s/p CABG in [2118] and "recent" PCI -CHF, last TTE [2138-9-12] EF 60% with mild LVH and some focal hypokinesis at base. -OSA -Dyslipidemia -HTN -Left total hip replacement-[1-27], elective. Complicated postoperative course with post-operative atrial fibrillation wtih RVR requiring cardioversion, sepsis, Pseudomonas VAP, VRE UT, and prolonged intubation leading to trach/PEG. Discharged to chronic wean facility but unable to decannulate. Bronchoscopy revealed tracheomalacia of subglottic region. -Supraglottic edema from GERD -Bipolar disorder -Depression -chronic atrial fibrillation, developed postop from THR, not anticoagulated -Chronic constipation -HIT during Fragmin therapy Social History: Married. Very supportive husband. When she is not hospitalized/in rehab, she lives with him. No ETOH or current smoking. Has 35 pack year smoking history, quit 13 years ago. Family History: Depression Physical Exam: Vitals: T:96.3 BP:94/51 P:83 R:17 SaO2: 100 BiPap 100% Fi02, Peep/PS 6/6 TVs 400s. General: Awake, alert, mildly anxious, tachypneic. HEENT: NCAT, MM dry. Hoarse voice Neck: supple, inspiratory wheeze on ascultation of trachea (louder than in lungs), + JVD with HJR. s/p tracheocutaneous fistula repair with bandage c/d/i, incision still partially open with sm amount white drainage. No surrounding erythema. No crepitus. Pulmonary: No crackles, inspiratory wheeze. Decreased at right base. Cardiac: Distant. RR, nl S1 S2, no murmurs, rubs or gallops appreciated Abdomen: soft, NT, ND, normoactive bowel sounds, no masses or organomegaly noted Extremities: No edema, 2+ radial, DP pulses b/l Neurologic: Alert, oriented x 3. Able to relate history without difficulty. Cranial nerves II-XII intact. Normal bulk, strength and tone throughout. No abnormal movements noted. No deficits to light touch throughout. Per ENT note: FOE: nasopharynx unremarkable. Moderate supraglottic edema at the level of the false cords. No erythema or exudates. Bilat true vocal folds with no edema, movement is symmetric. Good approximation. Scant pooling of thick mucus in the pyriform sinuses bilat. Pertinent Results: WBC 19.3 normal diff (52% neutrophils, no bands) Hct 41.8 Platelets 631 Na 140 K 5.3 Cl 101 CO2 26 BUN 14 Cr 1.34 Glucose 276 CPK 135 7.28/52/74 UA negative BNP 340 (nl <100) Trop I 0.05 . Imaging: . CXR: Persistent RLL infiltrate. Fluid overload worse than prior ([9-20]) . TTE [2138-9-12]: The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is grossly normal (LVEF 60%). However, the basal inferior wall is dyskinetic and tha posterior wall is hypokinetic. Right ventricular chamber size and free wall motion are normal. The number of aortic valve leaflets cannot be determined. The aortic valve is not well seen. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The left ventricular inflow pattern suggests impaired relaxation. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. . EKG: Sinus rhythm at 92 nl axis, nl intervals. Q waves in II, III, aVF. TWI V4-V6. Early r-wave progression. No change from prior. Brief Hospital Course: MICU COURSE: Pt was transferred from OSH ED on [9-22] in respiratory distress on bipap. Bipap was weaned off during the first hospital day. CTA negative for PE. She was initially treated with Vanc/Levo/Zosyn for ?PNA; these were discontinued on [9-25] as no clinical evidence of infection. She was also initially treated with IV steroids per ENT for upper airway edema. On [9-24] the patient developed sudden onset respiratory distress and desatted into the 50s. She was emergently intubated. This was thought to be due to flash pulmonary edema vs mucous plug. She subsequently did well, and was taken to the OR for bronchoscopy on [9-25]; no upper airway etiology of her respiratory failure was found. She was extubated for the procedure but reintubated due to lethargy/sedation post procedure. She was then extubated on [9-26]. Of note, she developed a small troponin leak in the setting of her respiratory distress. She was continued on her home cardiac medications. MEDICAL FLOOR COURSE: ## Respiratory distress: Patient was stable on xfer to the floor. Her O2 requirement was weaned and she was back to baseline 2L NC prior to discharge. . ## ARF:Ddx includes pre-renal in setting of possible infection vs ATN/AIN from meds given during last hospitalization. Stabilized prior to discharge. . ## CAD: No evidence for ischemia on ecg. Had slight trop leak in setting of acute resp decompensation in the ICU. Thought not ACS. Continued home meds. . ## CHF:Clinically and by CXR and BNP pt appeared moderately volume overloaded on presentation. She was diuresed and discharged on home meds. . ## COPD:Treated for exacerbation . ## Depression/anxiety: -ativan needed to be scheduled given her severe anxiety. -Continued home lamotrigine, quetiapine, sertraline . ## OSA: -BiPAP or CPAP at night . ## Hyperlipidemia: -Continued statin . ## Code status: FULL CODE Medications on Admission: 1. Lactulose prn 2. Sertraline 100 mg daily 3. Docusate 4. Senna 5. Lamotrigine 25 mg Tablet [Hospital1 ] 6. Quetiapine 25 mg TID 7. Quetiapine 100 mg QHS 8. Albuterol Sulfate Q 6 hours prn 9. Ipratropium-Albuterol Q4 prn 10. Aspirin 81 mg Tablet daily 11. Simvastatin 40 mg daily 12. Lisinopril 5 mg Tablet daily 13. Furosemide 40 mg daily 14. Potassium Chloride 20 mEq daily 15. Metoprolol Tartrate 12.5mg daily 16. Vicodin 5-500 mg Tablet 17. Guaifenesin 18. Bactroban 2 % Ointment Sig 19. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days: please take all pills on time and finish entire course. Disp:14 Tablet(s) Refills:0 Discharge Medications: 1. Please use 2-3 liters oxygen and keep saturation > 90% at all times 2. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 3. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 4. Lamotrigine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 9. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8 hours) as needed for hip pain. 10. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 11. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 12. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation QID (4 times a day) as needed. 15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 16. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. 17. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation PRN (as needed). 18. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 19. Outpatient Physical Therapy PT for 1-2 visits. Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Primary: -possible aspiration pneumonia -acute respiratory distress Secondary: -Coronary artery disease -Congestive heart failure -Obstructive sleep apnea -COPD -Depression -Hyperlipidemia Discharge Condition: afebrile, satting >90% on 2L NC, ambulating Discharge Instructions: You were admitted for respiratory distress. You stayed in the ICU and stabilized, at which point you were transferred to the general medicine floor. You are discharged home on your usual home oxygen therapy. Your lisinopril is held because of concerns that it would cause your blood pressure to be too low. Please follow-up with your primary care provider next week regarding whether or not to restart lisinopril. 1. Please take all medications as prescribed - we made no changes other than holding your lisinopril. 2. Please attend all follow-up appointments 3. If you develop fevers, chills, chest pain, severe shortness of breath, nausea, vomiting, or any other concerning symptoms, please contact your primary provider or report to the Emergency Room. Followup Instructions: Please follow-up with your primary care provider next week regarding whether or not to restart lisinopril. Dr.[Name (NI) 105297] office number is [Telephone/Fax (1) ]. Please see physical therapy for 1-2 visits during your first week after discharge.	[ "327.23", "V02.59", "933.1", "427.31", "414.8", "518.81", "491.21", "507.0", "V43.64", "790.7", "428.33", "V45.82", "V09.80", "519.19", "V45.81", "478.6", "E915", "584.9" ]	icd9cm	[ [ [] ] ]	[ "93.90", "96.04", "33.23", "38.93", "96.71" ]	icd9pcs	[ [ [] ] ]	9626, 9675	5458, 7354	322, 362	9908, 9954	3993, 5435	10762, 11026	2764, 2776		8068, 9603	9696, 9887		7380, 8045			9978, 10739							2791, 3974																262, 284								390, 1809													1831, 2556	2572, 2748
62,183	199,766	34736	Discharge summary	report	Admission Date: [2149-8-24] Discharge Date: [2149-8-30] Date of Birth: [2083-8-6] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5141] Chief Complaint: Fever, head/neck pain, confusion Major Surgical or Invasive Procedure: Lumbar puncture History of Present Illness: 66 yo male with hx of neuroendocrine small cell cancer likely [Location (un) 5668] cell s/p craniotomy/resection on [8-14] for resection of mass who presents w/ sudden onset of one day of AMS, diarrhea, vomiting, headache at [Hospital3 ]. He was initially dx with [Location (un) 5668] cell 2 years ago on his axilla. He had mass removed and was tx with chemo and radiation. He was feeling well until 1 month ago he started to feel dizzy and had head CT that showed left parietal-occipital mass. He than had uncomplicated craniotomy on [8-14] and he was discharge to rehabilitation facility on [2149-8-20]. Per wife, pt had some residual effects of craniotomy with his word finding, but was overall improving over the last several days. He was conversing with friends and family with no apparent complaints on Friday and on Saturday he appears to be confused. He had speech abnormalities "not speaking much", headache, as well as vomiting (non-bilious and non-bloody) and diarrhea. He has also been seen holding the back of his head and neck, but has not been complaining of neck stiffness specifically. He was brought to the ED for further evaluation. . In the ED, rectal temp 102.6 BP 123/63 P 83 R 22 Sat 100% 2L O2. He received 10 mg dexamethasone, along with 1 g Vancomycin, 1 g CTX, and 800 mg Acyclovir, as well as morphine x 1. Head CT was performed with contrast revealing a 8x3mm and 15x8mm hyperintense foci of material in the periphery of the resection bed, may indicate new foci of hemorrhage or redistribution of hemorrhage seen on prior scan, and a 6mm rightward midline shift that was stable, as well as an unremarkable CT abd/pelvis. Neurosurgery was consulted and recommended infection w/u with no surgical intervention at this time. WBC was 20.1 with 93% neutrophils. LP showed yellow and cloudy, moderately xanthochromic CSF, 9200 WBCs, 4225 RBCs, with 93% polys, 1 lymphs, and 6 monos, with total protein 515, glucose 0. . Pt was admitted to the Onc floor today and appeared to be more lethargic than earlier in the day, as per his wife. [Name (NI) ] had received 1mg of morphine earlier in the day. As per covering team, he was only occassionally following commands. His vitals were stable and he remained afebrile. Although he had episode of rigors. His CSF gram stain showed GNR. ID was consulted and his antibiotics were changed from cefx and vanco to Ceftaz, flagyl, ampicillin and vanco. He was continued on acyclovir and started on Dexa 10mg Q 6hrs and keppra 500mg IV Q12mg for seizures ppx. . On arrival to the [Hospital Unit Name 153], vitals were 98.5, HR 62-48, 110-40s, RR 12-15, 96% on RA. Pt is lethargic but easily arousable to verbal stimuli. Occ opening eyes spontaneously. Following some commands, such as squeezning hands, openning eyes, pupils 3mm, PERRLA. . Review of Systems: (+) Per HPI (-) Per wife- negative for fever, chest pain, cough, SOB, no urinary symptoms, no abd pain. Past Medical History: ONCOLOGIC HISTORY: # neuroendocrine small cell cancer likely [Location (un) 5668] cell: - diagnosed in [7-/2147] after patient incidentally found a left axillary lymph node. FNA was positive for malignant cells, positive for cytokeratin (AE1/3/CAM 5.2), CK20, synaptophysin, and chromogranin, negative for CD45, CK7, TTF-1, and S-100. The immunophenotype suggested a neuroendocrine carcinoma. Imaging studies showed FDG-avid enlarged left axillary lymph node without other concerning nodes or masses. - [2147-7-19]: colonoscopy showed an adenomatous ascending colon polyp - [7-/2147]: derm exam revealed 3 small lesions on the back consistent with basal cell carcinoma - [7-/2147]: axillary lymph node excision - [8-/2147]/[2146]: 4 cycles of cisplatin and etoposide - [11/2147]/[2147]: received radiation - [4-/2148]: imaging study showed no evidence of recurrence of cancer . OTHER MEDICAL HISTORY: 1. Neuroendocrine Tumor consistent with [Location (un) 5668] cell 2. [2149-8-14]: s/p Left parietal-occipital craniotomy for mass resection. Preliminary pathology report was consistent with a neuroendocrine tumor. 3. Treated for recent UTI and epididymitis as an outpatient prior to [2149-8-12] admission c/[Initials (NamePattern4) ] [Last Name (NamePattern4) 5668] cell cancer 4. Basal cell carcinoma 5. Left hip pain 6. H/o shooting pain to the left lower extremity after a fall in college Social History: He is married, lives with his wife. [Name (NI) ] has two daughters. [Name (NI) ] is a dentist. He never smoked. Both his parents died at age 85. Family History: His father did have melanoma and developed brain metastases. He mother had thyroid disease and congestive heart failure. He has two sisters, all healthy. History of malignant melanoma in his maternal aunt. Physical Exam: On admission: VS: T 99.8 BP 127/61 P 69 R 14 Sat 98%RA GEN: eyes closed (patient does not wish to open them when asked and closes them when opened manually), appears uncomfortable and lethargic, responsive to loud stimuli, unable to answer simple questions, does not follow commands HEENT: pupils equal and round, left appropriately responsive to light, but right pupil sluggish to light. Sclerae anicteric. Unable to assess EOM. Nares clear. MMM with no lesions noted. NECK: neck muscles not stiff on exam. Somewhat difficult to move neck to sides, no distinct nuchal rigidity. No cervical LAD. CV: RRR, S1/S2 normal. no murmurs/gallops/rubs. ABD: soft NTND, +BS normoactive. No rebound tenderness/guarding. No hepatosplenomegaly. No [Doctor Last Name 515] sign. MSK: Negative Kernig's and Brudzinski's sign EXT: WWP, no c/c/e. DPs, PTs 2+. SKIN: no rashes or bruising over chest, extremities NEURO/PSYCH: Patient unable to answer questions, but responds to loud stimuli. Appears annoyed when disturbed. Paucity of speech but intelligible. CN III, IV, VI as above. No facial droop noted. Tongue midline. Patient does not cooperate with strength testing, but good tone to extremity muscles bilaterally. DTRs 2+ bilaterally. Negative Babinski's bilaterally. On discharge: Tm/Tc 99.3/97.6 BP 100/70 (100-130/58-70) P 50 (47-95) R 18 Sat 97%RA I/O: 24 h: 1460/2110 GEN: eyes open, alert, oriented x2 (self and place, not time), responsive to questions, but confused, conversant, NAD HEENT: pupils equal and round. appropriately responsive to light. Sclerae anicteric. EOMI. Craniotomy scar in occipital region c/d/i NECK: neck muscles not stiff on exam. CV: RRR, S1/S2 normal. no murmurs/gallops/rubs. LUNGS: CTAB/l no w/r/r ABD: soft NTND, +BS . EXT: WWP, no c/c/e. DPs, PTs 2+. SKIN: no rashes or bruising over chest, extremities NEURO/PSYCH: able to answer some questions, oriented x2, can identify some objects, good language fluency. Intelligible speech. No facial droop noted. Tongue midline. strength testing [4-9] B/L UE and LE flex/ext, sensation to LT B/L UE & LE. slightly hyper-reflexive patellar DTRs 3+ . [Name2 (NI) ] DTRs (biceps) 2+ B/L, Negative Babinski's B/L CN II-XII grossly intact and symm b/l, w/o focal neuro deficit Pertinent Results: Blood [2149-8-23] 10:45PM BLOOD WBC-20.1# RBC-4.73 Hgb-14.7 Hct-42.0 MCV-89 MCH-31.1 MCHC-35.0 RDW-14.9 Plt Ct-236 [2149-8-23] 10:45PM BLOOD Neuts-93.9 Lymphs-2.0* Monos-3.8 Eos-0 Baso-0.2 [2149-8-23] 10:45PM BLOOD Glucose-180* UreaN-15 Creat-0.9 Na-136 K-4.0 Cl-99 HCO3-25 AnGap-16 [2149-8-24] 09:22PM BLOOD ALT-32 AST-20 CK(CPK)-135 TotBili-1.1 CSF [2149-8-24] 05:15AM CEREBROSPINAL FLUID (CSF) WBC-9200 RBC-4225* Polys-93 Lymphs-1 Monos-6 Other-0 [2149-8-24] 05:17AM CEREBROSPINAL FLUID (CSF) TotProt-515* Glucose-0 . HERPES SIMPLEX VIRUS PCR Test Requested -------------- Herpes Simplex Virus PCR Specimen Source: Cerebrospinal Fluid Result ------ Negative Report Status ------------- FINAL Analyte Specific Reagent . CYTOMEGALOVIRUS - PCR Test Result Reference Range/Units CMV DNA, QL PCR NOT DETECTED Not Detected Micro [2149-8-24] 8:45 am CSF;SPINAL FLUID Site: LUMBAR PUNCTURE MICRO LAB RECEIVED ONLY TUBE #1 AND #3. USED #3 THAT RECEIVED LESS THAN 0.5 ML. FINAL REPORT [2149-8-27] GRAM STAIN (Final [2149-8-24]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. REPORTED BY PHONE TO DR. [Last Name (STitle) ] ([Numeric Identifier 79612]) ON [2149-8-24] AT 09:40 AM. FLUID CULTURE (Final [2149-8-27]): SERRATIA MARCESCENS. SPARSE GROWTH. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ SERRATIA MARCESCENS \| CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S [2149-8-24] 1:55 am URINE Site: NOT SPECIFIED FINAL REPORT [2149-8-25] URINE CULTURE (Final [2149-8-25]): NO GROWTH. [2149-8-23] BLOOD CULTURE Blood Culture, Routine-PENDING [2149-8-24] BLOOD CULTURE Blood Culture, Routine-PENDING [2149-8-24] BLOOD CULTURE Blood Culture, Routine-PENDING CT head w/o contrast on admission: IMPRESSION: 1. Status post surgical resection of a mass in the left parieto-occipital lobe with expected post-surgical changes. There may be slightly more prominent hyperdense material layering along the margin of the surgical cavity but this may represent redistribution of hemorrhagic products. No definitely CXRnew areas of hemorrhage. 2. Stable configuration of the ventricles with enlargement of the left temporal [Doctor Last Name 534]. 3. Stable midline shift. 4. Resolution of previously denoted pneumocephalus. CXR on admission: IMPRESSION: No acute cardiopulmonary process. SPINAL FLUID [8-23] DIAGNOSIS: Cerebrospinal fluid: ATYPICAL. Atypical single cells in a background of abundant neutrophils and blood, see note. The atypical cells have scant neoplasm, increased nuclear to cytoplasmic ratio, finely dispersed chromatin, and small inconspicuous nucleoli. These cells are only present on one hematology slide (191C-[2149-8-24]). The cytology slide demonstrates only rare neutrophils and monocytes. The patient has a known history of CNS involvement by metastatic [Location (un) 5668] cell carcinoma. Clinical correlation is recommended. . CT Abd/Pelvis [8-24]: IMPRESSION: 1. Sigmoid diverticulosis without diverticulitis. Otherwise, no acute findings in the abdomen or pelvis. 2. Parapelvic cysts, stable. 3. Air in the bladder, which may be related to Foley catheterization. 4. Upper limits of normal prostate, correlate clinically. . CT head w/o contrast [8-24] IMPRESSION: 1. No new acute hemorrhage. 2. Unchanged region of hypodensity in the left occipital and temporoparietal lobes, with interval evolution of hyperdense foci layering along the posterior margin of the surgical cavity. 3. Unchanged enlargement of the left temporal [Doctor Last Name 534]. NOTE ADDED AT ATTENDING REVIEW: I agree with the above, but note that the hypodensity in the left thalamus and adjacent internal capsule, although unchanged since [8-23], is new since [8-15]. This, and the extensive swelling and sulcal effacement in the left occipital lobe, reflect evolving infarction. . CXR [8-25]: Cardiomediastinal silhouette is stable. Lungs are essentially clear with no evidence of interval development or aspiration. No change in minimal linear opacities at lung bases , consistent with atelectasis as on the prior radiographs. . On discharge: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2149-8-30] 06:00 8.9 4.37* 13.3* 39.0* 89 30.4 34.1 14.6 166 RENAL & GLUCOSE Glucose UN Creat Na K Cl HCO3 AnGap [2149-8-30] 06:00 1131 21 0.6 134 4.3 100 28 10 CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [2149-8-30] 06:00 8.3* 4.0 2.3 Brief Hospital Course: 66-year-old male with history of neuroendocrine small cell cancer, likely [Location (un) 5668] cell, s/p craniotomy who presents with altered mental status, fever, headache, N/V and diarrhea three days after discharge to rehab. . # Altered mental status/meningitis: Patient admitted with altered mental status, head CT with contrast with hyperintense intracranial foci at surgical site, suggestive of infection. Lumbar puncture with Gram-negative rods and cell count and chemistry suggesting bacterial meningitis. Sources were thought to be recent surgical procedure versus bacteremic seeding. However, UA was negative, CXR clear, CT abdomen negative. Prior to gram stain results, he was broadly covered for gram positive and gram negative organisms, listeria, anaerobes and viral organisms. He was started on Ceftazidime, Vancomycin, Flagyl, Ampicillin, Acyclovir. CSF culture grew out Serratia marcescens, which was sensitive to ceftriaxone. Infectious disease was consulted and recommended a 14-day course to eradicate the organism starting from [8-24], the date of presentation. Eventual antibiotic regimen was of ceftriaxone, since this adequately covered the cultured organism on sensitivity testing. Steroids were given IV and then dosage was decreased and eventually switched to a PO regimen, for which dose will be tapered upon outpatient follow-up. Keppra is being given per patient's home dose for seizure prophylaxis. Lethargy improved and patient began talking more and gaining more neurological function. Neuro-oncology and Infectious Disease follow up are scheduled. On transfer, patient has word-finding troubles, and is not oriented to time. He also tends to have some paucity of speech. # Nausea/vomiting/Diarrhea: Admitted with these symptoms, which diminished over the course of admission. These GI symptoms were thought to be secondary to meningitis and increased intracranial pressure. Further workup was not performed due to symptom abatement. Before discharge, however, patient began having loose stools. No tests were performed. If diarrhea continues upon discharge, recommend stool studies and C. diff testing. Etiology may be due to antibiotic use. # Bradycardia: On transfer to the ICU, patient had episodes of bradycardia to the 40s. EKG showed TWI in V2 otherwised unchanged from prior EKG. Patient was monitored on telemetry and was persistently sinus bradycardic, but was asymptomatic. At time of discharge it was thought that this bradycardia was secondary to a central process and not of cardiac etiology. # Hyperglycemia: patient developed glucose intolerance, requiring sliding scale insulin coverage. This was believed to be secondary to dexamethasone use. . # Small-cell neuroendocrine tumor: patient will have follow-up with his neuro-oncologist upon discharge, which has been scheduled. Medications on Admission: Zofran 4mg IV q6h Miralax 17 gm [Hospital1 ]:PRN Senna [Hospital1 ] Colace 100 mg TID Dulcolax supp 10 mg qdaily Prilosec 40 mg PO daily Decadron 2 mg PO BID Desyrel 50 mg PO qHS Keppra 500 mg PO BID Percocet 1 tab PO q8h:PRN Nystatin cream Dulcolax 10 mg PO daily Humulin qHS Discharge Medications: 1. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 3. Ceftriaxone 2 gram Recon Soln Sig: One (1) injection Intravenous twice a day for 8 days: Please continue for full 14-day course, which started on [2149-8-24], and will end on [2149-9-6]. Disp:16 doses Refills:0 4. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1) Injection every six (6) hours as needed for nausea. 5. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) powder PO once a day as needed for constipation. 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 9. Trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime. 10. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8 hours) as needed for fever, pain. 11. Codeine Sulfate 30 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Primary Diagnosis: Meningoencephalitis Altered mental status Hyperglycemia Secondary diagnosis: Small-cell neuroendocrine tumor (likely [Location (un) 5668] cell) s/p craniotomy and resection Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname 79613]. It was an absolute pleasure being involved in your care at the [Hospital1 18]. You were admitted to the hospital with fevers, confusion and head and neck pain. You underwent lumbar puncture (spinal tap) which revealed that you had bacterial meningitis (infection of the spinal fluid). You were treated with antibiotics and your mental status improved. It is important that you follow up with your oncologist, and continue to take your medications as indicated. Your medications have CHANGED as follows: 1. We ADDED the antibiotic CEFTRIAXONE for which you will complete a 14 day course (to end [9-6]) 2. We INCREASED the steroid DEXAMETHASONE to 4 mg every 6 hours- you will discuss with your outpatient neuro-oncologist (Dr [Last Name (STitle) ] how to taper this medication. Please continue to take your other medications as you have been Followup Instructions: Please follow-up with Neuro-Oncology and Infectious Disease doctors as below: (You will need to discuss your steroid taper as well as follow-up after your antibiotics are done) Department: NEUROLOGY When: MONDAY [2149-9-8] at 11:30 AM With: [First Name11 (Name Pattern1) 640] [Last Name (NamePattern4) 4861], MD and DR. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 1844] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 858] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: INFECTIOUS DISEASE When: WEDNESDAY [2149-9-17] at 10:30 AM With: [First Name11 (Name Pattern1) 1037] [Last Name (NamePattern4) 2335], MD [Telephone/Fax (1) 457] Building: LM [Hospital Unit Name ] Basement, [Last Name (NamePattern1) 439], [Location (un) 86], [Hospital ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage	[ "790.29", "V10.83", "V10.85", "320.82", "348.5", "368.46", "V10.79", "787.20", "198.3", "V10.91", "V87.41", "784.3", "V12.72", "V15.3", "E939.7", "V13.02" ]	icd9cm	[ [ [] ] ]	[ "03.31", "38.93" ]	icd9pcs	[ [ [] ] ]	17629, 17699	13271, 16127	347, 365	17942, 17942	7538, 10454	19014, 19972	5016, 5223		16462, 17606	17720, 17720		16153, 16439			18095, 18991							5238, 5238											12881, 13248			3244, 3349		275, 309								393, 3225			17819, 17921			17740, 17797	11012, 12867	17957, 18071					3371, 4830	4846, 5000
21,015	118,239	6039	Discharge summary	report	Admission Date: [2183-2-28] Discharge Date: [2183-3-6] Date of Birth: [2133-11-4] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 668] Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: [2183-2-28] transplant pancreatectomy History of Present Illness: 49 year old male s/p pancreas and kidney transplant in '[75] and '[77] presents from OSH with 2-3 day history of worsening abdominal pain, nausea, vomiting and diarrhea. Imaging at OSH was read as large abscess extending to the transplanted pancreas Past Medical History: Kidney tx Pancreas tx L. CEA CABG right fem-[Doctor Last Name ] HTN DM GERD viterectomy [2183-2-28] transplant pancreatectomy Social History: He was a past smoker but has quite several times with the latest time being six months ago. Alcohol use on a social level. No drug use. Family History: Significant for CAD. Physical Exam: T 97.0 P 120 BP 210/100 RR 28 O2 100RA PE: Gen - alert and oriented times 3, in acute distress CV - Tachycardic, regular rhythm Pulm - CTAB Abd - diffusely tender throughout to mild palpation,+guarding Ext - well healed incisions in bilateral lower legs, legs warm Labs: 9.7 135 99 28 90.2 18.3>----<356 ----\|---\|---<235 ----<11.7 28.8 4.1 27 1.3 57.0 Amylase 206 Lipase P Pertinent Results: [2183-2-28] 02:30PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.022 [2183-2-28] 02:30PM WBC-18.3# RBC-3.59 HGB-9.7* HCT-28.8* MCV-80* MCH-27.0 MCHC-33.6 RDW-14.3 [2183-2-28] 02:30PM ALBUMIN-3.4 CALCIUM-9.1 PHOSPHATE-2.7# MAGNESIUM-1.4* [2183-2-28] 02:30PM ALT(SGPT)-12 AST(SGOT)-14 CK(CPK)-71 ALK PHOS-74 AMYLASE-206* TOT BILI-0.4 [2183-2-28] 02:30PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [2183-2-28] 02:30PM URINE RBC-0-2 WBC-[1-22] BACTERIA-NONE YEAST-NONE EPI-0-2 [2183-2-28] 02:30PM GLUCOSE-235* UREA N-28* CREAT-1.3* SODIUM-135 POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-27 ANION GAP-13 [2183-3-5] 09:53AM BLOOD WBC-6.7 RBC-3.49* Hgb-9.9* Hct-29.4* MCV-84 MCH-28.3 MCHC-33.6 RDW-14.5 Plt Ct-383 [2183-3-5] 09:53AM BLOOD PT-16.9* INR(PT)-1.5* [2183-3-5] 09:53AM BLOOD Glucose-292* UreaN-36* Creat-1.7* Na-135 K-3.7 Cl-102 HCO3-23 AnGap-14 [2183-2-28] 02:30PM BLOOD ALT-12 AST-14 CK(CPK)-71 AlkPhos-74 Amylase-206* TotBili-0.4 [2183-3-5] 09:53AM BLOOD Calcium-9.0 Phos-2.3* Mg-1.4* [2183-3-5] 09:53AM BLOOD FK506-10.6 Brief Hospital Course: A kub was initially done showing no evidence of free air or acute intrathoracic process. CT scan demonstrated marked distention of what appeared to be the duodenal segment of the pancreas. Based upon clinical presentation, he was brought to the operating room by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] on [2183-2-28]. He underwent exploratory laparotomy, bowel resection, and transplant pancreatectomy for torsion of the pancreas and peritonitis. Per Dr.[Name (NI) 670] note, the Roux limb had marked congestion and distention extending down through the mesocolon of the sigmoid colon and into the pancreatic duodenal anastomosis. The duodenal segment of the pancreas also appeared to be very distended and necrotic. It appeared that there was a volvulus of the mesentery of the Roux limb as it traversed the mesocolon leading to congestion, obstruction, and ultimately necrosis of the duodenal segment and likely the very end of the Roux limb. A JP drain and NG were placed. Please see operative report for further details. In PACU iv lopressor and labetalol were given for elevated SBPs. Urine output was great. Aside from this, pacu stay was uneventful. Postop hct was 26.8 from preop hct of 28.8. Pod 0, he had a temp of 102. Blood and urine cultures were sent. Urine was negative and blood was negative to date. Initially, he was started on an insulin drip to manage his glucoses. When diet was advanced, the drip was changed to Glargine and sliding scale humalog insulin with good control. Once passing flatus, diet was slowly advanced and tolerated. Pain medication was switched to po pain medication. Creatinine decreased to 1.1, but then trended up to 1.8 on [3-4] POD 4. Lisinopril was held given that BP was well controlled. It was felt that tacrolimus contributed to the elevated creatinine given that tacrolimus level increased to 23.9 on pod 4. Several doses of Prograf were held and resumed on [3-5] when the trough level was 10.6. PT evaluated him and felt that he was safe for discharge home without PT. He became ambulatory without assist. [Month/Year (2) ] surgery was called on [2-28] given recent left fem-ant tib bypass with PTFE in [12-27]. Of note, pulses were as follows: RLE fem 2+ [Name (NI) 23724] PT-MP LLE fem 2+ DP=MP PT-Non-dopp L great toe ulcer, not infected and heal ulcer, not infected. No further recs were made. Coumadin was resumed at 1mg qd. INR was 1.5 on [3-6]. He will f/u with Dr. [Last Name (STitle) ]. The JP was removed and the abdominal incision was well approximated and without signs of infection. He was discharged home in stable condition. Medications on Admission: Fosamax 70/week, Norvasc 5', Lipitor 10', Lisinopril 10', Metoprolol 50'', Percocet, Panafil, Zemplar 1', Prednisone 5', Ranitidine 150'', Prograf 4'', Bactrim, Warfarin 5' Discharge Medications: 1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:30 Tablet(s) Refills:0 4. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Insulin Glargine 100 unit/mL Solution Sig: Twenty Eight (28) units Subcutaneous once a day. Disp:1 bottle Refills:2 6. Insulin Lispro 100 unit/mL Solution Sig: follow sliding scale Subcutaneous four times a day. Disp:1 bottle Refills:2 7. syringes Sig: One (1) four times a day: please provide Low dose insulin syringes (25 or 26 gauge needles) for 4-5x/day injection. Disp:1 box Refills:2 8. Glucometer One Touch Ultra 1 9. Test Strips One Touch Ultra Test Strips for qid testing 1 box Refill: 2 10. Lancets qid testing 1 box Refill:2 11. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day. 12. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 14. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:180 Tablet(s) Refills:2 15. Zantac 150 mg Tablet Sig: One (1) Tablet PO twice a day. 16. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 17. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. 18. Outpatient Lab Work cbc, chem 7, ast, t.bili, calcium, phosphorus, PT/INR, and trough prograf fax to transplant office [Telephone/Fax (1) 697] attention Transplant Coordinator Fax INR to [Telephone/Fax (1) 1106] surgeon ([Telephone/Fax (1) 9393] Dr. [Last Name (STitle) ] Discharge Disposition: Home With Service Facility: Gentiva Discharge Diagnosis: torsed pancreas transplant h/o renal transplant [2176] DM I Discharge Condition: good Discharge Instructions: Please call Transplant Office [Telephone/Fax (1) 673] if fever, chills, nausea, vomiting, inability to take any of your medications, decreased urine output, incision redness/bleeding/drainage or any concerns. Labs on Followup Instructions: Please call to schedule follow up appointment with [Last Name (un) ] Provider: [Name10 (NameIs) ] [Last Name (NamePattern4) ], MD Phone:[Telephone/Fax (1) 62] Date/Time:[2183-3-7] 11:00 Provider: [Name10 (NameIs) ] LAB Phone:[Telephone/Fax (1) 1237] Date/Time:[2183-5-1] 1:00 Provider: [Name10 (NameIs) 14633],EQUIPMENT Date/Time:[2183-5-1] 1:00 Completed by:[2183-3-6]	[ "401.9", "707.15", "577.0", "530.81", "414.01", "V45.81", "567.21", "250.01", "707.14", "996.86", "V42.0", "E878.0" ]	icd9cm	[ [ [] ] ]	[ "52.7" ]	icd9pcs	[ [ [] ] ]	7350, 7388	2724, 5398	328, 373	7496, 7503	1529, 2701	7772, 8189	988, 1010		5622, 7327	7409, 7475		5425, 5599			7527, 7749							1025, 1510																273, 290								401, 660													682, 817	833, 972
1,305	118,114	25898	Discharge summary	report	Admission Date: [2188-9-1] Discharge Date: [2188-9-10] Date of Birth: [2131-4-11] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4765] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: 1. Cardiac catheterization with stent placement 2. Central line placement History of Present Illness: 57 yo man with renal cancer metastatic to the lungs receiving IL-2 therapy with multiple cardiac risk factors including tobacco use, +FHx of MI by father in his 50s, possibly uncontrolled cholesterol, HTN, and overweight developed acute substernal CP the morning of admission. EKG showed Lateral ST elevations in leads I & aVL along with a new Left IVCD. Cardiology was called for urgent consultation. The patient had an ECHO which only showed a mildly depressed EF of 40-45% but had mild hypokinesis of inferior/lateral walls. Cardiology initially felt that the patient is not a cardiac catheterization candidate b/c of his low platelets and high creatinine. The patient will be medically treated in the ICU to monitor for ongoing CP & cardiac monitoring. He was intially admitted on [9-1] for elective IL-2 infusions for treatment of metastatic renal cell ca. He had a central line placed by general surgery on [9-1], started IL-2 infusions, and had 12 infusions over last few days, last given [2188-9-5] at 8 am. His hospital course was complicated by temp to 102 on [9-2] (thought to be infusion-related), ongoing diarrhea, nausea/vomiting (given anzemet), and acute renal failure (treated w/ fluids). He had an episode of hypotension the day prior to admission (thought to be IL-2 related) and was briefly on neo from [12-20] pm yesterday. Two doses of IL-2 were held [1-16] hypotension. The morning of admission/transfer, he patient complained of substernal chest pain and had EKG changes described above. He was given 1 SL nitro, aspirin, with alleviation of pain. Trop >7, CK pending. In the [Hospital Unit Name 153], the patient awoke with 2/10 CP ("fullness" more than CP), nonradiating, pleuritic in nature. The pain was previously worse and improved with SL NTG. He denied SOB, F/C, N/V, abdominal pain, diaphoresis. Past Medical History: 1. Renal Cell CA- mets to Lung- receiving IL-2 Tx -had painless hematuria [12-19] --> treated for UTI w/ resolution of sx's -recurrent hematuria [3-18] ---> ABD CT with right, large renal mass measuring 17 cm w/ extension into renal vein, IVC. Multiple pulmonary nodules noted bilaterally. -- radical nephrectomy on [2188-4-23]: clear cell renal carcinoma, [Last Name (un) 9951] grade IV high-grade with necrosis, invading through the renal capsule into the perinephric fat at the hilus -- follow up CT [5-18] w/ slight but definitive increase in most of his lungs nodules since the previous study with the largest increasing from ten millimeters to 13 mm -- presented for onc eval here by Dr [Last Name (STitle) ] in [6-17], planned for IL-2 this admission. 2. HTN 3. Hyperlipidemia 4. Left mastoiditis 5. nephrolithiasis Social History: Lives in [Location ], MA. Works at [Company 64406] and has been working until this admission. +50 pack yr hx of smoking. Weekend use of EtOH- no Hx of abuse, no IVDU. Wife with patient in room (she is emergency RN at OSH). Has 2 children. Family History: Father died of MI in 50s. Physical Exam: Admission PE VS: 96.7 91/69 61 16 99% on 3L NC I/O: 1273/650 out today so far at admission Genl: NAD, sleeping in bed, seems very sleepy but easily arousable HEENT/Neck: MMM, OP-clear, mild JVD w/ JVP at 9 cm CV: RR with distant heart sounds,no murmurs Pulm: Diffusely rhoncous lungs, fine crackles, some bronchial sounds, deep/productive cough. Abd: Soft, NT/ND, well healed right nephrectomy scar, +BS Ext: No C/C/E, warm Neuro: lethargic, falls asleep during conversation, but arousable, able to move all extremities, follow commands Pertinent Results: EKG: NSR at 88bpm, nl axis, nl intervals; low voltage in all leads; ST elevations in V2-V5, flat Ts in I, avL, V5-V6, improved from yesterday 0015, stable from yesterday 0810. . CXR: left subclavian in SVC, interstitial and alveolar pulmonary edema . Echo: LVEF 40% to 45% Mild LA enlargement. Mild (1+) MR Lateral and inferior hypokinesis. . Cath: R Heart Cath RA 25/22/22 RV 56/24 PA 55/40/45 PW 33/29/32 CO/CI 5.4/2.8 SVR 844 PVR 193 . MID-LAD 70% DISTAL LAD 70% MID CX 80% . RUQ u/s: Normal appearing liver and biliary system without evidence of biliary obstruction. CXR: Slight improvement in perihilar edema with residual perihilar haziness remaining. Brief Hospital Course: Assessment: 57 yo man with metastatic renal cancer to the lungs s/p IL-2 treatment with STEMI s/p stenting of LAD and LCX complicated by respiratory distress requiring intubation. Hospital course is reviewed by problem: 1. STEMI vs. myocarditis: Initially it was unclear whether his chest pain was secondary to an STEMI or myocarditis. However, after the cardiac catheterization that showed LAD and LCx disease, as well as the elevated cardiac enzymes and improvement in chest pain with stents, this was most likely an STEMI. Initially, this was medically managed due to high creatinine and low platelets, but he continued to have chest pain. The patient underwent stenting of the lesions in his LAD and LCx. He was started on ASA and plavix, metoprolol 50mg [Hospital1 ], and pravastatin 20mg. This was initially held given a transaminitis, but after discussion with the primary oncology team he was placed on the statin. It is possible that the STEMI was a side effect of the IL-2 therapy. This has been reported once in the past and is thought to be secondary to the significant cytokine effect. As such, he was determined to be a poor candidate for future IL-2 therapy. . 2. Congestive heart failure: The patient initially was transferred to the CCU with clinical volume overload. He was able to autodiurese and did not need to be continued on lasix. He had an ECHO which showed an EF of 30-35% with new anterior wall hypokinesis. . 3. Respiratory distress: He was noted to be in respiratory distress and needed to be intubated. This was likely secondary to volume overload, and he was shortly extubated. He was off any oxygen at discharge. . 4. Hypotension: He had several episodes of hypotension while in the [Hospital Unit Name 153]. He initially needed to be treated with pressors, but this eventually resolved and he was taken off the drips. The hypotension was thought to be secondary to decreased SVR. Etiology could have been sepsis - his sputum cx grew GNRs. Blood and urine cx negative. He was not treated with any antibiotics, but his hypotension resolved. . 5. Acidosis: He was noted to have a nongap acidosis, which resolved. This was thought to be secondary to a renal cause. . 6. Renal cell cancer: He was treated with IL-2 therapy, then supportive care once he was post-chemo. He was followed by Dr. [Last Name (STitle) 1729], who decided that they would not continue any more iterations of IL-2, given that it may have precipitated his MI. The patient was discharged with oncology outpatient follow-up. . 7. Acute renal failure: He was noted to have an elevation in his creatinine, with the peak at 3.4. This was likely secondary to IL-2, and it fell after treatment to 1.3 on discharge. . 8. Acute liver failure: This was also thought likely secondary to IL-2 or shock-liver from an MI. His LFTs trended down after his catheterization, with significantly lower values at discharge (ALT 64, AST 36, LDH 673, AP 139, TBili 2.8 from 128, [Telephone/Fax (1) 64407], 155, 7.3 respectively). . 9. Elevated amylase and lipase - amylase and lipase were elevated to 172 and 641. This may have been secondary to pancreatitis from low flow state to pancreas during MI. During the hospitalization, he denied nausea, vomiting, abdominal pain, and did not have any difficulty with po intake. . 10. Thrombocytopenia: Likely secondary to IL-2. Plt count dropped to 21 but were in the 90s at discharge. . 11. Leukocytosis: He was noted to have a leukocytosis throughout his hospitalization. This was likely secondary to MI, and could also have been due to IL-2. He remained afebrile and was thus not treated with antibiotics. . Code status: full Medications on Admission: Home Meds: -atenolol 50 daily MEDS on transfer: -IL 2 (last given 8 am [9-5]) -keflex 500 mg po bid -ranitidine 150 mg [Hospital1 ] -indomethacin 25 mg po q6 hr -aspirin 325 mg daily -atenolol 50 mg daily Discharge Medications: 1. Opium Tincture 10 mg/mL Tincture Sig: Ten (10) Drop PO WITH EACH LOOSE STOOL () as needed for diarrhea. Disp:60 mls Refills:0 2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 6. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours) for 3 days. Disp:9 Capsule(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: 1. ST-elevation myocardial infarction 2. coronary artery disease status post stenting of left anterior descending artery and left circumflex artery 3. congestive heart failure, ejection fraction 30-35% 4. Acute renal insufficiency 5. Acute liver failure 6. Thrombocytopenia Secondary diagnoses: 1. Metastatic renal cell carcinoma 2. Hypertension 3. Hyperlipidemia 4. Leukocytosis Discharge Condition: Stable, with normal mental status, oxygenating well and ambulating Discharge Instructions: You are discharged to home and should continue all medications as presribed. Please notify your primary care physician's office or present to the ER if you experience persistent fever, chills, inability to take food, abdominal pain, chest pain, shortness of breath or other concerns. Followup Instructions: You should contact your primary care physician to schedule [Name Initial (PRE) ] follow-up appointment within one week after discharge. Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 5387], MD Where: [Hospital6 29] HEMATOLOGY/ONCOLOGY Phone:[Telephone/Fax (1) 22] Date/Time:[2188-10-13] 4:00 Provider: [Name10 (NameIs) ],HEM/ONC HEMATOLOGY/ONCOLOGY-CC9 Where: [Hospital 4054] HEMATOLOGY/ONCOLOGY Phone:[Telephone/Fax (1) 22] Date/Time:[2188-10-13] 4:00	[ "276.2", "198.89", "458.29", "787.91", "518.81", "V17.3", "584.9", "287.5", "V58.1", "V10.52", "197.0", "428.0", "410.71", "997.1" ]	icd9cm	[ [ [] ] ]	[ "96.71", "38.93", "36.06", "00.17", "36.05", "96.04", "88.56", "00.15", "37.23" ]	icd9pcs	[ [ [] ] ]	9340, 9346	4728, 8398	325, 401	9790, 9859	4046, 4705	10192, 10711	3445, 3473		8662, 9317	9367, 9661		8424, 8455			9883, 10169							3488, 4027			9682, 9769													275, 287								429, 2289													2311, 3164	3180, 3429		8473, 8639
9,857	125,989	20435	Discharge summary	report	Admission Date: [2163-11-2] Discharge Date: [2163-11-6] Date of Birth: [2095-6-2] Sex: M Service: CSURG Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1267] Chief Complaint: unstable angina, CAD Major Surgical or Invasive Procedure: CABG x4 (LIMA to LAD, SVG to OM,RCA, PDA) History of Present Illness: Mr. [Known lastname ] is a 68year old male with exertional angina x12 years, which is relieved with rest. He had a routine stress in [2163-4-19]; the ETT showed 3-4mm ST depression in inferior and lateral leads with moderated fixd inferior wall defect; EF was 49%. He was initially reluctant to undergo surgery but has had increasing amounts of chest pain episodes. Cardiac cath on [5-15] showed 60% proximal RCA, 90% mid RCA, 70% R-post-lat, 50%LM, 90% proximal LAD, 80% distal LAD, 80% proximal LCX, and 90% OM. Past Medical History: unstable angina CAD HTN hypercholesterolemia GERD Social History: retired lithographer <15 pack year history, quit 35 years ago 2drinks/day beer+wine lives with wife in [Name (NI) 1411], MA Family History: Dad: died at age 41 of MI Physical Exam: On Discharge: Temp 99.4, HR 79, BP 150/56, R20, 93%RA NAD RRR; incis: no SOI CTA-B s/nt/nd; +BS LE incis: c/d/i, no SOI Brief Hospital Course: Mr. [Known lastname ] was taken to the OR for his CABG x4(LIMA to LAD, SVG to OM, RCA, PDA). Total cardiopulmonary bypass time was 83 minutes, total cross-clamp time was 72 minutes. Please see Dr. [Name (NI) 22446] Operative Note for greater detail. He was transferred to the CSRU in stable condition. On POD#0, he was extubated, but was immediately reintubated because of a stridorous airway. Hewas also hypotensive and Levofed was started. He was re-extubated on POD#1 without incident. On POD#2, his chest tubes were removed and he was transferred to the floor. While on the floor, Mr. [Known lastname ] was evaluated by Physical Therapy, and with inpatient treatments, they cleared him to go home by POD#4. His pacing wires were also removed on POD#2. On POD#3, his hematocrit was noted to be 23.7, down from the prior level of 25.7. Mr. [Known lastname ], however, was hemodynamically normal and asymptomatic. His iron supplements were continued; a repeat hematocrit on POD#4 was 24.4. Again, Mr. [Known lastname ] remained hemodynamically normal, asymptomatic, and no oozing from his incisions. At the time of discharge, he was cleared by Physical Therapy, tolerating a regular diet, voiding without difficulty, and had good pain control. He was discharged home in good condition. Medications on Admission: Lopressor 50mg QID Norvasc 5mg daily Zocor 80mg daily ASA 325mg daily Lisinopril 20mg daily Rolaids Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 4 weeks. 2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 4 weeks. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO QD (once a day). 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 6. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD (once a day). 7. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO QD (once a day). 8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1) Capsule PO QD (once a day). 10. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: status post CABG x4 hypertension hypercholesterolemia Discharge Condition: Good Discharge Instructions: If you experience any chest pain, difficulty breathing, nausea/vomiting, or fevers/chills, please seek medical attention. Followup Instructions: Please call Dr. [Last Name (STitle) ] for a follow-up appointment in 4 weeks: [Telephone/Fax (1) 170] Please follow up with your PCP [Last Name (NamePattern4) ]. [Last Name (STitle) 3142] in [3-15] weeks: [Telephone/Fax (1) 19980]	[ "E878.2", "411.1", "401.9", "458.29", "414.01", "272.0" ]	icd9cm	[ [ [] ] ]	[ "36.12", "39.61", "36.15", "96.04", "96.71" ]	icd9pcs	[ [ [] ] ]	3828, 3877	1355, 2678	332, 376	3975, 3981		4151, 4410	1168, 1195		2828, 3805	3898, 3954		2704, 2805			4005, 4128							1210, 1210											1225, 1332					272, 294								404, 934													956, 1007	1023, 1152
9,626	161,624	23415	Discharge summary	report	Admission Date: [2177-1-17] Discharge Date: [2177-1-20] Date of Birth: [2107-5-27] Sex: F Service: MEDICINE Allergies: Prednisone / Sulfa (Sulfonamides) / Iodine Attending:[Doctor First Name 1402] Chief Complaint: Syncope Major Surgical or Invasive Procedure: None. History of Present Illness: 69 year old female with extensive cardiac history who syncopized on day of admission while having a BM. Taken to OSH where, while being monitored, had an episode of unresponsiveness. Rhythm monitor showed VT, converted back to NSR with sternal thump. She was started on a lidocaine drip and transferred to [Hospital1 18]. At [Hospital1 18] she had another episode of pulseless VT which responded to another sternal thump. It was learned that her pacer had been changed approximately 2 weeks ago from DDD to VVI 45 at [Hospital1 2025], and therefore her pacer was interrogated here and changed back to DDD at 70. Subsequently she has been asymptomatic. She denies any SOB, CP, abdominal pain throughout. She feels at her baseline. On review of rhythm strip from OSH, patient had prolonged QT, U waves, and torsades, and on admission K 2.9. Past Medical History: 1) CAD - s/p 3 vessel CABG in [2170]. Last cath. at [Hospital1 2025] in [12/2176] with clean coronaries, PCWP 39, PA 86/35, CI 1.9, restrictive physiology based on RV,LV concordance. ETT-mibi also in [12/2176] normal. 2) AVR (porcine) 3) CHF, ascites, RHF (EF 72%) 4) CRF (bl 2.5-2.9) 5) Sick sinus syndrome - Had DDD pacemaker placed, changed to VVI at 45 bpm two weeks prior to admission. 6) PAF - On coumadin 7) HTN 8) Hypercholesterolemia 9) DM 2 10) PVD, L CEA 11) Ischemic colitis, partial R colectomy 12) COPD 13) Pulm hypertension Social History: Divorced. 3 children. Quit smoking [2171]. Physical Exam: VS: HR 69, 144/48, 22, 98% on 2L Gen: Obese caucasian female resting comfortably in bed. Neck: JVP at 10 cm Lungs: Fair air movement, CTA b/l. CVS: Irregularly irregular, audible valve closure Abd: NABS, tense, non-tender, non-palpable liver or spleen Extr: Trace pedal edema Pertinent Results: CXR [1-17]: Cardiomegaly and bibasilar atelectasis. Mild upper zonal distribution without overt CHF. Echo [2177-1-19]: MEASUREMENTS: Left Atrium - Long Axis Dimension: 4.2 cm (nl <= 4.0 cm) Left Ventricle - Diastolic Dimension: 4.4 cm (nl <= 5.6 cm) Left Ventricle - Ejection Fraction: >= 55% (nl >=55%) Mitral Valve - E Wave: 1.4 m/sec Mitral Valve - A Wave: 0.7 m/sec Mitral Valve - E/A Ratio: 2.00 Mitral Valve - E Wave Deceleration Time: 280 msec TR Gradient (+ RA = PASP): 33 mm Hg (nl <= 25 mm Hg) The left atrium is mildly dilated. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The right ventricular cavity is dilated with mild free wall hypokinesis. There is abnormal diastolic septal motion/position consistent with right ventricular volume overload. The aortic valve leaflets appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([1-26]+) mitral regurgitation is seen. There is mild-moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Right venticular cavity enlargement with free wall hypokinesis and pulmonary artery systolic hypertension c/w primary pulmonary process (PPH, pulmonary embolism, etc.). Moderate tricuspid regurgitation. Mild-moderate mitral regurgitation. [2177-1-17] WBC-5.5 RBC-3.87* Hgb-9.7* Hct-31.1* MCV-80* MCH-25.0* MCHC-31.2 RDW-20.3* Plt Ct-162 [2177-1-19] WBC-4.3 RBC-3.53* Hgb-9.0* Hct-28.5* MCV-81* MCH-25.6* MCHC-31.7 RDW-20.9* Plt Ct-137* [2177-1-17] PT-14.7* PTT-28.1 INR(PT)-1.4 [2177-1-17] Glucose-143* UreaN-61* Creat-2.3* Na-142 K-3.2* Cl-95* HCO3-34* [2177-1-20] Glucose-108* UreaN-36* Creat-1.7* Na-142 K-4.1 Cl-105 HCO3-31* [2177-1-17] ALT-14 AST-23 CK(CPK)-25* AlkPhos-60 TotBili-0.9 [2177-1-17] cTropnT-<0.01 [2177-1-17] Calcium-10.6* Phos-3.7 Mg-2.1 [2177-1-20] Calcium-10.4* Phos-2.7 Mg-2.2 [2177-1-19] VitB12-742 Folate-10.6 [2177-1-18] calTIBC-424 Hapto-218* Ferritn-63 TRF-326 Brief Hospital Course: 69 year old female with hx CAD s/p CABG [2170] (normal cath and ETT 2 weeks PTA), AVR, COPD and pulm HTN, pacemaker for SSS, admitted with hypokalemia and torsades de [Last Name (un) ] in the setting of recently reprogrammed pacer DDD to VVI at 45 bpm. 1) Rhythm: Pacer was changed to DDD at 70 on the night of admission, and potassium was supplemented and kept in normal range, without further VT. Patient's rhythm on the morning after admission showed pacemaker syndrome and failed atrial capture. It is suspected that her atrial lead is not working properly. She will need an EP study to check on atrial wire. Her amiodarone was held and she was instructed to discontinue this medication on discharge given the potential for QT prolongation and recurrence of torsades - on admission she was found to have a prolonged QTc (likely related to hypokalemia) which is believed to have led to her torsades. 2) Hypokalemia: Possibly related to recently increased dose of lasix. Lasix was held for the first 2 days of admission, and restarted at half of her usual dose on discharge (20mg [Hospital1 ]). In light of the decrease in lasix, we continued her aldactone at a higher dose of 100 mg daily while in house, but have decreased it to 50 mg daily on discharge (increased from her home dose of 25 mg daily). 3) Pump: Worsening RHF with ascites, restrictive physiology per report from [Hospital1 2025]. Repeat echo here showed right venticular cavity enlargement with free wall hypokinesis and pulmonary artery systolic hypertension c/w primary pulmonary process (PPH, pulmonary embolism, etc.). Moderate tricuspid regurgitation. Mild-moderate mitral regurgitation. She should have further workup for her pulmonary hypertension as an outpatient at [Hospital1 2025]. 4) CAD: Recent cath with clear coronaries, normal ETT. We continued her statin. She is not on ASA for an unclear reason. She was discharged on her outpatient beta blocker dose. 5) PAF: The patient's coumadin was held secondary to possible EP study, however has been restarted as the EP study was postponed to outpatient. 6) Depression: Continued paxil. 7) DM: RISS while in house. We have started an ACE-inhibitor in this diabetic patient. Medications on Admission: Coumadin 2 mg daily Toprol XL 100 mg daily Amiodarone 200 mg daily Paxil 20 mg daily Lipitor 40 mg daily Lasix 40 mg [Hospital1 ] Aldactone 25 mg daily Insulin 70/30 40 SQ [Hospital1 ] Discharge Medications: 1. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 4. Warfarin Sodium 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 7. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:15 Tablet(s) Refills:2 8. Outpatient Lab Work Chem 7 panel Discharge Disposition: Home With Service Facility: [Last Name (LF) 486], [First Name3 (LF) 487] Discharge Diagnosis: Pacemaker Syndrome Hypokalemia Torsades De [Last Name (un) ] Pulmonary hypertension Type 2 Diabetes Discharge Condition: Good, stable. Discharge Instructions: Resume your previous medications with the following exceptions: We have increased your aldactone to 50 mg daily. We have decreased your lasix to 20 mg twice a day. We have started an ACE-inhibitor called lisinopril, for your kidneys. You should see your primary care doctor/cardiologist at [Hospital3 5870] [Hospital3 ] within the next week. Please seek medical help if you experience any chest pain, fluttering in your chest, or you pass out again. Followup Instructions: You should make an appointment with your cardiologist at [Hospital1 2025] as soon as possible. You have a follow up appointment with Dr. [Last Name (STitle) ] on Wednesday [1-22] at 12 p.m. at the [Location (un) 436] of the [Hospital Ward Name 23] Building. Please come in at 10 a.m. to get your blood drawn prior to the appointment.	[ "397.0", "789.5", "996.01", "V58.61", "276.8", "496", "V45.81", "427.1", "428.0", "403.91", "V42.2", "416.8", "427.31", "272.0" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	7552, 7635	4375, 6620	312, 319	7783, 7798	2164, 4352	8306, 8664			6863, 7529	7656, 7762		6646, 6840			7822, 8283							1868, 2145																265, 274								347, 1207													1229, 1787	1803, 1853
5,774	108,018	25906	Discharge summary	report	Admission Date: [2169-8-16] Discharge Date: [2169-10-11] Date of Birth: [2117-5-3] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Last Name (NamePattern1) 4377] Chief Complaint: Initially admitted for: Fever and neutropenia Transferred to [Hospital Unit Name 153] for: A fib and hypotension Major Surgical or Invasive Procedure: A-line thoracentesis bronchoscopy bone marrow biopsy mediastinoscopy with LN biopsy History of Present Illness: Mr. [Known lastname 63305] is a 52 year old Cuban-American man who has resided in the US for 25 years. For the past year he has experienced aches and pains, especially worse in the past six months on stairs. He was working and feeling genrally well until the beginning of [Month (only) ] when he developed daily fevers to 102. These were associated with chills and body aches but no rigors or nightsweats. He went to his [Hospital 6435] clinic and had a CXR which was negative but was put on antibiotics and analgesics. He remained well for a few weeks but then suffered 2 syncopal attacks on [8-8] and was admitted to [Hospital3 ] Hosputal that day. At LGH, the patient was found to be neutropenic with 72% lymphocytes and a WBC of 0.5. He was also anemic with a HCT of 17 and was transfused 2 units of PRBCs. Further lab tests upon admission included a leukemia/lymphoma eval which yielded abundant myeloblasts with a probable diagnosis of AML. In addition, >100,000 colonies of E.coli were found in his urine resistent to Bactrim. ID put him on Zosyn, Vancomycin and Diflucan by [8-15]. At LGH, he had a negative CT scan of the head done for dizziness. CT of the chest and abdomen was performed as part of the lymphoma workup with the following key findings: 1) R paratracheal mass (3.2cm)with BL pleural effusions. 2) Multiple small liver and splenic lesions of intermediate nature. 3) Small pancreatic lesion (1.6cm) 4) BL inguinal hernias. Thoracic surgery was consulted and recommended a mediastinoscopy under general anesthesia when the patient was feeling better. He was subsequently transferred to [Hospital1 18] on [8-16] for further workup at the request of his wife. Past Medical History: Wisdom teeth extracted. Hypertension treated with Toprol XL 100mg daily at home for some time. No other medical issues or surgeries. Social History: Born and raised in [Country 5976]. Came to US 25 years ago. Lives with his wife and 3 children (14, 13, 11). Works as a machinist. Family History: Mother died age 53 of a heart attack. Father died in late 60's of unknown cause. 4 siblings, all living and all well. Physical Exam: Vitals: T 99.2 HR 120-130 RR 25 BP 90-100/70-80 100% O2 RA Gen: diaphoretic HEENT: PERRLA, No discharge from eyes, ears, nose. EOMI. Anicteric. Normal conjunctiva. Neck: No LAD, No JVD, Midline trachea. Normal sized thyroid with no palpable nodules. Chest: decreased breath sounds bilaterally CV: irregular, irregular, II/VI SM Abd: BS normoactive, nontender, nondistended, increased adiposity of gut. Ext: No C/C/E nontender calves Neuro: CN II-XII intact, A and O x 3. Skin: No visible lesions. No tender nodules. Pertinent Results: At [Hospital6 3105]: CT of the chest and abdomen was performed as part of the lymphoma workup with the following key findings: 1) R paratracheal mass (3.2cm)with BL pleural effusions. 2) Multiple small liver and splenic lesions of intermediate nature. 3) Small pancreatic lesion (1.6cm) 4) BL inguinal hernias. CT head was normal Admission labs at LGH ) WBC 0.5, 8%N, 72%L, 6%B ALT 69, AST 39 Alb 2.7 Alk Phos 159 T Bili 0.7 D Bili 0.22 HIV Neg Parvovirus Neg >100,000 E. coli in urine Discharge labs ([8-15]) WBC 0.8, 4%N, 72%L, 17%M, 5%B, 1.3% Eo RBC 3.13, Platelets 183. Labs lactate 2.5 Na 141 K 3.1 cl 105 Hco 21 BUN 22 Creat 1.2 gluc 110 Ca 8.1 Mg 1.6 P 2.4 ALT 37 AP 288 T bili 0.5 AST 53 LDH 461 WBC 11 (neutro 65%, 8% lymph 21 % mono) Hct 34 Plt 264 PT 16.4 PTT 28.7 INR 1.8 FIbrinogen 912 uric acid 7.8 U/A Tr bld [2169-10-11] 12:40PM BLOOD WBC-5.3# RBC-2.91* Hgb-9.1* Hct-26.9* MCV-92 MCH-31.2 MCHC-33.7 RDW-18.9* Plt Ct-83* [2169-10-11] 12:40PM BLOOD Gran Ct-4770 [2169-10-11] 12:40PM BLOOD Glucose-117* UreaN-23* Creat-0.8 Na-133 K-3.6 Cl-102 HCO3-18* AnGap-17 [2169-10-11] 12:40PM BLOOD ALT-29 AST-30 AlkPhos-186* TotBili-0.2 [2169-10-11] 12:40PM BLOOD Albumin-3.0* Calcium-8.6 Phos-3.1 Mg-1.8 UricAcd-5.4 [2169-8-19] 08:49PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-POSITIVE IgM HAV-NEGATIVE [2169-9-13] 04:14AM BLOOD HIV Ab-NEGATIVE [2169-9-27] 05:03PM PLEURAL WBC-750* RBC-[Numeric Identifier ]* Polys-49* Lymphs-40* Monos-11* [2169-9-27] 05:03PM PLEURAL TotProt-3.6 Glucose-97 Creat-1.0 LD(LDH)-271 Amylase-77 Albumin-1.8 Brief Hospital Course: 1.) AML: Leukemia/Lymphoma evaluation at outside hospital yielded probable AML. [8-18] BMT done at [Hospital1 18] confirmed leukemia (AML) and pt decided to undergo 7+3 induction treatment here. DAY 1 was [2169-8-18], BM bx completed three times, with the latest report from [10-2] showing no evidence of leukemic cells. Patient will need maintenance chemo, but was awaiting stabilization of ID status prior to starting further chemo. . 2.) Fever and neutropenia/ID: High fevers persisted, pt had multiple imaging studies including a CT Chest, Abd Pelvis that revealed multiple splenic and liver nodules and mediastinal LAD. Pt was seen by ID and pulm (for RLL effusion and mediastinal LAD seen on CT scan). ID thinks probably infectious source of liver, spleen nodules and mediastinal LAD. They asked for several cultures including acid fast bacilli, legionella, etc. Pulm completed bronch on [8-22], negative for malignant cells. Patient developed some diarrhea, C.diff sent, which was negative on multiple occasions. Stool also tested for cryptosporidium/O and P/campylobacter- all of which were negative. Patient underwent thoracentesis on [8-30], which showed exudative fluid that grew afb in cultures, although the afb smear was negative. All other cultures negative. Repeat thoracentesis failed to show further afb growth in culture, was also negative for CMV. CT chest on [9-5] revealed stable nodules but new pericardial effusion. Patient started on 4 drug anti-tuberculosis regimen on [9-8]. AFB in blood was sent to state lab and pending. Repeat AFB smears were neg x 3 and patient was taken off precautions. The patient was transferred to ICU [Date range (1) 64418]. When patient returned to BMT, he was placed on Rifabutin, Ethambutol, Pyridoxine, Clarithromycin for MAC coverage, as TB+ blood cxs likely MAC vs. TB, anti-TB meds d/ced, other atypical mycobacteria was also a consideration. Patient was started on Vanc empirically on [9-17] as blood cultures from [9-15] returned [2-14] gram + cocci=coag neg staph and those from [9-17]. On [9-21], patient underwent a TEE, which was negative for endocarditis, and a mediastinal LN biopsy, which was positive for afb on smear and culture. Patient placed back in respiratory isolation. In addition, pleural fluid from [9-12] returned TB PCR positive, therefore patient's abx regimen changed back to 4 drug anti-tuberculosis coverage. Vanc was discontinued as the +blood cultures were thought to be likely contaminates. [9-26], [9-27], [9-29] AFB smear neg x 3. Remains in isolation room as w/ likely disseminated TB w/ pulm nodules. Patient underwent repeat thorax CT, which showed enlarging abdominal LN and an increasing number of splenic and liver lesions. Amikacin was added to help potentiated anti-TB drug effects, however this was later discontinued, along with the clarithromycin, so that patient was only on anti-TB coverage. Patient underwent a repeat echo and chest x-ray which showed a small to moderate pleural effusion and a small decrease in the mediastinal LAD. The patient was placed on an 11 week steroid taper (beginning with 60mg prednisone daily) per ID recs to help lessen risk of constrictive pericarditis. Patient was arranged with follow-up in the [Hospital ] clinic in [Month (only) 359], and will be followed by the state center for tuberculosis as well for medication administration. . 3.) Cardiology: Patient developed AFib w/ rapid response to 180's, and unstable BP (SBP=90's) - therefore was transferred to the ICU on [9-11] where he underwent unsuccessful attempts at cardioversion x3. The pt became more tachypneic and went into hypoxic respiratory failure. He was intubated and brought to the [Hospital Unit Name 153]. He was found to be hypotensive, probably due to the decreased preload in the setting of intubation and the use of Propofol for intubation. BP improved when he was switched over to Fentanyl for sedation. He was put on AC, 600, 18, 40% and was tolerating the ventilation well. An CXR showed an increased interstitial and alveolar infiltrate especially on the R side with positive air bronchograms on the R side. He was started on Levofloxacin, Flagyl and Vancomycin for tx of an suspected pneumonia. An emergent ECHO showed no signs of cardiac tamponade. A therapeutic thoracentesis was done the next day and respiratory state improved significantly. Pt was extubated and supported it well. Abxs were stopped as repeat CXR did not show any signs of infection and WBC was back to normal. Acute respiratory failure was thought to have happened in the setting of intravascular fluid depletion with decreased preload leading to tachycardia and tachypnea, worsening the preload even more. In addition a pulmonary edema and an increasing pleural effusion pressing on the lund might have contributed. The ARF resolved within a day and was attributed to intravascular fluid depletion. Pt was then started and maintained on admiodarone, metoprolol, captopril per cards recs. Diagnosis per cards was MFAT w/ initial rate >200. Cardiology also recommended continued diuresis for pleural and pericardial effusions. Patient was decreased to 200mg of daily amiodarone on [10-2], with monitoring of LFTs and TSH, which were normal. Echo on [10-3] ECHO w/ EF=30%, global LV hypokinesis, and repeat on [10-9] shows small-moderate pleural effusion. . 4.) Splenic/Liver Lesions Initially thought to be mets, lymph nodes, or other primary cancer contributing to recent development of changes in blood glucose levels. Pt also experienced chronic RUQ abd pain during his hospitalization. CT abd [8-19] showed 1. Necrotic lymph nodes in the superior mediastinum and in the periportal region. 2. Multiple tiny areas of low attenuation in liver and spleen. Although non-specific, these could represent microabscesses from hematogenous spread of infection, including tuberculosis or fungal infections. MRI on [8-25] confirmed CT findings and showed potential renal involvement. Given AFB + in blood from [8-16], thought to be possibly disseminated TB. Follow-up CT on [10-2] showed an increased number of lesions in both liver and spleen (all < 1cm), still thought to be dissemintated TB. . 5.) Pulmonary nodules: Observed on first CT (approx 3mm in size) - thought related to other CT findings at the time (necrotic LNs in mediastinum, liver pancreas and spleen lesions). A repeat chest CT [9-18] showed increased size of pulm nodules 3mm->5mm. Read as likely infectious in nature, and assumed to be related to disseminated TB per mediastinal LN washings (see above). A repeat CT on [10-2] showed no change. . 6.) Elevated Blood Glucose Despite no prior history of DM, this patient has consistently had elevated glucoses on FS in the past week. Patient was monitored by glucose FS TID and covered with RISS and Lantus. On [8-20] pt seen by [Last Name (un) ] team and recs for BG control changed, scale adjusted and FS levels improved. [Last Name (un) ] followed patient throughout hospitalization and upon discharge, patient was given diabetic education by nurse [First Name (Titles) ] [Last Name (Titles) ] monitoring and insulin administration. As it was a concern that his sugars would be difficult to control give his long term steroid use and change in food intake (from TPN to normal diet), the patient's blood glucose levels will be monitored closely when he returns for oncology follow-up. An appointment was made at [Last Name (un) ] in [Month (only) 1096] (which was the first available). . 7.) SOB: On [9-27] pt experienced acute episode of SOB. CXR demonstrated pulmonary congestion, which was likely due to receiving a couple units of blood on the day prior. Given his increasing O2 requirements and increased work of breathing, he was intubated in the ICU. Stayed in ICU w/ an uncomplicated hospital course, and was successfully extubated and transferred back to the floor on [10-1] where his oxygen saturation remained 98% on room air throughout the remainder of his hospitalization. . 8.) FEN The patient was initially eating a normal diet, but on [9-25] he had lost 10lbs in the last 2 weeks due to inadequate food intake. A PICC was therefore placed and pt was started on TPN w/ boost supplementation and liberal po intake as tolerated. A calorie count on [10-9] per nutrition showed that patient was eating 1450 calories per day, and TPN was discontinued on [10-10]. . 9.) Coagulopathy: Pt w/ persistently elevated INR, PT. Given Vit K w/ minimal/no decrease in INR. As such, on [9-22] a mixing study was sent (elevated PT), vit K given - mixing study negative. Still unknown etiology of coagulopathy, but remained stable. Medications on Admission: RISS Temazepam 30mg QHS PO Glargine 10U Daily SC Zosyn 3.375g IV Q6 Robitussin AC [6-20] PRN Loperamide 2mg [Hospital1 ] PO PRN Ibuprofen 600mg PO Q4 Discharge Medications: 1. Ethambutol 400 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). Disp:148 Tablet(s) Refills:0 2. Isoniazid 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:37 Tablet(s) Refills:0 3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 4. Pyrazinamide 500 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:111 Tablet(s) Refills:0 5. Rifampin 300 mg Capsule Sig: Two (2) Capsule PO Q24H (every 24 hours). Disp:74 Capsule(s) Refills:0 6. Pyridoxine 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:74 Tablet(s) Refills:0 7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:2 9. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO twice a day. Disp:180 Tablet(s) Refills:0 10. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 11. Humalog Mix 75-25 75-25 unit/mL Suspension Sig: Twenty Five (25) units Subcutaneous twice a day. Disp:qs units Refills:2 12. glucometer glucometer: dispense 1 refills : 0 13. One Touch II Test Strip Sig: One (1) strip Miscell. twice a day. Disp:100 strips Refills:2 14. Lancets,Thin Misc Sig: One (1) lancet Miscell. twice a day. Disp:100 lancet Refills:2 15. Syringe Syringe Sig: One (1) syringe Miscell. twice a day: Insulin syringes . Disp:100 syringe Refills:2 Discharge Disposition: Home With Service Facility: Home Health Services VNA Discharge Diagnosis: AML TB a-fib HTN Discharge Condition: Good Discharge Instructions: We have prescribed you a number of new medications. Please take these and all of your medications as directed. You have a number of follow-up appointments scheduled. Please maintain all of these appointments. Please return to the [Location (un) ] of [Hospital Ward Name 1826] building on the [Hospital Ward Name 516] tomorrow at noon. Please call your doctor or return to the hospital if you develop fever/chills/nausea or vomiting. Please make sure to check your blood sugar and administer insulin as instructed. Followup Instructions: Provider: [Name Initial (NameIs) ]/ONC,INPT HEMATOLOGY/ONCOLOGY-7F Where: HEMATOLOGY/ONCOLOGY-7F Date/Time:[2169-10-12] 12:30 Provider: [Name10 (NameIs) 5373],[First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] CC-5 Where: [Hospital 273] [Hospital3 1935] CENTER Phone:[Telephone/Fax (1) 253] Date/Time:[2169-10-13] 10:30 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 16881], MD Where: LM [Hospital Unit Name 4341] DISEASE Phone:[Telephone/Fax (1) 457] Date/Time:[2169-11-13] 9:00 You have been scheduled for a follow-up appointment with the [Last Name (un) ] clinc for your diabetes on [2170-1-25] at 8:30 am. However, you may call [Telephone/Fax (1) 2384] to try and arrange an earlier appointment. Please call [Telephone/Fax (1) 62] to schedule an appointment with a cardiologist at the earliest time available. Please follow up as instructed with the state center for tuberculosis.	[ "704.8", "423.9", "511.9", "416.8", "518.81", "428.20", "427.31", "250.00", "284.8", "578.1", "205.00", "008.45", "286.9", "425.4", "012.15" ]	icd9cm	[ [ [] ] ]	[ "41.31", "99.05", "40.11", "86.11", "96.04", "34.22", "99.04", "34.91", "33.27", "88.72", "38.93", "99.25" ]	icd9pcs	[ [ [] ] ]	15609, 15664	4916, 13769	440, 526	15724, 15731	3290, 4893	16312, 17330	2612, 2731		13977, 15586	15685, 15703		13795, 13954			15755, 16289							2746, 3271																284, 402								554, 2283													2305, 2441	2457, 2596
17,754	194,553	47603	Discharge summary	report	Admission Date: [2116-5-7] Discharge Date: [2116-5-8] Date of Birth: [2048-7-15] Sex: F Service: MEDICINE Allergies: Bactrim / Aldactone Attending:[First Name3 (LF) 398] Chief Complaint: GI bleeding and hypotension Major Surgical or Invasive Procedure: none History of Present Illness: HPI: 67 yo F with h/o COPD (FEV1 0.6), CHF(EF 20-25%), MVR, CRI, transferred to ED from rehab w/ hypotension (sbp 70s), gross hematuria, and GI bleed w/ HCT 23. She was recently admitted to MICU [Date range (3) 100589] w/ GI bleed on EGD [2116-4-17] showed a few non-bleeding erosions and 1 angioectasia in duodenal bulb. Angiography revealed no source of bleeding, although occlusion of left renal artery and inferior mesenteric artery was noted as well as focal moderate stenosis of SMA (which was stented). Abdominal CT [2116-4-19] was negative for retroperitoneal bleed. Although no source of her bleeding was identified, given stabilization of her HCT, heparin gtt was restarted [2116-4-28]; coumadin was restarted [4-30]. She did not have further significant GI bleed. She was initally intubated [2116-4-17] for airway protection/EGD. Given failed extubation (attributed to CHF and baseline severe COPD), she underwent tracheostomy/PEG placement on [4-29]. Her hospital course was further complicated by acute on chronic renal failure believed pre-renal in etiology (only partially responsive to volume resuscitation), GNR bacteremia (pan-sensitive Serratia) treated w/ 10 day course of ceftazidime, MRSA in sputum s/p 10 day course of vancomycin, and adrenal insufficiency (discharged on Prednisone/florinef). She also had hematuria on [4-30] after foley reinsertion in setting of elevated PTT, which incompletely resolved with continuous bladder irrigation prior to transfer to rehab [2116-5-1]. * She continued to have hematuria at the vent facility, which did not clear despite bladder irrigation. She was also noted to have several episodes of BRBPR (amt not recorded in transfer materials). Her coumadin and heparin gtt were held since [2116-5-4]. She received 2u PRBC on [5-3] and 2u PRBC on [5-5]. HCT [2116-5-6] was noted to be 23.1. On the day of admission her sbp 70s, she received 2 u PRBC and hydrocortisone 100 mg IV X 1 prior to transfer to [Hospital1 18] for further management. Of note, there was a verbal report that CXR from [5-6] (no written report available) had free air noted under diaphragm. * In ED, HR 70 (V-paced), sbp 80s; transfused 2u PRBC, 1 L NS, levo/vanco/flagyl. PEG tube lavage (-), gauiac dk green gauiac (+). Currently, the pt is moving nonpurposefully, not responsive to voice, sternal rub, and not following commands. Past Medical History: PAST MEDICAL HISTORY: 1. Rheumatic heart disease status post mitral valve prolapse x2 with a mechanical valve. 2. COPD with a FEV1 of 0.6. 3. CHF with an EF of 20-30% by echocardiogram [2114-5-15]. 4. History of AFib status post ablation/pacer. 5. Peripheral vascular disease, history of aortofemoral bypass. 6. CAD with a previous one-vessel disease by cath in '[06]. 7. History of pulmonary hypertension. 8. History of bilateral renal artery stenosis. 9. Chronic renal insufficiency with baseline creatinine of 1.6-2.4. 10. History of secondary hyperparathyroidism. 11. Status post cholecystectomy Social History: Patient quit smoking 1 month ago, prior half pack per day, 50 pack year history. Denies any alcohol use. She lives with her husband and son in a single floor apartment. Family History: Noncontributory. Physical Exam: Physical Exam: T, pc 70 (V-pased), bp 80/30, resp 18, 100% AC TV 500, rate 18, FiO2 0.4, PEEP 5 Gen: elderly, chronically-ill appearing female, moving non-purposefully, not responsive to voice or commands HEENT: anicteric, PERRL, face symmetrical, OMM dry, OP clear, tracheostomy site clean, unable to assess JVP Cardiac: RRR, soft S1/S2, II/VI SM at apex Pulm: decreased LS at bases bilaterally; coarse LS throughout Abd: NABS, mildly distended, NT, ventral hernia, easily reducible. PEG tube with small amt serosanguinous drainage Ext: 2+ LE/UE/sacral edema, feet warm with non-palpable DP/PT bilaterally Skin: upper extremities weeping fluid, multiple scattered petechiae, multiple skin tears on upper extremities bilaterally Neuro: face symmetrical, moves upper and lower extremities non-purposefully, not following commands, 3+ LE reflexes, symmetric, 2+ UE reflexes, symmetric bilaterally. Toes downgoing right, withdrawal left. Pertinent Results: [2116-5-7] 02:18PM LACTATE-2.9* [2116-5-7] 02:10PM GLUCOSE-73 UREA N-104* CREAT-3.7* SODIUM-135 POTASSIUM-5.5* CHLORIDE-107 TOTAL CO2-18* ANION GAP-16 [2116-5-7] 02:10PM ALT(SGPT)-58* AST(SGOT)-95* LD(LDH)-180 CK(CPK)-163* ALK PHOS-76 AMYLASE-35 TOT BILI-0.7 [2116-5-7] 02:10PM LIPASE-9 [2116-5-7] 02:10PM CK-MB-11* MB INDX-6.7* cTropnT-0.19* [2116-5-7] 02:10PM ALBUMIN-1.8* CALCIUM-8.0* PHOSPHATE-5.3* MAGNESIUM-4.3* [2116-5-7] 02:10PM WBC-5.5 RBC-2.96* HGB-8.5* HCT-26.0* MCV-88 MCH-28.7 MCHC-32.7 RDW-16.2* [2116-5-7] 02:10PM NEUTS-47* BANDS-45* LYMPHS-3* MONOS-2 EOS-1 BASOS-0 ATYPS-0 METAS-1* MYELOS-1* [2116-5-7] 02:10PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [2116-5-7] 02:10PM PLT SMR-LOW PLT COUNT-101# [2116-5-7] 02:10PM PT-15.7 PTT-33.8 INR(PT)-1.6 [2116-5-7] 02:10PM FIBRINOGE-661# D-DIMER-925 Brief Hospital Course: On admission surgery and urology and GI were consulted for possible sources of bleed. She was deemed not a surgical candidate given her very high operative risk of mortality. The likely differential of her hematuria includes trauma by Foley, neoplasm, infection (although less likely to cause gross hematuria), renal infarcts/thrombosis. Bladder appears to be significantly distended on CT scan. She was conservatively managed initially by urology with continous bladder irrigation which produced significant amounts of clots.Urology planned cystoscopy when patient is much more stable. Regarding possible GI bleed, she was initially made NPO for possible EGD by GI consult. There was also concern that she had free air in her abdomen with sources from gastrointestinal perforation vs bladder perforation secondary to blood clot obstruction. Also of note, she was found elevated cardiac enzyme likely in the setting of increased demand. However, her very low mental status in the face of hypotension, hematuria, demand ischemia, possible GI bleed lead to discussion with the family regarding the very low likelihood of meaningful recovery for this patient. After extensive discussion between the ICU team and the family, her code status was changed from full code to comfort measure only. She was started on a morphine drip and her ventilator via trach tube was stopped after her family had a chance to have last moments together. She passed on [5-8] Medications on Admission: MEDS (on admit) 1) Florinef 0.05 mg NGT daily 2) Prednisone 10 mg PO daily 3) Epogen 4000 units qqMWF 4) Renagel 800 mg NGT TID 5) Zyprexa 5 mg NGT daily 6) Protonix 40 mg NGT daily 7) Coumadin on hold (last INR [2116-5-6] 1.5) 8) Heparin gtt (on hold) 9) Reglan 5 mg IV q6h prn 10) NaHCO3 2 tab NGT [Hospital1 ] 11) Ca acetate 667 mg NGT TID 12) Fentanyl 75 mcg TP q72h 13) Fluticasone-Salmeterol 250-50 mcg/Dose [Hospital1 ] 14) Tiotropium Bromide 18 mcg daily 15) Albuterol-Ipratropium [2-16] puff q6h pr Discharge Disposition: Expired Discharge Diagnosis: GI bleed Hypotension Discharge Condition: expired Discharge Instructions: none Followup Instructions: none	[ "440.20", "414.01", "427.31", "596.6", "518.81", "578.9", "496", "416.8", "458.9", "531.50", "585", "398.91", "584.9", "599.7", "V44.0", "V43.3" ]	icd9cm	[ [ [] ] ]	[ "38.93", "99.04", "96.48", "96.71" ]	icd9pcs	[ [ [] ] ]	7584, 7593	5551, 7010	305, 311	7657, 7666	4589, 5528	7719, 7726	3599, 3617			7614, 7636		7036, 7561			7690, 7696							3647, 4570																238, 267								339, 2765													2809, 3397	3413, 3583
2,425	155,053	29543	Discharge summary	report	Admission Date: [2118-7-15] Discharge Date: [2118-7-29] Date of Birth: [2050-10-3] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2485] Chief Complaint: Rigors, T 100.1, SOB Major Surgical or Invasive Procedure: None History of Present Illness: 67M h/o stage IIIB IgG kappa multiple myeloma d+55 autoSCT who presented to clinic with 1 day h/o T 100.1, rigors, fatigue, nonproductive coughing and SOB. Earlier that morning, he had urinated in bed because he could not get up to the bathroom. Pt. was noted to have WBC = 1.2, ANC = 888, BP 91/70, and T 97.4. Upon arrival on the floor, pt's BP was 79/54, and he was bolused 500 cc NS over 60 min, as well as placed on NS drip at 125 ml/hr. . Three days prior, pt.'s surgery to place a venous access device was postponed because of WBC = 0.8. Two days prior, pt had been seen in clinic, when he was noted to have WBC = 0.7. At that time, pt's PPx Abx was changed from acyclovir and sulfamethoxale/trimethoprim, to atovaquone. Pt took his first two doses of atovaquone one day prior to admission. On day of admission, pt c/o feeling "strange" and "bad", attributing this to atovaquone. . ROS: Pt. denies frank fever, N/V, abdominal pain, joint and muscle pain, presyncope or syncope, hematuria, and bloody stool. Past Medical History: PAST ONC HX: - Multiple myeloma, Stage IIIA ([2117-10-6]): Presented with hypercalcemia, hematuria, UPEP w/ monoclonal protein --- CT abd with lytic lumbar and sacral lesions --- BMbx with 30-50% plasma cells, elevate IgG Kappa = 6781 - Thalidomide and dexamethasone with response ([2-9]) - Stem cell mobilization with high dose cytoxan ([2118-3-9]) - AutoSCT with Melphalan ([2118-5-13]), c/b neutropenic fever, TPN [2-4] mucositis --- Melphalan-associated lung toxicity, treated with high-dose steroids ([2118-6-6]) . PMH: - Pituitary adenoma ([2112]), s/p transsphenoidal resection/adrenal insufficiency - Intrasellar meningioma (resected [2118-3-31]) - Melanoma in situ - Hypotestosterone - Hypothyroidism [2-4] pituitary ablation - Type II diabetes [2110]-[2111]: Per wife, controlled with glyburide only, then pt presented to clinic in [2111] with glucose = 20, resulting in d/c glyburide, and no subsequent need for glucose-controlling agents. With onset of prednisone use, pt has been taking NPH insulin. Social History: Retired engineer. Married, lives with wife in [Name (NI) 3320], [State 350]. One son who lives in [Name (NI) 86], has close relationship. No tobacco, EtOH, illicits, IVDA. Family History: Immediate family died in [Country 2784] during WWII. Maternal uncle died from "blood" cancer Physical Exam: VS = T 97.9, HR 96, O2sat 97%, BP 79/54 . Gen: NAD, cachectic, nodded off while examiner was talking to wife. [Name (NI) 4459]: [Name2 (NI) 12476], EOMI, CNII-XII grossly intact CV: RRR, S1S2, no m/r/g Chest: Bibasilar crackles, faint rhonchi and expiratory wheezes. Dullness to percussion on LLL. (Pt. had difficulty taking deep breaths.) Abd: BS+, soft, NTND, no HSM Ext: No c/c/e, BLE cachetic. Lymph: No LAD noted at B axillary, neck, supraclavicular, B femoral Skin: No rashes Pertinent Results: Admission labs: . [2118-7-15] 03:50PM GLUCOSE-247* UREA N-20 CREAT-0.7 SODIUM-126* POTASSIUM-5.0 CHLORIDE-89* TOTAL CO2-25 ANION GAP-17 [2118-7-15] 03:50PM ALT(SGPT)-26 AST(SGOT)-26 LD(LDH)-528* ALK PHOS-74 TOT BILI-0.6 DIR BILI-0.2 INDIR BIL-0.4 [2118-7-15] 03:50PM ALBUMIN-3.6 PHOSPHATE-3.2 MAGNESIUM-2.0 [2118-7-15] 03:50PM WBC-1.2# RBC-4.03 HGB-13.7* HCT-38.4* MCV-95 MCH-34.0* MCHC-35.7* RDW-17.8* [2118-7-15] 03:50PM NEUTS-20* BANDS-16* LYMPHS-28 MONOS-12* EOS-0 BASOS-0 ATYPS-0 METAS-24* MYELOS-0 [2118-7-15] 03:50PM PLT SMR-LOW PLT COUNT-117* [2118-7-15] 03:50PM GRAN CT-888* . Studies: . CHEST (PORTABLE AP) [2118-7-15] 6:36 PM Please note this examination is limited due to marked patient rotation and portable technique. Given these limitations, no focal underlying consolidation, pneumothorax, pulmonary edema, or pleural effusion is identified. The left costophrenic angle was not completely included on the current film. There are slightly prominent interstitial markings projecting over the left hemithorax, which may represent the sequelae of previously identified pneumonia on a recent admission. Cardiomediastinal silhouette and hilar contours are within normal limits. IMPRESSION: No definite focal consolidation identified. Slightly increased interstitial markings projecting over the left hemithorax may be related to technique or residual opacities from known recently treated pneumonia. These may be better evaluated with dedicated PA and lateral chest radiographs. . CT CHEST W/O CONTRAST ([2118-7-18]) HRCT CHEST: Images are limited by motion. There is interval development of numerous bilateral nodules affecting all five lobes of the lungs. There also smaller ground-glass nodules. There are two small areas of consolidation in the lung apices bilaterally. There is a larger area of consolidation in the left lower lobe and a linear area of scarring or atelectasis in the right lower lobe. Resolution of the previously demonstrated right middle lobe collapse. The airways appear patent to the level of the segmental bronchi bilaterally. There is no pleural effusion. There are no pathologically enlarged axillary, mediastinal, or hilar lymph nodes. Expiratory images show mild air trapping, most pronounced in the lower lobes bilaterally. Limited, noncontrast evaluation of the heart and great vessels is unremarkable. Limited noncontrast evaluation of the abdomen shows nonspecific perinephric stranding, unchanged compared to the previous study. Bone windows reveal degenerative changes with no suspicious lytic or sclerotic lesions. IMPRESSION: 1. New diffuse bilateral pulmonary nodules of varying sizes and density, with two small areas of focal consolidation in the apices bilaterally and a larger area of consolidation in the left lower lobe. Given the patient's history of auto stem cell transplant less than 100 days ago, primary consideration should be given to opportunistic [Month/Day/Year 1065] infection such as invasive Aspergillus. Superimposed bacterial infection is also possible. 2. No evidence of pulmonary fibrosis. . [2118-7-17] Cytogenetics BONE MARROW - CYTOGENETICS . [2118-7-17] 9:34 am SPUTUM Source: Expectorated. GRAM STAIN (Final [2118-7-17]): [10-27] PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI. 2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. RESPIRATORY CULTURE (Preliminary): SPARSE GROWTH OROPHARYNGEAL FLORA. MORAXELLA CATARRHALIS. HEAVY GROWTH. GRAM NEGATIVE ROD(S). SPARSE GROWTH. . MR HEAD W & W/O CONTRAST [2118-7-20] 8:06 AM FINDINGS: There is a new area of slow diffusion in the right medial occipital lobe and the adjacent portion of the splenium of the corpus collosum. These areas demonstrates high signal on T2-weighted images. The occipital [Doctor Last Name 534] of the right lateral ventricle is partially compressed by the associated mass effect. The involved occipital cortex demonstrates gyriform enhancement on postcontrast images. The enhancement does not extend into the portions of the white matter involved with this abnormality. These findings are most consistent with a subacute infarction. An infectious process is much less likely given the gyriform nature of the enhancement, and the lack of additional enhancing lesions. Two small foci of high T2 signal in the deep white matter of the right and left inferior frontal lobes are unchanged, likely representing chronic microvascular disease. The right sphenoid [Doctor First Name 362] mass which involves the right cavernous sinus and the pituitary fossa, and which extends posteriorly along the clivus, is unchanged. Encasement and narrowing of the right cavernous carotid artery are unchanged. There is a persistent fluid level in the sphenoid sinus. Mild mucosal thickening is noted in the right frontal, ethmoid, and maxillary air cells, as well as in a left posterior ethmoidal air cell. Findings and recommendations were discussed with Dr. [Last Name (STitle) 2455] at 10:15 a.m. on [2118-7-20]. IMPRESSION: 1. Probable subacute infarction involving the right medial occipital lobe and the splenium of the corpus callosum. An infectious process is much less likely, given the enhancement [Doctor Last Name 5926] and the absence of multiple lesions. Follow-up MRI is suggested in 1 week to assess for the expected evolution of the presumed infarction. 2. Unchanged right sphenoid [Doctor First Name 362] mass involving the right cavernous sinus, the pituitary fossa, and extending along the clivus, consistent with a meningioma. 3. Persistent fluid level in the sphenoid sinus. Brief Hospital Course: Pt is a 69yo M with h/o Stage IIIB IgG kappa MM d+55 autoSCT who presented with one day history of shaking, elevated temperature, ANC 888, low BP, dullness to percussion on physical exam, and recent ICU admission for melphalan-related lung toxicity. Pt died on [2118-7-29]. . 1. Intracranial hemorrhage: Pt had an LP on [7-27] that was concerning for a SAH due to 1200 RBCs on 4th tube and yellow color. Pt had a head CT on [7-28] that did not show evidence for a bleed. Then, on [7-29] AM, pt was noted to have an increased O2 requirement. On exam, he was minimally responsive to pain and was found to have a fixed and dilated right pupil. An emergent head CT was obtained that revealed a new, large right parietal and occipital hemorrhage with extensive mass effect including herniations. Neurology and Neurosurgery were following throughout this episode. Upon learning the results of the CT scan, Neurosurgery felt prognosis would be poor. Family discussed the issue and decided on comfort care measures only. Pt was extubated later in that afternoon and made comfortable with morphine drip. Pt passed on [2118-7-29]. . 2. Mental status changes prior to [7-29]: This was likely multi factorial given hyponatremia, known infectious process in lung along with findings on MRI suggestive of septic emboli, and toxic-metabolic insults resulting in encephalopathy. Meningitis, vasculitis ([Doctor First Name ] neg), and ongoing seizure activity were also in differential. He was admitted to ICU on [7-26] due to worsening MS changes with possible trouble protecting airway. Mental status waxed and waned while in the ICU. Pt had an EEG that did not show acute foci of seizure activity. He had a repeat LP on [7-27] that was sig. for hazy and yellow fluid, mildly elevated protein, relatively low glucose compared to serum glucose, and WBC of 8 and 4, which is slightly above normal but pt was neutropenic, with lymph predominance, suggesting an infectious process (more likely viral v. [Month/Year (2) 1065] then bacterial). Cultures and multiple viral studies were sent. He was on high dose steroids for desired effect of decreasing the lesions in the brain as well as broad spectrum antibiotics Meropenam and Vancomycin as well as acyclovir, voriconazole, and ambisone. A TEE was attempted pn [7-27] to look for evidence of endocarditis; however, the probe could not be passed through his upper esophageal sphincter. Neurology and ID had been following. . 3. ID: Patient has pulmonary nodules, which seem improved on CT, and infectious process in lungs (BAL from [7-20] grew HSV, moraxella, stentotrophomonas; negative for PCP). There is also concern for septic emboli on head MR, which seems to have worsen. Also, pt has developed new firm, erythematous skin lesions and subcutaneous nodules on his LEs and abdomen that are concerning for septic emboli as well. A lesion was biopsied by dermatology and felt to show vasculitis/panniculitis, which was most likely due to an infectious process. Culture of the skin biopsy was sent. Ophthomology was also consulted to evaluated erythema around his eyes. This was felt to be preseptal/early facial cellulitis vs. erythema [2-4] scratching. Dilated eye exam did not show any evidence for infectious process. Pt was on broad coverage with Meropenam, vancomycin, acyclovir, voriconazole, and ambisone. ID was following closely. . 3. Neutropenia: Pt is s/p autoSCT almost 2 months ago and not on chemotherapy, so, the cause of neutropenia is unknown but suspected to be due to bactrim or infectious process. Viral studies including CMV and B parvovirus were sent. Due to concern for possible development of myelodysplastic syndrome, bone marrow aspirate was performed, which revealed hypocellular marrow, likely sulfamethoxazole/trimeth related injury. Pt was also noted to be thrombocytopenic (received 4 units of platelets) as well as anemic (received 1 unit of PRBCs). Pt was started on filgrastim on [7-17]. Pantoprozale was stopped [7-21] due to pancytopenia. . 4. Multiple myeloma, s/p autoSCT: For prophylaxis pt had been on Bactrim for PCP as has been on high dose steroids for a long time. He was on double strength Bactrim MWF, but was switched to atovaquone due to neutropenia which he took one day prior to admission. He was started on aerosolized pentamine on [2118-7-17]. . 5. Labile blood pressure: Pt was noted to have a BP of 79/54 on admission while dozing off while examiner was talking with the pt's wife. This was possibly due to bacteremia v. adrenal insufficiency [2-4] resected pituitary adenoma. Pt was fluid resuscitated and placed temporarily on stress dose steroids of Hydrocort 100mg q8 hrs. His hypotension resolved by [7-21] and then was found to be occasionally hypertensive. On [7-29] AM, pt required Levophed while being taken down for his emergent head CT. . 6. Hyponatremia: This was thought to be c/w SIADH with sodium ranging from 123-138 since admission. He was managed with fluid restriction starting on [7-23] and furosemide. Endocrine was following. . 7. Elevated glucose in context of high dose steroids for melphalan lung toxicity: Pt was placed on long-acting insulin (NPH or glargine) with an insulin sliding scale. This was closely followed by endocrine and adjusted accordingly. Pt did have a tendency to run high. . 8. Panhypopituitarism [2-4] transphenoid resection of pituitary adenoma: Pt was on prednisone, which was occasionally changed to stress dose steroids for hypotension and later in effort to decrease brain lesions. Pt was continued on home regimen of androderm patch 2.5 mg and levothyroxine 137 mcg daily. Medications on Admission: Androderm patch 2.5 mg Levothyroxine 137 mcg daily prednisone 20 mg in a.m., 10 mg in p.m. NPH 12 units in a.m., 10 units in p.m. Fluconazole 200 mg [Hospital1 ]: Pt. reports that he has only been taking this if he feels like he is developing oral thrush, and therefore has only been taking this intermittently. Pantoprazole 40 mg PRN for heartburn Discharge Disposition: Expired Discharge Diagnosis: (1) Intracranial hemorrhage (2) Pulmonary aspergillus (3) Pneumonia (4) Pancytopenia (5) Diabetes mellitus [2-4] steroid use Discharge Condition: Expired Discharge Instructions: None Followup Instructions: None	[ "117.3", "253.6", "E932.0", "484.6", "434.11", "729.30", "V58.67", "518.81", "V42.82", "284.8", "447.6", "054.79", "431", "225.2", "288.00", "482.83", "780.6", "203.00", "253.2", "251.8", "E933.1" ]	icd9cm	[ [ [] ] ]	[ "96.04", "38.93", "33.24", "96.71", "86.11", "88.72", "03.31", "41.31", "99.15", "99.05" ]	icd9pcs	[ [ [] ] ]	15236, 15245	9081, 14833	336, 342	15417, 15426	3316, 3316	15479, 15486	2691, 2789			15266, 15396		14859, 15213			15450, 15456							2804, 3297							6837, 9058									276, 298								370, 1386					3332, 6802								1408, 2473	2489, 2675
49,031	126,903	39842	Discharge summary	report	Admission Date: [2147-2-2] Discharge Date: [2147-2-4] Date of Birth: [2080-10-4] Sex: F Service: MEDICINE Allergies: Hydrochlorothiazide Attending:[First Name3 (LF) 3984] Chief Complaint: hypotension, bradycardia, hyperkalemia Major Surgical or Invasive Procedure: intubated extubated History of Present Illness: 66 y/o F transferred from [Hospital 1562] Hospital, where she presented on morning of [2-2] for nausea and vomiting. Per OSH records, she developed severe weakness and had a presyncopal episode this morning, developed nausea and abdominal pain, and was subsequently sent home from work. She was brought to the ED at [Hospital 1562] Hosp by her husband. There, she was found to be hypotensive to 50/30 and bradycardic to 31. EKG reportedly showed complete heart block. Vital sign flow sheets show bradycardia with BPs of 50-80s/20-40s between 12:47 and 14:11. The patient was intubated for airway protection, was given atropine 1 mg, and was started on a dopamine gtt, with aggressive IVF resuscitation. Norepinephrine was later added for persistent hypotension. Bedside echo reportedly showed no tamponade, but did reveal septal hypokinesis and a heavily calcified aorta. . OSH labs were notable for hyperkalemia of 6.8. She was given calcium gluconate, calcium chloride, bicarb, insulin, dextrose, and albuterol. Labs also revealed creatinine 1.72, elevated transaminases (AST 105, ALT 52) and pancreatic enzymes (lipase 100). Cardiac biomarkers were negative. She was given glucagon and calcium gluconate to reverse presumed beta-blocker and calcium channel blocker toxicity, respectively. She also received pip/tazo for potential infectious etiology for her hypotension. She was intubated because of her hypotension and for episodes of vomiting. She was placed on dopamine and norepinephrine en route to [Hospital1 18]. . In the [Hospital1 18] ED, initial VS were 98.3 69 148/66 16 100%, intubated. Her vasopressors were discontinued, and her blood pressure remained stable. ECG revealed normal sinus rhythm and normal QRS interval, without peaked T waves. She was given 30 mg of kayexelate. Toxicology was consulted, and recommended checking a digoxin level. Glucose was 55, for which the patient was given one amp of D50. She was also given 120mg of hydrocortisone, after a cortisol level was sent. She was sedated with versed and fentanyl, and later switched to a propofol gtt. Her ventilator was set to CMV/assist at 430 x 10, with the patient overbreathing; this was changed to CPAP, [6-15] prior to transfer to the floor. She underwent CT head and torso, which revealed no acute intracranial process. . On transfer to the MICU, she remains intubated. She is alert and responds to commands appropriately. Past Medical History: HTN Social History: +Smoking, +drinking Family History: NC Physical Exam: On admission: VS: Temp:97.9 BP:154/74 HR:79 RR:23 O2sat:100% CPAP/PSV GEN: Intubated, but easily arousable HEENT: PERRL, anicteric, MMM, Neck: no supraclavicular or cervical lymphadenopathy, no jvd,+ Right carotid bruit RESP: CTA b/l with good air movement throughout on anterior exam CV: RR, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e SKIN: no rashes/no jaundice/no splinters NEURO: easily arousable, follows commands appropriately. Able to move feet and hands to command. 1+DTR's-patellar Pertinent Results: [2147-2-2] 05:45PM LACTATE-1.8 [2147-2-2] 05:30PM GLUCOSE-75 UREA N-22* CREAT-1.4* SODIUM-137 POTASSIUM-4.8 CHLORIDE-102 TOTAL CO2-24 ANION GAP-16 [2147-2-2] 05:30PM estGFR-Using this [2147-2-2] 05:30PM ALT(SGPT)-269* AST(SGOT)-685* CK(CPK)-103 ALK PHOS-88 TOT BILI-1.5 [2147-2-2] 05:30PM LIPASE-71* [2147-2-2] 05:30PM cTropnT-<0.01 [2147-2-2] 05:30PM ALBUMIN-4.6 [2147-2-2] 05:30PM CORTISOL-36.4* [2147-2-2] 05:30PM DIGOXIN-<0.2* [2147-2-2] 05:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-POS barbitrt-NEG tricyclic-NEG [2147-2-2] 05:30PM WBC-13.7* RBC-3.85* HGB-13.9 HCT-41.8 MCV-109* MCH-36.1* MCHC-33.2 RDW-12.8 [2147-2-2] 05:30PM NEUTS-87* BANDS-2 LYMPHS-4* MONOS-4 EOS-0 BASOS-0 ATYPS-0 METAS-3* MYELOS-0 [2147-2-2] 05:30PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL [2147-2-2] 05:30PM PLT SMR-NORMAL PLT COUNT-282 [2147-2-2] 05:30PM PT-13.3 PTT-23.0 INR(PT)-1.1 [2147-2-4] 04:07AM BLOOD WBC-6.8 RBC-3.36* Hgb-12.0 Hct-37.1 MCV-111* MCH-35.7* MCHC-32.3 RDW-12.1 Plt Ct-194 [2147-2-4] 04:07AM BLOOD Glucose-88 UreaN-11 Creat-0.7 Na-141 K-3.5 Cl-103 HCO3-29 AnGap-13 [2147-2-4] 04:07AM BLOOD ALT-163* AST-155* LD(LDH)-238 CK(CPK)-149 AlkPhos-63 TotBili-0.6 [2147-2-3] 03:55AM BLOOD GGT-124* [2147-2-2] 05:30PM BLOOD cTropnT-<0.01 [2147-2-3] 03:55AM BLOOD proBNP-1355* [2147-2-3] 05:16PM BLOOD CK-MB-4 cTropnT-<0.01 [2147-2-4] 04:07AM BLOOD CK-MB-4 cTropnT-<0.01 [2147-2-4] 04:07AM BLOOD Calcium-8.6 Phos-2.2* Mg-1.8 [2147-2-3] 03:55AM BLOOD VitB12-955* Folate-17.6 [2147-2-3] 03:55AM BLOOD TSH-0.72 [2147-2-3] 03:55AM BLOOD TSH-0.72 [2147-2-2] 05:30PM BLOOD Cortsol-36.4* [2147-2-2] 05:30PM BLOOD Digoxin-<0.2* [2147-2-2] 05:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG [2147-2-2] 05:45PM BLOOD Lactate-1.8 Brief Hospital Course: 66 y/o F with abrupt onset of constellation of symptoms on the morning of her admission including nausea, vomiting, and weakness, followed by hypotension and bradycardia. . # Hemodynamics/Shock: On presentation to OSH was noted to have bradycardia to the 40's with profound hypotention and EKG showing slow wide complex idioventricular rythm. Pnt was given atropine 1 mg, dopamine+norepinephrine gtt and was aggressively IVF resuscitated prior to her transfer to our institution. On arrival at [Hospital1 18] was still intubated and on pressors which were quickly discontinued on admission, EKG showed normal sinus rythm and blood pressures were good. Patient was transfered to the ICU where her home meds continued to be held and she was observed for 24 hours remaining stable without further need for pressors and without recurrence of hypotension or bradycardia. The etiology for her hypotention and bradycardia is likely dehydration and increased vagal tone in the setting of nausea and vomiting [3-15] to a likely viral gastroenteritis with inappropriately low heart rate d/t her home nodal blocking agents. Patient was on labetolol + verapamil, she denies any ingestions and had negative tox screen on admission . She denies recent changes in medication dosages but has been known to have labile and difficult to control hypertension in the past. Bed-side echo in OSH reportedly demonstrated focal LV wall hypokinesis. Patient had no anginotic symptoms, in [Hospital1 18] serial ECG's and cardiac enzymes where not suggestive of myocardial ischemia. LV hypokinesis could conceivabley be attributable to negative ionotropic effect of verapamil. She otherwise has no known history of dysrhythmias, sick sinus syndrome, or other forms of heart block. Residence on [Location (un) ] increases likelihood of exposure to Lyme disease, as potential etiology of heart block though this would not be expected to be so easily reversible; OSH ecg with peaked T waves and wide-complex bradycardia may also represent hyperkalemic changes, but this is less likely as K of 6.8 in OSH was a one time finding and did not recur, suggesting perhaps a hemolized specimen. Presentation was also unlikely to have resulted from sepsis, as BP improved without further pressor support, and only received a single dose of pip/tazo post transfer. Cultures were so far negative with final results pending at time of discharge. In conclusion seems that patient's presentation was secondary to viral gastroenteritis and pharmacological over-blockade of the AV node. She is discharged with Labetolol at half her home dose: i.e. Labetolol 100mg [Hospital1 ] at discharge. Verapamil continues to be held at discharge. She will follow-up with her PCP, [Name10 (NameIs) ] [Name11 (NameIs) ] regimen with less nodal blocking and negative ionotropic effects may be considered. Also an echocardiogram to assess cardiac function may be considered in the outpatient setting. . # Nausea/vomiting/weakness/malaise: Likely viral gastroenteritis. Had 1 large loose bowel movement in the ICU. Stool was sent for cultures which were still pending at discharge. No recent Abx exposure. No recurrence of nausea or vomiting during her hospital course. . # Hyperkalemia: Unclear initial precipitant possibly [3-15] to acute renal failure in the setting of dehydration. Patient not on ACE/[Last Name (un) ] inhibition, not taking potassium supplements, and initial labs at OSH did not reflect acidosis. Improved with aggressive management at OSH. Potassium was stable on follow-up. . # Elevated LFTs: reversed AST/ALT ratio and her macrocytosis in the setting of normal B12 abd Folate are concerning for changes secondary to alcohol. Pnt endorses 2 alcohlolic drinks per day, CAGE questioneer was negative. Baseline LFT's are unavailable. Given profound hypotension shock liver may also be a possibility. LFT's down trending on follow-up, will need to be followed up in the outpatient setting with appropriate work-up if not normalized. . # Ambulatory desaturation: pnt found to desaturate to 86% upon minimal exertion. Her resting saturation is > 92% on RA. In conjunction with her history of heavy smoking and the finding of reduced [Hospital1 ]-lateral air movement on exam there is high suspicion of emphysema. We recommend pulmonology clinic follow-up. . # Leukocytosis w/mild bandemia: Pt afebrile at OSH and since arriving at [Hospital1 18]. Only infectious symptoms as reported at OSH were nausea and vomiting, in [Hospital1 18] developed diarrhea likely pointing to viral gastroenteritis. Alternatively may represent reactive leukocytosis in setting of increased physiologic stress. Did receive single dose of pip/tazo in ED which was not continued in the ICU. . # Renal insufficiency: Baseline creatinine not known, but kidneys may have received ischemic insult during period of hypotension. Creatinin subsequently down trended from 1.4 to 0.7 on dicharge. . # Mechanical ventilation: Pt was on minimal vent settings and responsive despite propofol infusion. Extubated on admission without complications. Medications on Admission: Verapamil 240mg Labetalol 200mg PO BID Celexa Xanax qHS MVI Discharge Medications: 1. labetalol 200 mg Tablet Sig: 0.5 Tablet PO twice a day. 2. Celexa Oral 3. Xanax Oral 4. multivitamin Oral Discharge Disposition: Home Discharge Diagnosis: hypotension, bradycardia, hyperkalemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to [Hospital1 69] for hypotension, bradycardia, and hyperkalemia. You were initially intubated to help you breathe. When your condition improved, you were extubated and able to breathe on your own. The following changes were made to your home medications: - STOP VERAPAMIL - REDUCE LABETOLOL 200mg from one tablet to half tablet [Hospital1 ]. . Please continue your other home medications without change Followup Instructions: Please see your primary care physician [Name Initial (PRE) 176] 1-2 weeks. Please return to the emergency department if your symptoms recur. We recommend you see a Lung Specialist as we suspect you have chronic lung disease. You may call Dr. [Last Name (STitle) ] to make an appointment at his clinic in [Hospital1 18] or ask about recommended providers in your area: Name: [Last Name (LF) ], [First Name8 (NamePattern2) 122] [Last Name (NamePattern1) ] Office Phone: ([Telephone/Fax (1) 513] Office Location: E/KSB-23 Department: Medicine Organization [Hospital1 18] . [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2437] MD [MD Number(1) 2438] Completed by:[2147-2-4]	[ "E941.3", "305.1", "276.7", "401.9", "426.0", "593.9", "E942.4", "008.8", "300.00", "276.51", "790.6" ]	icd9cm	[ [ [] ] ]	[ "96.71" ]	icd9pcs	[ [ [] ] ]	10824, 10830	5456, 10576	318, 339	10913, 10913	3478, 5433	11554, 12312	2893, 2897		10687, 10801	10851, 10892		10602, 10664			11096, 11359							2912, 2912				11377, 11531												239, 280								367, 2811							2926, 3459	10928, 11072					2833, 2839	2855, 2877
81,103	193,103	47597	Discharge summary	report	Admission Date: [2163-8-24] Discharge Date: [2163-9-2] Date of Birth: [2099-9-25] Sex: F Service: PLASTIC Allergies: Oxycodone / tramadol Attending:[First Name3 (LF) 36263] Chief Complaint: nonhealing R ankle wound Major Surgical or Invasive Procedure: R ankle subtalar fusion, coverage with R gracilis free flap and split thickness skin graft History of Present Illness: Pt is 63 yoF who splits her time between [Country 16573] and US who sustained a MVC late [1-/2163] in [Country 16573]. She was taken to the OR [2-/2163] for a right ankle dislocation but intraop was found to have a fracture. She was closed after manipulation and no hardware placement and casting. The pt developed a draining sinus that would not heal; conservative treatment including daily dressings were attempted but were refractory to care from [2-/2163]/[2163]. At that time, the pt returned to the US and sought care at Dr. [Name (NI) 65714] clinic. The pt was taken to the OR [2163-6-10] for I&D Rt ankle, talectomy for avascular necrosis of the talus, placement of abx spacer, and wound vac application. Wound culture from the OR grew out MRSA. Pt went back to OR with Ortho for another I&D, abx bead change, and exfix application with plan for ankle fusion (in 6 wks). A PICC line was placed for long term IV vancomycin. Patient returns today for removal of the antibiotic spacer, fusion of ankle joint, ? bone graft and flap repair of ankle wound defect. Past Medical History: Measles c/b cataracts s/p surgery [2125] - Fe deficiency anemia (refusing colonoscopy) - Sensorineural hearing loss bilaterally - R open fx-dislocation R talus [2-24] MVA with course c/b chronic draining sinus tract Social History: see hpi Family History: see hpi Physical Exam: Please see HPI Pertinent Results: [2163-8-24] 11:10PM WBC-6.9 RBC-3.76* HGB-11.1* HCT-32.8* MCV-87 MCH-29.4 MCHC-33.8 RDW-14.2 Brief Hospital Course: The patient was admitted to the plastic surgery service on [8-24] with nonhealing R ankle wound. Patient was taken to the operating room and underwent R ankle subtalar fusion, coverage with R gracilis free flap and STSG . Patient tolerated the procedure without difficulty and was transferred to the PACU, then the floor in stable condition. Please see operative report for full details. Neuro: The patient received Dilaudid with good effect and adequate pain control. CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. GI/GU: A po diet was tolerated well. Patient was also started on a bowel regimen to encourage bowel movement. Intake and output were closely monitored. ID: The patient's temperature was closely watched for signs of infection. Prophylaxis: The patient received subcutaneous heparin during this stay, and was encouraged to get up and ambulate as early as possible. At the time of discharge on [9-2], the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. All questions were answered, and patient has appropriate follow-up care. Discharge Medications: 1. Enoxaparin Sodium 40 mg SC DAILY RX enoxaparin 40 mg/0.4 mL Inject subcutaneously once a day for 6-11 days, until you are fully mobile once a day Disp #14 Syringe Refills:0 2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 3. Levofloxacin 750 mg PO Q24H RX Levaquin 750 mg 1 tablet(s) by mouth once a day Disp #21 Each Refills:0 4. Metoprolol Tartrate 5 mg IV Q6H:PRN HR >100 Hold for HR < 60, or SBP < 90 5. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain RX tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp #30 Each Refills:0 6. Calcium Carbonate 1250 mg PO Q 24H 7. Docusate Sodium 100 mg PO BID RX Colace 100 mg 1 capsule(s) by mouth twice a day Disp #30 Each Refills:0 8. Aspirin 121.5 mg PO DAILY Duration: 1 Months Take one and a half 81mg baby aspirin tablets, once a day for a month. RX Adult Low Dose Aspirin 81 mg 1.5 tablet(s) by mouth once a day Disp #45 Each Refills:0 Discharge Disposition: Extended Care Facility: [First Name4 (NamePattern1) 1188] [Last Name (NamePattern1) ] - [Location (un) 538] Discharge Diagnosis: Nonhealing ankle wound Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Discharge Instructions: Followup Instructions: -You should continue taking the antibiotics as prescribed. -Elevate your right leg as much as possible and maintain it in a splint. -Do not bear weight on right foot for 6 wks. -Dangle right foot over bed for 30 minutes, three times a day. -Please keep your right leg dry -If your right leg begins to worsen after discharge home with an acute increase in swelling or pain, please call the Plastic Surgery Clinic at the number given and ask to speak with a doctor. . Medications: Resume your regular medications unless instructed otherwise. * You may take your prescribed pain medication for moderate to severe pain. You may switch to Tylenol or Extra Strength Tylenol for mild pain as directed on the packaging. Please note that Percocet and Vicodin have Tylenol as an active ingredient so make sure that your Tylenol intake does NOT exceed 4 grams/day. * Take prescription pain medications for pain not relieved by tylenol. * Take Colace, 100 mg by mouth 2 times per day, while taking the prescription pain medication to prevent constipation. You may use a different over-the-counter stool softener if you wish. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. * Continue lovenox injections . Return to the ER if: * If you are vomiting and cannot keep in fluids or your medications. * If you have shaking chills, fever greater than 101.5 (F) degrees or 38 (C) degrees, increased redness, swelling or discharge from incision, chest pain, shortness of breath, or anything else that is troubling you. Followup Instructions: Infectious Disease: [Name6 (MD) ] [Name8 (MD) 32437], MD Phone:[Telephone/Fax (1) 457] Date/Time:[2163-9-8] 10:30am LM [Hospital Ward Name ] BLDG ([Doctor First Name ]), BASEMENT Orthopedics: [Name6 (MD) 13978] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 1228] Date/Time:[2163-9-8] 12:30pm [Hospital Ward Name ] CENTER, [Location (un) ] Please follow up with the Plastic Surgery clinic within [1-24] weeks of discharge from rehab. Completed by:[2163-9-2]	[ "V12.04", "V13.89", "998.83", "905.4", "E878.8", "718.87", "389.18", "E929.0" ]	icd9cm	[ [ [] ] ]	[ "83.85", "86.69", "81.13", "38.93", "83.82", "80.87", "81.49", "84.57", "80.47" ]	icd9pcs	[ [ [] ] ]	4267, 4389	1999, 3316	305, 398	4456, 4456	1876, 1976	6384, 6898	1817, 1826		3339, 4244	4410, 4435					4563, 4563							1841, 1857																241, 267								426, 1526								4471, 4539					1548, 1775	1791, 1801
47,469	176,978	19908	Discharge summary	report	Admission Date: [2107-9-22] Discharge Date: [2107-10-4] Date of Birth: [2050-5-20] Sex: F Service: NEUROLOGY Allergies: Nystatin Attending:[First Name3 (LF) 5167] Chief Complaint: Agitation, auditory hallucinations Major Surgical or Invasive Procedure: Lumbar Puncture Intubation/Extubation History of Present Illness: The patient is a 57 year old woman with a history of spastic paraparesis, hypertension, and autoimmune hepatitis on azathioprine who presents with a 7 day history of herpes zoster rash in left V1 distribution on Valtrex for 4 doses, and a 2 day history of increased agitation and auditory hallucinations. On Friday evening (7 days PTA), she developed an erythematous, raised rash on her left forehead and eyelid. She took some Benadryl thinking the rash may have been an allergy, with no change in the rash. At the same time she developed a headache which improved with ibuprofen and the Benadryl. On Monday (4 days PTA), she went to her PCP who diagnosed her with shingles, and prescribed Valtrex. She took a total of 4 doses of Valtrex. She was also seen by opthomology as an outpatient given the V1 involvement of her zoster. On Tuesday night (2 days PTA) around 11 pm, she became very agitated. Her husband found that she was hearing things that weren't there and talking to people who weren't in the room. He reports that she thought she was "talking to friends on the internet via telepathy." Overnight that night she continued to be agitated and confused, having conversations with people who were not there. However, if her husband asked her a question, she responded appropriately and apparently was aware of her surroundings and location. She also was having an exaggeration of her normally spastic movements of her feet. She has never had any symptoms of agitation like this before, and her husband is not aware of any recent ingestions or sick contacts. Because of these symptoms, she was taken to an OSH ED. On ROS, she did not have any subsequent headaches after the headache 7 days PTA. One week ago she had an episode of diarrhea, but did not have any abdominal pain. Five days ago she vomited up some juice that she was drinking, and did complain of nausea. They have a vacation home in [Location (un) 3844], and the last time they visited was [9-4]; however, she did not complain of any tick bites or rashes. She was initially seen at [Hospital6 1597] on [2107-9-21], where she was noted to have "uncontrolled movement extremities, also hearing voices, talking back to them, paranoid." Their differential was exacerbation of movement disorder, valtrex induced vs. drug interaction, or HSV encephalitis. UA was normal. It was dtermined LP was a high risk procedure given her involunatary movements. She was transferred to [Hospital1 18] for neurological evaluation. In the [Hospital1 18] ED, vitals on admission were temp 99.2, HR 70, bp 132/72, RR 20, SaO2 99%. She was intubated with Rocuronium 60 mg IV, Etomidate 20 mg IV x1, and started on a Propofol gtt, as she was unable to lay still for LP or head CT. Neurology was consulted. LP showed 101 WBC with 76% lymphocytes, Head CT showed no acute intracranial process, and CXR showed right basal atelectasis, which in this setting, may be secondary to aspiration. She was given Ceftriaxone 2 gm IV and Acyclvir 700 mg IV x1, Tylenol 1 gm PO x1, and 2 L NS. She was admitted to the NeuroICU. Past Medical History: -Spastic Paraparesis, CSF negative for HTLV-I/II, VDRL, oligoclonal bands [1-10], seen by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 951] in Neurology as an outpatient -Hypertension -Autoimmune hepatitis, s/p liver biopsy [12-7], previously [Doctor First Name ] and Anti-Smooth Muscle Ab positive -Depression -Fractured vertebrae at age 20 -s/p left ankle arthroscopic surgery/repair Social History: She smoked as a teenager but does not currently smoke, has an occasional glass of wine, and denies illicit drug use. She lives with her husband in [Name (NI) 1468]. Family History: (per outpatient Neurology note): Her mother died at age 70 and had taken DES during pregnancy. She also had suffered from hypertension, high cholesterol, and melanoma. Her father died at 62 and had a very unsteady gait and [Last Name ] problem/dementia when older. Her father also suffered similarly stiff legs with onset at around age 55, though apparently he was diagnosed as possibly having "Parkinson's disease". She does not know any significant history regarding her grandparents other than that her maternal grandfather died at a young age from a fall. Her sister is aged 57 and has high blood pressure, high cholesterol, and gallbladder problems. Physical Exam: VS: temp 95.6, bp 118/74, HR 53, RR 14, SaO2 100% on CMV, PEEP 5, PIP 20, Vt 513 Genl: Intubated. HEENT: Sclerae anicteric, left scleral conjunctival injection, no nuchal rigidity CV: Regular rate, Nl S1, S2, no murmurs, rubs, or gallops Chest: CTA bilaterally anteriorly and laterally, no wheezes, rhonchi, rales Abd: +BS, soft, NT, slightly distended abdomen Ext: Pneumoboots bilaterally Skin: Crusted erythematous papules on left forehead, eyelid, and nasal bridge. Neurologic examination: Mental status: Does not open eyes on command but does grasp fingers on command bilaterally, shows 2 fingers. Agitated with Propfol gtt off. Cranial Nerves: Pupils 5 mm and sluggishly reactive to light (to 4.5 mm bilaterally). Corneal reflex intact bilaterally. Unable to assess facial symmetry or tongue protrusion as intubated. Motor: Normal bulk and tone bilaterally. No observed myoclonus, asterixis, or tremor. Moving all 4 extremities against gravity. Sensation: Withdraws all 4 extremities to nailbed pressure. Reflexes: [Hospital1 ] Tri Br K A Right 2+ 2+ 2+ 3+ 8 beats clonus Left 3+ 3+ 3+ 3+ 8 beats clonus Toe upgoing on the left, downgoing on the right. Pertinent Results: [2107-9-21] 05:35PM WBC-4.2 RBC-4.18* HGB-13.1 HCT-36.7 MCV-88 MCH-31.4 MCHC-35.8* RDW-14.7 [2107-9-21] 05:35PM ALBUMIN-4.4 CALCIUM-10.2 PHOSPHATE-3.9 MAGNESIUM-2.4 [2107-9-21] 05:35PM LIPASE-38 [2107-9-21] 05:35PM ALT(SGPT)-18 AST(SGOT)-25 ALK PHOS-107 TOT BILI-0.5 [2107-9-21] 05:35PM GLUCOSE-94 UREA N-20 CREAT-0.8 SODIUM-136 POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-26 ANION GAP-13 [2107-9-22] 01:35AM CEREBROSPINAL FLUID (CSF) WBC-101 RBC-12* POLYS-2 LYMPHS-76 MONOS-19 MACROPHAG-3 [2107-9-22] 01:35AM CEREBROSPINAL FLUID (CSF) WBC-87 RBC-16* POLYS-0 LYMPHS-77 MONOS-17 MACROPHAG-6 [2107-9-22] 01:35AM CEREBROSPINAL FLUID (CSF) CSF-PEP-NO OLIGOCL [2107-9-22] 01:35AM CEREBROSPINAL FLUID (CSF) PROTEIN-76* GLUCOSE-51 [2107-9-22] 10:10AM [Doctor First Name ]-POSITIVE TITER-1:160 PAT dsDNA-NEGATIVE [2107-9-22] 10:10AM CRP-2.5 [2107-9-22] 10:10AM SED RATE-55* [2107-10-3] 03:30PM BLOOD WBC-2.5* RBC-3.67* Hgb-11.3* Hct-32.4* MCV-88 MCH-30.9 MCHC-35.0 RDW-16.4* Plt Ct-189 [2107-10-3] 03:30PM BLOOD Glucose-136* UreaN-9 Creat-1.0 Na-143 K-3.7 Cl-109* HCO3-28 AnGap-10 [2107-10-3] 03:30PM BLOOD ALT-23 AST-24 LD(LDH)-237 AlkPhos-88 TotBili-0.2 [2107-9-25] 04:15PM BLOOD ANCA-NEGATIVE B [2107-9-26] 07:25PM BLOOD HIV Ab-NEGATIVE [2107-9-25] 04:15PM BLOOD CERULOPLASMIN-35 wnl [2107-9-27] 12:18PM CEREBROSPINAL FLUID (CSF) WBC-30 RBC-1* Polys-0 Lymphs-90 Monos-9 Atyps-1 [2107-9-27] 12:18PM CEREBROSPINAL FLUID (CSF) TotProt-54* Glucose-46 [2107-9-22] 01:35AM CEREBROSPINAL FLUID (CSF) CSF-PEP-NO OLIGOCL [2107-9-27] 10:56AM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS PCR-Test Name [2107-9-27] 12:18PM CEREBROSPINAL FLUID (CSF) VARICELLA DNA (PCR)-Test EEG [9-25]: Normal EEG in the waking and drowsy states. There was plentiful movement artifact. There were no areas of prominent focal slowing, and there were no clearly epileptiform features. MRI Brain [9-23] IMPRESSION: 1. Subtle enhancement within a slightly enlarged left fifth cranial nerve, which can be seen with Lyme disease. The enhancement can also be seen in herpes infection but is less typical. No additional areas of leptomeningeal or cranial nerve enhancement identified. 2. Cerebral atrophy and nonspecific FLAIR hyperintensities which likely represent small vessel ischemic disease. Brief Hospital Course: IMPRESSION/PLAN: The patient is a 57 year old woman with a history of spastic paraparesis, hypertension, and autoimmune hepatitis on azathioprine who presents with a 7 day history of herpes zoster rash in the left V1 distribution on Valtrex for 4 doses, and a 2 day history of increased agitation and auditory hallucinations. Her mental status on admission was significant for decreased attention and concentration, and agitation. She was intubated for LP, which showed 101 WBC with 76% lymphocytes and 12 RBC, and head CT which showed no acute intracranial process. Extubated [9-23] She most likely has a viral encephalitis, VZV being the most likely [Doctor Last Name 360]. Her symptoms were preceded by herpes zoster in the V1 distribution, and she was on immunosuppression with azathioprine which puts her at risk for infection. She has also recently been to her cabin in [Last Name (LF) 3844], [First Name3 (LF) ] Lyme was tested and found to be negative. Given her history of autoimmune disease, she was worked up for vasculitis and SLE causing her symptoms, also negative. Her initial CSF was not sent for VZV PCR secondary to lab error so a second LP was performed on [9-27]. This was done after several days of treatment with acyclovir and VZV and HSV were negative. The CSF studies were improved with a WBC count of 30. As part of her work-up she also had an MRI showing trigeminal nerve enhanceement and EEG which was unremarkable. With the improvement in her symptoms and CSF leukocytosis her acyclovir dose was decreased to (5mg/kg) 250mg IV q8. On [9-30] she had a low grade temperature and small suspicious vesicle on her face. This was sent for VZV testing but the sample was not adequate. With help from ID, her acyclovir dose was increased to 10mg/kg. She continued to improve over the weekend and her dose was changed back to 5mg/kg on [10-3]. She is due to complete a 21 day course of IV acyclovir at 250mg IV q8. Day 1 is [2107-9-23]. -Ophtho consulted: No evidence of herpes zoster ophthalmicus, no corneal involvement, will need ophtho follow up as outpatient - Psychiatry consulted to help manage her psychosis - she was initially started on seroquel with minimal effect. She was then changed to zyprexa and as the dose was titrated up, she has an improvement in her symptoms. Most of her delusions and hallucinations are centered around her husband hurting or abusing other people. Social work and psychiatry, as well as the primary team, feel these thoughts are not based in any reality after talking to several family members and friends. - Cards - Her BP meds were initially held but gradually restarted as her BP's trended upward. She has been hemodynamically stable throughout admission. - FEN/GI:-LFTs normal -Holding Azathioprine for now as do not want to immunosuppress during infection, Has liver follow up as outpatient. She will require IVF while on Acyclovir 7. PPx: Heparin SC tid, Pneumoboots, Tylenol prn, RISS, Colace, Famotidine 20 IV q12 Medications on Admission: Azathioprine 50 mg daily Toprol XL 100 mg daily Norvasc 5 mg daily Celexa 20 mg qAM, 10 mg qPM Valtrex (started [2107-9-19], stopped [2107-9-20]) Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever. 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) 5000 Injection TID (3 times a day). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 5. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO QPM (once a day (in the evening)). 6. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. 7. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 8. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for hallucination. 10. Polyethylene Glycol 3350 100 % Powder Sig: One (1) cap PO DAILY (Daily). 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 12. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 13. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 14. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 15. Olanzapine 2.5 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 16. Acyclovir Sodium 500 mg Recon Soln Sig: 0.5 Recon Soln Intravenous Q8H (every 8 hours) as needed for meningitis: 250mg q8. Discharge Disposition: Extended Care Facility: [Hospital6 979] - [Location (un) 246] Discharge Diagnosis: VZV Encephalitis Discharge Condition: Improved Discharge Instructions: Please follow-up with neurology and GI as arranged. Because of the severity of your infection, you will need to complete 21 days total of IV antiviral therapy. If you do not finish this course you would be at risk of not fully treating the infection. All your symptoms may not be cleared by the time the therapy is completed but should continue to improve after you are done. If you have any new symptoms, please call the hospital and ask for the on call neurologist. Followup Instructions: Neurology: [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) 396] [Name8 (MD) ], M.D. Phone:[Telephone/Fax (1) 1040] Date/Time:[2107-11-4] 4:00. [Hospital Ward Name 23] [Location (un) ], [Hospital1 18] [Hospital Ward Name 516]. Gastroenterologist Dr [First Name (STitle) 679]: Thursday [11-10] at 10:15, at [Last Name (NamePattern1) 12939] #8A After discharge from rehab, call your PCP: [Name10 (NameIs) ],[First Name8 (NamePattern2) 2671] [Last Name (NamePattern1) ] [Telephone/Fax (1) 26774] to arrange a follow up appointment.	[ "401.9", "311", "052.0", "334.1", "333.5", "571.49", "518.0", "293.0" ]	icd9cm	[ [ [] ] ]	[ "96.04", "96.71", "03.31" ]	icd9pcs	[ [ [] ] ]	13094, 13166	8415, 11445	305, 344	13227, 13238	6012, 8392	13758, 14368	4111, 4777		11651, 13071	13187, 13206		11471, 11628			13262, 13735							4792, 5262																231, 267								372, 3464	5443, 5993							5301, 5427			5286, 5286		3486, 3908	3924, 4095
9,753	196,780	48746	Discharge summary	report	Admission Date: [2169-11-14] Discharge Date: [2169-11-24] Date of Birth: [2102-6-3] Sex: M Service: MEDICINE HISTORY OF THE PRESENT ILLNESS: The patient is a 67-year-old man with a history of ventricular tachycardia, status post ICD placement, hypertension, hypercholesterolemia, who sustained head trauma in a motor vehicle accident in [2169-7-28] and had a resultant right-sided subdural hematoma. His hematoma was initially followed by observation. However, he subsequently developed a left-sided hematoma. Approximately one week prior to this admission, he had a right-sided craniotomy and was discharged from that procedure on [2169-11-10]. Over the next few days preceding this admission, he began to notice some numbness in his left hand and his family subsequently noticed a left-sided facial droop. He also noted that he was more clumsy and was dropping objects when trying to use his left arm and he was brought into the hospital by his family on [2169-11-14] when they noted an increasing facial droop, slurred speech, and drooling out of the left side of his mouth. PAST MEDICAL HISTORY: 1. Atrial fibrillation. 2. Ventricular tachycardia, status post AICD placement. 3. Hypertension. 4. COPD. 5. Systolic congestive heart failure with an ejection fraction of 25%. 6. Dilated cardiomyopathy. 7. Hypercholesterolemia. ALLERGIES: Penicillin. ADMISSION MEDICATIONS: 1. Amiodarone 200 mg once daily. 2. Lipitor 10 mg once daily. 3. Spironolactone 12.5 mg once daily. 4. Lasix 40 mg alternating with 20 mg p.o. q.o.d. 5. Carvedilol 6.25 mg p.o. b.i.d. 6. Flomax 0.4 mg p.o. q.d. 7. Diovan 80 mg p.o. q.d. 8. Multivitamin. 9. Colace. 10. Aspirin 81 mg daily. SOCIAL HISTORY: The patient is a former smoker, quit 25 years ago, rare alcohol use. The patient is a retired painter. FAMILY HISTORY: The patient's mother had a myocardial infarction at age 74. The patient's father had lung cancer at age 84. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature 98.3, heart rate 110, blood pressure 115/70, respiratory rate 20, oxygen saturation 98% on room air. General: The patient was in no acute distress. HEENT: The pupils were equal, round, and reactive to light. Anicteric sclerae. Supple neck. Moist mucosal membranes. The extraocular muscles were intact. Slight droop of the right eyelid and corner of the right mouth. There was 2-3 cm of JVD. Cardiovascular: Irregularly/irregular, tachycardia, faint systolic ejection murmur at the left lower sternal border, radiating to the apex. Lungs: Crackles at the bases, otherwise clear to auscultation. Abdomen: Soft, nontender, nondistended, obese. Extremities: Trace to 1+ peripheral edema. Neurologic: Cranial nerves II through XII intact bilaterally, strength 5/5 in all four extremities proximally and distally, normal gait. No finger-to-nose dysmetria. Negative Romberg sign. Biceps and quadriceps reflexes 2+ bilaterally. LABORATORY/RADIOLOGIC DATA: White blood cell count 9.8, hematocrit 35.6, platelets 388,000. INR 1.2, PTT 29.2, sodium 141, potassium 3.9, BUN 13, creatinine 1.0, glucose 106, calcium 8.7, magnesium 1.9. The EKG showed atrial fibrillation with rapid ventricular response, right bundle branch block, left axis deviation. EEG showed mildly abnormal EEG due to bifrontal slowing and then frequent right hemisphere or left frontal slowing suggesting multifocal subcortical abnormalities. However, there were no areas of persistent slowing and no epileptiform features. Carotid studies showed minimal plaques with bilateral less than 40% carotid stenosis. Serial CAT scans of the head revealed stable appearance of the right subdural hematoma and right frontal craniotomy. HOSPITAL COURSE: 1. LEFT FACIAL DROOP AND WEAKNESS: The patient was admitted to the Neurosurgical Service and Neurology consult was obtained. It was felt that the patient's symptoms were likely due to local irritation from the subdural hematoma and much less likely to be due to stroke. However, the patient subsequently underwent several echocardiograms. Transesophageal echocardiogram revealed a definite thrombus in the left atrial appendage along with dilated right atrium and severe global left ventricular hypokinesis. Therefore, it was felt that the patient's symptoms may be due to TIAs resulting from small emboli from his left atrial thrombus. The patient was transferred to the Medicine Service and seen by Cardiology in consultation. It was felt that the patient will require anticoagulation for this left atrial thrombus in preparation for eventual cardioversion. However, due to his recent subdural hematomas and craniotomy there was concern that anticoagulation with an INR of [1-30] result in a recrudescence of his subdural hematoma. After multiple serial CAT scans, the Neurosurgical Service thought that it was safe to anticoagulate the patient to a goal INR of 1.5 to 1.8 with the hopes of increasing that INR goal to 2.0 within two to three weeks if the subdural hematomas remain stable on serial CAT scans. The patient was started on Coumadin on the day of discharge. His Coumadin dose was 4 mg and his INR was 1.4. He will take 4 mg of Coumadin on [2169-11-25] and 3 mg of Coumadin on [2169-11-26] and will have his INR checked on Monday, [2169-11-27] and have this result called into his cardiologist, Dr. [Last Name (STitle) ], who will adjust his Coumadin dose. 2. ATRIAL FIBRILLATION: The patient on admission was in atrial fibrillation with a rapid ventricular response with a heart rate ranging from 90s to 150s. The patient had low systolic blood pressures with his rapid ventricular rate with systolic blood pressures in the mid 80s to mid 90s. An attempt was made to medically control his rapid ventricular rate; however, the patient did not respond to increased Amiodarone, digoxin, and increased beta blockers. Therefore, the Electrophysiology Service was consulted and the patient underwent an AV junction ablation and his ICD was reprogrammed to DDD. His digoxin was discontinued. He was continued on his daily Amiodarone dose of 200 mg and he was switched from Lopressor to Carvedilol 3.125 mg p.o. b.i.d. The patient will follow-up with Dr. [Last Name (STitle) 73] in the Device Clinic. 3. CONGESTIVE HEART FAILURE: The patient was maintained on a beta blocker, statin, spironolactone, Lasix, and an angiotensin receptor blocker. He was instructed to weight himself daily and to call his primary care physician if his weight increased by more than 5 pounds as he would likely need extra Lasix doses. He also was instructed to maintain a 2 gram sodium diet and to try to restrict his fluid intake to 1.5 to 2 liters per day. 4. ASPIRATION PNEUMONIA: During the hospital stay, the patient developed a mildly productive cough with right-sided pleuritic chest pain and was found to have a right lower lobe aspiration pneumonia on his chest x-ray. He was started on a seven day course of Levaquin and Clindamycin which he will complete as an outpatient. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To home with follow-up. DISCHARGE INSTRUCTIONS: Please have your INR checked on Monday, [2169-11-27], and have the results called in to Dr. [Last Name (STitle) ] as he will need to adjust your Coumadin dose to keep your INR at around 1.8. Please follow-up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 73], telephone number [Telephone/Fax (1) 902]. Please follow-up with Dr. [Last Name (STitle) ], [0-0-], within one week of discharge. DISCHARGE DIAGNOSIS: 1. Subdural hematoma. 2. Left atrial thrombus. 3. Atrial fibrillation with rapid ventricular response. 4. Aspiration pneumonia. 5. Congestive heart failure with an ejection fraction of 25%. DISCHARGE MEDICATIONS: 1. Lipitor 10 mg daily. 2. Lasix 20 mg alternating with 40 mg every other day. 3. Amiodarone 200 mg q.d. 4. Valsartan 40 mg p.o. daily. 5. Coumadin 4 mg on [2169-11-25] and 3 mg on [2169-11-26], have your INR checked on [2169-11-27] and have your dose adjusted by Dr. [Last Name (STitle) ] on that day. 6. Aspirin 81 mg daily. 7. Carvedilol 3.125 mg p.o. b.i.d. 8. Clindamycin 450 mg p.o. q.i.d. for five days. 9. Levofloxacin 500 mg p.o. q.d. for five days. 10. Spironolactone 12.5 mg p.o. daily. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 8471], M.D. [MD Number(1) 18174] Dictated By:[Last Name (NamePattern1) 9609] MEDQUIST36 D: [2169-11-24] 02:49 T: [2169-11-25] 18:34 JOB#: [Job Number 102460]	[ "E929.0", "507.0", "852.21", "425.4", "427.31", "424.90", "435.8", "428.0", "496" ]	icd9cm	[ [ [] ] ]	[ "89.39", "37.34", "37.26", "88.72" ]	icd9pcs	[ [ [] ] ]							1870, 2001		7883, 8690	7664, 7860			3776, 7102		7205, 7643	1431, 1731																																					2016, 3758						1146, 1408	1748, 1853	7127, 7180
11,280	185,210	7942	Discharge summary	report	Admission Date: [2130-5-20] Discharge Date: [2130-6-12] Date of Birth: [2087-5-28] Sex: M Service: Transplant HISTORY OF THE PRESENT ILLNESS: The patient is a 42-year-old male status post pancreas transplant in [2129-10-10] and kidney transplant in [2127], who presented with a lower GI bleed, aspiration pneumonia, E. coli sepsis, and worsening kidney function. The patient was admitted to the surgical tagged red cell scan that revealed a likely bleeding source in the mid jejunum. It was felt that due to this instability and immunosuppression that was onboard, endoscopy would not be pursued by the gastroenterology. Once his GI bleed was stabilized and resuscitated adequately, he was ultimately discharged to the floor. dependent diabetes times 35 years. He has coronary artery disease and he has a myocardial infarction in the past; end-stage renal disease; and he was transplanted in [2127]; he had a pancreas after kidney transplantation in [2129-10-10]. He has no history of COPD. The patient's pancreas transplantation does have an enteric anastomosis. HOSPITAL COURSE: (by system) NEUROLOGICAL: The patient was admitted in extremis secondary to GI bleed issues. He was ultimately intubated due to his question of aspiration. He was serially weaned off the vent. He did require protracted ventilatory support. Ultimately, he was extubated on [2130-6-4]. He was noted to have a high O2 requirement and large bilateral effusions. These were ultimately tapped on [2130-6-9]. The left pleural effusion was tapped for a total of 600 cc. The right pleural effusion was tapped for a total of 520 cc. This was a sterile transudative tap. The white cells were [Pager number ]; red cells [Pager number ]; total protein 0.8; glucose 125; LDH 92; albumin less than 10. No cultures were positive from the portal tap and it was presumed to be just to be secondary to likely volume issues and acute inflammatory response and his acute inflammatory response and his gram-negative rod sepsis. At the time of discharge, the patient had a discharge x-ray showing a left pleural effusion greater than right, but decreased status post tap. He was requiring nasal cannula O2 for a total of approximately two liters to four liters to keep his saturations between 92% to 95% on room air. He was getting Albuterol and ipratropium MDI p.r.n. He will continue his aggressive pulmonary toilet and work with the Department of Physical Therapy to get control of his pulmonary status. It is possible that he has a component of reactive airway disease induced secondary to his question aspiration pneumonia and prolonged ventilation in the ICU. CARDIAC: The patient has a history of CAD, status post MI. He did not have MI this time, nor did he have any ischemic changes on EKG, ICU, or floor stay. He was being maintained on Isordil 10 mg t.i.d.; Diltiazem 60 mg q.i.d. At the time of discharge, the blood pressure was ranging 140 to 150/60 diastolic. Heart rate was begun 70 and 80 and, otherwise, stable. Most recent EKG was on [2130-5-27] showing normal sinus rhythm, no ST/T segment changes; no evidence of ischemia. FEN/GASTROINTESTINAL: The patient had worsening BUN and creatinine requiring some dialysis early on in the course, likely secondary to the angiography dye. He was on dialysis for several days and then ultimately he was weaned off it once the allograft nephropathy improved. BUN and creatinine at the time of discharge were 55 and 4.4 and he was making approximately 1000 cc per day; not requiring any more hemodialysis support. He was tolerating diet appropriately. Discharge chemistries were the following: 143 sodium, 4.4 potassium, 112 chloride, 22 bicarbonate, 58 BUN, creatinine 4.3, and blood glucose 113. The patient had received intermittent dosing of Lasix during his stay for his volume issues, but at the time of discharge, he was not on any standing dose of Lasix. He is getting aluminum hydroxide 5 cc to 10 cc q.8, as well as Renagel 800 mg t.i.d. and Protonix 40 mg q.d. The patient is still getting sodium bicarbonate 13 mg p.o.b.i.d. for some slight persistent acidosis secondary to his allograft dysfunction as the Renal Department had been following and recommending this to continue. GU/RENAL: The patient had a Foley during his resuscitation and intubation course in the ICU. This was ultimately removed approximately a week prior to discharge. He was off dialysis and actually making adequate urine up to 1100 cc to 1800 cc per 24 hours, but usually around 1000 per 24 hours. BUN and creatinine are as stated above. Otherwise, somewhat stable. He does have chronic allograft nephropathy, as previously stated. ENDOCRINE: After the pancreas transplantation, the patient was not insulin requiring. Although, during his course here he did require intermittent dosing of Insulin to control his blood sugars, as he had insulin resistance as a result of his bacteremia. Otherwise, the blood sugars ranged anywhere from 122 to 198. He, otherwise, seems to have good pancreatic allograft function. HEMATOLOGY: The patient did received a 21 day course of Levaquin for a blood culture from [5-23] revealing E. coli. This was also positive from [5-22]. The patient had blood cultures from [5-30], but had no growth. Gram stain of the pleural fluid from [6-8] was negative. He had an RPR during his stay for metal status issue workup, which was negative from [2130-6-4]. He had a C. difficile assay for loose stools from [6-3]; negative times two. Cap tip from the central line was sent off on [6-2] and was negative. Bronchial/alveolar lavage had been performed on [2130-5-25], two days into this patient's admission revealing gram-negative rods. He was treated for presumed aspiration with Clindamycin, Ceftazidime, and Levaquin and this was carried out for a total of 14 days. The E. coli in his blood was treated for 21 days with Levaquin. He did have HSV type I and II, as well as Varicella Zoster. Culture sent and assay sent on [2130-5-30] were also negative. On [5-25] he had blood cultures, which were sent, which were additionally negative. The patient will continued on Epogen dose of 4000 subcutaneously two times per week. At the time of discharge, the patient's CBC revealed the following: White count 5.8, hematocrit 28, platelet count 80, and he was somewhat thrombocytopenic. He was off any DVT prophylaxis. He was no longer getting any heparin flush or any subcutaneous heparin. He was not on any H2 antagonist as he was getting PPI. Platelet count was stable and he had no evidence of bleeding at this point. He remained afebrile for more than a week prior to discharge. Temperature maximum on the day of discharge was 99.4. Prophylaxis antibiotics include Valcyte 450 mg p.o.q.d.; Bactrim single strength one tablet p.o.q.d. IMMUNOSUPPRESSION: The patient will go out on Rapamycin 1 mg q.d., Prednisone 5 mg q.d.; CellCept [Pager number ] mg q.i.d.; Rapamycin level at the time of this dictation was pending. The last Rapamycin level that we have for this patient is from [2130-6-6], which was 17.3. The patient was on Prograf during his hospitalization here and this was ultimately stopped. TUBES, LINES, AND DRAINS: At the time of discharge the patient had only had a peripheral IV, which was removed. He no longer had a Foley catheter and no central access. He has an old A-V loop graft on his left arm from his previous dialysis-therapy days. DISPOSITION: The patient is to be discharged to rehabilitation, where he will continue to get PT/OT consultation, as well as aggressive pulmonary toilet issues. He will follow up with the Pulmonology Clinic as an outpatient. Dr. [Last Name (STitle) ] felt that the patient did not require inpatient consultation as he was stable, otherwise. He may ultimately require some home oxygen depending on how he does during his rehabilitation stay. After he has completed approximately a one week rehabilitation stay, he will be likely discharged to home after which time he should be following up in the [Hospital 1326] Clinic. He will require a laboratory draw during his stay at the rehabilitation facility, including CBC, BMP with calcium-magnesium phosphatase, as well as a Rapamycin level. These should be sent to the Transplant Office at [Last Name (NamePattern1) 21589], [Location (un) 86], MS. DISCHARGE DIAGNOSES: 1. GI bleed secondary to platelet dysfunction, aspirin, and uremia. 2. Allograft nephropathy. 3. Aspiration pneumonia ADDITIONAL FOLLOW-UP INSTRUCTIONS: The patient will have his endoscopy, esophagogastroduodenoscopy, and colonoscopy to be done as outpatient as this was not done during his hospitalization here. The GI attending will be Dr. [First Name8 (NamePattern2) 1158] [Last Name (NamePattern1) 679]. He will perform the procedure. The patient will followup with Dr. [Last Name (STitle) ] as well. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 3598], MD [MD Number(1) 3599] Dictated By:[Last Name (NamePattern4) 3204] MEDQUIST36 D: [2130-6-12] 09:02 T: [2130-6-12] 09:11 JOB#: [Job Number 28506]	[ "585", "511.9", "996.81", "250.01", "276.2", "038.42", "584.9", "507.0", "578.9" ]	icd9cm	[ [ [] ] ]	[ "34.91", "96.6", "38.93", "96.56", "96.04", "38.95", "88.47", "33.23", "96.72" ]	icd9pcs	[ [ [] ] ]								8515, 8645					1137, 8494																																											8670, 9313

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