ChanBeDu/relevant_section_length · Datasets at Hugging Face

17,758

183,648

46249

Discharge summary

report

Admission Date: [**2117-2-1**] Discharge Date: [**2117-2-5**] Date of Birth: [**2058-5-20**] Sex: F Service: ICU HISTORY OF PRESENT ILLNESS: The patient was admitted for severe metabolic acidosis and hypotension. The patient is a 58 year-old woman with a complicated past medical history who was recently admitted from [**2116-12-4**] to [**2117-1-16**] with multiple graft infections requiring revision. She was again admitted on [**1-13**] to [**2117-1-26**] for similar complaints. On that admission she had a tonic clonic seizure. Workup included a head CT, which showed multiple "abnormalities" in the frontal and occipital lobes and question of metastatic disease versus infarct disease. An LP was done on that admission, which was unremarkable. She was started on Dilantin. A transesophageal echocardiogram was done given her recent history of MRSA bacteremia to rule out cardioembolic phenomena. This was negative as was the carotid ultrasound. Further management consisted of starting the patient on aspirin. All chest x-rays throughout that admission were negative. She was discharged to [**Hospital3 **] where staff states she just was not herself. She was progressively more lethargic and confused. On the day of admission after hemodialysis she was found to be hypotensive. She was brought to the Emergency Department for further evaluation. She was found to be hypotensive in the Emergency Room with systolics in the 80s. She was started on Dopamine and Neo-synephrine was subsequently added on. She was placed on Levo and Flagyl and she was intubated and admitted to the MICU for further management. PAST MEDICAL HISTORY: 1. Coronary artery disease. 2. Diabetes type 2. 3. End stage renal disease. 4. Cerebrovascular disease. 5. Congestive heart failure. 6. Peptic ulcer disease. 7. Peripheral vascular disease. 8. Hypercholesterolemia. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Protonix. 2. Aspirin. 3. Prednisone. 4. Multivitamin. 5. Zocor. 6. Dilantin. PHYSICAL EXAMINATION ON ADMISSION: Blood pressure 107/67. Heart rate of 96. Respirations 24. She was intubated on examination. The patient was sedated and on the vent. Pupils are equal, round and reactive to light. Her endotracheal tube was in place. Her neck was supple. Cardiac examination demonstrated normal S1 and S2 with no murmurs. Chest was clear anteriorly. Abdomen she had absent bowel sounds, firm. Extremities were cool throughout. Her distal pulses were not palpable in the lower extremities. She had dopplerable femoral pulses. She had a necrotic right second digit. LABORATORIES ON ADMISSION: White blood cell count was 16.0 with 92% neutrophils, 5.2 lymphocytes and 0 basophils. Her hematocrit was 26.8, platelets were 111. INR 1.3. Chem 7 showed a sodium of 146, potassium 3.2, chloride 102, bicarb 20, BUN 24, creatinine 2.9 and glucose of 256. She had a lactate of 19. Her electrocardiogram showed sinus tachycardia at 110 beats per minute with a normal axis. HOSPITAL COURSE: The patient is a 58 year-old woman with multiple medical problems including three vessel coronary artery disease, diabetes, hypercholesterolemia, severe peripheral vascular disease complicated by multiple cerebrovascular accidents and multiple lower extremity bypasses now being admitted in presumed septic shock after dialysis treatment on the morning of admission. In terms of the patient's shock she was treated according to the Must protocol. She got aggressive blood pressure support including intravenous fluids. She was on Vasopressin and Levophed. Broad spectrum antibiotics were started including Vancomycin, Gentamycin and Flagyl. Her central venous pressure was monitored. She received blood transfusion to keep her hematocrit above 30. In terms of the coffee ground emesis that was found in the Emergency Room she was started on intravenous Protonix. Surgery was asked to follow her for this reason as well as her severe peripheral vascular disease. The Vascular Surgery team saw the patient and felt that her lower extremity graft that she had recently had revised had most likely clotted. The General Surgery team saw the patient and felt that she was most likely experiencing ischemic bowel, but given her comorbidities no surgical intervention was indicated. As per the patient's family and a long discussion with the attending the patient was made DNR/DNI. Over the next couple of days of the patient's admission she continued to show little signs of improvement. She remained on two pressors for blood pressure support. Her pressure would drop precipitously if one pressor was removed. her mental status remained very poor, very sedated and lethargic without any pharmacological sedation. Given the poor prognosis of the patient and prolonged discussion with the family the patient was made comfort measures only and all pressors were withdrawn from the patient. The patient died on hospital day five at 11:10 p.m. at night. DISCHARGE DIAGNOSIS: Sepsis. DISCHARGE MEDICATIONS: Not applicable. FOLLOW UP PLANS: Not applicable. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-AAN Dictated By:[**Last Name (NamePattern1) 3809**] MEDQUIST36 D: [**2117-4-27**] 02:08 T: [**2117-4-28**] 06:38 JOB#: [**Job Number 98317**]

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icd9cm

[ [ [] ] ]

[ "99.04", "96.04", "38.93", "96.71", "00.14" ]

icd9pcs

[ [ [] ] ]

5062, 5348

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159, 1648

2652, 3029

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15,370

189,034

10492

Discharge summary

report

Admission Date: [**2149-7-27**] Discharge Date: [**2149-8-4**] Service: MEDICINE Allergies: Heparin Agents Attending:[**First Name3 (LF) 4760**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: Cystoscopy Cystolithostomy Left ureteral stent placement History of Present Illness: 87 y/o F NH resident with PMH of CAD, dCHF, COPD on home O2 p/w LLQ pain. The pain, which was new for her, began the night prior to admission, as a severe intermittent sharp pain [**8-24**]. She distinguishes this from pain she often feels in her right abdomen after meals. She reports having been treated for a UTI which caused her to have urinary frequency and dysuria, but that the infection came back. The pain was unrelated to meals, and was associated with nausea, as well as vomiting the morning of admission. She also noted diarrhea, but unrelated to the abdominal pain. She did not have CP, SOB, cough, wheezing, orthopnea, hematuria, or edema. Blood work at the NH revealed WBC 20,000 so the patient was referred to the ED. In the ED T102.8 HR 97 BP 55/35 RR 24 92% RA. She received 2 L NS, repeat BP was 101/45. Rec'd additional 3L NS without much improvement in BP. UOP 150 cc in 3.5 hr. Blood and urine cultures were sent. Rec'd [**Month/Year (2) 1378**] 750 IV, vanco 1 g IV, flagyl 500 mg IV for LLL infiltrate on CXR and +U/A. The patient is DNR/DNI, and refused central line placement. She was transferred to the ICU for further management of hypotension. V/S upon transfer to the ICU T 96.2 HR 82 BP 85/40 RR 18 O2sat 99% 4LNC. Past Medical History: CAD, MI [**2-/2142**] RCA stent placed in [**2142**] & [**2146**] COPD on home O2 gastritis seizure disorder HTN dilantin toxicity peripheral neuropathy hypothyroidism spinal stenosis left THR bilateral TKR appendectomy TAH Social History: Lives at [**Hospital 100**] Rehab x ~2 yrs,former 60+ pack-yr smoker, denies illicits/etoh Family History: Non-contributory Physical Exam: V/S: T 96.8 HR 85 BP 87/61 RR 17 O2sat 95% 4L GEN: Awake, conversant, NAD HEENT: PERRL, OP clear w/ dry MM NECK: JVD not appreciated CV: RRR nl S1S2 no m/r/g PULM: diffuse wheezes, bibasilar rales L>R ABD: soft ND minimally tender in LLQ to deep palp +BS, no rebound, no guarding EXT: warm, dry +PP trace pitting edema bilat NEURO: A&Ox3 Pertinent Results: ADMISSION LABS: [**2149-7-27**] 06:20PM BLOOD WBC-16.6*# RBC-3.67* Hgb-11.9* Hct-36.3 MCV-99*# MCH-32.4* MCHC-32.7 RDW-14.5 Plt Ct-189 [**2149-7-27**] 06:20PM BLOOD Neuts-87* Bands-7* Lymphs-4* Monos-2 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2149-7-27**] 06:20PM BLOOD PT-12.6 PTT-33.3 INR(PT)-1.1 [**2149-7-27**] 06:20PM BLOOD Glucose-92 UreaN-39* Creat-1.8* Na-140 K-5.8* Cl-106 HCO3-21* AnGap-19 [**2149-7-28**] 01:51AM BLOOD ALT-18 AST-31 CK(CPK)-121 AlkPhos-70 TotBili-0.3 [**2149-7-28**] 01:51AM BLOOD CK-MB-6 cTropnT-LESS THAN [**2149-7-28**] 01:51AM BLOOD Albumin-2.9* Calcium-6.9* Phos-2.9# Mg-1.7 [**2149-7-28**] 01:51AM BLOOD VitB12-256 Folate-10.1 [**2149-7-27**] 06:19PM BLOOD Lactate-4.2* MICROBIOLOGY: [**2149-7-28**] C. diff: negative [**2149-7-27**] Blood cultures, two sets: GNR [**2149-7-27**] Urine cultures: pending EKG - SR HR 96 LAD RBBB (old) TWI V4-V6 (new), no ST elev/depr. c/w exam [**2147-11-7**] Imaging: [**2149-7-27**] CXR: (dictation) cardiomediastinal silhoutte unchanged, hazy opacity at LL base effusion/atelectasis vs. infiltrate, likely small right pleural effusion. [**2149-7-27**] CT ABD:no evidence of diverticulitis or bowel obstruction. moderate stool in rectum. moderate left hydronephrosis and hydroureter, with prominent perinephric and periureteral stranding. possible obstructing 6 mm stone at left UVJ, though eval limited by artifact from left hip prosthesis. Given clinical and UA findings, concerning for obstructive pyelonephritis, though without IV contrast, this cannot be confirmed. cardiomegaly and extensive vascular calcification. large hiatal hernia. [**7-30**]: Abd/pelvis CT: 1. Renal ureteric and bladder calculi. The calculus in the left mid-ureter region appears to have increased in size from 6 mm to 8 mm. 2. Moderate left hydronephrosis and hydroureter with perinephric and periureteral inflammatory stranding. 3. Newly developed peripancreatic fat stranding is concerning for acute pancreatitis. 4. Mild intra-hepatic biliary duct dilatation, most likely secondary to previous cholecystectomy. The common bile duct is mildly dilated with presence of stone. 5. Lung bases consolidations bilaterally, slightly increased on the right side than the previous examination. 6. Calcified lung granulomas which are stable from the previous examinations. 7. Extensive vascular calcification consistent with significant atherosclerotic disease. There is also saccular infrarenal abdominal aortic aneurysm. 8. Large hiatal hernia. [**2149-7-31**] ECHO: IMPRESSION: no clear-cut evidence of endocarditis or abscess. The non and right cusps of the aortic valve have focal thickening and calcification, most likely representing age related changes. A chronic, healed vegetation is also a possibility but not likely. Mild focal LV systolic dysfunction. Diastolic dysfunction. Mild mitral regurgitation. Moderate pulmonary artery systolic hypertension. Compared with the prior study (images reviewed) of [**2147-10-3**], the calcifications on the aortic valve are slightly larger. Diastolic dysfunction is now evident. There is now pulmonary artery systolic hypertension. The other findings are similar. [**8-2**] CXR: FINDINGS: In comparison with the study of [**7-28**], there is little change. Enlargement of the cardiac silhouette persists with mild prominence of interstitial markings that could reflect elevated pulmonary venous pressure, chronic lung disease, or both. Left basilar opacity most likely represents a combination of effusion and atelectasis, though superimposed infection cannot be excluded. The right lung remains clear. DISCHARGE LABS: ============== COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2149-8-4**] 06:55AM 7.7 2.96* 9.5* 28.2* 95 32.2* 33.8 13.5 250 RENAL & GLUCOSE Glu UreaN Creat Na K Cl HCO3 AnGap [**2149-8-4**] 06:55AM 100 15 0.9 146* 4.3 109* 30 11 Brief Hospital Course: A/P: 87 y/o F h/o CAD, COPD, HTN a/w sepsis in the setting of UTI with c/f obstructive pyelonephritis, and PNA. She was admitted to the ICU [**Date range (1) 34617**]. . #klebsiella bacteremia/ urosepsis - obstructing left-sided stone and +U/A. Has had multidrug resistant urinary pathogens in the past, including Klebsiella and Proteus sp. that were sensitive to meropenem and zosyn. Diverticulitis or colitis less likely based on CT findings. 4/4 bottles GNR returned while in the [**Hospital Unit Name 153**]. Patient was treated with meropenem for hx ESBL UTIs. We also covered for PNA with [**Last Name (un) 2830**], vanco, and azithro given possible infiltrate. Her antibiotics were narrowed to meropenem when cultures finalized. Her BC on [**7-29**] was still + GNR, BC from [**7-31**] and [**8-1**] with no growth to date. She will need to remain on total 2 week course of antibiotics (Meropenem started [**7-27**] so should complete course [**8-11**]. A PICC line was placed under IR on [**2149-8-4**] for administration of IV antibiotics. #Obstructive ureteral stone: had stone on left urinary system. Urology attempted perc IR nephrostomy but were unsuccessful so she went to the OR on [**8-1**] for cystoscopy and stent placement. She was on flomax for 4 days per urology recommendations but was stopped after stent placement. She has had blood-tinged urine after procedure. HCT remained stable. This should clear over next couple days. She will need outpatient urology follow up. Please see appt scheduled. . #Diarrhea - she had several loose stools in the setting of multiple bowel meds while on her home narcotics. She was not OOB very much due to her illness, so her pain was much better, not requiring the opioids. Three c. diff samples were negative. Bowels stabilized. She then had not had BM for two days and bowel meds were restarted. #ARF - b/l Cr 0.8; BUN:Cr ratio c/w pre-renal physiology in the setting of sepsis, likely has element of obstructive uropathy as well. Thought primarily prerenal in setting of infection. Cr improved during ICU stay with IVF. Discharge creatine was at baseline(0.7). Foley d/c'd on [**8-2**]. Uriantely without difficulty. #Hypertension/Orthostatic hypotension: She had persistently elevated blood pressures to sbp 140-160, discussed with PCP [**Last Name (NamePattern4) **]. [**Name (NI) 34618**] and midrodine was held as it was initiated previously for severe hypotension (orthostatic). The patient was found to drop her SBP from 130s to 80s from laying to standing, so it was restarted. . #CAD: The patient was found to have new lateral TWI on EKG, no symptoms ACS, likely demand ischemia in the setting of sepsis/hypotension. Enzymes were cycled and were negative. Statin was added, but beta blocker and ACE inhibitors were not started given the patients history of severe orthostatic hypotension. She was continued on [**Name (NI) **]. . #diastolic CHF: on day of discharge she seemed mildly volume overloaded on exam. She was given lasix 10mg IV x1. Labs then came back and Na and Cl slightly elevated at 146 and 109. She was given 750cc D5W. During this time her O2sat remained stable at 95% RA. Please check lytes in am. #COPD: She was continued on advair and combivent nebs . #Prophylaxis: venodynes, PPI, bowel regimen . #CODE STATUS: DNR/DNI: no lines or pressors per d/w patient Medications on Admission: acetaminophen 975 mg PO QID alendronate 70 mg PO qThurs [**Name (NI) **] 81 mg daily TUMS 650 PO BID cholecalciferol 1000 U PO daily docusate 250 mg PO qAM advair 250/50 1 INH [**Hospital1 **] levothyroxine 75 mcg PO daily lidocaine patch 5% top neck midodrine 5 mg PO TID mirtazapine 30 mg PO qHS morphine sulfate 4 mg SL QID omeprazole 40 mg PO daily senna 2 tab PO BID sorbitol 15 ml PO daily zolpidem 10 mg PO qhs combivent nebs PRN maalox 30 ml PO q4h PRN indigestion lorazepam 0.5 mg q8h/prn anxiety Discharge Medications: 1. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QTHUR (every Thursday). 2. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day): rinse mouth with water and spit after using. 4. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): to neck, on 12hrs/day. 6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 9. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day). 10. Zolpidem 10 mg Tablet Sig: One (1) Tablet PO at bedtime. 11. Mirtazapine 30 mg Tablet Sig: One (1) Tablet PO at bedtime. 12. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation QID (4 times a day). 13. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed for wheezing/SOB. 14. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q12H (every 12 hours): Last dose 7/28 am. 16. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO twice a day. 17. Docusate Sodium 100 mg Tablet Sig: Two (2) Capsule PO DAILY (Daily). 18. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 19. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 20. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 21. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 22. Midodrine 5 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 23. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary Diagnosis: Klebsiella bacteremia Urosepsis Ureteral stone Acute renal failure Diarrhea Secondary Diagnosis: COPD CAD Hypothyroidism Chronic pain Anxiety Orthostatic hypotension Discharge Condition: Good Discharge Instructions: You were admitted with an infection in your urine and your blood that required IV antibiotics. You had a kidney stone and had a stent placed. You will need to remain on IV antibiotics for a total of 14 days. Follow- up with Dr. [**Last Name (STitle) 3748**] in urology on [**8-28**] at 8:30am. Return to [**Hospital1 18**] emergency for fever, chills, nausea, abdominal or flank pain. Followup Instructions: 1. Urology Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 274**] or [**Telephone/Fax (1) 164**] Date/Time:[**2149-8-28**] 8:30 2. electrolytes on [**8-5**]

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icd9cm

[ [ [] ] ]

[ "57.0", "59.8", "87.74", "38.93" ]

icd9pcs

[ [ [] ] ]

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22323

Discharge summary

report

Admission Date: [**2158-9-11**] Discharge Date: [**2158-9-15**] Service: [**Last Name (un) **] Allergies: Coumadin / Sulfa (Sulfonamides) / Penicillins Attending:[**First Name3 (LF) 5880**] Chief Complaint: fall Major Surgical or Invasive Procedure: 1. Casting of Left forearm for Colles fracture 2. Hinge casting of bilateral lower extremities for spiral fracture of the right distal femoral diaphysis extending to the supracondylar region and oblique fracture of the distal left femur metaphysis 3. Placement of percutaneous left nephrostomy tube 4. Transfusion of 2U PRBC History of Present Illness: 82 y.o. female nursing home resident who fell during transfer from bed to wheelchair on [**2158-9-9**]. The patient landed on her knees bilaterally and struck her nose on the bed. After this event, she complained of bilaterally leg pain. On [**2158-9-10**] X-rays were taken at the nursing home, showing bilateral femur fractures. She was then transferred to [**Hospital1 18**] for treatment. Past Medical History: A fib HTN Depression Non-insulin dependent DM Chronic venous stasis w/ hx of foot ulcers Bilateral hip fractures s/p bilateral hip replacement Osteoporosis Arthritis Degenerative joint disease Chronic UTI Social History: lives at [**Location 58139**] [**First Name9 (NamePattern2) 58140**] [**Doctor First Name 533**] center for extended care has two goddaughters who both have POA: [**Name (NI) 58141**] [**Name (NI) 58142**] and [**Last Name (un) **] [**Name (NI) 58143**] Family History: non-contributory Physical Exam: on arrival to the ED vitals: Temp 101.6 rectal HR 138 BP 153/52 RR 23 Sats 100% on NRB FSBG 280 GEN: awake, alert, able to answer yes and no to questions, follows commands NAD HEENT: PERRL, EOMI, right perorbital ecchymosis, midface stable, no oral pharyngeal trauma NECK: c-collar in place, trachea midline CHEST: equal BS bilaterally CV: irregularly irregular, no M/R/G ABD: SNTND PELVIS: stable to AP and lateral compression RECTAL: normal tone, no gross blood, heme neg BACK: no palpable step-offs, no visible abrasions EXT: left wrist swelling and ecchymosis, Right leg in flexion, no grossly apparent deformities of bilateral LE Skin: warm, dry, intact NEURO: CN II-XII intact, able to move all 4 ext, no apparent motor or sensory deficits Pertinent Results: [**2158-9-10**] 10:11 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST IMPRESSION: 1) No evidence of acute traumatic intraabdominal injury. 2) 9 mm obstructing stone in the proximal left ureter with moderate hydronephrosis. CT evidence of bilateral pyelonephritis [**2158-9-10**] 10:11 PM CT C-SPINE W/O CONTRAST; CT RECONSTRUCTIONIMPRESSION: Severe degenerative changes and demineralization. No definite acute fracture seen. [**2158-9-10**] 10:10 PM CT HEAD W/O CONTRAST IMPRESSION: Likely remote right MCA distribution infarct. Subacute to chronic right PCA distribution infarct, but exact timing is indeterminate without a prior study. MRI could be performed for further evaluation, if the patient is a candidate for MRI [**2158-9-10**] 9:36 PM ELBOW (AP, LAT & OBLIQUE) LEFT; WRIST(3 + VIEWS) LEFTIMPRESSION: 1. Suspicion for fracture of the radial head. 2. Colles' fracture. [**2158-9-11**] 3:57 PM L-SPINE (AP & LAT); T-SPINE IMPRESSION: 1. Loss of height in multiple midthoracic vertebral bodies and in the L1 vertebral body. These are of uncertain chronicity. 2. Grade I anterolisthesis of L4 on L5. 3. Diffuse demineralization. No acute fracture can be identified, noting that evaluation is limited in the presence of diffuse demineralization. [**2158-9-11**] 12:52 AM FEMUR (AP & LAT) BILAT There is a spiral fracture of the right distal femoral diaphysis extending to the supracondylar region. There is an oblique fracture of the distal left femur metaphysis. Neither of these fractures appear to extend intraarticularly. There is posterior displacement of the distal fracture fragments bilaterally. There is diffuse demineralization. Degenerative changes are seen in both knees. There is a dynamic compression screw in the proximal right femur with extensive foreshortening of the femoral neck region and associated heterotopic bone formation. A bipolar left hip prosthesis is present without evidence of fracture. [**2158-9-10**] 09:10PM BLOOD WBC-21.3* RBC-3.16* Hgb-9.9* Hct-29.0* MCV-92 MCH-31.5 MCHC-34.3 RDW-13.9 Plt Ct-360 [**2158-9-11**] 08:50AM BLOOD WBC-17.6* RBC-2.44* Hgb-7.7* Hct-23.4* MCV-96 MCH-31.7 MCHC-33.1 RDW-13.7 Plt Ct-329 [**2158-9-11**] 10:35PM BLOOD Hct-27.6* [**2158-9-12**] 01:59AM BLOOD WBC-15.6* RBC-3.24*# Hgb-10.2*# Hct-29.4* MCV-91 MCH-31.4 MCHC-34.5 RDW-15.3 Plt Ct-270 [**2158-9-12**] 03:47PM BLOOD WBC-14.0* RBC-3.22* Hgb-10.3* Hct-28.5* MCV-89 MCH-32.1* MCHC-36.3* RDW-15.6* Plt Ct-250 [**2158-9-13**] 05:27AM BLOOD WBC-11.7* RBC-3.21* Hgb-10.3* Hct-28.9* MCV-90 MCH-32.0 MCHC-35.5* RDW-15.2 Plt Ct-267 Brief Hospital Course: [**2158-9-10**]: X-ray studies revealed bilateral femur fx and left Colles' fx. CT of Abd/Pelvis also revealed obstructing 9mm ureteral stone on left with bilateral hydronephrosis. The pt was empirically started on Levofloxacin for treatment of presumed pyelonephritis. The pt was initially admitted to the TSICU because she was requiring Diltiazem IV for management of her rapid a fib. Vascular and Ortho services were also consulted for evaluation of the pt's injuries. Based on clinical exam, the pt's fractures did not compromise blood flow to the lower extremities. A confirmatory angiogram was deferred secondary to the risks of the procedures and the [**Hospital **] medical comorbidities. Close neurovascular surveillence of the pt's LE was continued throughout her hospital course and no changes were noted. Orthopedics performed a closed reduction of the pt's left Colles' fracture with good success. Her left forearm was then placed in a hard cast. Urology was also consulted for the pt's obstructing ureteral stone. Their decision to place a diverting percutaneous nephrostomy tube would be determined based on the pt's urine culture. [**2158-9-11**] to [**2158-9-15**]: The pt's C-spine was cleared after flex-ex films were obtained. T/L spine films revealed old compression fx. The pt's HCT dropped to 23 and she was transfused 2U PRBC. After clearance of the pt's C-spine, she was switched to PO meds and transferred to the hospital floor. Options for treatment of the pt's bilateral femur fx were discussed and the POA's decided on non-surgical management with casting under fluoroscopy. This was performed by orthopedics and the pt tolerated the procedure well. The pt's initial urine ctx came back with diffuse contamination. Urology decided to place a percutaneous nephrostomy tube due to the high likelihood of infxn. This was performed by interventional radiology on [**2158-9-14**]. After the procedure, the pt's foley remained in place and will be removed at the nursing care facility at the request of the pt's health care POA. She had no difficulty urinating and clear urine was draining from the tube. She was tolerating PO without difficulty and placed back on all of her home meds. The bilateral hinged casts on her LE fit well with no evidence of pain, swelling, or erythema of the skin or her toes. Physical therapy worked with the pt in house to facilitate her rehab. On [**2158-9-15**] the pt was discharged home to her previous rehab facility. She will be continued on PO antibiotics for five days after discharge. Medications on Admission: 1. Bupropion HCl 75 mg Tablet Sig: Two (2) Tablet PO QD (once a day). Disp:*60 Tablet(s)* Refills:*2* 2. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*120 Tablet(s)* Refills:*2* 3. Glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 5. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO at bedtime. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Effexor 37.5 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*2* 7. Isordil Titradose 40 mg Tablet Sig: 1.5 Tablets PO once a day. Disp:*45 Tablet(s)* Refills:*2* 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* Discharge Medications: 1. Bupropion HCl 75 mg Tablet Sig: Two (2) Tablet PO QD (once a day). Disp:*60 Tablet(s)* Refills:*2* 2. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*120 Tablet(s)* Refills:*2* 3. Glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 5. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO at bedtime. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Effexor 37.5 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*2* 7. Isordil Titradose 40 mg Tablet Sig: 1.5 Tablets PO once a day. Disp:*45 Tablet(s)* Refills:*2* 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 9. Enoxaparin Sodium 40 mg/0.4mL Syringe Sig: One (1) injection Subcutaneous QD (once a day) for 6 weeks. Disp:*30 injection* Refills:*2* 10. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. Disp:*5 Tablet(s)* Refills:*0* 11. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:*90 Tablet(s)* Refills:*0* 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 533**] [**Last Name (NamePattern1) **] for Extended Care - [**Location 1268**] Discharge Diagnosis: 1. Pyelonephritis 2. A fib 3. GERD 4. Degenerative joint disease 5. Bilateral hip replacement 6. Left Colles' fracture requiring reduction and casting 7. Spiral fracture of the right distal femoral diaphysis requiring reduction and casting 8. Oblique fracture of the distal left femur metaphysis requiring reduction and casting 9. HTN 10. Depression 11. Non-insulin dependent DM 12. Chronic venous stasis w/ hx of foot ulcers 13. Osteoporosis 14. Blood loss anemia requiring transfusion 2U PRBC 15. Obstructive nephrolithiasis requiring placement of percutaneous nephrostomy tube in the left ureter Discharge Condition: Stable Discharge Instructions: You may resume your regular diet. Continue physical therapy as tolerated to help improve your movement with the leg casts. Your weight bearing status is: non-weight bearing on bilateral lower extremities and non-weight bearing on left upper extremity. You will be on the Lovenox injections for anticoagulation for a total of six weeks. Please leave the foley catheter in place until arrival at the health care facility, then it may be removed. Followup Instructions: You should follow up with Dr. [**Last Name (STitle) **] in the [**Hospital **] clinic located in the [**Hospital Ward Name 23**] building on the [**Location (un) 1773**]. An appointment has been scheduled for you on [**10-20**] @ 9:10 AM. Please call ([**Telephone/Fax (1) 58144**] if you have any questions or need to change the appointment. Prior to this appointment, please obtain AP and Lateral x-rays of bilateral femurs and an x-ray of the pt's left wrist. Please have these transported with the pt on the day of the clinic appointment so Dr. [**Last Name (STitle) **] may see the films. Follow up with Dr. [**Last Name (STitle) 770**] of Urology in 4 weeks. Call ([**Telephone/Fax (1) 58145**] to schedule an appt. The clinic is located in the [**Hospital Ward Name 23**] building. If possible, you may want to schedule the appt for the same day as your orthopedic visit.

[ "285.1", "591", "821.29", "E884.4", "592.1", "590.80", "821.22", "427.31", "813.41" ]

icd9cm

[ [ [] ] ]

[ "99.04", "79.02", "55.03", "79.05" ]

icd9pcs

[ [ [] ] ]

9740, 9875

4913, 7462

271, 597

10517, 10525

2334, 4890

11017, 11903

1534, 1552

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7488, 8348

10549, 10994

1567, 2315

227, 233

625, 1019

1041, 1247

1263, 1518

49,683

113,533

53989

Discharge summary

report

Admission Date: [**2106-8-19**] Discharge Date: [**2106-8-25**] Date of Birth: [**2066-11-7**] Sex: M Service: MEDICINE Allergies: lisinopril Attending:[**First Name3 (LF) 16851**] Chief Complaint: hypotension Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname **] is a 39M with ESRD on HD and renal cell CA with brain, pulmonary, and hepatic mets. He underwent MRI this morning on [**Hospital Ward Name 516**]. Shortly after receiving gadolinium contrast he developed worsening RLQ abdominal pain, then developed shaking of all 4 extremities. He reports that he was awake and alert throughout the episode. He was noted to be alert and oriented x3 directly afterward. BP noted to be 70s/40s on machine and manual recheck. He has had worsening RLQ pain for the last five days. Today he noticed his abdomen to be more distended than usual. Approximately one week ago his oxycodone was increased. Last HD session yesterday. Last round of chemotherapy was [**8-11**]. In ED, he received 2L NS but SBP still in 80s. Started peripheral levophed at 0.09 with response to 100s-110s. Initial VS in ED: T 98.1 HR 105 BP: 104/68 RR 22 O2Sat 97 on 4L NC In the ED, he started empiric vancomycin and cefepime for broad-spectrum coverage. CT revealed significant progression of his metastases (pulmonary, hepatic) but could not rule out pneumonia. New ascites but no evidence of appendicitis or acute abscess. Initial VS in MICU: T 98.5 HR 101 BP 105/72 RR 19 O2Sat 96% on 4L NC Past Medical History: Metastatic renal cell carcinoma: -- [**2106-3-10**]: cough x 2 weeks -- [**2106-4-15**]: Chest/Abd/Pelvis CT with pulm nodules, RUL mass, mediastinal/hilar lymphadenopathy, retroperitoneal adenopathy -- [**2106-5-3**]: Brain MRI with lesions in R choroid plexus, L parieto-occipital junction, L frontal lobe -- [**2106-5-5**]: VATS wedge resection of RUL mass; path confirmed renal cell carcinoma with clear cell features as well as the presence of a TFE3 gene fusion -- [**2106-6-10**]: CyberKnife radiosurgery to brain met -- [**2106-7-23**]: CyberKnife radiosurgery to brain met ESRD - secondary to focal glomerulonephritis, on HD since [**2089**] HTN Anxiety Past Surgical History: -multiple AV fistula placements/repairs -2 breast reduction procedures -2 operations for undescented testes -right orchiectomy -kidney biopsy -repair of a ruptured quadriceps tendon Social History: Mr. [**Known lastname **] is single. He is currently on disability. Smoked 1PPD x 20yrs and quit approximately one month ago. Prior history of alcohol dependence, but quit approximately four years ago. He has been living with friends in [**Name (NI) 1110**]. Family History: His mother is healthy at age 60. His father died at age 48 from throat cancer (he consumed cigarettes and alcohol) and colon cancer. His sister and brother are healthy but another brother has the "gene" for colon cancer and gets yearly check ups Physical Exam: At [**Hospital Unit Name 153**] admission: General: Alert, oriented, appears uncomfortable HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops. JVP flat. Lungs: Shallow breathing with accessory muscle use. Distant breath sounds, crackles at bilateral bases, no wheezes, rales, ronchi. Posterior lung fields not examined due to patient's pain attempting to sit up. Abdomen: Distended, tense, diminished bowel sounds. Nontender to palpation. Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. AV fistula in RUE; scars of prior AV fistula in LUE. R hand exquisitely tender to palpation. Neuro: CNII-XII intact, 2+ reflexes bilaterally, gait deferred. At discharge: VS: 97.4 92/60 97% on 2L pain 3 GEN: nad, laying in bed NECK: supple HEENT: op clear, poor dentition CHEST: faint wheezing anteriorly CV: rrr no m/r/g ABD: distended EXT: feet tender (chronic) no edema NEURO: AAOx3 PSYCH: appropriate, pleasant Pertinent Results: CT C/A/P on admission: 1. New enhancing hepatic mass and increased number and size of pulmonary nodules at the lung bases compatible with worsening metastatic disease. Several osseous metastatic lesions with soft tissue components are not significantly changed in the interval. 2. Worsening diffuse septal thickening, likely reflective of worsening pulmonary edema, though lymphangitic carcinomatosis is not excluded. Small bilateral pleural effusions, right larger than left. 3. New moderate volume ascites. 4. Atrophic kidneys with multiple cysts, likely related to dialysis. Dominant, peripherally calcified complex cystic lesion in the right upper pole of the kidney could reflect the patient's primary renal carcinoma. [**2106-8-24**] 09:36AM BLOOD WBC-4.3# RBC-3.18* Hgb-9.2* Hct-29.6* MCV-93 MCH-29.0 MCHC-31.1 RDW-18.6* Plt Ct-204 [**2106-8-24**] 09:36AM BLOOD Glucose-95 UreaN-22* Creat-6.5*# Na-140 K-4.2 Cl-102 HCO3-26 AnGap-16 [**2106-8-24**] 09:36AM BLOOD Calcium-9.2 Phos-4.0 Mg-1.8 [**2106-8-20**] 10:53AM ASCITES WBC-2050* RBC-1475* Polys-80* Lymphs-3* Monos-14* Atyps-0 Mesothe-3* Brief Hospital Course: Mr. [**Known lastname **] is a 39M with ESRD on HD and renal cell CA with brain, pulmonary, and hepatic mets admitted to the MICU with hypotension after receiving gadolinium during MRI on day of admission. Active Issues: --------------- # Septic shock: [**3-11**] SBP: He met SIRS criteria (HR, RR, WBC)on admission and required levophed after 2L NS with most likely etiology SBP. He was treated with ceftriaxone (see SBP for further details). Hypersensitivity reaction to gadolinium has been described but is rare, and he has previously received gadolinium. He received HD to remove gadolinum once he was hemodynamically stabilized. Adrenal insufficiency was ruled out. His shock resolved and he was transferred to the general medical floor without any further infectious issues. # SBP: He completed a course of ceftriaxone and given albumin on day 1 and day 3. He will continue on norfloxacin for prophylaxis. #New Onset Ascites: likely due to new hepatic mets and or carcinomatosis. No portal or splenic vein thrombosis seen. # ESRD: The patient received HD to remove gadolinum for MRI . He then continued on a MWF HD schedule. He had difficulty removing fluid during HD due to hypotension, which had been a problem at his out patient facility as well and so he was started on midorine. # Pain: pt with groin, leg, feet, back and abdominal pain. Pain regimen adjusted to increased home oxycontin dose, continued home oxycodone, tramadol, started naproxen and tylenol around the clock. # HTN: pt remained normo-tensive with his baseline SBP in the 100s. He was not discharged on his previous anti-hypertensive, nifedipine. # Anemia: likely [**3-11**] chronic disease and chemo. No evidence of bleeding. - cont epo # Metastatic renal cell CA: Pt had been followed by Dr. [**Last Name (STitle) 22658**] in [**Location (un) 1110**]. Will establish care in [**Location (un) 86**] with Dr. [**Last Name (STitle) **]. His records from Dr. [**Last Name (STitle) 22658**] were faxed to the new office on the day of discharge. He was found to have progression of known brain and pulmonary mets and new hepatic mets during admission. Patient and mother are aware of this. Pt expressed wishes to be resuscitated but not intubated. Explained that this was not possible. Discussed his poor prognosis of weeks to months and the likelyhood of suscessful resuscitation would be at most 5%. Patient stated that he would remain full code for now and would discuss it with his friends and mother. Medications on Admission: NIFEDIPINE 60 mg QSunday/Tues/Thurs OXYCODONE-ACETAMINOPHEN PRN TRAMADOL 50 mg TID Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H 2. Docusate Sodium 100 mg PO BID 3. Midodrine 5 mg PO TID 4. Naproxen 500 mg PO Q12H 5. Nephrocaps 1 CAP PO DAILY 6. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain hold for sedation 7. Oxycodone SR (OxyconTIN) 30 mg PO Q12H hold for sedation or RR<10, 8. Polyethylene Glycol 17 g PO DAILY Hold if patient having daily BMs. 9. Senna 1 TAB PO BID constipation 10. TraMADOL (Ultram) 50 mg PO TID 11. Lorazepam 0.5-1 mg PO Q4H:PRN anxiety 12. norfloxacin *NF* 400 mg Oral daily SBP prophylaxis Discharge Disposition: Expired Facility: [**First Name4 (NamePattern1) 5279**] [**Last Name (NamePattern1) **] Center Discharge Diagnosis: spontaneous bacertial peritonitis new hepatic metastasis of renal cell carcinoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted due to an infection in your abdomen which has been treated.You will require prophylactic antibiotics from now on to prevent this infection from returning. Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [**2106-8-31**] at 4:00 PM With: DRS. [**Name5 (PTitle) **]/[**Doctor Last Name **] [**Telephone/Fax (1) 13016**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

[ "54.91" ]

icd9pcs

[ [ [] ] ]

8359, 8456

5173, 5381

284, 291

8581, 8581

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233, 246

5396, 7670

319, 1557

4069, 5150

8596, 8733

1579, 2243

2466, 2730

20,479

141,061

49377

Discharge summary

report

Admission Date: [**2159-6-1**] Discharge Date: [**2159-6-12**] Date of Birth: [**2079-5-13**] Sex: M Service: SURGERY Allergies: Morphine Attending:[**Doctor Last Name 19844**] Chief Complaint: Trauma: fall small rigth pneumothorax with pulmonary contusion Right rib [**11-27**] Fracture (3, [**4-27**] have segmental fracture) Right scapula fracture Right clavicular fracture T2,T6,T7 transverse process fracture Major Surgical or Invasive Procedure: none History of Present Illness: HISTORY OF PRESENTING ILLNESS This patient is a 80 year old male who complains of S/P FALL. Time seen was 6:15, upon arrival. The patient fell 15-20 feet. He is complaining of right-sided rib pain. The pressure was 1:30 systolic. His heart rate was 70. He is breathing at 32-36. He has right shoulder pain according to the paramedics previous complaining of slight shortness of breath. There was no loss of consciousness. He got up and walked into his house. Past Medical History: 1. Coronary artery disease status post CABG, MVR in [**2146**]. 2. Peripheral vascular disease status post bilateral carotid stenting 3. HTN 4. RCC s/p resection 5. DM 6. AAA 7. Hyperparathyroidism Social History: Married, Russian only speaking and lives with his wife who works at [**Hospital3 328**] and translates for him. Has one daughter and two granddaughters. His daughter will drive them to and from the hospital. Family History: Father had CVA. Physical Exam: PHYSICAL EXAMINATION: upon admission: [**2159-6-1**] Constitutional: Back board and collar HEENT: Normocephalic, atraumatic, Pupils equal, round and reactive to light, Extraocular muscles intact, right occipital abrasion Neck is nontender Chest: Clear to auscultation, right chest wall tenderness Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Soft, Nontender Pelvic: Pelvis stable Rectal: Rectal is normal tone normal sensory Extr/Back: Back is nontender. There is no extremity tenderness. Right shoulder is without deformity or tenderness. Neuro: A/O X 3, CN 3-12 intact, normal sensory, normal motor, normal cerebellar function, normal gait, downgoing toes, DTRs normal Physical examination upon discharge: [**2159-6-12**] vital signs: t=97.6, hr=73, bp=152/47, rr 20, oxygen sat 90% room air General: Sitting in chair CV: Ns1, s2, -s3, ,-s4, +grade 2 systolic murmur, 2nd ICS, LSB, RSB RESP: Diminished bs right base ABDOMEN: Rounded, soft, non-tender EXT: no calf tenderness bil. Neuro: Speaking broken English, follows commands Musculskeltal: Right sided rib tenderness, right arm in sling, fingers warm, + radial pulse Pertinent Results: [**2159-6-9**] 01:25AM BLOOD WBC-6.8 RBC-3.29* Hgb-10.0* Hct-30.0* MCV-91 MCH-30.2 MCHC-33.2 RDW-14.9 Plt Ct-211 [**2159-6-8**] 12:45AM BLOOD WBC-7.8 RBC-3.26* Hgb-9.9* Hct-29.6* MCV-91 MCH-30.5 MCHC-33.6 RDW-14.7 Plt Ct-180 [**2159-6-1**] 07:45PM BLOOD WBC-13.6* RBC-4.33* Hgb-13.2* Hct-38.8* MCV-90 MCH-30.5 MCHC-34.1 RDW-14.1 Plt Ct-188 [**2159-6-9**] 01:25AM BLOOD Plt Ct-211 [**2159-6-8**] 12:45AM BLOOD Plt Ct-180 [**2159-6-1**] 07:45PM BLOOD PT-10.7 PTT-26.4 INR(PT)-1.0 [**2159-6-1**] 07:45PM BLOOD Fibrino-257 [**2159-6-12**] 06:35AM BLOOD Glucose-211* UreaN-42* Creat-1.5* Na-139 K-4.1 Cl-97 HCO3-33* AnGap-13 [**2159-6-10**] 09:23AM BLOOD Glucose-86 UreaN-46* Creat-1.6* Na-142 K-4.0 Cl-99 HCO3-35* AnGap-12 [**2159-6-9**] 01:25AM BLOOD Glucose-121* UreaN-46* Creat-1.5* Na-145 K-4.5 Cl-103 HCO3-35* AnGap-12 [**2159-6-1**] 07:45PM BLOOD UreaN-36* Creat-1.7* [**2159-6-5**] 01:15AM BLOOD CK(CPK)-224 [**2159-6-1**] 07:45PM BLOOD Lipase-52 [**2159-6-5**] 05:14PM BLOOD cTropnT-0.21* [**2159-6-5**] 01:15AM BLOOD CK-MB-4 cTropnT-0.30* [**2159-6-4**] 04:31PM BLOOD CK-MB-7 cTropnT-0.31* [**2159-6-4**] 08:26AM BLOOD CK-MB-8 cTropnT-0.23* [**2159-6-4**] 04:13AM BLOOD CK-MB-4 cTropnT-0.10* [**2159-6-10**] 09:23AM BLOOD Calcium-10.3 Phos-2.9 Mg-2.2 [**2159-6-1**] 07:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2159-6-7**] 01:38AM BLOOD freeCa-1.40* [**2159-6-1**]: EKG: Sinus rhythm. Left bundle-branch block. Occasional ventricular premature beats. Prolonged P-R interval. Compared to the previous tracing of [**2156-8-23**] no clear change. [**2159-6-1**]: chest x-ray: IMPRESSION: Limited exam. Multiple displaced right-sided rib fractures with adjacent subcutaneous emphysema. Comminuted right scapular fracture. Atelectasis versus contusions in the right lung base. [**2159-6-1**]: cat scan of abdomen and pelvis: IMPRESSION: 1. Small right pneumothorax without evidence of tension. Right upper lobe and right lower lobe pulmonary contusions. 2. Comminuted right scapular fracture with right subscapular hematoma. No evidence of active extravasation. 3. Flail chest with right 6th-8th rib segmental fractures. Multiple additional minimally displaced rib fractures as detailed above, with small associated extrapleural hematomas. Extensive right posterolateral chest wall subcutaneous emphysema. Minimally displaced right proximal clavicle fracture. 4. Multiple right thoracic vertebrae transverse process fractures, as detailed above. 5. Esophagus is fluid-filled and may predispose the patient to aspiration. 6. Intact infrarenal aortobiiliac stent-graft without evidence of endoleak. Excluded aneurysm sac measures 5.9 x 5.4 cm. [**2159-6-1**]: cat scan of the c-spine: IMPRESSION: 1. No cervical spine fracture, acute alignment abnormality, or prevertebral soft tissue abnormality. 2. Fractures of right T2 transverse process, right 1st, 2nd, and 3rd posterolateral ribs, right proximal clavicle, and right scapula. Numerous other transverse process and rib fractures are not imaged, seen on accompanying CT torso. 3. Irregular sclerosis in right aspect of C2 vertebral body. Clinical correlation with history of malignancy should be made and a bone scan can be obtained for further evaluation. [**2159-6-1**]: cat scan of the head: IMPRESSION: 1. No intracranial hemorrhage or calvarial fracture. 2. Probable subacute to chronic infarct within the right frontal lobe, with chronic infarcts in the left cerebellum and right subinsular region as well. If there is concern for an acute stroke, MR may be obtained for further evaluation [**2159-6-1**]: right shoulder x-ray: Comminuted fracture of the right scapula and displaced fracture of the right proximal clavicle. Known right-sided rib fractures are better seen on the previous CT. No dislocation. [**2159-6-4**]: Echo: IMPRESSION: Suboptimal image quality. Well seated mitral valve bioprosthesis with high normal gradient and mild mitral regurgitation. Normal left ventricular cavity size with regional systolic dysfunction c/w CAD. Pulmonary artery hypertension. Pulmonary artery hypertension. Mild aortic valve stenosis. Compared with the prior study (images reviewed) of [**2158-10-16**], the severity of aortic stenosis has increased. The mitral valve gradient, severity of mitral regurgitation, and the egional and global left ventricular systolic function are similar. [**2159-6-4**]: EKG: Sinus rhythm with ventricular premature contractions. Variable A-V conduction, possible dual A-V nodal pathways. Compared to the previous tracing of variable A-V nodal conduction is seen. The other findings are similar. [**2159-6-5**]: EKG: Sinus rhythm with atrial ectopy. Left axis deviation. Non-specific intraventricular conduction delay. Non-specific ST-T wave changes. Compared to the previous tracing of [**2159-6-4**] atrial ectopy is new. [**2159-6-6**]: x-ray of abdomen: IMPRESSION: Nonspecific bowel gas pattern with no obvious signs of ileus or obstruction [**2159-6-8**]: chest x-ray: Current study demonstrates that the patient has been extubated. Heart size and mediastinum are stable. No pneumothorax is seen on the current examination. Bibasal atelectasis and bilateral pleural effusions appear to be slightly improved as compared to the prior study. [**2159-6-10**]: chest x-ray: Heart size and mediastinum are stable. There is interval improvement in pulmonary edema with also improvement of bibasal lung aeration. Current study demonstrates no evidence of pneumothorax. Bilateral pleural effusion is most likely present. [**2159-6-3**] 5:00 pm SPUTUM Source: Induced. **FINAL REPORT [**2159-6-6**]** GRAM STAIN (Final [**2159-6-3**]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS AND IN SHORT CHAINS. 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). RESPIRATORY CULTURE (Final [**2159-6-6**]): MODERATE GROWTH Commensal Respiratory Flora. STAPH AUREUS COAG +. MODERATE GROWTH. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE. HEAVY GROWTH. Beta-lactamse negative: presumptively sensitive to ampicillin. Confirmation should be requested in cases of treatment failure in life-threatening infections.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S TETRACYCLINE---------- =>16 R TRIMETHOPRIM/SULFA---- <=0.5 S Brief Hospital Course: The patient was admitted to the acute care service after falling off a ladder and stricking a tree on the way to the ground. Upon admission he was complaining of right shoulder and rib pain. He was made NPO, given intravenous fluids, and [**Month/Day/Year 1834**] imaging. Review of the imaging showed right sided rib fractures [**11-27**] (3, [**4-27**] segmental fractures, right clavicle and scapular fracture, and T2-7 transverse process fracture. He was also reported to have a small right pneumothorax. He was admitted to the intensive care unit for monitoring where he had an epidural cathete placed for pain control with a resultant drop in his blood pressure requiring additional intravenous fluids. The epidural catheter was removed on HD #2. On HD #4, he was intubated for increased work of breathing, progressive hypoxia, and copious secretions. He was bronched with minimal remaining secretions. Sputum cultures grew MSSA and H. Flu and he was started on vancomycin, nafcillin, and ceftriaxone. The vancomycin was discontinued within 24 hours and he was maintained on nafcillin and cetriaxone. During this time, he had an eppisode of blood pressure instability where he required pressor support. He was also noted to have an irregular heart rate which was controlled with metoprolol. His pulmonary status worsened and on chest x-ray was found to have a right lung collapse requiring placement of a chest tube with re-expansion of the lung. With his hemodynamic instability, cardiology was consulted for a mild elevation in the troponins and an echocardiogram was done on HD # 4. The echo showed an ejection fraction of 40% and an increase in the severtiy of the aortic stenosis. His troponins were monitored and they gradually decreased. Recommendations were made by cardiology for resumption of his home medications. They recommended holding his metoprolol because of progression on EKG to Type 1 second degree heart block. The patient self-extubated on #5, and required re-intubation. He was reported to have periods of agitation and the weaning process was delayed. On HD #8, he developed stridor and difficulty ventilating. He was bronched and his pulmonary status markedly improved. He was extubated on HD #8. At this time his chest tube was removed and his pain medication was changed to patient controlled analgesia. On HD #9, after his pulmonary and cardiac status stabilized, he was transferred to the surgical floor. His rib pain has been controlled with oral analgesics. His vital signs have been stable. He has resumed his home medications except for his metoprolol. His intravenous antibiotics were discontinued on HD # 12 and he will start a 10 day renal course of levofloxacin for MSSA in his sputum. He has been tolerating a regular diet and voiding without difficulty. He has been instructed in the use of the incentive spirometer. He has been evaluated by physical therapy and recommendations made for discharge to an extended care facility where he can further regain his strength and mobility. Follow-up appoinments have been made with Orthopedic service, acute care service, and with his Cardiologist. Medications on Admission: amlodipine 10', lipitor 80', HCTZ 25', lisinopril 40', metformin 850', glipizide 10', metoprolol 25'', ASA' Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. Amlodipine 10 mg PO DAILY hold for systolic blood pressure <110, hr <60 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 80 mg PO DAILY 5. Calcium Carbonate 500 mg PO QID:PRN indigestion 6. GlipiZIDE 10 mg PO DAILY please monitor blood sugar 7. Heparin 5000 UNIT SC TID 8. Hydrochlorothiazide 25 mg PO DAILY 9. Lidocaine 5% Patch 1 PTCH TD DAILY rib pain apply to right posterior chest 10. Lisinopril 40 mg PO DAILY hold for systolic blood pressure <110, hr <60 11. Milk of Magnesia 30 mL PO Q6H:PRN constipation 12. Omeprazole 20 mg PO DAILY 13. OxycoDONE (Immediate Release) 5-15 mg PO Q3H:PRN pain hold for increased sedation, resp. rate <10 14. Sarna Lotion 1 Appl TP QID:PRN itching 15. Senna 1 TAB PO BID 16. traZODONE 25 mg PO HS:PRN insomnia 17. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing/shortness of breath 18. Ipratropium Bromide Neb 1 NEB IH Q6H 19. MetFORMIN (Glucophage) 850 mg PO DAILY ON HOLD...ELEVATED CREAT 1.5, resume when creat <1.5 20. Levofloxacin 750 mg PO Q48H Duration: 10 Days started on [**6-12**] 21. Docusate Sodium 100 mg PO BID hold for diarrhea Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Trauma: fall small right pneumothorax with pulmonary contusion Right rib [**11-27**] Fracture (3, [**4-27**] have segmental fracture) Right scapula fracture Right clavicular fracture T2,T6,T7 transverse process fracture Discharge Condition: Mental Status: Clear and coherent ( Russian speaking, but speaks broken English) Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital after falling from a ladder and striking a tree. You were brought to the hospital. After imaging, you were found to have several rib fractures, fractures segments to your spine, clavicle and scapula fractures, and a collapse to your lung. You were noted to have increased difficulty breathing and required a breathing tube for assistance. You were also noted to have an irregular heart rate and mild increase in cardiac blood work. You were seen by Cardiology and recommendations made for your care. Fortunately, you did not require any surgery and you are slowly recovering from your fall. Your vital signs and blood work have been stable. You are now preparing for discharge to an extended care facility where you can further regain your strength. Followup Instructions: Name: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD Specialty: Primary Care Location: [**Hospital3 249**] [**Hospital1 **]/EAST Address: [**Location (un) **], E/CC-6, [**Location (un) **],[**Numeric Identifier 2260**] Phone: [**Telephone/Fax (1) 2010**] Please discuss with the staff at the facility a follow up appointment with your PCP when you are ready for discharge. Department: ORTHOPEDICS When: TUESDAY [**2159-6-26**] at 1:20 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: TUESDAY [**2159-6-26**] at 1:40 PM With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**] Building: [**Hospital6 29**] [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: GENERAL SURGERY/[**Hospital Unit Name 2193**] With: [**First Name4 (NamePattern1) 5877**] [**Last Name (NamePattern1) 16471**], MD When: FRIDAY [**2159-6-29**] at 11:00 AM With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage You will need a chest x-ray prior to this appointment. Please go to [**Hospital1 7768**], [**Hospital Ward Name 517**] Clinical Center, [**Location (un) **] Radiology 30 minutes prior to your appointment. Please arrive at 10:30am. Completed by:[**2159-6-19**]

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icd9cm

[ [ [] ] ]

[ "96.04", "33.23", "96.6", "03.90", "34.04", "96.05", "96.72", "33.22" ]

icd9pcs

[ [ [] ] ]

14410, 14480

9952, 13112

491, 498

14746, 14746

2690, 9929

15758, 17417

1452, 1469

13270, 14387

14501, 14725

13138, 13247

14943, 15735

1484, 1484

1507, 1509

229, 453

2241, 2671

526, 988

1524, 2224

14761, 14919

1010, 1210

1226, 1436

57,276

171,108

51

Discharge summary

report

Admission Date: [**2118-7-10**] Discharge Date: [**2118-7-11**] Date of Birth: [**2034-1-26**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 594**] Chief Complaint: Respiratory Distress Major Surgical or Invasive Procedure: BiPAP History of Present Illness: 84M PMhx metastatic papillary thyroid CA (s/p resection, radioactive iodine) c/b lung mets, found to have large cavitary mass in RLL, recent admission with malignant effusion + for SCC recently treated for presumed post-obstructive pna. Prior hospitalization was also notable for PET scan that revealed widely metastatic disease. He presents today from rehab with acute respiratory distress. Pt is [**Name (NI) 595**] speaking so history was obtained from family. At baseline he is on 2L o2, yesterday he was doing well, but last night he woke up in respiratory distress. The rehab reported that he was sating at 80% on a non-rebreather mask. EMS was called and he was transferred the the [**Hospital1 18**] ED. Prior to event, pt denies any fevers or chills, nausea, vomiting. He has a chronic cough secondary to his lung ca but the quality of the cough did not change. he is not experiencing any pain. Of note, pt's recent PMH is notable for rapid progression of metastatic lung SCC. He started experiencing chronic cough and hemoptysis in [**Month (only) 547**] and symptoms have progressed since. In [**Month (only) 596**] he was noted to have a large cavitary mass in RLL with satellite nodules suggestive of primary lung Ca. At the end of [**Month (only) **] he was admitted to osh with fever, leukocytosis and cough and treated with ctx. His symptoms did not improve. At this time a CT showed cavitary lesion as above and a new large r exudative pleural effusion. Effusion reaccumulated resulting in supplemental O2 requirement. As such a chest tube was placed and the cytology came back + for SCC. He was started on vanc zosyn for obstructive pna and was transferred to [**Hospital1 18**]. Hospital course was notable for r/o PE, attempted pleurx catheter placement on [**6-27**] that failed due to loculated effusions not amenable to pleurx. At this point a PET scan was done that showed extensive metastatic dz. In the ED, initial VS were: t 98.1 80 106/46 80s on [**Last Name (LF) 597**], [**First Name3 (LF) **] he was started on bipap 60 15/5 and his sats improved to 96%. He was noted to have bilaterally crackles throughout lung fields, and a power picc was in place in right ac fossa. CXR is consistent with prior xrays from earlier this month, but RLL effusion appears to have expanded. Labs were notable for wbc of 38k with 94% N, hct was 25 and platelets 504. He was given vanc and cefepine and transferred to the unit. On arrival to the MICU, pt is somnolent, on bipap and sating in the low 90s. he is with his family and easily arousable. He is answering questions appropriately. His family was concerned that he has been over sedated since he last left [**Hospital1 18**]. The report that he has been sleeping all day and are concerned that he is receiving too much narcotics. Apparently he was recently started on a fentanyl patch 50mcg at rehab. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. 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: - metastatic thyroid CA followed by Dr. [**Last Name (STitle) 574**] - metastatic SCC of the lung - Hypothyroidism - Hiatal hernia - Shingles - Prostate Cancer - metastatic primary lung NSCLC - COPD Social History: Lives w wife in [**Name (NI) 577**], moved from [**Country 532**] in [**2094**]; 30pkyr tobacco, no illicits or etoh Family History: no history of lung cancer Physical Exam: Admission: Vitals: see metavision, on bipap [**3-31**] with 60% sating at 91 General: somnolent, but arousable. family reports that he is aox3. HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated CV: Regular rate and rhythm, distant heart sounds that are obscured by rhonchorus lung sounds Lungs: diffuse rhonchi throughout, decreased breath sounds throughout the R lung field particularly at the base Abdomen: soft, non-tender, slightly distended, bowel sounds present, no organomegaly GU: no foley Ext: cool 2+ pulses, no clubbing, cyanosis or edema Neuro: moving all extremities spontaneously, awakens to voice, no focal deficits Discharge: N/A as expired Pertinent Results: I. Labs [**2118-7-10**] 03:05AM BLOOD WBC-38.0*# RBC-2.91* Hgb-7.7* Hct-24.9* MCV-85 MCH-26.3* MCHC-30.8* RDW-16.4* Plt Ct-504* [**2118-7-10**] 03:05AM BLOOD PT-13.8* PTT-30.0 INR(PT)-1.2* [**2118-7-10**] 03:05AM BLOOD Fibrino-698*# [**2118-7-11**] 02:57AM BLOOD Glucose-124* UreaN-31* Creat-0.9 Na-131* K-4.4 Cl-95* HCO3-28 AnGap-12 [**2118-7-10**] 06:08AM BLOOD Type-ART pO2-65* pCO2-46* pH-7.42 calTCO2-31* Base XS-4 [**2118-7-10**] 03:05AM BLOOD Glucose-157* Lactate-1.2 Na-132* K-4.6 Cl-97 calHCO3-28 II. Microbiology [**2118-7-10**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-PRELIMINARY INPATIENT [**2118-7-10**] URINE Legionella Urinary Antigen -FINAL INPATIENT [**2118-7-10**] MRSA SCREEN MRSA SCREEN-PENDING INPATIENT [**2118-7-10**] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [**Hospital1 **] [**2118-7-10**] BLOOD CULTURE Blood Culture, Routine-PRELIMINARY {GRAM POSITIVE COCCUS(COCCI)}; Anaerobic Bottle Gram Stain-FINAL EMERGENCY [**Hospital1 **] Brief Hospital Course: 84M history of metastatic papillary thyroid cancer (s/p resection, radioactive iodine) complicated by lung metastases, found to have large cavitary mass in RLL with recent admission for malignant effusion positive for small cell lung cancer recently treated for presumed post-obstructive pna that presents with acute respiratory distress. His respiratory distress was thought to be secondary to aforementioned metastatic disease. It was discussed with family and patient that his disease was terminal without many further options. He was stabilized on biPAP. Goals of care discussion yielded to make the patient comfort measures only. He expired at 11:55 AM on [**2118-7-11**] with family at the bedside including his wife and son. [**Name (NI) 6**] autopsy was declined. Given death was within 24 hours of admission, the medical examiner was notified but declined the case for further review. The etiology of death was respiratory distress from lung cancer. Medications on Admission: 1. Aspirin 81 mg PO DAILY 2. Terazosin 4 mg PO HS 3. Acetaminophen 1000 mg PO Q8H 4. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **] 5. Amlodipine 5 mg PO DAILY 6. Gabapentin 800 mg PO TID 7. Docusate Sodium 100 mg PO BID 8. Ibuprofen 600 mg PO TID 9. Ipratropium Bromide Neb 1 NEB IH Q6H dyspnea, hypoxia 10. Levothyroxine Sodium 225 mcg PO DAYS (SA) 11. Levothyroxine Sodium 150 mcg PO DAYS ([**Doctor First Name **],MO,TU,WE,TH,FR) 12. Lidocaine 5% Patch 1 PTCH TD DAILY 13. Mucinex *NF* (guaiFENesin) 600 mg Oral [**Hospital1 **] Reason for Ordering: metastatic lung cancer and dysphagia to liquid 14. Multivitamins 1 TAB PO DAILY 15. Omeprazole 40 mg PO DAILY 16. Senna 1 TAB PO BID:PRN constipation 17. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea 18. Benzonatate 100 mg PO TID:PRN cough 19. OxycoDONE (Immediate Release) 5 mg PO Q4H pain Pt may refuse do not wake at 4 am. hold for over sedation or RR < 12 20. OxycoDONE (Immediate Release) 5 mg PO Q2H:PRN pain Hold for sedation or RR < 12. fentanyl patch 50 mcg/hr Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Expired

[ "V15.82", "511.81", "553.3", "197.2", "162.8", "518.81", "496", "198.5", "185", "V10.87", "244.0", "V66.7" ]

icd9cm

[ [ [] ] ]

[ "93.90", "96.71" ]

icd9pcs

[ [ [] ] ]

7907, 7916

5821, 6782

324, 332

7967, 7976

4820, 5798

4055, 4083

7875, 7884

7937, 7946

6808, 7852

8000, 8010

4098, 4801

3281, 3681

264, 286

360, 3262

3703, 3904

3920, 4039

29,247

187,584

31509

Discharge summary

report

Admission Date: [**2190-8-5**] Discharge Date: [**2190-8-19**] Date of Birth: [**2109-11-20**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 165**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2190-8-5**] Cardiac Catheterization [**2190-8-6**] Four Vessel Coronary Artery Bypass Grafting with Placement of an IABP(Left internal mammary artery to left anterior descending, vein grafts to obtuse marginal, PDA and PLB. History of Present Illness: Mr. [**Known lastname 11135**] is a 80 yo man with known CAD s/p anterior MI [**2184**], who has resisted cardiac catheterization in the past and has been medically managed for some time. He was in his usual state of health until the morning of admission where he reported chest pain that woke him from sleep. He took Aspirin without relief and called EMS. Found to have EKG changes and was treated with the STEMI protocol including Heparin, Integrilin, Aspirin, Plavix, Nitro and beta blockade with improvement in symptoms. He was subsequently transferred to [**Hospital1 18**] for cardiac catheterization. Past Medical History: Coronary Artery Disease, History of MI in [**2184**] Hypertension Hypercholesterolemia Basal Cell Cancer Appendectomy Cataract Surgery Social History: Lives with wife. Denies alcohol use. Denies tobacco use. Family History: Mother died of MI at 87 years Physical Exam: Admission: VS HR 68 BP 111/76 RR 16 O2sat 95% RA Gen: NAD, lying flat in bed posst cath CV: RRR no M/R/G, no carotid bruits Pulm: CTA bilat Abdm: benign Ext: cool, palpable pedal pulses, no varicosities Discharge VS T 98.6 HR 85SR BP 104/57 RR 20 O2sat 93%RA Gen: NAD Neuro: A&Ox3, nonfocal exam CV: RRR, sternum stable, incision CDI Pulm: slightly diminished bases bilat Abdm: soft, NT/ND/+BS Ext: cool, bilat SVG harvest-Rt open w steris/CDI, Lft EVH w/steris Pertinent Results: [**2190-8-5**] 02:41PM BLOOD WBC-9.6 RBC-3.81* Hgb-12.6* Hct-35.7* MCV-94 MCH-33.1* MCHC-35.4* RDW-13.1 Plt Ct-194 [**2190-8-5**] 02:41PM BLOOD PT-12.5 PTT-35.2* INR(PT)-1.1 [**2190-8-5**] 02:41PM BLOOD Glucose-153* UreaN-13 Creat-0.6 Na-132* K-3.8 Cl-101 HCO3-22 AnGap-13 [**2190-8-5**] 02:41PM BLOOD ALT-27 AST-79* AlkPhos-88 TotBili-1.1 [**2190-8-5**] 02:41PM BLOOD Albumin-3.4 [**2190-8-5**] 02:41PM BLOOD %HbA1c-5.8 [**2190-8-5**] Cardiac Catheterization: 1. Coronary angiography in this right dominant system demonstarted three vessel coronary artery disease. The LMCA had a 40% distal stenosis. The LAD had severe diffuse stenosis proxiamlly, the mid LAD is totally occluded after the septal branch. The distal LAD fills with left to right collaterals. The LCx has a 90% proximal stenosis, the distal LCx has a subtotal occlusion supplying 2 PL branches. The OM1 had an 80% stenosis. The RCA had a proximal 90% stenosis. 2. LEFT VENTRICULOGRAPHY: LV end diastolic volume index 44.54(nl 50-90 ml/m2). LV end systolic volume index 27.23 (nl 15-30 ml/m2). LV stroke volume index 17.31 (nl 35-75 ml/m2). LV ejection fraction 39% (nl 50%-80%). 3. Other findings: Mitral valve was normal. Aortic valve was normal. [**2190-8-6**] Intraop TEE: PRE-BYPASS: 1. Overall left ventricular systolic function is severely depressed (LVEF= 20 %). 2. The right ventricular cavity is moderately dilated. 3. The ascending aorta is mildly dilated. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. 4. There are three aortic valve leaflets. The aortic valve leaflets are mildly thickened. Trace aortic regurgitation is seen. 5. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. 6. The tricuspid valve leaflets are mildly thickened. POST-BYPASS: Pt off CPB on levophed and milrinone gtt. 1. Maintained biventricular function EF 20-25%. 2. Minimal improvement in septal and anterior septal wall performance. 3. Mitral regurgiation unchanged. 4. Aortic contours are intact. 5. An IABP was passed over a wire with TEE guidance. Well-positioned and functional. [**2190-8-11**] Brain MRI: A single small focus of T2/FLAIR hyperintensity seen in the right cerebellum corresponding to an area of bright signal on the diffusion-weighted images, but without corresponding dark high or low signal on the ADC map, most likely indicating a subacute infarction. Several foci of T2 and FLAIR prolongation in the corona radiata and periventricular white matter of both cerebral hemispheres probably indicates chronic microvascular change. The appearance of the ventricles and sulci are normal. The [**Doctor Last Name 352**]-white differentiation is preserved. [**2190-8-11**] Normal-appearing liver and biliary tree. [**2190-8-9**] 01:45AM BLOOD ALT-261* AST-377* LD(LDH)-475* AlkPhos-62 TotBili-8.9* [**2190-8-10**] 02:34AM BLOOD ALT-247* AST-238* AlkPhos-81 Amylase-34 TotBili-12.8* [**2190-8-11**] 02:03AM BLOOD ALT-205* AST-192* AlkPhos-116 Amylase-23 TotBili-15.6* DirBili-11.8* IndBili-3.8 [**2190-8-12**] 02:19AM BLOOD ALT-133* AST-105* LD(LDH)-331* AlkPhos-126* Amylase-28 TotBili-14.2* [**2190-8-13**] 02:01AM BLOOD ALT-91* AST-87* AlkPhos-139* TotBili-14.5* [**2190-8-14**] 01:53AM BLOOD ALT-75* AST-86* AlkPhos-174* TotBili-11.6* [**2190-8-17**] 06:05AM BLOOD ALT-53* AST-78* AlkPhos-178* TotBili-8.2* [**2190-8-17**] 06:05AM BLOOD Albumin-2.5* [**2190-8-12**] 02:19AM BLOOD UreaN-27* Creat-0.7 Na-138 Cl-104 HCO3-25 [**2190-8-13**] 02:01AM BLOOD UreaN-29* Creat-0.6 Na-141 Cl-110* HCO3-26 [**2190-8-14**] 01:53AM BLOOD Glucose-130* UreaN-27* Creat-0.7 Na-143 K-3.4 Cl-106 HCO3-31 AnGap-9 [**2190-8-15**] 04:45AM BLOOD Glucose-98 UreaN-33* Creat-0.7 Na-139 K-3.6 Cl-102 HCO3-30 AnGap-11 [**2190-8-17**] 06:05AM BLOOD PT-13.1 INR(PT)-1.1 [**2190-8-11**] 12:54PM BLOOD WBC-16.9* RBC-4.19* Hgb-13.5* Hct-38.1* MCV-91 MCH-32.2* MCHC-35.4* RDW-15.5 Plt Ct-128* [**2190-8-12**] 02:19AM BLOOD WBC-13.5* RBC-3.97* Hgb-12.7* Hct-36.3* MCV-92 MCH-32.1* MCHC-35.1* RDW-15.5 Plt Ct-138* [**2190-8-13**] 02:01AM BLOOD WBC-10.2 RBC-3.75* Hgb-11.7* Hct-34.4* MCV-92 MCH-31.2 MCHC-34.0 RDW-15.4 Plt Ct-120* [**2190-8-14**] 01:53AM BLOOD WBC-9.2 RBC-3.65* Hgb-11.6* Hct-33.6* MCV-92 MCH-31.7 MCHC-34.5 RDW-15.4 Plt Ct-154 [**2190-8-15**] 04:45AM BLOOD WBC-13.0* RBC-4.05* Hgb-12.9* Hct-38.2* MCV-94 MCH-31.9 MCHC-33.9 RDW-15.4 Plt Ct-206 [**2190-8-17**] 06:05AM BLOOD WBC-14.1* RBC-3.75* Hgb-11.8* Hct-35.6* MCV-95 MCH-31.6 MCHC-33.2 RDW-15.5 Plt Ct-312# Brief Hospital Course: Mr. [**Known lastname 11135**] was admitted and underwent urgent cardiac catheterization which revealed severe three vessel disease and severe diastolic left ventricular dysfunction. (Please see result section for more detail). Given his critical coronary anatomy and poor ventricular function, he was brought to the operating room the following day and underwent coronary artery bypass grafting by Dr. [**First Name (STitle) **]. Operative course was notable for cardiogenic shock which required placement of an IABP. For additional surgical details, please see seperate dictated operative note. Following the operation, he was brought to the CSRU for invasive monitoring. He initially required multiple inotropes to maintain hemodynamics. Given his critical condition, he required prolong ventilation and sedation. Tube feedings were eventually started to maintain nutritional support. Over several days, his hemodynamics gradually improved and pressor support was weaned. The IABP was removed on postoperative day four without complication. Transaminases and bilirubin were elevated which was attributed to shock liver secondary to intraoperative hypotension. Abdominal ultrasound was obtained which showed normal-appearing liver and biliary tree. Platelet count also dropped as low as 32K but HIT assays remained negative. Despite wean from sedation, he initially remained relatively lethargic and unresponsive. The stroke service was therefore consulted and MRI was obtained. MRI was notable for a small focus of signal abnormality in the right cerebellum, which likely corresponded to an infarction of subacute age. Despite the above findings, the stroke service attributed his lethargy to metabolic encephalopathy. Over the next several days, his neurologic status improved and he was extubated without incident. Postoperative bedside swallow evaluation was obtained which revealed evidence of aspiration. He was therefore kept NPO and maintained on tube feedings. From a cardiac standpoint, he continued to maintain good hemodynamics and oxygenation. Medical therapy was optmized and he was responding well to gentle diuresis. Unfortunately, he remained very weak and deconditioned, requiring aggressive physical therapy. He eventually transferred to the SDU on postoperative day eight. For the remainder of his hospital stay, he continued to make clinical improvements. Neurologic status returned to baseline with no residual deficits. His swallow improved without further signs of aspiration. His diet was slowly advanced and by discharge, he was tolerating a regular diet. He continued to maintain stable hemodynamics and remained in a normal sinus rhythm. His platelet count normalized, and there was improvement in his transaminases and bilirubin. AST and ALT peaked at 377 and 261, while total bilirubin peaked around 15. Due to steady progress, he was medically cleared for discharge to rehab on postoperative day 13. At discharge, he was empirically started on Keflex, as his Albumin is low and is a set up for wound infection. Medications on Admission: Atenolol 50 qd, Zocor 10 [**Last Name (LF) **], [**First Name3 (LF) **] 81 qd Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] - [**Location (un) **] Discharge Diagnosis: Coronary Artery Disease, Cardiogenic Shock - s/p CABG, IABP Placement Diastolic Congestive Heart Failure Postop Encephalopathy, Question of Postop Stroke Postop Shock Liver Postop Aspiration Postop Thrombocytopenia History of MI in [**2184**] Hypertension Hypercholesterolemia Discharge Condition: Stable Discharge Instructions: 1)Please shower daily. No baths. Pat dry incisions, do not rub. 2)Avoid creams and lotions to surgical incisions. 3)Call cardiac surgeon if there is concern for wound infection. 4)No lifting more than 10 lbs for at least 10 weeks from surgical date. 5)No driving for at least one month. Followup Instructions: Dr. [**First Name (STitle) **] 4-5 weeks, please call for appt Dr. [**Last Name (STitle) 1637**] 2-3 weeks, please call for appt Dr. [**Last Name (STitle) **] 2-3 weeks, please call for appt Dr. [**First Name (STitle) **] re: basal cell carcinoma lesion on back - call for appt [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2190-8-19**]

[ "348.31", "997.02", "570", "E878.2", "272.0", "287.4", "428.0", "412", "401.9", "428.32", "785.51", "411.1", "414.01", "434.91" ]

icd9cm

[ [ [] ] ]

[ "36.15", "99.05", "37.61", "99.04", "99.20", "39.61", "37.22", "88.53", "96.72", "88.55", "36.13", "96.6", "99.07" ]

icd9pcs

[ [ [] ] ]

9702, 9817

6528, 9574

331, 560

10138, 10147

1981, 6505

10483, 10883

1445, 1476

9838, 10117

9600, 9679

10171, 10460

1491, 1962

281, 293

588, 1197

1219, 1355

1371, 1429

41,269

157,868

36655

Discharge summary

report

Admission Date: [**2199-7-20**] Discharge Date: [**2199-9-17**] Date of Birth: [**2143-3-14**] Sex: M Service: SURGERY Allergies: Olanzapine / Ciprofloxacin Attending:[**First Name3 (LF) 2534**] Chief Complaint: mandible fracture s/p fall Major Surgical or Invasive Procedure: 1. Open reduction and internal rigid fixation of R and L mandible 2. Extraction of teeth numbers 2, 12, 15 and 22 3. Tracheostomy. 4. Percutaneous endoscopic gastrostomy converted to open [**Last Name (un) **] gastrostomy. History of Present Illness: 56 yo male with h/o of HTN and ETOH abuse presented to [**Hospital1 18**] ED from an area hospital with bimateral mandible fractures s/p ?syncopal episode and fall onto face from chair to concrete. + LOC and no recall of event. Reportedly he consumes [**1-4**] pint of alcohol daily and had been drinking normal amount when fell. No history of seizures or alcohol withdrawal. Past Medical History: HTN ETOH abuse Social History: smokes cigarrettes alcohol abuse no family or friends to sign for patient Family History: None known Physical Exam: Upon admission: Vitals: 100.5 106 109/84 16 98%RA Gen: unkempt older man in NAD HEENT: PERRL, EOMI, +sceral icterus, no occiput injury or tendernes, marked swelling and tenderness of lower jaw and lips with bleeding from tongue and mouth with small lacertaion on anterior surface of tonque, no teeth, unable to protrude toungue from mouth, swallowing without difficulty, no stridor. Not able to visualizeze L tympanic membrane secondary to wax; right tympanic membrane with blood in canal and possible ruptured membrane. CV: RRR Lungs: CTAB Abd: soft, NT/ND ext: no deformities, 2+ DP/PT b/l, no tenderness, no edema neuro: alert and oriented x 2 (Got month wrong). CN II-XII grossly intact Pertinent Results: [**2199-7-19**] 06:34PM GLUCOSE-124* UREA N-27* CREAT-1.2 SODIUM-141 POTASSIUM-3.8 CHLORIDE-108 TOTAL CO2-17* ANION GAP-20 [**2199-7-19**] 06:34PM WBC-11.3* RBC-3.18* HGB-10.7* HCT-32.6* MCV-103* MCH-33.5* MCHC-32.7 RDW-13.4 [**2199-7-19**] 06:34PM PLT COUNT-154 [**2199-7-19**] 06:34PM PT-12.0 PTT-23.3 INR(PT)-1.0 [**2199-7-19**] 06:29PM LACTATE-1.6 [**2199-7-19**] 06:34PM ASA-NEG ETHANOL-61* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2199-7-20**] 1. Head CT demonstrate no acute intracranial process. There is mild atrophy, and scattered lacunar infarcts. There is no hemorrhage, mass effect, or edema. 2. Cervical spine CT demonstrating no evidence for traumatic injury, including no fracture, subluxation, or prevertebral soft tissue swelling. 3. Facial bones CT demonstrating comminuted right mandibular condyle fracture, with additional non-displaced fracture of the right mandibular angle, and comminuted, slightly displaced fracture of the left mandibular body extending into the left mandibular angle. There are no other facial fractures identified. 4. Incidental note of paraseptal emphysema, large tracheal diverticulum, and dense atherosclerotic disease involving the carotid bulbs and supraclinoid/cavernous internal carotid arteries. There is a small amount of fluid in the right mastoid air cells. [**2199-8-28**] ECHO LEFT ATRIUM: Moderate LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. LEFT VENTRICLE: Normal LV wall thickness and cavity size. Normal LV wall thickness. Top normal/borderline dilated LV cavity size. Severe global LV hypokinesis. Transmitral Doppler and TVI c/w Grade III/IV (severe) LV diastolic dysfunction. No resting LVOT gradient. RIGHT VENTRICLE: Mildly dilated RV cavity. Severe global RV free wall hypokinesis. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild (1+) MR. LV inflow pattern c/w restrictive filling abnormality, with elevated LA pressure. TRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+] TR. Indeterminate PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. Large left pleural effusion. Conclusions The left atrium is moderately dilated. Left ventricular wall thicknesses and cavity size are normal. Left ventricular wall thicknesses are normal. The left ventricular cavity size is top normal/borderline dilated. There is severe global left ventricular hypokinesis (LVEF = 15 %). Transmitral Doppler and tissue velocity imaging are consistent with Grade III/IV (severe) LV diastolic dysfunction. The right ventricular cavity is mildly dilated with severe global free wall hypokinesis. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. Moderate [2+] tricuspid regurgitation is seen. [**2199-9-2**] MRA Brain IMPRESSION: 1. Study limited by motion artifact, however, no evidence for infarction. 2. Relative paucity of distal M2 branches of right MCA likely due to motion artifact. However if clinically indicated CTA can be performed for further evaluation. Brief Hospital Course: He was admitted to trauma service for management of pain and mandible fracture. His imaging from the outside hospital included a head CT which demonstrated no acute intracranial process with scattered lacunar infarcts; C-spine CT was negative for acute injury and facial bone CT showed communi [**Male First Name (un) **] right mandibular condyle fracture, displaced fracture of left condyle. ECG on admission revealed sinus tachycardia and a left bundle-branch block. This remained unchanged with serial EKG's throughout admission. Neurology was consulted to work up his possible seizures vs syncopal event leading to his fall. It was felt that because of lack of post-ictal fatigue that seizure was unlikely cause; rather his alcohol intoxication was likely more of a factor. A syncopal event could not be completely ruled out. The recommendations were to check orthostatics, consider routine EEG, continue to monitor on telemetry, check echocardiogram (ECHO showed dilation of RA and LV and ventricular hypokinesis (LVEF = 25%)) and not to rule out ETOH as cause of fall. At 2200 on HD1 he was noted to be actively withdrawing from alcohol with tachycardia, elevated blood pressure, agitation, and tremors. He was transferred to the ICU for closer monitoring and adjustment of his CIWA scale. On HD3 he was intubated due to worsening oxygenation. He was found to have RLL infiltrate possibly related to aspiration pneumonia. He was cultured and put on vancomycin, cefepime, and Flagyl. Fentanyl and versed drip were started. He required transfusion with PRBC's for falling hematocrit. (Last Hct on [**9-5**] was 29) On HD6 patient had open reduction and internal rigid fixation of an open comminuted left mandibular body fracture and closed right mandibular angle fracture by Dr. [**First Name (STitle) **]. He was noted with intermittent fevers; cultures (sputum, blood, urine) negative at HD8. Antibiotics were stopped and he underwent a bronchoscopy to send BAL for culture. He was noted with fever spike with stopping of antibiotics and so they were restarted. Multiple attempts were made to wean him from ventilator support but were unsuccessful. Because there were no immediate family or friends to give consent for tracheostomy guardianship was pursued. Once this was obtained a tracheostomy and gastric tube placement was performed. Tube feedings initiated on postoperative day 1. He was eventually weaned from ventilator; sputum cultures grew out coag negative staph and enterococcus species for which he was treated with vancomycin and cefepime for 7 days. A PICC line was placed for this therapy. During this treatment, he WBC normalized and he was transferred to the floor tolerating trach mask. Once on the nursing unit he was noted with what was thought to be runs of ventricular tachycardia. Cardiology was then consulted and upon further ECG examination it was felt that it was more consistent with left bundle branch block. Several recommendations were made pertaining to his medications which included stopping antipsychotic which cause prolongation of QT interval. He was continued on his ACE and beta blockade. Electrolytes were monitored and repleted accordingly. He underwent evaluation of Physical, Occupational and Speech therapy during his stay. He was initially recommended for rehab after acute hospital stay but because of insurance barriers he was unable to get into a rehab facility and continued his rehab here. He underwent a swallow evaluation due to dysphagia and was found to initially be at risk for aspiration and so he was placed on ground diet and thickened liquids. His diet was eventually advanced and he was able to tolerate soft diet due to absent teeth and thin liquids. He was followed by Social work closely throughout his hospital stay for counseling, emotional support and for assistance with finding a suitable shelter for him to go to given his reports of being homeless. A shelter in the [**Hospital1 487**] area was found and he was discharged there with instructions for follow up. Medications on Admission: MVI Discharge Medications: 1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 5. Acetaminophen 160 mg/5 mL Solution Sig: Six [**Age over 90 1230**]y (650) MG PO every 4-6 hours as needed for pain. Discharge Disposition: Home Discharge Diagnosis: s/p Fall Bilateral Mandibular fractures Respiratory failure Left bundle branch block Delirium tremors Rib fractures (left 6,7) Liver contusion C. difficile colitis Acute blood loss anemia Discharge Condition: Hemodynamically stable, tolerating a regular diet, pain adequately controlled. Discharge Instructions: Return to the Emergency room if you develop any fevers, chills, headaches, drainage from your wounds, chest pain, shortness of breath, nausea, vomiting, diarrhea and/or any other symptoms that are concerning to you. The wound on the front of your neck from the tracheostomy will heal completely over the next 1-2 weeks. If you notice that it is not closing after 2 weeks please call the Trauma clinic at [**Telephone/Fax (1) 2359**] to be seen. It is important that you do not drink or take illicit drugs. Followup Instructions: Follow up in [**3-6**] weeks with Dr. [**Last Name (STitle) **], Trauma Surgery, call [**Telephone/Fax (1) 2359**] for an appointment. Follow up in [**3-6**] weeks with Dr. [**First Name (STitle) **], OMFS for your mandible fracture and postoperative evalaution. Call [**Telephone/Fax (1) 55393**] for an appointment. Completed by:[**2199-9-25**]

[ "807.02", "041.19", "425.5", "426.3", "303.00", "518.5", "291.0", "V60.0", "348.39", "802.29", "E935.2", "507.0", "802.38", "263.8", "041.04", "285.1", "305.1", "521.00", "571.3", "V15.88", "997.31", "780.2", "008.45", "787.20", "E884.2", "401.9", "V85.1" ]

icd9cm

[ [ [] ] ]

[ "23.19", "31.1", "38.93", "96.72", "96.04", "76.76", "43.19", "96.6", "33.24", "76.92" ]

icd9pcs

[ [ [] ] ]

10014, 10020

5392, 9447

313, 542

10252, 10332

1837, 5369

10888, 11238

1093, 1105

9501, 9991

10041, 10231

9473, 9478

10356, 10865

1120, 1122

247, 275

570, 948

1136, 1818

970, 986

1002, 1077

72,308

111,559

33879

Discharge summary

report

Admission Date: [**2196-9-25**] Discharge Date: [**2196-10-3**] Date of Birth: [**2151-12-9**] Sex: M Service: NEUROSURGERY Allergies: Dilaudid Attending:[**First Name3 (LF) 3227**] Chief Complaint: confusion Major Surgical or Invasive Procedure: [**9-27**]: left parietal craniotomy History of Present Illness: 44 right handed male with hx of melanoma metastatic to the brain treated with surgical resection and CyberKnife, presented originally with R arm numbness and weakness, now transferred from an OSH after his wife noticed that he was acutely confused around 1AM this morning. He was reportedly fine when she returned from work, but 20 minutes later he was speaking nonsensically and agitated. 911 was called and he was brought to [**Hospital3 **], where a CT scan of the head revealed 1.7 cm R frontal hemorrhage and 3.9 cm L fronto-parietal hemorrhage with associated edema with local effacement of sulci without midline shift. Other lab values were WNL. He received 10 mg of IV dexamethasone and 250 mg of Phenytoin and was transferred to [**Hospital1 18**] for further eval. Currently he attests to feeling confused, but denies any dizziness, nausea, visual changes, or headache. Past Medical History: Melanoma originally diagnosed in left axilla, metastatic to brain. MRI [**2196-7-19**] showed 3 lesions - 2 in the left parietal and 1 in the right frontal regions. He underwent resection of the larger parietal tumor on [**2196-7-20**] by Dr. [**First Name (STitle) **], and pathology confirmed metastatic melanoma. He was treated with CyberKnife on [**2196-8-8**] to the resection cavity and to the remaining parietal lesion. A repeat MRI on [**8-3**] showed slight increase in the size of both tumors, and a third MRI [**9-5**] showed a new right parietal metastasis. He underwent a second CyberKnife treatment to the two right sided lesions on [**2196-9-9**]. Social History: Married, resides at home with wife and children Family History: Non-contributory Physical Exam: Exam upon admission: Neuro: Mental status: Awake and alert, cooperative with exam. Orientation: Disoriented to person, place, time. Recall: able to repeat, 0/3 objects at 5 min. Language: Speech fluent but occasionally inappropriate, poor naming. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**6-7**] throughout, except [**5-8**] on R finger grip. Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Reflexes: B T Br Pa Ac Right 2+ 2+ 2+ Left 2+ 2+ 2+ Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin Exam upon discharge: Alert, Oriented to person, place and date, with minimal prompting. PERRL. Face is symmetric, tongue is midline. Full strength and power throughout LUE, and bilateral LE. RUE with 4/5 weakness diffusely. Pertinent Results: MRI HEAD W & W/O CONTRAST [**2196-9-25**]: FINDINGS: The study is compared with very recent enhanced MR examination (with tumor volumetry) of [**2196-9-5**]. Over the short interval, the hemorrhagic left temporoparietal lesion has substantially increased in size, now measuring at least 4.0 cm (AP) x 2.6 cm (TRV), with substantial hemorrhagic component and significant associated vasogenic edema and increased mass effect upon the occipital [**Doctor Last Name 534**] and atrium of the left lateral ventricle (4:15). Similarly, the lesion in the right frontal lobe, which measured only 8 mm, is significantly larger, now measuring 17 x 16 mm, and also demonstrates significant hemorrhagic (and/or melanotic) component with small zone of vasogenic edema which, too, has substantially increased since the recent study. There has been no significant interval growth in the small lesion in the central aspect of the right parietal lobe, adjacent to the occipital [**Doctor Last Name 534**] of that lateral ventricle, and no new enhancing lesion is identified. Again demonstrated is thick, irregular rim enhancement at the margins of the left frontovertex resection cavity likely representing residual neoplasm (as suggested previously). The cavity also demonstrates residual marginal and internal blood products. There is no restricted diffusion to indicate acute ischemia and the principal intracranial vascular flow voids, including those of the dural venous sinuses, are preserved and these structures enhance normally. IMPRESSION: Marked short-interval progression of the hemorrhagic and/or melanotic dominant left temporoparietal and right frontal metastases, now measuring up to 4.0 and 1.7 cm, respectively. There is corresponding significant interval increase in associated vasogenic edema, but no overall shift of midline structures or evident herniation. CT Torso [**2196-9-26**]: CT CHEST: Left axillary dissection changes are stable. 6 mm right apical lung nodule is unchanged since [**2196-7-21**]. There are no other lung nodules. Small bilateral effusions have resolved since [**2196-7-21**]. The pulmonary arteries and airways are patent to the subsegmental level. Heart size is mildly enlarged. There is no pericardial effusion. Scattered central nodes do not meet CT size criteria for enlargement. CT ABDOMEN: A 1 cm liver lesion in segment VII (2:42) enhances similar to the blood pool and are probably present since [**2195-9-27**]. The gallbladder, pancreas, spleen, kidneys are unremarkable. There is no intrahepatic or extrahepatic biliary dilatation. The abdominal loops of bowel are unremarkable without evidence of obstruction or free air. Well circumscribed fluid density (20 [**Doctor Last Name **])3.4 X 1.9 cm and 2 x 1.7 cm lesions adjacent to the left adrenal gland and superior to the pancreas, respectively (2:54), are new since [**2196-7-21**]. CT PELVIS: The bladder, rectum, prostate, and seminal vesicles are unremarkable. There is no pelvic or inguinal lymphadenopathy. Bone windows demonstrate no lesion concerning for metastasis or infection. IMPRESSION: 1. No new lesion concerning for metastasis. 2. Segment VII liver lesion likely represents flash filling hemangioma given similar enhancement to blood pool, but is not fully characterized. MRI suggested for more definitive characterization given history of malignancy. 3. New fluid density collections near the pancreas likely represent pancreatic pseudocysts. MRI Head [**9-28**](post-op): FINDINGS: There is a new left parietal/temporal craniotomy, with associated post-operative changes in the overlying scalp. The previously noted left parietal/temporal mass has been resected. There are blood products in the new resection bed, with high signal on the pre-contrast T1-weighted images. This limits evaluation for any residual enhancing tumor components on the post-contrast T1-weighted images, though none definitively seen. An apparent 5 mm focus of slow diffusion along the anterolateral margin of the new resection cavity (image 12 of series 700 and series 702), most likely represents an artifact related to the post-operative blood products, although a small contusion or infarction of adjacent tissue cannot be excluded. There is high T2 signal surrounding the new resection cavity, likely representing a combination of post-operative edema and pre-existing tumor-related and therapy-related changes. There is a minimal decrease in mass effect following the new resection. The pre-existing left parietal resection cavity, superior to the new cavity, appears stable, with linear enhancement along its margins. The greatest thickness of the linear enhancement is located medially, as before (image 9:19). The hemorrhagic lesion in the right frontal lobe is unchanged in the interim (image 9:19). Enhancing and hemorrhagic lesions in the right parietal lobe (image 9:17) and in the left frontal lobe (image 1000:50) are unchanged.The ventricles are stable in size. The major arterial flow voids are unremarkable.There is mild mucosal thickening in the maxillary sinuses. IMPRESSION: 1. Status post left parietal/temporal mass resection, with blood products in the resection cavity limiting evaluation for any residual enhancing components. Continued follow-up is recommended. 2. The other previously noted hemorrhagic masses are unchanged in the short interim. MRI Abdomen [**9-29**]: There is minimal dependent atelectasis at the right lung base. There is a subcapsular lesion measuring 10 x 10 mm in segment VIII of the liver, corresponding to the enhancing abnormality on prior CT, which demonstrates uniform high signal on T2- weighted images, low signal on T1- weighted sequences and arterial phase hyperenhancement with continued enhancement on the dynamic series. The appearance is consistent with a hemangioma (image 41, series 100). A 1.4-mm lesion in segment II of the liver also shows features consistent with a hemangioma. There are scattered up to 3 mm hepatic cysts which demonstrate low signal on T1- weighted sequences and high signal on T2-weighted sequences without enhancement (image 37, 41 and 56, series 300). There are again demonstrated peripancreatic fluid collections which have high signal on T1-weighted sequences, low signal on T2-weighted sequences and demonstrate subtle rim enhancement suggestive of focal collections with hemorrhagic or proteinaceous contents. The larger collection in the region of the pancreatic tail measures 4.4 x 1.6 cm and the smaller collection abutting the anterosuperior aspect of the pancreatic body measures 1.8 x 1.2 cm (image 63 and 67, series 200). The spleen, gallbladder, adrenal glands, and kidneys appear unremarkable. The pancreatic parenchyma shows homogeneous enhancement. There is no upper abdominal lymphadenopathy. The visualized loops of bowel appear unremarkable. The visualized bones appear unremarkable. IMPRESSION: 1. The lesion of interest in the right lobe of the liver represents a hemangioma. Additional simple hepatic cysts and hemangiomas as described above. 2. Hemorrhagic or proteinaceous peripancreatic collections which may represent sequelae of pancreatitis. The pancreatic parenchyma, however, enhances homogeneously. Brief Hospital Course: The patient was admitted to the Neurosurgical stepdown unit at [**Hospital1 18**] through the Emergency Department. An MRI Scan performed upon admission demonstrated 3 brain lesions, either hemorrhagic or increased size of tumors. He was initially agitated secondary to steroids, and IV ativan, seroquel, and haldol were started and the steroids were subsequently stopped. His keppra was increased to 1000mg, and a 1000mg bolus was given for a possible focal seizure in his RUE. The patient went to the operating room on Tuesday, [**9-27**] for a resection of a L parietal mass. He tolerated the procedure well and following a short stay in the ICU he was transferred to the Neurosurgical Floor. An MRI of the Head and Abdomen were ordered d/t concerning findings of a Segment VII liver lesion per CT Scan. This MRI revealed mutliple small cysts that did not required acute intervention per the GI team. The patient was given instruction for these findings to be followed from an outpaient standpoint. He was seen and evaluated by PT and OT; after working with him for several days; he was ultimatley improved enough to the point of disposition to home with services. He was discharged as such on [**2196-10-3**]. At the time of discharge, the patient continues to experience mild sensory ataxia of his right hand (though the ataxia had improved significantly post-resection) Medications on Admission: Keppra 500'', Decadron taper finished the day before admission. Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for Pain. Disp:*40 Tablet(s)* Refills:*0* 3. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*0* 4. Metronidazole 1 % Gel Sig: One (1) Appl Topical DAILY (Daily). Discharge Disposition: Home with Service Discharge Diagnosis: Metastatic melanoma to the brain Discharge Condition: Neurologically stable Discharge Instructions: ??????Have a friend/family member check your incision daily for signs of infection. ??????Take your pain medicine as prescribed. ??????Exercise should be limited to walking; no lifting, straining, or excessive bending. ??????Your wound closure uses dissolvable sutures, you must keep that area dry for 10 days. ??????You may shower before this time using a shower cap to cover your head. ??????Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ??????Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ??????You have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ??????Clearance to drive and return to work will be addressed at your post-operative office visit. ??????Make sure to continue to use your incentive spirometer while at home. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ??????New onset of tremors or seizures. ??????Any confusion or change in mental status. ??????Any numbness, tingling, weakness in your extremities. ??????Pain or headache that is continually increasing, or not relieved by pain medication. ??????Any signs of infection at the wound site: increasing redness, increased swelling, increased tenderness, or drainage. ??????Fever greater than or equal to 101?????? F. Followup Instructions: ??????Please return to the office in [**8-12**] days (from your date of surgery) for a wound check. This appointment can be made with the Nurse Practitioner. Please make this appointment by calling [**Telephone/Fax (1) 1669**]. ??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**2196-10-17**] @11:30am . The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building. Their phone number is [**Telephone/Fax (1) 1844**]. Please call if you need to change your appointment, or require additional directions. ??????You will need an MRI of the brain on [**2196-10-13**] 12:20 You also have an appointment with Dr. [**Last Name (STitle) 1729**] on [**2196-10-19**] at 9:45am During your hospitalization and imaging performed; multiple small cysts were identified on your liver. These do not require intervention at this time; however should be monitored by your PCP [**Name Initial (PRE) 78297**]. Completed by:[**2196-10-3**]

[ "334.4", "577.2", "431", "348.5", "511.9", "V10.82", "573.8", "458.29", "228.04", "198.3" ]

icd9cm

[ [ [] ] ]

[ "01.59" ]

icd9pcs

[ [ [] ] ]

12589, 12608

10678, 12059

283, 322

12685, 12709

3441, 10655

14267, 15307

2010, 2028

12174, 12566

12629, 12664

12085, 12151

12733, 14244

2043, 2050

234, 245

350, 1237

2343, 3197

2064, 2071

2086, 2327

1259, 1928

1944, 1994

3218, 3422

11,989

122,977

30252

Discharge summary

report

Admission Date: [**2137-2-13**] Discharge Date: [**2137-2-19**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2160**] Chief Complaint: hypoxia Major Surgical or Invasive Procedure: R-sided thoracentesis History of Present Illness: 82 M w/ A fib (not on coumadin), dyslipidemia, hypertension, alzheimer's disease, who presents with fatigue, cough, slurred speech and a question of a right facial droop. Neurology examined patient in ED and thought he was non-focal, facial droop may be old. Pt also had CXR showing large right pleural effusion. While in [**Name (NI) **] Pt desatted to 80s on NRB. Deep suctioning resulted in his sats returning to 90s on high flow face mask. Patient also had CT revealing near complete collapse of RML & RLL. Patient was admitted to the ICU for monitoring and he did not require intubation or pressors. Past Medical History: --alzheimers --afib (not on coumadin) --htn --dyslipidemia --COPD --GERD --old R occipital infarct Social History: Lives with girlfriend of 28 years. Daughter in charge of his finances, girlfriend does shopping, cooking, helps him with meds, assists with bathing and dressing. Has VNA that visits. No tobacco or EtOH (heavy drinker in the past) Family History: non-contributory Physical Exam: T:97.6 BP:136/95 HR:73 RR:20 02 sat: 95 2L GENERAL: laying in bed, NAD SKIN: warm and well perfused, no excoriations or lesions, no rashes HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva, dry MM, supple neck, no LAD CARDIAC: RRR, S1/S2, III/VI SEM @ RUSB w/o radiation to carotids, JVD @ 8 cm LUNG: decreased breath sounds on right base and middle lobe, clear to auscultation within L lung lobes ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly M/S: moving all extremities well, no cyanosis, clubbing or edema, no obvious deformities PULSES: 2+ DP pulses bilaterally NEURO: R-sided upper lower facial droop, CN II-VI, VIII-XII intact, alert and oriented to person and place Pertinent Results: Imaging: CT HEAD W/O CONTRAST [**2137-2-12**] 10:19 PM IMPRESSION: 1. No evidence of acute intracranial hemorrhage. 2. Remote infarct of the right occipital lobe and possible additional lacunar infarctions as described. . CHEST (PORTABLE AP) [**2137-2-12**] 9:42 PM IMPRESSION: Large right pleural effusion. An underlying consolidation or other process is not excluded . CT CHEST W/O CONTRAST [**2137-2-13**] 12:01 PM IMPRESSION: 1. Near complete collapse of the right lower and middle lobes, with retained secretions seen in the right main bronchus and throughout the right-sided airways. Bronchoscopy is recommended as the patient is at risk for complete right-sided collapse, in order to clear secretions and to exclude a fixed obstructing lesion. Findings discussed with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1022**] at 3 p.m., [**2-13**], [**2136**]. 2. Possible aspirated contrast noted within the right lower lobe. 3. Likely right renal cyst. . RENAL U.S. [**2137-2-13**] 12:10 PM IMPRESSION: Limited study demonstrating no hydronephrosis on either side. Right renal atrophy. . CHEST (PORTABLE AP) [**2137-2-13**] 5:05 AM IMPRESSION: No short interval change, with large right pleural effusion. . ECHO Study Date of [**2137-2-13**] Conclusions: The left atrium is moderately dilated. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is top normal/borderline dilated. There is global hypokinesis with moderate regional left ventricular systolic dysfunction (septal, anterior and apical near akinesis). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. The right ventricular cavity is moderately dilated. Right ventricular systolic function is borderline normal. The ascending aorta is mildly dilated. The aortic valve leaflets are moderately thickened. There is no signficant aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. . CHEST (PORTABLE AP) [**2137-2-14**] 1:53 AM IMPRESSION: 1. No significant interval change to moderate-sized right pleural effusion and atelectasis of right middle and right lower lobes. 2. Persistent mild pulmonary edema. . CHEST (PORTABLE AP) [**2137-2-15**] 4:26 PM IMPRESSION: Status post right thoracentesis, with small right pleural effusion persisting. No pneumothorax. . MRA BRAIN W/O CONTRAST [**2137-2-15**] 8:37 AM IMPRESSION: 1. No acute infarct. 2. Right occipital encephalomalacic changes and chronic microvessel disease and bilateral centrum semiovale. 3. Atherosclerotic disease involving right distal vertebral, bilateral MCA with possible mid basilar, short segment moderate stenosis. To consider CT angiogram for better evaluation of these vessels, as this study is limited in accurate assessment due to artifacts. . . Micro: [**2137-2-12**] Blood Culture: NGTD . [**2137-2-13**] Urine Culture: Staph spp. Sputum Cx: MRSA . [**2137-2-15**] PLEURAL FLUID Procedure Date of [**2137-2-15**] NEGATIVE FOR MALIGNANT CELLS. Culture: No growth to date Brief Hospital Course: 82 M w/ COPD who presents with O2 desaturation in setting of large right pleural effusion s/p large volume R thoracentesis. RESPIRATORY DISTRESS: Probably some component of mucous plug given RLL & RML with retained bronchial secretions. Patient is s/p thoracentesis, which he tolerated well and has been off oxygen since. Etiology of large R-sided pleural effusion is unclear, but may be secondary to chronic parapneumonic effusion as a result of chronic aspiration. Patient was initially treated with Vancomycin/Levo/Flagyl that was subsequently tailored to just Levofloxacin. His pleural fluid was no growth to date at the time of discharge. His sputum culture grew out MRSA and he was started on bactrim in preparation for discharge and azithromycin for atypicals. The patient was also treated with standing albuterol and ipratropium and progressed well throughout the hospital course. His O2 sat became greatly improved s/p thoracocentesis and at the time of discharge he was satting well on room air and during ambulation. . ARF: Patient with increased Creatinine from baseline that resolved with hydration. FeNA was < 1% suggesting pre-renal etiology. This was follow throughout the hospital course and constant lab values with Cr of 1.3 suggests that patient may have a new baseline. . CARDIAC: - Ischemia - Patient without history of CAD, although does have hx of afib, and patient not on coumadin, perhaps he was thought to be a fall risk. Continued patient on aspirin & statin. - Pump - EF 30% - Continued Carvediolol & lisinopril. He was evaluated for ICD placement by EP give low EF and brief episode of 9 beat NSVT that was asymptomatic. EP recommended no ICD placement at this time given dementia and comorbidities. ICD placement can be reevaluated as an outpatient. - Rhythm - Patient with hx of afib, not on Coumadin. Carvedilol was continued for rate control. Monitored on telemetry and patient has some NSVT and was bradycardic at times, although asymptomatic with both rhythms. As above, patient was evaluated by EP and he is not a candidate for ICD at this time. . NEURO CHANGES: no focal deficits on exam. Patient with hx of stroke, not currently on aggrenox. Patient with MRI negative for acute stroke (results above) . ALZHEIMERS: --continued Aricept . GERD --Continued Ranitidine . After discussion with the patient and the medical staff, and physical therapy, all were in agreement that [**Known firstname 449**] [**Known lastname 15273**] was a suitable candidate for discharge. Medications on Admission: --ASA 81 --Lisinopril 10 mg QD --Aricept 10 mg QD --Protonix 40 QD --Plavix 75 QD --Coreg 3.125 QD --Ambien 5 mg QHS --Pravachol 40 mg QD --Klonopin 1 mg TID --Albuterol Inhaler 2 puffs TID Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*0* 2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*0* 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*0* 6. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. Atrovent 0.03 % Aerosol, Spray Sig: One (1) Nasal every [**3-29**] hours as needed. Disp:*1 1* Refills:*2* 8. Ranitidine HCl 150 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 9. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO twice a day for 6 days. Disp:*12 Tablet(s)* Refills:*0* 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 11. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours) for 6 days. Disp:*6 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary Diagnosis: hypoxia . Secondary Diagnoses: --alzheimers --afib (not on coumadin) --htn --dyslipidemia --COPD --GERD --old R occipital infarct Discharge Condition: Afebrile, stable vital signs, tolerating POs, ambulating with assistance on room air. Discharge Instructions: You were admitted with shortness of breath and found to have a large right-sided pleural effusion. You were given antibiotics and underwent removal of fluid surrounding the Right lung. . 1. Please take all medications as prescribed. 2. Please go to all medical appointments. 3. Please return to the Emergency Room if you have any concerning symptoms. Followup Instructions: Follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] on [**2-20**] at 2:15pm Have your doctor follow up your pleural fluid cultures which at the time of your discharge from the hospital was negative for bacteria.

[ "427.31", "287.5", "496", "V09.0", "584.9", "530.81", "331.0", "482.41", "427.89", "401.9" ]

icd9cm

[ [ [] ] ]

[ "34.91" ]

icd9pcs

[ [ [] ] ]

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270, 294

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223, 232

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129,158

13588+56468

Discharge summary

report+addendum

Admission Date: [**2119-9-29**] Discharge Date: [**2119-10-6**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2387**] Chief Complaint: acute renal failure Major Surgical or Invasive Procedure: none History of Present Illness: This is a 82 year old woman with history of CAD s/p recent cardiac catheterization, DM, and CHF presents with ARF and hyperkalemia after followup bloodwork showed Cr of 4.6. Her cardiac catheterization was performed on [**9-25**] and on discharge her Cr had increased from her baseline of 1.7 to 2.5. Between her admissions, she noticed decreased fluid intake and urinating less frequently. The patient denies hematuria or discharge or NSAID use. Past Medical History: 1. Type II diabetes on oral hypoglycemic agents 2. Coronary artery disease --CABG [**2107**] (LIMA to LAD, SVG to OM, SVG to RCA). --Cardiac cath [**6-11**] with Cypher stents placed in distal LAD and OM1 --Cardiac cath [**1-11**] with bare metal stent OM1 --Cardiac cath [**2119-9-25**] showed 3 vessel disease. LAD was 100% occluded, LCX had patent Cypher stent with new 99% stenosis post stent and 100% occlusion of bare metal stent in OM1. RCA was 100% occluded. LIMA was patent but SVG graft was 100% occluded. She underwent repeat stenting of the OM1 lesion with a Cypher stent and 20% residual stenosis. 3. Congestive heart failure with an ejection fraction of 25%. 4. Atrial fibrillation off coumadin 5. Chronic kidney disease with baseline creatinine 1.6-1.9. 6. Peripheral vascular disease bypass surgery bilaterally and later had below the knee amputation on the right ([**7-11**]) and stent to left bypass graft ([**3-14**]), s/p stent to L native peroneal artery and stent to L peroneal bypass graft in 4/[**2118**]. 7. Anemia with baseline hematocrit low 30's. 8. Hypertension. 9. Status post appendectomy. 10. Status post cholecystectomy. 11. History of diverticulosis 12. History of internal hemorrhoids. 13. History of GIB (presumed lower, EGD negative [**7-/2118**], [**Last Name (un) **] neg in [**8-/2118**]) Social History: She lives at home with her husband (husband in nursing home). Independent of ADLs. No etoh, 20 pack year smoking history and quit 20 yrs ago. No h/o drug use. Family History: Her father had diabetes and coronary artery disease. Sister died of MI. Son has CHF Physical Exam: VS: 98.1 112/60 60 18 96% RA Gen: well appearing, NAD, left facial palsy. HEENT: PERRLA, cracked lips, dry mucous membranes Neck: JVP 8cm Cards: irreg, 2/6 SEM apext. Lungs: CTAB, no crackles Abd: BS+ NT ND soft Ext: No c/c/e. No femoral bruits. 2+ DP pulses bilaterally. Right BKA, flap intact. No flank pain Pertinent Results: [**2119-9-29**] 06:20PM WBC-4.8 RBC-3.02* HGB-9.8* HCT-27.9* MCV-93 MCH-32.5* MCHC-35.1* RDW-15.5 [**2119-9-29**] 06:20PM NEUTS-68.4 LYMPHS-25.3 MONOS-4.0 EOS-1.9 BASOS-0.3 [**2119-9-29**] 06:20PM PLT COUNT-147* [**2119-9-29**] 06:20PM GLUCOSE-112* UREA N-94* CREAT-4.6*# SODIUM-131* POTASSIUM-5.6* CHLORIDE-93* TOTAL CO2-24 ANION GAP-20 [**2119-9-29**] 06:20PM CALCIUM-8.3* PHOSPHATE-6.3*# MAGNESIUM-2.7* [**10-5**] Cr 2.3, K 4.0 . Cardiac enzymes [**10-3**] 11am CK 31, Tropn 0.03 [**10-3**] 5pm CK 43, Tropn 0.09 [**10-3**] 11pm CK 50, Tropn 0.22 [**10-5**] 6am CK 46, Tropn 0.10\ . CXR [**9-30**] The lungs are hyperinflated, and the diaphragms are flattened, together with parenchymal scarring, all consistent with COPD. The patient is status post sternotomy, with mediastinal clips. There is moderate cardiomegaly. The aorta is calcified and unfolded. There is a minimal blunting of the left costophrenic angle consistent with a small effusion, new compared with [**2119-9-22**]. There is associated patchy opacity - this likely represents atelectasis, though an early infiltrate would be difficult to exclude. Minimal new opacity is seen at the right base peripherally, with slight blunting of the right costophrenic angle. There is upper zone re-distribution, probably with mild CHF. Some atelectasis is seen in the right mid zone, together with some thickening of the minor fissure. Clips are noted over the right shoulder/axilla. IMPRESSION: Probable very mild CHF, worse compared with [**2119-9-22**]. Small left and right pleural effusions, more pronounced than on [**2119-9-22**]. Bibasilar atelectasis. It would be difficult to exclude the earliest findings of infiltrate at the left base. . EKG [**10-3**] 9am sinus tachycardia with pseudonormalization of T waves in V4-V6 . Micro URINE CULTURE (Preliminary): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Brief Hospital Course: 1. Acute on chronic renal failure: The patient's elevated creatinine in the setting of recent cardiac catheterization most likely represented contrast nephropathy. Her creatinine improved with time, but was still above baseline (1.7) at time of discharge. Her ACEI and digoxin were held. Her creatinine will need to be rechecked in the next week as an outpatient. . 2. Hyperkalemia: The patient's potassium in the emergency department was 5.6, with no peaked T waves on EKG. She received kayexalate once with return of her potassium to the normal range. Her ACEI and spironolactone were held. . 3. Dyspnea, CAD, CHF: The patient developed chest discomfort on the floor and was subsequently transferred to the CCU for further evaluation. EKG obtained the morning of transfer to the CCU showed pseudonormalization of T waves laterally. Due to her elevated creatinine, the decision was made to manage her medically rather than proceed to cardiac catheterization. Upon arrival in the CCU, her primary complaint was dyspnea. Her symptoms improved following a nitroglycerin drip and lasix diuresis. Her troponins were mildly elevated (peaking at 0.22, but CK's remained flat) consistent with a NSTEMI. She did become tachycardic in the setting of her respiratory distress so there was likely a component of demand ischemia to her troponin leak. She will continue on imdur at home for additional control of her angina. She will continue on her aspirin, plavix, statin, beta-blocker, and lasix. Her ACEI and digoxin will be resumed following further recovery of her renal function. . 4. Urinary tract infection: The patient had a foley in hospital, and subsequently developed a urinary tract infection due to pan-sensitive E. coli. She will complete a 7 day course of ciprofloxacin. . 5. Atrial fibrillation: She continued rate control with metoprolol. She is not on anticoagulation at home. . 6. Diabetes: The patient's glyburide was held initially and her sugars were controlled with a sliding scale. Her glyburide was subsequently restarted prior to discharge. . 7. Anemia, chronic: The patient was seen by the hematology-oncology service on the floor who felt that the patient's chronic anemia was most likely due to her chronic renal insufficiency. She will start on epoetin per their recommendations. She has had some heme+ stools in hospital, in the setting of hemorrhoids, and her iron studies did not indicate significant iron deficiency. Medications on Admission: Aspirin 325 mg daily plavix 75 daily ntg prn glyburide 10mg [**Hospital1 **] lisinopril 2.5m daily spirono 25mg daily digoxin 125mg MWF simvastatin 10mg daily MVI gabapentin 300mg qhs PPI toprol xl 50mg [**Hospital1 **] Vit D percocet prn lasix 20mg daily Discharge Medications: 1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 5 days: take ciprofloxacin 2 hours before or 6 hours after taking your calcium supplements. Disp:*5 Tablet(s)* Refills:*0* 2. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for leg Pain: Do not take more than 4 grams of acetaminophen in all forms daily. 8. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 9. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 10. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day. 11. Nitroglycerin 0.4 mg/SPRAY Spray, Non-Aerosol Sig: One (1) spray Translingual every 5 minutes as needed for chest pain. 12. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 13. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a day. 14. Gabapentin 300 mg Tablet Sig: One (1) Tablet PO at bedtime. 15. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 16. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 17. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*2* 18. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 19. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) injection Injection QMOWEFR (Monday -Wednesday-Friday) for 3 doses. Disp:*3 vials* Refills:*0* 20. Epoetin Alfa 40,000 unit/mL Solution Sig: One (1) injection Injection once a week: Hold for Hct>35% Start after one week of Epoetin 10,000 TIW completed. Disp:*4 vials* Refills:*2* 21. Outpatient Lab Work Please have hematocrit and hemoglobin checked twice weekly while on epoetin and have results sent to Dr.[**Name (NI) 16553**] office [**Telephone/Fax (1) 2394**]. Discharge Disposition: Home With Service Facility: All Care [**Telephone/Fax (1) 269**] of Greater [**Location (un) **] Discharge Diagnosis: 1. acute renal failure 2. chf 3. coronary artery disease 4. NSTEMI Discharge Condition: good Discharge Instructions: You were admitted to the hospital for worsened kidney function, which has now improved. The kidney troubles were likely related to the recent cardiac catheterization that you recently underwent. While in the hospital, you had some worsened shortness of breath and chest discomfort likely due to your coronary artery disease and congestive heart failure. You did have blood tests showing that you may have had a mild heart attack. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Call your doctor and seek medical attention at once if you develop: **worsening shortness of breath, chest discomfort that does not respond to nitroglycerin, fevers, chills, sweats, abdominal or back pains, or other symptoms that worry you Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 11679**] [**10-10**] 2pm (you may arrive at 1pm if convenient for you). . You will be starting epoetin, a medicine to raise your red blood cell count, so it is important that you receive tests to monitor your blood count twice a week while you are receiving epoetin. The [**Name (STitle) 269**] will help you take epoetin and will collect samples for these blood tests. Name: [**Known lastname 7400**],[**Known firstname 7401**] V Unit No: [**Numeric Identifier 7402**] Admission Date: [**2119-9-29**] Discharge Date: [**2119-10-6**] Date of Birth: [**2036-12-14**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 276**] Addendum: ** Correction: patient to resume her home lasix schedule as below. Discharge Medications: 1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 5 days: take ciprofloxacin 2 hours before or 6 hours after taking your calcium supplements. Disp:*5 Tablet(s)* Refills:*0* 2. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for leg Pain: Do not take more than 4 grams of acetaminophen in all forms daily. 8. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 9. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 10. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day. 11. Nitroglycerin 0.4 mg/SPRAY Spray, Non-Aerosol Sig: One (1) spray Translingual every 5 minutes as needed for chest pain. 12. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 13. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a day. 14. Gabapentin 300 mg Tablet Sig: One (1) Tablet PO at bedtime. 15. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 16. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*2* 17. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 18. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) injection Injection QMOWEFR (Monday -Wednesday-Friday) for 3 doses. Disp:*3 vials* Refills:*0* 19. Epoetin Alfa 40,000 unit/mL Solution Sig: One (1) injection Injection once a week: Hold for Hct>35% Start after one week of Epoetin 10,000 TIW completed. Disp:*4 vials* Refills:*2* 20. Outpatient Lab Work Please have hematocrit and hemoglobin checked twice weekly while on epoetin and have results sent to Dr.[**Name (NI) 7403**] office [**Telephone/Fax (1) 7404**]. 21. Lasix 40 mg Tablet Sig: Two (2) Tablet PO twice a day: Tuesday, Thursday, Saturday, Sunday. 22. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day: Monday, Wednesday, Friday. Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) 102**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 284**] MD [**MD Number(1) 285**] Completed by:[**2119-10-6**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

15185, 15418

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282, 288

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42,274

145,920

54928

Discharge summary

report

Admission Date: [**2123-9-7**] Discharge Date: [**2123-9-11**] Date of Birth: [**2042-11-17**] Sex: M Service: MEDICINE Allergies: Aleve / Gemfibrozil / Lescol / Motrin Attending:[**First Name3 (LF) 2736**] Chief Complaint: OSH transfer for CHF/NSTEMI Major Surgical or Invasive Procedure: cardiac catheterization with drug eluting stents x2 to left anterior descending artery History of Present Illness: 80 y/o M with PMH of DMII, [**Hospital **] transferred from OSH for management of NSTEMI and CHF. He originally presented to OSH from [**Hospital3 **] facility with SOB. His symptoms started on Saturday when he was moving from his home to an [**Hospital3 **] facility. He started having chest burning heaviness lasting about an hour associated with some SOB that eventually subsided. He thought that this was d/t GERD and took some tums. On Monday, he reported his sxs to the NP[**MD Number(3) 31663**] new [**Hospital3 **] facility, who noted bilateral LE edema and advised him to sleep on 2 pillows that night and she set him up for a EKG this morning. However, Monday evening he noticed he was SOB around 12am when he got out of bed to turn on the air conditioner. He went back to bed and at 3am he was still SOB, when his symptoms persisted he called his daughter at 5am and took a baby aspirin. [**Name2 (NI) **] activated the help code at his assisted facility who called the ambulance for transport to the OSH. At OSH he was found to have a troponin I of 0.38, CR 1.3, hyponatremia to 129, and CXR showed infiltrative changes at both lung bases with minimal fluid. EKG showed NSR with RBBB, non-specific ST changes and some ST depressions. He was treated with DuoNebs, heparin gtt, nitro gtt was transferred to [**Hospital1 18**] for further management. . In the ED, initial vitals were 97.1 79 154/74 18 90% 4L Labs and imaging significant for worsening interstitial edema compared to OSH CXR. Patient given Lasix 20mg IV with 900cc urine output. He required bipap for RA sats in low 80s. EKG showed RBBB and TWI precordially and <1mm STE in AVR. Repeat troponin was 0.2. Vitals on transfer were 96.6 ??????F (35.9??????C) (Axillary), Pulse: 54, RR: 18, BP: 118/53,(nitro o.28mcg/kg) On arrival to the floor, patient was resting comfortable in NAD. He states that he endorses PND. He sleeps on 1 pillow, although he slept on 2 pillows last night on the advice of a NP[**MD Number(3) 31663**] [**Hospital3 **] facility. He has been using a cane to ambulate over the last few weeks (more per his family) due to low back pain and has a hx of arthritis. In addition, over the last year he has assumed full care of his wife who has worsening dementia and has been eating microwaved meals with high salt content since that time. Of note, EKG from PCP [**Last Name (NamePattern4) **] [**2122-7-14**] showed Sinus bradycardia (49), normal axis, Q waves in II, III, aVF, and non-specific TWI, RBBB. REVIEW OF SYSTEMS On review of systems, s/he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, hemoptysis, black stools or red stools. S/he denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, palpitations, syncope or presyncope. Past Medical History: PMH: Unspecified Anemia BPH w/o urinary obstruction Carotid Artery Stenosis Cervical Radiculopathy Chronic Kidney Disease, Stage I CAD Dermatitis Diabetes Mellitus, II Esophageal Reflux Essential Hypertriglyceridemia Hearing Loss Liver Enlargement Hypertension Murmur Overweight Proteinuria RBBB Sciatica Vitamin D Deficiency PSH: Carpel Tunnel ~[**2118**] Social History: Retired Businessman. Recently moved to New [**Hospital3 400**] so that his wife with Dementia can have 24hr care. Smoked 1PPD for 20 years, quit 25 years ago. Drinks 1 bourbon per day. Denies illegal drug use. [**First Name8 (NamePattern2) 1154**] [**Last Name (NamePattern1) **]: home [**Telephone/Fax (1) 112180**] dtr cell [**Telephone/Fax (1) 112181**] Family History: Son had MI at 52 Mom died in sleep at 83 Father - emphysema Physical Exam: ADMISSION: PE: 97.9 134/58 71 22 93%5L APPEARANCE: WDWN in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 7 cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. 2/6 systolic murmur No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB: b/L crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ DISCHARGE: PE: 98.3 131/55 64 18 99%RA I/O: 730/700 APPEARANCE: WDWN in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 7 cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. 2/6 systolic murmur No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB: b/L crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: Admission Labs: [**2123-9-7**] 10:50AM PT-12.6* PTT-150* INR(PT)-1.2* [**2123-9-7**] 10:50AM PLT COUNT-270 [**2123-9-7**] 10:50AM NEUTS-85.5* LYMPHS-9.8* MONOS-3.3 EOS-0.9 BASOS-0.6 [**2123-9-7**] 10:50AM WBC-10.0 RBC-3.35* HGB-11.2* HCT-32.7* MCV-98 MCH-33.3* MCHC-34.1 RDW-13.8 [**2123-9-7**] 10:50AM HDL CHOL-53 CHOL/HDL-2.3 LDL([**Last Name (un) **])-64 [**2123-9-7**] 10:50AM CALCIUM-9.2 PHOSPHATE-4.0 MAGNESIUM-1.9 CHOLEST-122 [**2123-9-7**] 10:50AM CK-MB-6 [**2123-9-7**] 10:50AM cTropnT-0.21* [**2123-9-7**] 10:50AM CK(CPK)-145 [**2123-9-7**] 10:50AM estGFR-Using this [**2123-9-7**] 10:50AM GLUCOSE-151* UREA N-27* CREAT-1.2 SODIUM-133 POTASSIUM-3.8 CHLORIDE-94* TOTAL CO2-22 ANION GAP-21* [**2123-9-7**] 11:10AM URINE MUCOUS-RARE [**2123-9-7**] 11:10AM URINE RBC-1 WBC-<1 BACTERIA-NONE YEAST-NONE EPI-0 [**2123-9-7**] 11:10AM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2123-9-7**] 11:10AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.005 [**2123-9-7**] 05:40PM PT-13.2* PTT-150* INR(PT)-1.2* [**2123-9-7**] 05:40PM %HbA1c-5.5 eAG-111 [**2123-9-7**] 05:40PM CALCIUM-8.8 PHOSPHATE-3.9 MAGNESIUM-1.7 [**2123-9-7**] 05:40PM CK-MB-5 cTropnT-0.25* [**2123-9-7**] 05:40PM GLUCOSE-175* UREA N-26* CREAT-1.1 SODIUM-131* POTASSIUM-3.6 CHLORIDE-96 TOTAL CO2-22 ANION GAP-17 .CXR [**2123-9-7**]: Bilateral perihilar and basilar opacities, compatible with Preliminary Reportpulmonary edema or bilateral pneumonia in the correct clinical setting. DISCHARGE: [**2123-9-10**] 07:40AM BLOOD WBC-7.7 RBC-2.98* Hgb-9.8* Hct-29.5* MCV-99* MCH-32.8* MCHC-33.1 RDW-13.9 Plt Ct-268 [**2123-9-10**] 07:40AM BLOOD PT-11.9 PTT-28.3 INR(PT)-1.1 [**2123-9-11**] 07:40AM BLOOD UreaN-22* Creat-1.2 Na-134 K-4.2 Cl-97 Brief Hospital Course: 80 y/o M with multiple cardiac risk factors including long-standing DM, HTN, HPL and CAD with prior hx of cardiac ischemia presenting with 1 episode of chest burning and heaviness and 3 day hx of worsening SOB found to have elevated troponin and pulmonary edema likely new onset CHF in the setting of an NSTEMI. Contributing factors include multiple cardiac risk factors in addition to increased salt intake over the last year and stress this past weekend in the setting of him moving from his home to an [**Hospital3 **]. In addition, his wife has been in and out of the hospital over the last 3 weeks which has been a source of stress for him as well. #NSTEMI: Pt was taken to to cath on [**9-8**], given high risk cad decomp hf, low ef, potentialy viable vasculature - RHC show PA sat 52%, CO 4.2, CI 2.3, wedge 35, PA pressure 66/34; LHC - totally occluded RCA (old with collaterals), LAD 90% prox, 70% mid lesion, very calcified - needed rota - and received 2 DES to LAD. Post procedure he was hemodynamically stable with no evidence of distal embolization. We started Carvedilol 25mg PO BID, Atorvastatin 80mg PO daily, plavix 75mg PO daily(after loading with 300mg pre-cath), Lisinopril 40mg PO daily and ASA 325mg daily. We also added back his home dose of Cardura at 8mg PO for both blood pressure control and BPH. He will follow up Dr. [**Last Name (STitle) **] in cardiology on [**10-1**] as an outpatient further management of post NSTEMI medications. #CHF: Echo on admission showed moderately depressed LV function with EF 35-40%, with inferior/inferoseptal akinesis and anterior/anteroseptal. He was diuresed with Lasix IV with good response and goal urine output 100cc/hr. He was started on Lisinopril 40mg PO daily and carvedilol 25mg PO BID with good blood prssure control. He will follow up with cardiology as an outpatient for further titration of HF medications. #RESPIRATORY DISTRESS: likely [**2-11**] new onset CHF with pulmonary edema on CXR. He wasa treated with Lasix IV for diuresis with good response and urine output of 100cc/hr. Upon admission to the CCU he was descalated from BIPAP to Nasal cannula and had 98-99% O2 saturation on RA by the day of discharge. #DM: Controlled on Metformin alone, Last A1c 5.6% per patient Metformin was held on admission. A1C checked on admission was 5.5%. His renal function remained stable during admission with a creatinine ranging from 1.1-1.2. He was placed on insulin sc during this admission and was instructed to restart metformin upon discharge. Transitional issues: Mr. [**Known lastname 112182**] will followup with Dr. [**Last Name (STitle) **] in cardiology ([**2123-10-1**]) for repeat echo and further management of NSTEMI long-term effects. In addition, he will be scheduled to see his new PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] as an outpatient for hospital follow-up. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient Outside records. 1. Aspirin 162 mg PO DAILY 2. Atenolol 25 mg PO DAILY 3. Doxazosin 8 mg PO HS 4. Fish Oil (Omega 3) 1000 mg PO BID 5. Hydrochlorothiazide 25 mg PO DAILY 6. Lisinopril 40 mg PO DAILY 7. melatonin *NF* 3 mg Oral HS 8. Multivitamins 1 TAB PO DAILY 9. Simvastatin 10 mg PO DAILY 10. Calcium Carbonate 500 mg PO BID 11. NIFEdipine 30 mg PO Q8H 12. Vitamin D [**2111**] UNIT PO DAILY 13. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY Do Not Crush Discharge Medications: 1. Aspirin 81 mg PO DAILY RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 2. Lisinopril 40 mg PO DAILY 3. Atorvastatin 80 mg PO DAILY RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. Carvedilol 25 mg PO BID RX *carvedilol 25 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 5. Clopidogrel 75 mg PO DAILY RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 6. Furosemide 40 mg PO DAILY RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 7. Spironolactone 12.5 mg PO DAILY RX *spironolactone 25 mg 0.5 (One half) tablet(s) by mouth daily Disp #*15 Tablet Refills:*0 8. Calcium Carbonate 500 mg PO BID 9. Doxazosin 8 mg PO HS 10. Fish Oil (Omega 3) 1000 mg PO BID 11. melatonin *NF* 3 mg Oral HS 12. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY 13. Multivitamins 1 TAB PO DAILY 14. Vitamin D [**2111**] UNIT PO DAILY 15. Outpatient Lab Work Please check chem-7 on Tuesday [**9-14**] with results to Dr. [**Last Name (STitle) **] at Phone: [**Telephone/Fax (1) 6662**] Fax: [**Telephone/Fax (1) 13889**] ICD 9: 428 16. Nitroglycerin SL 0.4 mg SL PRN chest pain RX *nitroglycerin 0.4 mg 0.4 mg sublingually every 5 minutes for 3 [**Telephone/Fax (1) 4319**] Disp #*30 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] home care Discharge Diagnosis: Primary: Acute systolic congestive heart failure Non ST elevation myocardial infarction . Secondary: Diabetes mellitus hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname 112182**], . It was a pleasure taking care of you here at [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1675**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **]. You were admitted to [**Hospital1 18**] on [**9-7**] for a heart attack and congestive heart failure. It is thought that you had the heart attack a few days before you came to the hospital and an echocardiogram shows an area of your heart that is not moving well. Because your heart was weak, you had fluid that backed up in your lungs and you needed some support for your breathing until we were able to remove the fluid. A cardiac catheterization showed a blockage in your left heart artery and two drug eluting stents were placed to keep the artery open. You will need to take aspirin and Plavix (clopidogrel) every day without fail to prevent the stents from clotting off and cuasing another heart attack. Do not stop taking aspirin and Plavix or miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] unless Dr. [**Last Name (STitle) **], your new Cardiologist, says that it is OK. You are now doing well and have been started on many new medicines to help your heart recover from the heart attack. . You will need to watch yourself very closely to make sure the fluid does not return. Monitor your breathing and any swelling in your legs. Please weigh yourself daily in the morning before breakfast and record the weight. Call Dr. [**Last Name (STitle) **] for any symptoms of fluid return or if your weight increases more than 3 pounds in 1 day or 5 pounds in 3 days. Your weight at discharge is 168 pounds and this should be considered your ideal weight. . We would like you to have labwork done on Tuesday to check your salts and kidney fuction with all the the new medicine we started. Followup Instructions: Department: ADULT SPECIALTIES When: FRIDAY [**2123-10-1**] at 11:00 AM With: [**Name6 (MD) **] [**Name8 (MD) 10828**], MD [**Telephone/Fax (1) 21928**] Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**] Campus: OFF CAMPUS Best Parking: Free Parking on Site . Name: [**Last Name (LF) 1576**],[**First Name3 (LF) 1575**] Location: BIDHC [**Location (un) **] SUBACUTE CARE EXTENDED COMMUNITY PRACTICE Phone: [**Telephone/Fax (1) 14405**] *Your primary care provider will visit you at home within 72 hours of being discharged from the hospital. If you have any questions or concerns please call the office.

[ "410.71", "250.00", "428.21", "600.00", "276.1", "530.81", "403.90", "585.1", "268.9", "428.0" ]

icd9cm

[ [ [] ] ]

[ "17.55", "00.46", "88.56", "89.64", "00.40", "37.21", "00.66", "36.07" ]

icd9pcs

[ [ [] ] ]

12733, 12872

7881, 10419

326, 415

13048, 13048

6039, 6039

15067, 15712

4213, 4274

11380, 12710

12893, 13027

10802, 11357

13199, 15044

4289, 6020

10440, 10776

259, 288

443, 3438

6055, 7858

13063, 13175

3460, 3819

3835, 4197

24,242

185,235

1885+1923

Discharge summary

report+report

Admission Date: [**2179-10-16**] Discharge Date: [**2179-10-25**] Service: CARDIOTHOR HISTORY OF PRESENT ILLNESS: The patient is an 81-year-old male with no history of coronary artery disease, who presented with new onset substernal chest pain, pressure and diaphoresis times roughly four hours. The substernal chest pain was relieved with two sublingual nitroglycerin. Upon presentation, the patient had an electrocardiogram who showed atrial fibrillation at 50 beats per minute with left axis deviation, left bundle branch block, ST depression in lead III and ST elevations in leads V2, V3, V4, V5 and V6. The patient was diagnosed with an acute myocardial infarction. PAST MEDICAL HISTORY: The past medical history included a history of atrioventricular nodal reentry, status post ablation about eight to nine years ago, and atrial fibrillation. He also had a history of back pain and hip pain. He had a left hip replacement complicated by a staphylococcus infection three to four years ago. He was status post back surgery. He was also status post bilateral cataract surgery. MEDICATIONS ON ADMISSION: Captopril 25 mg p.o. b.i.d. Tylenol. Coumadin 5 mg on Monday, Wednesday and Friday and 2.5 mg on Tuesday, Thursday, Saturday and Sunday p.o. q.d. HOSPITAL COURSE: The patient had a cardiac catheterization done on [**2179-10-18**]. The report showed the left main coronary artery which was calcified at 30-40%; the left anterior descending artery with 80% eccentric origin calcified, 90% mid and diffuse 70% mid to distal; the left circumflex coronary artery with 80% origin calcified; the right coronary artery with diffuse 30-40% calcification and 80% involving the posterior descending artery origin. Th[**Last Name (STitle) 1050**] was evaluated by Dr. [**Last Name (Prefixes) **] from the cardiothoracic surgery service and was subsequently taken to surgery on [**2179-10-21**]. He had coronary artery bypass grafting times three done with a left internal mammary artery graft to the left anterior descending artery and saphenous vein grafts to the posterior descending artery and obtuse marginal artery. Postoperatively, the patient did well. The chest tubes were pulled without incident. The pericardial wires were discontinued on [**2179-10-26**]. The patient was transported to the floor. The patient was able to ambulate with physical therapy and his condition was stable. The physical therapy level was approximately 2 to 3. DISPOSITION: The patient will be discharged to rehabilitation. DISCHARGE MEDICATIONS: Percocet one to two tablets p.o. every four to six hours p.r.n. Lasix 20 mg p.o. every 12 hours. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mEq p.o. every 12 hours. Ranitidine 150 mg p.o. b.i.d. Coumadin 5 mg p.o. on Monday, Wednesday and Friday and 2.5 mg on Tuesday, Thursday and Sunday p.o. q.d. Captopril 6.25 mg p.o. t.i.d. CONDITION ON DISCHARGE: The patient's condition was stable. The sternum was stable and the sternal wound showed no drainage. The chest was clear to auscultation bilaterally. FO[**Last Name (STitle) 996**]P: The patient was advised to follow up with Dr. [**Last Name (Prefixes) **] in three to four weeks. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Name8 (MD) 186**] MEDQUIST36 D: [**2179-10-26**] 10:11 T: [**2179-10-26**] 11:10 JOB#: [**Job Number 10510**] Admission Date: [**2179-10-16**] Discharge Date: [**2179-10-25**] Service: CARDIOTHOR REASON FOR ADMISSION: The patient was admitted for coronary artery bypass grafting times three. PAST MEDICAL HISTORY: The patient's past medical history included atrioventricular nodal reentrant tachycardia, atrial fibrillation, status post ablation and low back pain. HOSPITAL COURSE: Coronary artery bypass grafting was performed on [**2179-10-21**]. Postoperatively, the patient did well with no complications. DISCHARGE MEDICATIONS: Percocet one to two tablets p.o. every four to six hours p.r.n. Lasix 20 mg p.o. every 12 hours. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mEq p.o. every 12 hours. Ranitidine 150 mg p.o. b.i.d. Coumadin 5 mg p.o. q. Monday, Wednesday and Friday and 2.5 mg p.o. q. Tuesday, Thursday, Saturday and Sunday. Captopril 6.25 mg p.o. t.i.d. The patient is to have his prothrombin time and INR rechecked on [**2179-10-26**]. The results will be called to Dr. [**Last Name (STitle) **] and Dr. [**First Name (STitle) **]. REHABILITATION STATUS: The patient is status 2. CONDITION ON DISCHARGE: Upon discharge, the patient's condition was stable. FOLLOW UP: The patient is to be followed up in three to four weeks. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Name8 (MD) 186**] MEDQUIST36 D: [**2179-10-25**] 08:44 T: [**2179-10-25**] 08:51 JOB#: [**Job Number 10681**]

[ "V45.61", "305.1", "428.0", "414.01", "724.5", "410.71", "997.1", "427.31", "V43.64" ]

icd9cm

[ [ [] ] ]

[ "88.56", "36.15", "39.61", "36.12", "37.22" ]

icd9pcs

[ [ [] ] ]

4031, 4631

1129, 1276

3878, 4008

4721, 5029

127, 688

3708, 3860

4656, 4709

53,578

114,063

8229

Discharge summary

report

Admission Date: [**2157-8-1**] Discharge Date: [**2157-8-18**] Date of Birth: [**2083-7-26**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Morphine / Erythromycin Base / Desipramine / Ace Inhibitors / Codeine / Nifedipine Attending:[**First Name3 (LF) 1253**] Chief Complaint: Shortness of breath, tachycardia Major Surgical or Invasive Procedure: DC Cardioversion History of Present Illness: 74 yo F with PMH significant for pancreatic CA s/p Whipple's procedure and chemotherapy, HTN, HLD, CKD, DM 2, recurrent C. diff and UTI, and recent left femur fracture, presents with shortness of breath and tachycardia, found to have pulmonary embolism and atrial flutter with RVR. . Patient reports that she was experiencing shortness of breath this AM at [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **] and was noted to be tachypneic up to the 30s. Denied chest pain, chest pressure, diaphoresis, vomiting, syncope. Otherwise, reports diarrhea from C. diff, increased upper extremity edema over the past 2 days, and worsening wheeze. . Of note, patient was found to have a non-occlusive left popliteal DVT on LENI in [**2157-5-29**]. Lovenox and IVC filter were recommended and patient declined both. On [**2157-7-16**], she syncopized and sustained a fall from standing height at rehab, resulting in left oblique displaced comminuted midshaft femur fracture. This was repaired at [**Hospital1 18**] on [**2157-7-20**] when she underwent a retrograde femoral nail for left femur fracture. Post-operatively, patient was discharged on prophylaxis dose of lovenox 40 mg/0.4 ml sc qd. . Two day prior to admission, patient noted increased swelling in her upper extemities. Also reports having a repeat LENI done of the left leg which showed disappearance of the previously noted DVT. . In the ED, initial VS were 98.2 141 126/87 24 98% 4L Nasal Cannula. EKG showed A-flutter and she was given an adenosine challenge. Received IV diltiazem (5 mg x 3) and then diltiazem gtt, which was stopped after the CTA showed PE. CT head was performed to ruled out metastasis which was negative. She was guaiac negative and started on heparin gtt. Labs were notable for BNP 7400, troponin 0.08, Cr 1.4 (baseline 1.7), positive UA, and patient was given vancomycin + zosyn. Per report, bedside echo did not show RV collapse. On transfer, VS were HR 141 BP 109/71 RR 16 O2sat 97% 3L (NC). . On the floor, patient was tachypneic and in slight distress. Denied chest pain however does report wheezing and shortness of breath. Past Medical History: - Pancreatitis in [**2156-3-15**] at [**Hospital1 112**]. MRI/MRCP on [**2156-9-29**] showed a 2 cm cystic mass of the pancreatic head with obstruction of the pancreatic and bile ducts. She underwent ERCP on [**2156-10-4**] and a stent was placed. CEA was 32.8 on [**2156-10-5**]. Brushing at the time of ERCP was suspicious for adenocarcinoma. She had an EUS on [**2156-11-8**] and FNA biopsy revealed malignant cells consistent with adenocarcinoma. Staging CT on [**2156-11-13**] revealed a 1.9 cm x 1.6 cm hypoattenuating pancreatic head mass with post-obstructive pancreatic ductal dilatation to 6mm. No evidence of local, hepatic or vascular invasion; scattered celiac axis and porta hepatis LNs measuring up to 1.2 cm. She was seen by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital1 **] surgery service and had Whipple surgery on [**2156-12-2**]. She had stayed in Rehab until the beginning of [**2157-1-12**] and then shortly after she was discharged from rehab, she was admitted to [**Hospital1 **] on [**2157-1-28**] for C diff, UTI and acute renal failure. . Chemotherapy: [**2157-2-17**] Cycle 1 Gemzar 800mg/m2, week 3 treatment on [**3-3**] was held due to poor PS. [**2157-3-11**] Cycle 2 Gemzar 800mg/m2 [**2157-3-25**] 2u pRBC tx [**Hospital1 **] [**2157-4-7**] Cycle 3 week 1 Gemzar 800mg/m2 [**2157-4-14**] Cycle 3 week 2 Gemzar 800mg/m2 [**2157-4-21**] Cycle 3 week 3 Gem 800 mg/m2, 25% dose reduction [**2157-4-21**] 2u pRBC tx [**Hospital1 **] [**2157-5-12**] Cycle 4 week 1-delayed by one week due to diarrhea, elevated Cr and fatigue [**2157-5-19**] Cycle 4 Week 2 Gemzar 800mg/m2 [**Date range (1) 29228**] Admitted to [**Hospital1 18**] for chemotherapy induced anemia, transfused 3 units PRBCs, diagnosed with left popliteal DVT, declines anticoagulation [**2157-6-9**] Cycle 5 Week 1 Gemzar 800mg/m2-start 2 weeks on/ 1 week off [**2157-6-23**] 2u pRBC tx [**Hospital1 **] . - History of DVT ([**2157-5-29**]) on LENI at [**Hospital1 18**] - Clostridium difficile colitis as above - Stage III chronic kidney disease (baseline Cr 1.7) - Diabetes mellitus type 2 - Hypertension - Hyperlipidemia - Gastroesophageal reflux disease - Diverticulosis with recurrent lower GI bleeding, etiology has been unclear despite workup but presumed diverticular. - Renal Stone: Left staghorn calculus - Depression, which is longstanding and difficult to treat. - Degenerative joint disease - Gout Social History: Patient lives alone in [**Location (un) 86**], and relies on her sister for needed support. She is independent, and cares for herself without any assistance. There is no recent ETOH use, no tobacco use (she quit smoking 25 yrs ago), no illicit drug use. Family History: Sister with breast cancer, diagnosed at age 58. Physical Exam: Adm PE: General: obese woman, lying in bed, in mild distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP difficult to appreciate due to body habitus Lungs: Diffuse expiratory wheezes, crackles at both bases CV: Regular and tachycardic, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, distended, well-healed scar, left LLQ with subcutaneous edema, no rebound tenderness or guarding, no organomegaly GU: Foley draining dark fluid Ext: warm, venous stasis changes on right shin, with 2+ edema up to the knee, left leg with surgical scar at knee, in airboot, intact PD pulses Discharge PE: 97.6 140/86 87 18 97% 2L Pertinent Results: 1. Labs in admission: [**2157-8-1**] 11:30AM BLOOD WBC-9.2 RBC-3.72*# Hgb-12.6# Hct-40.5# MCV-109* MCH-33.9* MCHC-31.1 RDW-23.3* Plt Ct-467* [**2157-8-1**] 11:30AM BLOOD PT-14.1* PTT-29.2 INR(PT)-1.2* [**2157-8-1**] 10:00PM BLOOD PT-18.5* PTT-150* INR(PT)-1.7* [**2157-8-1**] 11:30AM BLOOD Glucose-112* UreaN-23* Creat-1.4* Na-140 K-4.7 Cl-110* HCO3-23 AnGap-12 [**2157-8-1**] 11:30AM BLOOD ALT-11 AST-41* LD(LDH)-308* CK(CPK)-39 AlkPhos-334* TotBili-0.3 [**2157-8-1**] 11:30AM BLOOD CK-MB-3 proBNP-7400* [**2157-8-1**] 11:30AM BLOOD cTropnT-0.08* [**2157-8-1**] 10:00PM BLOOD CK-MB-3 cTropnT-0.07* [**2157-8-1**] 11:30AM BLOOD Albumin-1.9* Calcium-8.1* Phos-4.1 Mg-1.9 [**2157-8-1**] 12:32PM BLOOD Lactate-1.5 . 2. Labs on discharge: - CA [**65**]-9 ****** . 3. Micro: [**2157-8-15**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-POSITIVE {CLOSTRIDIUM DIFFICILE} INPATIENT [**2157-8-11**] URINE URINE CULTURE-FINAL {YEAST} INPATIENT [**2157-8-5**] URINE URINE CULTURE-FINAL {YEAST} INPATIENT [**2157-8-1**] STOOL FECAL CULTURE-FINAL; CAMPYLOBACTER CULTURE-FINAL; CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-Negative [**2157-8-1**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [**2157-8-1**] BLOOD CULTURE Blood Culture, Routine-FINAL EMERGENCY [**Hospital1 **] [**2157-8-1**] BLOOD CULTURE Blood Culture, Routine-FINAL EMERGENCY [**Hospital1 **] [**2157-8-1**] URINE URINE CULTURE-FINAL {YEAST, PROBABLE ENTEROCOCCUS} EMERGENCY [**Hospital1 **] 4. Imaging/diagnostics: - CTA chest ([**2157-8-1**]): 1. Acute PE involving segmental lower lobe pulmonary arteries. 2. Moderate pericardial effusion with possible tamponade given flattening of the interventricular septum. Correlate clinically. 3. Bilateral pleural effusions, lower lobe atelectasis and ground-glass alveolar opacities suggesting mild pulmonary edema. 4. Rib lesions as detailed, most focal at the 7th right posterior rib, ?? metastasis. . - CT head ([**2157-8-1**]): No acute intracranial process. . - Echocardiogram ([**2157-8-2**]): The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). The right ventricular cavity is mildly dilated with borderline normal free wall function. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is a very small pericardial effusion. There is significant, accentuated respiratory variation in mitral/tricuspid valve inflows, likely secondary to a sizeable *pleural* effusion. IMPRESSION: Very small pericaridial effusion without tamponade physiology. Mild right ventricular systolic dysfunction. Preserved global and regional left ventricular systolic function. Compared with the prior study (images reviewed) of [**2157-7-18**], right ventricle is slightly hypokinetic. Pleural effusion is new. The other findings, including a very small pericardial effusion, are similar. [**2157-8-5**] left femur xray: Atherosclerotic vascular calcifications. Status post ORIF of the left femur with retrograde intramedullary nail and interlocking screws. The hardware is intact. No evidence for hardware loosening or osteolysis. Again seen is a spiral distal femoral diaphysis fracture with improved anatomic alignment. No significant healing. Degenerative changes of the left hip and left knee, not significantly changed. [**2157-8-7**] CXR: Left-sided PICC line with tip in the SVC is again seen. The heart continues to be moderately enlarged. There is pulmonary vascular redistribution with perihilar haze and ill-defined vasculature consistent with CHF. There is a small left effusion and volume loss in both lower lungs. Compared to the prior study, the CHF appears worse. [**2157-8-9**] CXR: Radiographically there is no indication of deterioration relative to [**8-7**], in fact lung volumes have improved. There is still substantial atelectasis at both lung bases and a small left pleural effusion. Heart is at least mildly enlarged, but there is no pulmonary edema and vascular congestion is minimal. There may have been pulmonary edema previously. There is none today. No pneumothorax. Left PICC line can be traced as far as the mid-to-low SVC. [**2157-8-18**] TEE Conclusions No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). There are simple atheroma in the descending thoracic aorta and aortic arch to 35 cm from the incisors. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is a trivial/physiologic pericardial effusion. IMPRESSION: No evidence of spontaneous echo contrast or intracardiac thrombus. Simple atheroma in the aortic arch and descending thoracic aorta. Anticoagulation: INR Warfarin dose 7/4 3 4 [**8-16**] 3.3 3 [**8-17**] 3.8 (am)- 4.7 (pm) [Vitamin K 1 mg po x1] [**8-18**] 3 pending Discharge labs: WBC 5.9 Hgb 11.1 HCT 34.9 PLT 308 Na 141 K 3.7 Cl 109 HCO3 25 BUN 18 Cr 1.5 Glu 63 TSH 12 CA19-9 8 Brief Hospital Course: 74 yo F with PMH significant for pancreatic CA s/p Whipple's procedure and chemotherapy, HTN, HLD, CKD, DM 2, recurrent C. diff and UTI, and recent left femur fracture, presented with shortness of breath and tachycardia, found to have pulmonary embolism and atrial flutter with RVR leading to hypotension requiring transfer to the ICU. . # Respiratory distress: In part due to fluid overload. She was found to have pleural effusions and paricardial effusion (no tampanade). She required 2-3 days of 25% albumin followed by high dose lasix which she responded to, and on [**8-10**] she began to diurese well on her own. Her dyspnea and oxygen requirment continued to improve with this diuresis, and was 1.7L negative without lasix for 24 hours as of 8am [**2157-8-12**]. She was subsequently transferred to the floor where her lasix was restarted with goal of 1 liter negative per day. Her lasix was continued on the floor with ongoing improvement. Her lasix may need further dose titration for response. # Pulmonary embolism: CTA showed right basal segmental PE with ? left segmental PE, which corrolates to her presenting symptoms of dyspnea and tachycardia. Patient had been on prophylaxic doses of lovenox after previous hospitalization. She had a small pericardial effusion on CTA but no tamponade physiology on echocardiogram or pulsus paradoxus (8mmHg -> 8mmHg) exam. Patient started on heparin gtt and warfarin bridge initiated. Pt's INR had become supratherapeutic, likely d/t interaction with amiodarone. Pt received 1 mg po Vit K evening of [**2157-8-17**] to avoid supratherapeutic INR while undergoing DCCV. Note that Amiodarone dose is being reduced again at discharge, which will likely affect coumadin dosing/INR response. Please see results section for recent INR's and corresponding warfarin dosing. Her INR will need to be monitored very closely, especially given changing amiodarone dosing. # Aflutter with RVR/Hypotension: On admission, HR >130 with sBP 80-90s. Received adenosine challenge and then IV diltiazem/diltiazem gtt treatment in the ED with poor response. Attempted to rate control with esmolol gtt but blood pressure did not tolerate it. Loaded with IV amiodarone and then transitioned to po amiodarone, and oral diltiazem which was subsequently discontinued. Despite amiodarone, she remained in atrial flutter with sustained HR approx 100. She therefore underwent TEE / DC cardioversion, with return to sinus rhythm. Her amiodarone dose was reduced at time of discharge per Cardiology recommendations. TSH was checked and returned at 12. Unclear if this represents true hypothyroidism vs euthyroid sick. Recommend repeat TSH as pt continues to improve from her current illness. # Urinary tract infection: Urinalysis on admission was grossly positive. Urine culture showed yeast and and 3000 colony count of enterococcous. Patient treated with ciprofloxacin 500 mg po q12hr for 5 days. Her UA was persistently elevated with leukocytes. Patient was insistent that foley not be discontinued, so her foley was changed on [**8-10**]. Given lack of fever or WBC, the decision was made to wait until urine culture resulted before starting antibiotics despite a UA with persistent pyuria. Subsequent urine culture grew 10k-100k yeast, which given her absece of symptoms, dd not require further treatment at this time. Her foley was attempted to be dc'd on [**2157-8-18**], however pt refused, and will need to be discontinued at rehab. # [**Last Name (un) **]: Likely pre-renal secondary to poor forward flow in the setting of afib with RVR and volume overload.Her creatinine peaked at 2.3, five days after contrast load. She required [**3-17**] days of 25% albumin followed by high dose lasix (as recommended by nephrology) which she responded to, and on [**8-10**] she began to diurese well on her own. She was 1.7L negative without lasix for 24 hours as of 8am [**2157-8-12**]. Her Cr improved to 1.5 by the time of discharge. # Anasarca/Edema # Severe malnutrition Pt was treated with IV lasix during this admission to treat severe diffuse edema and whole body fluid overload. Her lasix was converted from IV to po, and may need further titration as an outpatient. Treatment should also focus on nutrition to improve hypoalbuminemia. # C. diff colitis: C. diff toxin positive in [**6-22**] and has long history of C. diff colitis since Whipple procedure in [**2156**]. She was supposed to complete a 2-week course of Metronidazole 500 mg po q8hr on during admission. This was extended given her treatment for suspected UTI as above. Despite treatment with po flagyl, she began to develop severe diarrhea, and c-diff tox screen turned positive (negative earlier in the admission). She was changed to po vancomycin, and her diarrhea improved. She will need to complete at least 2 weeks of po vancomycin. # Type 2 Diabetes: Pt was treated with Lantus and sliding scale insulin during this admission. Please see sliding scale provided. # Left femur fracture on previous admission: She was seen by orthopaedics who removed sutures/staples. They recommended touch-down weight bearing for at least 6wks post-op. Pt is touch down weight bearing until [**2157-8-27**]. She will need ongoing inpatient physical therapy. # Pancreatic cancer: Followed by Atrius oncologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 349**] who followed during the admission. CA [**65**]-9 rechecked and was normal at 8. Medications on Admission: 1. aspirin 81 mg po qd 2. bupropion HCl 450 mg Tablet Extended Release PO QAM 3. docusate sodium 100 mg PO BID 4. insulin Insulin SC Sliding Scale 5. insulin glargine 22 units qhs 6. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule, Delayed Release(E.C.) PO TID 7. losartan 50 mg PO BID 8. multivitamin PO DAILY 9. simvastatin 40 mg PO DAILY 10. Flagyl 500 mg PO q8hr (planned for [**2157-7-20**] - [**2157-8-2**]) 11. senna 8.6 mg PO BID prn constipation 12. bisacodyl 10 mg PO DAILY (Daily) prn constipation 13. oxycodone 10 mg PO Q3H 14. Tylenol Extra Strength 500 mg PO TID 15. Lovenox 40 mg/0.4 mL 1 syringe qd 16. lorazepam 0.5 mg PO Q8H prn for anxiety. 17. calcium carbonate 200 mg calcium (500 mg) Tablet PO QID (4 times a day) prn for heart burn. Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. bupropion HCl 150 mg Tablet Extended Release Sig: Three (3) Tablet Extended Release PO QAM (once a day (in the morning)). 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. lipase-protease-amylase 5,000-17,000 -27,000 unit Capsule, Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 7. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety. 8. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for heart burn. 9. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for rash. 10. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for SOB. 11. amiodarone 400 mg Tablet Sig: One (1) Tablet PO once a day. 12. vancomycin 125 mg Capsule Sig: One (1) Capsule PO every six (6) hours for 10 days: Please note that pt did not respond to po flagyl. 13. furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 14. Coumadin 3 mg Tablet Sig: One (1) Tablet PO q daily at 1600: Please follow INR closely and titrate as needed. 15. Lantus 100 unit/mL Solution Sig: Twenty Two (22) units Subcutaneous at bedtime. 16. Humalog 100 unit/mL Solution Sig: as per sliding scale units Subcutaneous QACHS: As per sliding scale provided. Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 533**] [**Last Name (NamePattern1) **] for Extended Care - [**Location 1268**] Discharge Diagnosis: # Pulmonary embolism # Atrial flutter # C-diff colitis # Anasarca/Edema # Severe malnutrition # Acute renal failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted with a fast heart rate and were found to have a new pulmomary embolism as well as a heart rhythm called atrial flutter. The pulmonary embolism (=blood clot in lung) was treated with heparin and transitioned to coumadin. The fast heart rate did not respond well to several medications but was ultimately controlled with electric cardioversion. You'll need to continue on both of these medications. Your INR will need to be followed closely. Followup Instructions: Department: SURGICAL SPECIALTIES When: MONDAY [**2157-12-26**] at 2:00 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD [**Telephone/Fax (1) 274**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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Discharge summary

report

Admission Date: [**2136-1-6**] Discharge Date: [**2136-1-8**] Date of Birth: [**2057-2-3**] Sex: F Service: MEDICINE Allergies: Penicillins / Amoxicillin / Sulfa (Sulfonamide Antibiotics) / Cephalosporins / Macrodantin / Clindamycin / Hayfever / Ativan Attending:[**First Name3 (LF) 348**] Chief Complaint: Altered Mental Status, Hypotension Major Surgical or Invasive Procedure: None History of Present Illness: 78 year old female with history of chronic pain on narcotics, lumbar spinal stenosis, L2 discectomy, chronic venous stasis dermatitis, chronic R heel ulcer now healed, deconditioning and recent admit for lower extremity edema, aspiration pneumonitis, and UTI returning with generalized weakness and RUE swelling. She was sent in from [**Hospital3 2558**] with nursing noting mental status changes and lethargy. Notes point out right upper hand swelling. BP at the time noted to be 90/55 with temp 98.5. Per report this right hand swelling was of four days duration but gradually worsened. Denies erythema, warmth, pain, or prior swelling like this. Denies f/c, -n/v/d, -CP/SOB/cough, -abd pain, -dysuria, -focal n/t/w. No trauma. No exacacerbating or relieving factors. . In the ED, initial VS were: T 97 80 146/76 18 97% RA. Physical exam with HDS, AAOx3, no evidence of lethargy, mild edema of the right hand. Differential diagnosis for her decreased energy and concern for lethargy in the ED was recurrent common infections versus metabolic versus electrolyte abnormality. In regard to swollen right hand, there are no features to suggest neuro, motor, vascular deficits, no underlying bony tenderness; they felt this may be a possible DVT. Right upper extremity ultrasound: no dvt. Labs were notable for an elevated d-dimer and a lactate of 2. CXR was done. CTA was obtained which identified large right main pulm artery embolus. She was started on a heparin gtt. UA was dirty and concerning for UTI. Based on prior resistance to cipro and allergies she was given gentamicin IV x1. Pt was admitted to the MICU based on the extensive nature of the embolus. Past Medical History: HTN Hyperlipidemia Hypothyroidism Chronic pain syndrome on narcotics Spinal stenosis s/o lumbar fusion, L2 disectomy Type II Diabetes, controlled w/o complications Asthma with hospitalization in past, no hx of intubation Chronic venous stasis Chronic Anemia Depression Cervical spondylosis Chronic shoulder pain/left rotator cuff tear Chronic constipation Metatarsal Fracture 3rd, 4th right Social History: Currently resides at rehab facility, was living in an apartment with her husband prior to previous admission. Uses a walker to ambulate. Has two children. No tobacco (quit 30 yrs ago), no etoh or illicits. Family History: No known malignancies Physical Exam: Vitals: afeb 83 129/63 16 98% on RA General: Alert, oriented, no acute distress, fatigued HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL 4mm bilaterally Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, 3/6 SEM best heard at RUSB, occaisional extra beats Lungs: Clear to auscultation laterally and anteriorly, no wheezes, rales, ronchi Abdomen: soft, non-tender, distended, trympanetic, bowel sounds present, no organomegaly Ext: warm, well perfused, 2+ pulses, trace LE edema bilaterally, right heel intact without breakdown Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact Pertinent Results: [**2136-1-6**] 04:50PM URINE RBC-0 WBC-61* BACTERIA-FEW YEAST-NONE EPI-9 [**2136-1-6**] 05:15PM WBC-3.4* RBC-3.30* HGB-9.0* HCT-28.4* MCV-86 MCH-27.3 MCHC-31.7 RDW-15.8* [**2136-1-6**] 05:15PM PLT COUNT-271 [**2136-1-6**] 05:15PM D-DIMER-3053* [**2136-1-6**] 05:15PM GLUCOSE-157* UREA N-20 CREAT-0.7 SODIUM-136 POTASSIUM-4.6 CHLORIDE-100 TOTAL CO2-25 ANION GAP-16 [**2136-1-6**] 09:10PM PT-11.5 PTT-23.5* INR(PT)-1.1 CT OF THE CHEST [**2136-1-6**]: A pulmonary embolism is noted within the right main pulmonary vessel extending into the right upper lobe pulmonary vessels. Bibasilar atelectasis is noted. Mediastinal, axillary and hilar lymph nodes do not meet CT size criteria for pathologic enlargement. The thoracic aorta shows no evidence of acute aortic injury and dissection. There are coronary atherosclerotic calcifications. No pericardial effusion is noted. Mild interstitial changes are noted within the lungs. The study is not optimized for subdiaphragmatic evaluation. Within this limitation, the upper abdominal structures appear unremarkable. Visualized osseous structures show multilevel degenerative changes with no lytic or sclerotic lesions suspicious for malignancies. IMPRESSION: 1. Right main pulmonary vessel embolus extending into the right upper lobe pulmonary vessels. 2. Bibasilar atelectasis. 3. Coronary artery calcifications. Brief Hospital Course: 78 yo F hx chronic pain and multiple prior UTI's presents with lethargy found to have a UTI and PE. . ACUTE # UTI - Reported burning with urination and had a UA with 61 WBC, few bacteria, and 9 epis. Possibly dirty, but given her history of recurrent E. coli UTIs in the past, decided to treat it. She was initially given aztreonam but then switched to one time dose of fosfomycin (she has extensive allergies and fosfomycin has worked in the past). Her symptoms resolved. # PULMONARY EMBOLISM - PE was likely an incidental finding on CTA of the chest as she had no dyspnea, hypoxia nor tachycardia. She remained completely asymptomatic in spite of her large R main PE. No ECG changes were present. She was started on heparin and warfarin then transitioned to lovenox and warfarin. She will need followup of INR with cessation of lovenox once her INR is therapeutic. The etiology of the clot is unclear but may be due to malignancy given her age. CHRONIC # CHRONIC PAIN SYNDROME - continued oxycontin and oxycodone. Continued bowel regimen incl colace, senna, miralax, lactulose # DM: Metformin held while in house. Restarted no discharge. Covered with ISS while in hour. # HTN: continued lisinopril, metoprolol # HL: continued rosuvastatin TRANSITIONAL CARE - INR should be monitored at least twice a week until therapeutic between a range of [**2-3**]. Warfarin should be adjusted accordingly. Lovenox should be discontinued when therapeutic. - Unprovoked clot is concerning for malignancy, though she has been somewhat sedentary given her chronic pain and poly-pharmacy. If warranted, search for malignancy should be pursued as an outpatient. Medications on Admission: 1. metformin 750 mg Tablet ER 24 hr PO at bedtime, and 250mg at 5pm 2. fluticasone-salmeterol 250-50 mcg/dose 1 puff [**Hospital1 **] 3. levothyroxine 175 mcg Tablet PO 6 days/week: except on saturday, with 100mcg on saturday. 4. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. iron 325mg daily 6. trazodone 100 mg Tablet PO HS 7. montelukast 10 mg Tablet PO DAILY 8. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler inh q6h prn sob, wheezing 9. alprazolam 0.25 mg Tablet PO BID 10. docusate sodium 100 mg PO BID 11. senna 8.6 mg Tablet PO BID as needed for constipation. 12. Miralax 17 gram Powder in Packet PO once a day prn constipation. 13. metoprolol tartrate 25 mg Tablet PO BID 14. fluticasone 50 mcg/Actuation Spray, Susp 2 sprays Daily. 15. gabapentin 300 mg Capsule PO Q12H 16. lidocaine 5 %(700 mg/patch) Adhesive Patch daily 17. rosuvastatin 5 mg Tablet PO daily 18. acetaminophen 500 mg Tablet 2 Tablet PO Q6H prn fever 19. lisinopril 10 mg Tablet PO DAILY 20. lactulose 10 gram/15 mL Solution 30ml PO once a day. 21. Vitamin B-12 1,000 mcg/mL 1000 mcg Injection once a month. 22. Vitamin D 50,000 unit Capsule PO once a week. 23. OxyContin 60 mg Tablet ER q8h 24. oxycodone 10 mg Tablet po q6h prn pain Discharge Medications: 1. metformin 750 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO at bedtime: and 250mg at 5pm. 2. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) puff Inhalation twice a day. 3. levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily): except saturdays. 4. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO SATURDAYS (). 5. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO once a day. 7. trazodone 100 mg Tablet Sig: One (1) Tablet PO at bedtime. 8. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) puff Inhalation every six (6) hours as needed for shortness of breath or wheezing. 10. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO twice a day. 11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 13. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) packet PO DAILY (Daily) as needed for constipation. 14. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO twice a day. 15. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). 16. gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 17. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 18. rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for fever or pain. 20. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 21. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO DAILY (Daily). 22. Vitamin B-12 1,000 mcg/mL Solution Sig: One (1) injection Injection once a month. 23. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a week. 24. OxyContin 60 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO every eight (8) hours. 25. oxycodone 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 26. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day. 27. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) injection Subcutaneous Q12H (every 12 hours). Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: PRIMARY: Pulmonary embolism Urinary Tract Infection SECONDARY: Chronic pain HTN Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Ms. [**Known lastname 2405**], You were admitted to the hospital with a urinary tract infection and a clot in your lungs. We gave you antibiotics for your urinary tract infection. We also gave you blood thinners to treat your clot. You will likely need to continue on blood thinners for 6 months. Medication changes: # START lovenox injections 80mg every 12 hours (blood thinner) # START warfarin 5mg daily (blood thinner) You will need to have your INR monitored twice weekly until we can find the correct dose of warfarin for you. Followup Instructions: Please contact your primary care physician for followup in [**1-2**] weeks.

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icd9cm

[ [ [] ] ]

[ "38.97", "99.21" ]

icd9pcs

[ [ [] ] ]

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3325

Discharge summary

report

Admission Date: [**2173-5-17**] Discharge Date: [**2173-6-4**] Date of Birth: [**2107-3-10**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 4327**] Chief Complaint: Worsening shortness of breathx 6 months Major Surgical or Invasive Procedure: Core valve placement oropharyngeal laceration s/p 3 sutures pulmonary intubation History of Present Illness: Mrs. [**Known lastname **] is a 66 year old woman with multiple medical problems including CAD s/p DES to RCA in [**2172-11-28**], severe aortic stenosis (valve area 0.5 cm2), recent DVT treated with coumadin, and SLE who is transferred from [**Hospital3 3583**] CCU for evaluation of severe aortic stenosis earlier this year. . Her cardiac history dates to [**2172-11-28**] for SOB when diagnosed with severe CHF and aortic stenosis. She also underwent a cardiac catherization at [**Hospital1 3278**] during that admission, and had a DES placed to the RCA, which was complicated by acute renal failure in the setting of contrast load. She was deemed to be an inoperable candidate by the cardiac surgeons at [**Hospital1 3278**]. . She then presented to the [**Hospital3 3583**] ED on [**2173-2-20**] after several days of increasing cough productive of sputum, fevers, and worsening SOB. She was admitted to the CCU and treated for a pneumonia with broad spectrum antibiotics,diuresed with lasix gtt and developed acute renal failure (Cre1.9->3.3->2.3)renal thought it was secondary to diuresis versus worsening aortic stenosis and less likely lupus nephritis given negative complement. . During her hospitalization in early [**Month (only) 547**], she was seen in consultation with the [**Hospital1 18**] (Dr. [**First Name (STitle) **] cardiac surgery service who deemed her an Extreme Risk surgical candidate due to porcelain aorta. Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 914**] later concurred in his findings. . She was re-admitted to [**Hospital3 3583**] on [**2173-3-21**] with worsening of her shortness of breath and suspicion of pneumonia secondary to her immunocompromised status. She was transferred to the [**Hospital1 18**] for further evaluation and treatment of her CHF. . Due to her worsening renal function (creatinine = 3.3 mg/dl), left and right heart diastolic heart failure, and shortness of breath, balloon aortic valvuloplasty was performed on [**2173-3-25**] with a 22 mm and 23 mm aortic valvuloplasty balloons without complications. The final aortic valve area was 0..86 cm2. . Following BAV, she symptoms improved and her creatinine fell to 1.8 mg/dL. She mobilized over 1 kg of fluid in a 24 hour period. Her dyspnea is substantially improved. She was discharged to home on daily furosemide. . She was readmitted [**4-12**] for CTA to complete her workup. Her renal function remained stable. . She has continuted to have NYHA Class III symptoms with exertion. Past Medical History: 1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: Cardiac Cath at [**Hospital1 3278**] in [**11/2172**]: DES to RCA -PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: Severe Aortic Stenosis Systemic Lupus Erythematosis TIA PVD (65% stenosis in carotid arteries) HLD L vocal chord dysfunction GERD COPD MVR (mild) DVT (s/p anticoagulation with coumadin discontinued approximately three weeks ago in [**1-/2173**]) Carpal Tunnel Syndrome CKD baseline Cre 1.2->1.7 Retrosternal calcification (chronic) Social History: Married. Retired hairdresser. Lives in [**Location 3320**]. -Tobacco history: 20 ppy smoking hx, quit 27 years ago -ETOH: [**11-29**] EtOH drinks weekly -Illicit drugs: denies Family History: Father died at 75 from CAD. Aunt died of MI at 49. Sister with a pacemaker. Physical Exam: General: Alert pleasant cauc female in NAD at rest. Skin: pale,tan. Upper ext. ecchymotic. Turgor poor. HEENT: Normocephalic, edentulous. Anicteric, conjunctiva pale. Neck: (+)JVD. (+)bilat carotid bruit vs. murmer. Chest: No obvious deformity. Rales bilaterally one third way up. Heart: RRR. III/VI Murmer RSB, radiating throughout. Abdomen:Soft,NT/ND, (+)BS x 4 quad. Extremities: 2+ pitting lower extemity edema bilaterally, healed scarring bilat calf ulcerations. Feet warm. Neuro: A+O x 3, pleasant, repositions self. Gross FROM. Denies pain. Pulses: 1+ peripheral pulses. . On Discharge: Gen: alert, oriented, NAD HEENT: supple, bounding jugular veins bilat when lying down. CV: RRR, no murmurs RESP: clear bilat ABD: soft, pos BS, NT, no tenderness EXTR: left arm with extensive old ecchymosis extending down the back, mild swelling and tenderness at left axilla. Stable L groin hematoma with old ecchymosis along the medial thigh and extending laterally along lower back. [**11-29**]+ pitting edema from mid shins bilat L>R. Pt states edema always worse on left. Skin: stage 1 on coccyx, skin tear as described above Pertinent Results: Admission labs: [**2173-5-17**] 12:44PM BLOOD WBC-8.6 RBC-2.91* Hgb-8.4* Hct-26.2* MCV-90 MCH-29.0 MCHC-32.1 RDW-18.0* Plt Ct-187 [**2173-5-17**] 06:00PM BLOOD PT-11.8 PTT-24.0 INR(PT)-1.0 [**2173-5-17**] 12:44PM BLOOD Glucose-103* UreaN-59* Creat-1.8* Na-140 K-4.4 Cl-109* HCO3-20* AnGap-15 [**2173-5-17**] 12:44PM BLOOD ALT-21 AST-21 CK(CPK)-22* AlkPhos-127* TotBili-0.3 [**2173-5-17**] 12:44PM BLOOD CK-MB-2 proBNP-[**Numeric Identifier 15453**]* [**2173-5-18**] 02:04PM BLOOD Calcium-6.6* Phos-8.6*# Mg-1.6 [**2173-5-17**] 12:44PM BLOOD %HbA1c-5.0 eAG-97 . Discharge Labs: [**2173-6-4**] 05:27AM BLOOD WBC-7.1 RBC-2.48* Hgb-7.6* Hct-23.5* MCV-95 MCH-30.5 MCHC-32.2 RDW-17.8* Plt Ct-258 [**2173-6-4**] 05:27AM BLOOD Glucose-74 UreaN-53* Creat-1.8* Na-143 K-4.3 Cl-114* HCO3-22 AnGap-11 [**2173-6-4**] 05:27AM BLOOD PT-17.0* INR(PT)-1.5* . EKG [**5-17**]: Sinus rhythm. Left ventricular hypertrophy with secondary repolarization abnormalities. Compared to the previous tracing of [**2173-4-14**] the findings are similar. . [**5-18**]: ECHO Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. An aortic CoreValve prosthesis is present. The prosthetic aortic valve leaflets appear normal. A mild to moderate ([**11-29**]+) paravalvular aortic valve leak is present. The mitral valve leaflets are mildly thickened. There is severe mitral annular calcification. Moderate (2+) mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: Normally-seated CoreValve aortic prosthesis with mild to moderate paravalvular leak. Moderate mitral regurgitation. Normal global and regional biventricular systolic function. Compared with the prior study (images reviewed) of [**2173-3-26**], severely stenotic native aortic valve has been replaced with a CoreValve prosthesis. . [**5-18**] CXR: In comparison with study of [**5-17**], CoreValve is now in place in the aorta. No evidence of pneumothorax or acute pneumonia or definite pulmonary vascular congestion. Right IJ pacer extends to the region of the apex of the right ventricle. . [**6-3**] Gastric Motility Test: Normal esophageal motility, limited study. . [**5-28**] LUE U/S 1. Resolution of previously visualized DVT in one of the two brachial veins with no evidence of residual DVTs in the left upper extremity. 2. Left axillary hematoma with expected evolutionary changes. . [**5-21**] LUE U/S 1. Deep vein thrombosis seen within one of the two brachial veins. Normal flow is seen in the remainder of the veins of the left arm. 2. Left axillary hematoma, which appears slightly smaller on today's exam, although note is made that a different technique was used. Brief Hospital Course: 66 year old female with critical aortic stenosis s/p coreValve percutaneous aortic valve replacement with a 26 mm CoreValve with course complicated by left arm and left groin hematoma, hypopharyngeal laceration which was sutured and hypotension requiring pressors. . ACTIVE ISSUES . # Critical aortic stenosis s/p CoreValve: Pt with hx of critical AS (valve area 0.5) admitted for elective core valve placement [**5-18**]. Pt with successful core valve placement as well as R common femoral art PTCA (70% lesion). Transferred to the CCU with R IJ w/ temporary pacing wire for 48 hours, L groin 8Fr venous sheath which was removed after 24h. Pt received 190cc contrast, 3 liters IVF, 4units PRBC??????s, 1Gm vancomycin, 2 doses Kefzol, 100mg hydrocortisone and 50mcgs Fentanyl. Pt required Neo 2mcg/kg/min for hypotension 2/2 L groin bleed. While in CCU pt required two additional units of pRBC??????s for L thigh hematoma and phenylephrine gtt to maintain SBP >110. Phenylephrine gtt was weaned off [**5-19**] with light fluid boluses and continued transfusions and fentanyl given for groin/abd discomfort related to hematoma. Aspirin and plavix will need to be continued for 3 months after CoreValve placement. . # Hypotension: Intra-op and immediately post-op, pt was hypotensive and pressor dependent. Etiology likely cardiogenic. Differential also includes adrenal insufficiency in setting of surgical stress in patient on chronic steroids. Pt given stress dose steroids and tapered with IV methylprednisone to 50 mg q8, then transitioned back to her home dose of 5 mg PO of prednisone daily. She was successfully weaned off all pressors by [**5-19**]. . # Hypertension: Pt's blood pressures remained elevated to the 160s for most of her stay, sometimes going as high as 190s. We resumed all of her home medications and up-titrated her hydralazine. Would recommend re-initiation of an ACE/[**Last Name (un) **] once pt's kidney function as stabilized. . # Oropharyngeal laceration: Pt sustained oropharyngeal laceration during intraoperative TEE. ENT placed dissolvable sutures with resolution of bleeding -sutures have since dissolved. Pt initially started on IV clindamycin but switched to po amoxicillin when able to tolerate. Pt completed her course of amoxicillin prior to discharge. Pt was evaluated by speech/swallow and ENT and was given permission to wear her dentures so that her diet could be advanced. Pt can follow up with ENT if needed after discharge in clinic ([**Telephone/Fax (1) 41**]. . # [**Last Name (un) **] on CKD: On admission, her baseline creatinine of 1.8 increased to 2.9, likely due to hypotension during the procedure as well as the large load of contrast (190 mL) she received without pre-cath mucomyst. Pt's creatinine continued to trend upward, peaking at 4.8, so renal was consulted. They followed the patient and temporarily initiated phosphate binders, sodium bicarbonate and low potassium diet, but ultimately felt initiation of HD was not required after pt had good response to IV lasix. Pt's urine output remained robust and her creatinine trended down steadily to 1.8 at the time of discharge. . # Left groin hematoma: Reversed in the OR with protamine sulfate. Required 4u transfusions pRBCs. Initially, pt's left thigh was large and quite tender with limited range of motion though she had palpable pulses throughout. By discharge pt's left thigh was still larger than her right though significantly less tender than before and with improved range of motion. . # Left axillary hematoma: Pt's axillary arterial line was pulled with subsequent development of a large hematoma under her left arm, extending to her forearm and down the side of her back to her waist. Pt began complaining of pain in the left arm on [**5-20**] and ultrasound showed development of a hematoma at the site of the line removal. On [**5-23**], she was noted to have enlargment of her arm hematoma with increased pain, swelling and edema in addition to a significant Hct drop to 20.8 from 28.6. Pt continued to have good pulses so concern for compartment syndrome was low. Pt remained hemodynamically stable and responded well to pRBC transfusion, ultimately requiring 4u over the next several days. The pain, erythema, and questionably demarcated appearance of the hematoma, particularly over the forearm raised suspicion for cellulitis so patient was started on vancomycin for an eight day course, which she has completed. The left arm hematoma and left flank ecchymoses seem to be resolving at the time of discharge. . # Left arm DVT: Ultrasound of the L arm on [**5-21**] showed interval development of a left-sided DVT, likely due to compression and stasis from the neighboring hematoma. She was started on anticoagulation with coumadin bridged with heparin. Pt's INR has been difficult to regulate, going up to 5.6 on [**6-1**] with some complaints of bleeding in her mouth, so pt received 0.5 mg vitamin K. At discharge pt was subtherapeutic on coumadin. Difficulty regulating her INRs likely due to her poor nutritional status. Follow-up ultrasound on [**5-29**] ultimately showed resolution of the left arm DVT but it is still recommended that pt continue coumadin for a one month course. . # Nausea: Unclear etiology though likely related to a combination of mood/anxiety, pain, and medication effect, as it often happens in the setting of taking medication. Pt's nausea better controlled now with IV Zofran three times a day prior to meals and medications. It was also suggested that she drink protein shakes prior to taking her medications. GI was consulted to investigate potential causes of patient's nausea but LFTs were within normal limits and barium swallow evaluation were both negative. Nausea had been a limiting factor for quite some time during patient's stay as she was not eating well and her nutritional status was poor at baseline. On discharge, pt's appetite had improved significantly with some relief of her nausea though she was still receiving IV Zofran three times a day. We would like for patient to be transitioned off of IV as soon as possible and to PO Zofran medication for nausea, so her PICC can be removed. . # Abdominal pain: Likely from left groin hematoma vs musculoskeletal pain from lying down during the procedure. Differential also includes mesenteric ischemia but unlikely with improving lactate and abdominal pain. Also concerning for pancreatitis vs gallbladder/liver etiology which are unlikely with normal liver enzymes and lipase. Pt no longer complaining of pain at time of discharge. . CHRONIC ISSUES . # Coronary artery disease s/p DES to RCA in 01/[**2172**]. Stable and continued on metoprolol, aspirin, plavix and simvastatin. . # Iron deficiency anemia: Continued iron. . # Lupus: Stable on home dose prednisone. . # COPD: Stable on home albuterol/ipratropium . TRANSITIONAL ISSUES Patient's nutritional status remains poor (albumin of 2.2) though she seems to respond well to protein shakes. Nausea remains an issue for her - currently she requires IV Zofran three times a day. However, given pt's fragile vasculature and her history of significant hematomas, would prefer that patient will be transitioned to PO Zofran as soon as possible so her PICC can be discontinued. Also, we recommend re-starting an ACE/[**Last Name (un) **] once her creatinine can tolerate it as her blood pressures remain difficult to control even on her current regimen. Patient should follow-up after discharge with cardiology, renal, and ENT (see above for office number for ENT). Pt will need to be on coumadin for her DVT for a one month course. Medications on Admission: Amlodipine 10 mg PO daily ASA 81 mg PO daily Prednisone 5 mg OPO daily Metoprolol succinate 100mg q24h Plavix 75 mg PO daily Protonix 40 mg PO daily albuterol sulfate 1-2puffs q4h prn SOB Calcium acetate 667mg po tid calciium carbonate-vitamin D3 600mg/400unit poqday docusate sodium 100mg po bid ferrous sulfate 325mg po qday furosemide 40mg po qday loratiadine 10mg po qday simvastatin 40mg po qhs tiotropium bromide 10mcg inh daily Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: Three (3) Tablet Extended Release 24 hr PO DAILY (Daily). Tablet Extended Release 24 hr(s) 6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for SOB. 8. Calcium 600 + D(3) 600 mg(1,500mg) -400 unit Tablet Sig: One (1) Tablet PO twice a day. 9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. simvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 13. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 14. hydralazine 50 mg Tablet Sig: One (1) Tablet PO four times a day. 15. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) packet PO DAILY (Daily). 16. senna 8.6 mg Tablet Sig: One (1) Tablet PO at bedtime. 17. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 18. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 19. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety. 20. 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. 21. Ondansetron 8 mg IV TID W/MEALS Please give 30 min prior to meals. [**Month (only) 116**] take with meds if not taking meals Discharge Disposition: Extended Care Facility: Radius [**Hospital1 392**] Discharge Diagnosis: Critical Aortic Stenosis s/o percutaneous aortic valve replacement (CoreValve) Hypertension Acute on chronic kidney disease Extensive left upper arm and left groin hematoma Left brachial vein DVT Chronic nausea Coronary artery disease Iron defeciency anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You had a percutaneous aortic valve replacement (CoreValve). The procedure went well and the valve is functioning normally. However, you had some complications that led to a prolonged hospital stay. You had some bleeding in the upper palate of your mouth that required stiches and has healed. You also had acute kidney failure requiring filtration of your blood. Your kidney function is now the same was [**Doctor Last Name **] your were admitted. You had an extensive bleed in the left arm and left groin that is slowly resolving. The swelling in your left arm led to a blood clot that is now gone but you will need to be on coumadin for another 2 months to prevent a reoccurance. Your blood pressure has been high and we have adjusted your medicines to better control your blood pressure. Weigh yourself every morning, call Dr. [**Last Name (STitle) **] if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. . We made the following changes to your medicines: 1. Stop Calcium acetate and loratidine 2. Increase calcium to twice daily 3. Increase lasix to twice daily, you may take the second dose at 3pm 4. Start miralax and senna to prevent constipation 5. Start hydralazine to lower your blood pressure 6. STart warfarin to prevent another blood clot 7. STart lorazepam to take as needed for anxiety 8. Start Zofran intravenously as needed to treat nausea before meals. You should try to wean this medication as you are able. Once you no longer need the medicine, your PICC line can be removed. Followup Instructions: Department: CARDIAC SERVICES When: FRIDAY [**2173-6-18**] at 9:00 AM With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: ECHO LAB When: FRIDAY [**2173-6-18**] at 11:00 AM With: ECHOCARDIOGRAM [**Telephone/Fax (1) 62**] Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage

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icd9cm

[ [ [] ] ]

[ "35.22", "88.72", "88.56", "88.42", "39.64", "37.23", "38.93", "27.61" ]

icd9pcs

[ [ [] ] ]

17834, 17887

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128,991

32055

Discharge summary

report

Admission Date: [**2185-12-7**] Discharge Date: [**2185-12-26**] Date of Birth: [**2115-11-26**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 8961**] Chief Complaint: UGIB Major Surgical or Invasive Procedure: Endotracheal intubation Arterial line placement Central line placement History of Present Illness: This is a 70 yo M with a past medical history significant for CAD s/p MI x 2 and CABG, cirrhosis with a history of variceal bleeds s/p banding in [**8-13**], who is transferred to [**Hospital1 18**] from an OSH after several episodes of large hematemesis. The patient was feeling generally unwell when he saw his PCP for [**Name Initial (PRE) **] regularly scheduled appointment today. He was sent to get some bloodwork drawn, which he did, and then returned home. He reports being in his bathroom around 4pm the day of admission, had one episode of melena and then suddenly he became extremely nauseated and had three episodes of hematemesis, described as projectile by the patient. He felt paralyzed but does not endorse dizziness, lightheadedness, LOC, blurred vision or pain. Paramedics found the patient confused, bradycardic with systolics in the 70's. He was taken to the OSH, where he received some IV fluid resuscitation. Labs were notable for H/H [**9-2**] (labs drawn by pcp earlier in the day 12/35), INR 1.5, Ammonia 136. In the OSH ED, he remained hemodynamically stable with SBP's 100-120. He received zofran for nausea, IV protonix and 1 unit pRBC's before transport. . He was transferred directly from OSH ED to [**Hospital1 18**] MICU for further work up and treatment. On arrival, the patient is hemodynamically stable, mentating well and communicative. He currently denies nausea, vomiting, abdominal pain, lightheadedness, dizziness, chest pain, headache, confusion. He denies EtOH and has never had an EtOH abuse history. . Of note, he was recently admitted here at [**Hospital1 18**] for hematemesis on [**2185-8-14**], at which time he was evaluated by both GI and hepatology. He was initially seen at an OSH for 3 episodes hematemesis and epistaxis begining on the morning of [**2185-8-14**]. He was severely hypotensive, put on pressors, and given blood and FFP before being medflighted to [**Hospital1 18**]. Here, he was intubated for airway protection during EGD [**8-15**], which showed a variceal bleed which was rebanded. He was extubated successfully [**8-17**]. He received blood transfusions to Hct goal of 28 and received IV PPI and octreotide drip. He was to be discharged on nadalol at that time. Work up to explore the etiology of the patient's cirrhosis was negative at that time for SLA, [**Doctor First Name **] and the viral hepatitides, but smooth muscle antibodies were positive. . Also of note on his last admission was the incidental finding on chest xray of extensive pleural disease likely related to asbestos exposure, which was followed up by a chest CT which additionally noted a loculated effusion at the left base with no pleural masses only plaques as well as a 15mm paraesophageal lymph node. This was to be worked up as an outpatient Past Medical History: PMH: -Cirrhosis-unclear etiology, no history of etoh or hepatitis. -portal hypertension -esophageal varices: s/p UGIB X 2. Banding twice (8 bands then 18 bands placed). Last EGD [**2185-7-26**] with extensive varices beginning inside cricopharyngeus and extending all the way to the GE junction. No normal mucosa and some scarred areas with new varices on top. In the stomach there were large varices in the cardia. Mucosa of body and stomach with portal hypertensive gastropathy worst from last endoscopy. No banding done at this time. -Diabetes mellitus -Hypertension -Rheumatic fever x 2 and a "rheumatic heart" -CAD s/p MI--s/p 3v CABG at [**Hospital1 2025**] (confusion per wife re: 3v vs 1v). Patient with chronic stable angina since procedure. -Kidney stones s/p penile urethra surgery to remove the stone -Migraine headaches -Asbestosis . Social History: married, no children, no tob, etoh, drugs. retired pipe fitter and was involved with asbestos removal. He lives in [**Location 730**], MA with his wife. Family History: mother died of MI at age 70, father died of MI at age 70. Sister died of TB. Physical Exam: Physical Exam on admission to MICU: VS: Temp: 97.5 BP: 108/56 HR: 101 RR: 19 O2sat 100% 3L NC GEN: pleasant, comfortable, NAD HEENT: PERRL, EOMI, but sluggish, no nystagmus, anicteric, +conjunctival pallor. MM dry, op without lesions, poor dentition. NECK: no supraclavicular or cervical lymphadenopathy, no jvd, brisk carotid upstroke, no carotid bruits, no thyromegaly or thyroid nodules RESP: CTA but decreased breath sounds at the left base. In general decreased air movement throughout. CV: RR, S1 and S2 wnl, harsh III/VI SEM heard best at the LUSB, louder with inspiration, nonradiating. ABD: distended abdomen with +BS, +fluid wave. Nontender, soft. EXT: no c/c/e, cool, 1+ pulses SKIN: no rashes/no jaundice NEURO: AAOx3. Cn II-XII intact, except very sluggish EOM. [**4-10**] strength throughout, but weakness of biceps/triceps secondary to old injuries. No sensory deficits to light touch appreciated. Downgoing babinski bilaterally. Very mild asterixis. No pronator drift. Pertinent Results: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2185-12-23**] 04:39AM 10.0 2.48* 8.2* 25.9* 105* 33.3* 31.9 21.2* 120* [**2185-12-13**] 04:08AM 9.8 3.02* 9.9* 29.4* 97 32.9* 33.8 17.4* 75* [**2185-12-9**] 05:10AM 1.6* 3.24* 10.7* 30.3* 94 33.1* 35.4* 16.8* 65*1 [**2185-12-7**] 08:26PM 7.9 2.99* 10.2* 29.7* 99* 34.0* 34.3 15.8* 127* . RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2185-12-23**] 04:39AM 105 114*1 1.9* 149* 3.6 121*2 23 9 [**2185-12-13**] 04:08AM 189* 47* 1.2 144 3.7 113* 22 13 [**2185-12-9**] 09:32AM 89 31* 1.6* 142 3.1* 112* 20* 13 [**2185-12-7**] 08:26PM 294* 28* 1.1 136 4.7 106 20* 15 . . CXR on admission [**2185-12-7**]: extensive pleural disease along the lower right heart border and evidence of a LLL infiltrate vs. effusion, perhaps slightly larger than prior study in [**8-13**]. . EGD [**2185-8-14**]: 5 cords of grade III varices were seen in the lower third of the esophagus. The varices were bleeding. There were signs of previous banding, however there were grade 3 varices distal to previous banding scars with 2 varices actively bleeding. 5 bands were successfully placed. Portal Hypertensive Gastropathy. . ECHO [**2185-8-22**]: The left atrium is normal in size. Left ventricular wall thickness, cavity size, and systolic function are normal LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. . CT Chest [**2185-8-17**]: IMPRESSION: 1. Asbestos related pleural calcifications with a loculated effusion noted at the left base. No pleural masses. 15mm paraesophageal lymph node as described. 2. Extensive coronary artery atherosclerotic calcifications status post CABG. 3. Cirrhotic liver with ascites. Brief Hospital Course: ASSESSMENT/PLAN: 70 yo M with idiopathic hepatic cirrhosis, esophageal variceal bleeding MICU callout, deteriorated significantly with resp failure, hypotention, abd.compartment syndrome, made CMO. . # Respiratory failure: Pt developed in the setting of recieving blood, there was a question of TRALI, ARDS [**1-7**] infection, hepatopulmonary syndrome and fluid overload - negative w/u for TRALI here, aggressively diuresed, contaminated sputum and bubble study significant for intracardiac shunt. Pt intubated as hypoxic, however after discussion with family, made CMO and extubated with goals of care mainly comfort. Also IV antibiotics stopped. Pt was transferred to the medicine wards. . # Abdominal compartment syndrome: Chronic based on pt history, bladder pressure remained elevated during admission. Pt had several therapeutic thoracentesis. . # DM2: Initially started on insulin gtt for improved glycemic control then converted to NPH [**Hospital1 **]. However, once decision was made for CMO, fingersticks were stopped with goal of care being pt's comfort. . # Hepatic cirrhosis: Unclear etiology, not transplant candidate given his cardiac history. Didnot undergo a TIPS procedure during admission, pt was treated with lactulose, rifaximin for encephalopathy; ciprofloxacin for SBP ppx. Hepatology team followed cloesly.After discussion with family, pt made CMO. . # AMS: Likely [**1-7**] hepatic encephalopathy initially but later with midazolam/fentanyl for sedation. Head CT negative for ICH or infarct; EEG demonstrated encephalopathy. After sedation discontinued, took approximately 7 days to have marked mental improvement, which is consistent with underlying organ dysfunction decreasing ability to clear sedatives. See hepatic cirrhosis above. . # Hypotension: Initially found to be hypotensive as well as bradycardic when seen by paramedics. Pt required vasopressors, however weaned off after aggressive fluid resusitation. Etiology remained unclear during hospitalization, [**Last Name (un) 104**] stim equivocal, no evidence of sepsis or cardiogenic shock. . # Leukocytosis: also with fevers during hospitalization. No evidence of SBP, blood, urine and sputum cultures negative. Received antibiotics for a short while, cipro for SBP prophylaxis. Leukocytosis resolved. . # Thrombocytopenia: Likely [**1-7**] hepatic dysfunction or marrow suppression with antibiotics (meropenum/vanc), PPI. Remained stable during admission. . # Hematemesis: Known hx of variceal bleeding with banding in 09/[**2184**]. EGD on [**2185-12-7**] showed new variceal bleeding. Received several units of FFP's as well as PRBC, also completed octreotide infusion x 48hrs then stated on pantoprazole [**Hospital1 **]. Hematocrit remained stable after initial episode in MICU. . # CAD: Had an episode of chestpain during admission, however no EKG changes or troponin rises consistent with acute ischemia. Did not have any further episodes of chestpain during admission. . # Loculated effusion [**1-7**] asbestosis: Stable during admission. Pt & family had refused further workup as LLL effusion was larger and there was concern for mesothelioma given extensive pleural plaques and history of asbestos exposure. . # Goals of care: After long discussion with family, pt was made CMO with the goals of care being primarily comfort after which pt was transferred to the medicine [**Hospital1 **]. No further labs were drawn, also no more vital signs. . Pt expired on [**2185-12-26**] Medications on Admission: Spironolactone 75mg [**Hospital1 **] Lasix 40mg Qdaily Glipizide 10mg Qdaily Famotidine 20mg [**Hospital1 **] Colace Protonix 40mg Qdaily . Allergies: penicillin (dizzy, n/v) Discharge Medications: EXPIRED Discharge Disposition: Expired Discharge Diagnosis: EXPIRED Discharge Condition: EXPIRED Discharge Instructions: EXPIRED Followup Instructions: EXPIRED [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 8965**]

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icd9cm

[ [ [] ] ]

[ "99.04", "42.33", "38.91", "99.07", "88.72", "96.72", "96.04", "54.91", "38.93" ]

icd9pcs

[ [ [] ] ]

11148, 11157

7411, 10891

279, 351

11208, 11217

5329, 7388

11273, 11405

4231, 4309

11116, 11125

11178, 11187

10917, 11093

11241, 11250

4324, 5310

235, 241

379, 3172

3194, 4044

4060, 4215

4,211

162,691

45657

Discharge summary

report

Admission Date: [**2128-9-17**] Discharge Date: [**2128-9-20**] Service: MEDICINE Allergies: Codeine Attending:[**First Name3 (LF) 1973**] Chief Complaint: Dyspnea, Nausea/Vomitting Major Surgical or Invasive Procedure: None History of Present Illness: Patient is an 83 y/o M with a PMH significant for Parkinsons, DM, HTN, s/p CVA with R-sided weakness and hyperlipidemia who presented from his NH this morning with nausea, vomiting and SOB. Per the chart, at 4:45am this morning the patient awoke and vomited a small amount of light green mucous material and appeared flushed and clammy. Temp at the NH was 100.4, FS 154, RR 24-28 BP 147/71 and )2 sat 84% on RA. He became SOB and began coughing. He was placed on NRB and sent to [**Hospital1 18**] via EMS. En route the patient received albuterol nebs x2 with improvement. The patient reports that he was feeling in his USOH until this morning when he vomited. He denies recent CP or pleuritic pain. He notes a chronic non-productive cough that is unchanged. He denies any recent fever, chills or URI symptoms. He denies any unusual foods or recent travel. He also denies abdominal pain. He notes that his appetite and energy level have been normal until this morning. . In the ED VS were T 98.7 HR 115 BP 124/60 RR 24 91% 4L. He was noted to have diffuse expiratory wheezes with use of accessory muscles. He was given continuous nebs with improvement. CXR showed a patchy RLL opacity and he was given levo 500mg and flagyl 500mg IV x1. A CTA was not performed due to ARF, however heparin gtt was initiated given concern for PE. . On arrival to the ICU the patient appeared comfortable and was sating 96% on 4L NC. He denied nausea and reported that his SOB was improved. He continued to deny CP and abdominal pain. Past Medical History: Parkinsons s/p L MCA CVA with residual R-sided hemiparesis Aphasia Dysphagia DM HTN Hyperlipidemia Social History: Patient currently resides in NH ([**Location (un) 582**]/[**Location (un) 583**]) since stroke. Former saxon in a church. Prior smoking history, smoked 2ppd x30 years, quit [**2091**]. Denies alcohol use. Family History: non-contributory Physical Exam: T 98.5, 122/67, 99, 22, 90 General: Well-appearing elderly man, NAD, speaking slowly HEENT: EOMI, PERRL, MM dry, poor dentition with multiple missing teeth Neck: no carotid bruits, supple, JVP hard to assess Heart: regular, no m/r/g appreciated Lungs: mild diffuse expiratory wheezes Abdomen: obese, soft, NT/ND, +BS, guaiac neg. in ED Ext: trace edema b/l LE, no calf tenderness Neuro: muscle strength 4/5 in R ext. and [**5-22**] in L ext Pertinent Results: [**2128-9-20**] 06:45AM BLOOD WBC-15.8* RBC-3.33* Hgb-9.8* Hct-29.5* MCV-89 MCH-29.3 MCHC-33.1 RDW-14.8 Plt Ct-482* [**2128-9-17**] 11:10AM BLOOD PT-13.4* PTT-26.2 INR(PT)-1.2* [**2128-9-20**] 06:45AM BLOOD Glucose-114* UreaN-26* Creat-1.2 Na-140 K-4.3 Cl-102 HCO3-28 AnGap-14 [**2128-9-17**] 06:20AM BLOOD Glucose-183* UreaN-23* Creat-1.6* Na-137 K-4.5 Cl-97 HCO3-29 AnGap-16 [**2128-9-17**] 01:50PM BLOOD ALT-12 AST-15 LD(LDH)-227 CK(CPK)-99 AlkPhos-130* Amylase-42 TotBili-0.4 [**2128-9-17**] 07:04PM BLOOD CK-MB-5 cTropnT-0.06* [**2128-9-20**] 06:45AM BLOOD Calcium-8.9 Phos-2.7 Mg-2.0\ CXR: AP CHEST: The heart size and mediastinal contours are within normal limits. There is normal pulmonary vascularity. There is patchy opacity of the right lower lung concerning for pneumonia or aspiration. The left lung is grossly clear. There is no pleural effusion or pneumothorax. The bones are demineralized. IMPRESSION: Right lower lobe airspace opacity concerning for aspiration and/or pneumonia. BILAT LOWER EXT VEINS PORT [**2128-9-17**] 2:43 PM Grayscale, color flow and Doppler images of both lower extremities are obtained. The common femoral veins, superficial femoral veins and deep femoral veins demonstrate normal compressibility, respiratory variation, venous flow and venous augmentation. IMPRESSION: No evidence of DVT in both lower extremities. Brief Hospital Course: Impression/Plan: 83 y/o M with a PMH significant for Parkinsons, DM, HTN, s/p CVA with R-sided weakness and hyperlipidemia who presented from his NH with Aspiration Pneumonia and COPD exacerbation . 1. Aspiration Pneumonia and COPD exacerbation: - To ICU on [**9-17**] - Rapid improvement on levofloxacin/flagyl - steroid taper for COPD. - O2 requirement 4 LPM on admit, now on RA. - Called out to floor on [**9-18**] evening - Continue levofloxacin/flagyl on discharge - Of note, in ER and [**Hospital Unit Name 153**], placed on heparin transiently with concern for PE. NO CTA obtained due to acute renal failure. LENI's negative and given rapid improvement, heparin stopped [**9-17**]. 2. Nausea, vomiting: - Unclear etiology. ? gastroenteritis. Now resolved. LFT's, lipase within normal limits. Did not recur during admission. 3. Acute Renal Failure/CKD Stage III: - patient's baseline Cr 1.1-1.2, 1.6 on admission - Likely prerenal given recent vomiting and dry appearing on exam, which returned to baseline with gentle hydration - Captopril and lasix re-started [**9-19**] after initially being held. 4. Type 2 DM - Controlled: - On metformin and insulin as outpatient. - Continued outpatient NPH 20 units qAM and 8 units qPM inhouse along with ISS. - Re-start metformin on discharge. - RISS - FS qid - Diabetic diet 5. Parkinsons: - continued sinemet 6. Benign Hypertension: - Metoprolol/captopril initally held and then re-started. 7. Hyperlipidemia: - Zocor Continued . 8. H/O CVA: - Has residual R-sided weakness and dysphagia. Continued aggrenox - aspiration precautions - pureed diet Medications on Admission: Tylenol prn Thiamine 100mg daily MVI daily Lasix 40mg daily Citalopram 30mg daily Sinemet 25/100 tid Duoneb qid Senna 2 tabs qhs MOM 30ml qod Xalatan 0.005% 1 gtt OU qhs Simvastatin 10mg qhs Flomax 0.8mg qhs Metformin 500mg daily Hydroxyzine 25mg daily Colace 100mg [**Hospital1 **] Flovent 2 puffs [**Hospital1 **] Captopril 12.5mg [**Hospital1 **] Aggrenox [**Hospital1 **] Lansoprazole 30mg [**Hospital1 **] Metoprolol 25mg [**Hospital1 **] NPH 20 units qAM and 8 units qPM RISS Discharge Medications: 1. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Hospital1 **]: One (1) Neb Inhalation Q2H (every 2 hours) as needed. 2. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Neb Inhalation Q6H (every 6 hours). 3. Acetaminophen 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H (every 6 hours) as needed. 4. Thiamine HCl 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 5. Therapeutic Multivitamin Liquid [**Hospital1 **]: One (1) Cap PO DAILY (Daily). 6. Carbidopa-Levodopa 25-100 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a day). 7. Latanoprost 0.005 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic HS (at bedtime). 8. Simvastatin 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at bedtime). 9. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr [**Hospital1 **]: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 10. Fluticasone 110 mcg/Actuation Aerosol [**Hospital1 **]: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 11. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 hr [**Hospital1 **]: One (1) Cap PO BID (2 times a day). 12. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 13. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). 14. Citalopram 20 mg Tablet [**Last Name (STitle) **]: 1.5 Tablets PO DAILY (Daily). 15. Furosemide 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 16. Prednisone 10 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO daily () for 3 doses. 17. Prednisone 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO daily () for 3 doses. 18. Prednisone 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO daily () for 3 doses. 19. Captopril 12.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). 20. Levofloxacin 250 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO Q48H (every 48 hours) for 5 days. 21. Metronidazole 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times a day) for 5 days. 22. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at bedtime). 23. Docusate Sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID (2 times a day). 24. Insulin NPH Human Recomb 100 unit/mL Cartridge [**Last Name (STitle) **]: Twenty (20) Units Subcutaneous QAM: Hold for FS < 100. 25. RISS Glucose Sliding Scale Parameters: Start at 0, Increment by 50 mg/dl Ending Point: 400 mg/dl When Glucose < or = 80 Give: 4 oz. Juice 4 oz. Juice & 15 gm crackers [**1-20**] amp D50 1 amp D50 Notify M.D. if Glucose > 400 Glucose Value to begin administering insulin: 151 mg/dl Starting Point: 2 Units Increment By: 2 Units Discharge Disposition: Extended Care Facility: [**Location (un) 582**] of [**Location (un) 583**] Discharge Diagnosis: 1. Aspiration pneumonia 2. COPD Exacerbation 3. Acute Renal Failure Secondary: 1. Parkinson's Disease 2. Chronic Kidney Disease 3. Hypertension Discharge Condition: Good Discharge Instructions: Follow up as below. You are one 2 antibiotics, and you should complete the full course. One of the antibiotics is Flagyl (Metronidazole), which reacts badly to alcohol. Please make sure that you are not consuming any products with alcohol, such as mouthwash, or violent vomitting may result. This medication may also make you more sun-sensitive Followup Instructions: With your PCP. [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 48975**], [**Telephone/Fax (1) 97337**].

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9063, 9140

4056, 5664

241, 247

9327, 9333

2671, 4033

9727, 9881

2176, 2194

6197, 9040

9161, 9306

5690, 6174

9357, 9704

2209, 2652

176, 203

275, 1812

1834, 1934

1950, 2160

48,032

166,079

2605

Discharge summary

report

Admission Date: [**2155-2-10**] Discharge Date: [**2155-2-20**] Service: CARDIOTHORACIC Allergies: Motrin / Sulfa (Sulfonamide Antibiotics) / Lisinopril Attending:[**First Name3 (LF) 165**] Chief Complaint: Aortic stenosis Major Surgical or Invasive Procedure: [**2155-2-13**]: Aortic valve replacement with size 23-mm St. [**Male First Name (un) 923**] Epic tissue valve. History of Present Illness: 89 yr old F with severe aortic stenosis and atrial fibrillation scheduled for AVR who was admitted prior to cath. She was recently admitted [**Date range (1) 13127**]/11 with increasing SOB and extremity edema and was diuresed for acute on chronic diastolic CHF. At home, she continued to have SOB with exertion. She has chronic LE edema, but otherwise has been doing well since her last admission, initally at rehab then d/c'd home. Her baseline Cr 1.3-1.4 and she was admitted for pre-cath hydration. Currently patient denies any SOB or chest pain. She does report using home oxygen at 1.5 liters. Cath today revealed clean coronaries. She was transferred to cardiac surgery with plans for AVR on Thurs [**2-13**]. Past Medical History: Hypertension Atrial fibrillation on Coumadin Chronic diastolic CHF Severe aortic stenosis (AV area 0.6 cm?????? on [**10/2154**] OSH echo) Compression fracture s/p kyphoplasty Hypothyroidism Osteoarthritis Osteoporosis Chronic renal insufficiency (baseline Cr 1.3) Probable Alzheimer's dementia (mild) T10 compression fracture s/p vertebroplasty in [**10/2154**] S/p appendectomy S/p hysterectomy S/p hernia repair S/p bilateral cataract surgery Social History: Currently at rehab but usually lives with husband who is also healthcare proxy, four adult children. Retired clerk in admitting dept at [**Hospital 13128**]. # Tobacco: Denies # Alcohol: Denies # Drugs: Denies Family History: Daughter s/p valve replacement due to rheumatic fever. Sister with breast cancer, brother with skin cancers, another sister died at age 47 of stomach cancer (and her daughter died of pancreatic cancer). Physical Exam: Pulse:65 Resp:18 O2 sat: 2L 98% B/P Right:100/60 Left: Height:5'0" Weight:55.1 kg General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [] Bibasilar crackles Heart: RRR [] Irregular [x] Murmur IV/VI harsh SEM Abdomen: Soft [x] mildly distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] 2+ LE Edema Varicosities: None [x] Superficial veins B/L lower extremities Neuro: Grossly intact Pulses: Femoral Right:cath site - no hematoma Left:2+ DP Right:dopperlable Left:dopplerable PT [**Name (NI) 167**]:dopperable Left:dopplerable Radial Right:2+ Left:2+ Carotid Bruit: Transmitted murmur B/L Pertinent Results: [**2155-2-13**] Prebypass: No spontaneous echo contrast is seen in the left atrial appendage. The left atrial appendage emptying velocity is depressed (<0.2m/s). No thrombus is seen in the left atrial appendage. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is moderately dilated with normal free wall contractility. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area 0.5-0.6cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. Moderate to severe [3+] tricuspid regurgitation is seen. There is a trivial/physiologic pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results. Postbypass: There is preserved biventricular systolic function. There is a well seated, well functioning bioprosthesis in the aortic position. No AI is visualized. The MR now appears mild. The TR now appears moderate. Remaining study is unchanged from the prebypass exam. [**2155-2-19**] 05:08AM BLOOD WBC-7.8 RBC-2.61* Hgb-8.7* Hct-26.2* MCV-100* MCH-33.2* MCHC-33.1 RDW-16.8* Plt Ct-164 [**2155-2-19**] 05:08AM BLOOD Plt Ct-164 [**2155-2-19**] 05:08AM BLOOD Glucose-119* UreaN-36* Creat-1.6* Na-140 K-4.0 Cl-101 HCO3-33* AnGap-10 Brief Hospital Course: Pt was admitted after catherization after IV hydration. On [**2155-2-13**] she went to the operating room where she underwent an aortic valve replacement with size 23-mm St. [**Male First Name (un) 923**] Epic tissue valve. See operative note for full details. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable on no inotropic or vasopressor support. Low dose beta blocker was initiated but then stopped due to hypotension with a SBP in the 80's. The patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes were split due to high drainage and mediatinal chest tubes were removed with subsequent removal of left pleural chest tube once drainage had decreased. She was anticoagulated with Coumadin for chronic atrial fibrillation. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD #7 the patient was ambulating with assistance, the wound was healing well and pain was controlled with Tylenol only due to somnolence with Ultram. The patient was discharged to [**Hospital **] in [**Location (un) 246**] in good condition with appropriate follow up instructions.First INR check day after discharge. Target INR 2.0-2.5 . Medications on Admission: 1. alendronate 70 mg Tablet Sig: One (1) Tablet PO QTUES (every Tuesday). 2. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: Two (2) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 4. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day: On Sunday, Tuesday, Wednesday, Friday and Saturday. Disp:*30 Tablet(s)* Refills:*0* 5. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12 hours on, 12 hours off. 7. metoprolol succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO HS (at bedtime). 8. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 9. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 12. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for pain. 13. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. 14. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation every 4-6 hours as needed for wheezing/sob. 15. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation every 4-6 hours as needed for wheezing/sob. Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks. 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. 4. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. ipratropium bromide 0.02 % Solution Sig: One (1) IH Inhalation Q6H (every 6 hours) as needed for wheezing. 7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb IH Inhalation Q6H (every 6 hours) as needed for wheezing. 8. warfarin 1 mg Tablet Sig: daily dosing per rehab provider Tablet PO DAILY (Daily): for A Fib target INR 2.0-2.5. 9. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 10. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. alendronate 70 mg Tablet Sig: One (1) Tablet PO QTUES (every Tuesday). 12. Vitamin D-3 400 unit Capsule Sig: One (1) Capsule PO DAILY (Daily). 13. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 14. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 15. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 1 weeks: please monitor creatinine. 16. Outpatient Lab Work BUN/creatinine to be checked at rehab ( baseline 1.3) daily until at baseline Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: Aortic stenosis S/P AVR tricuspid regurgitation hypertension atrial fibrillation chronic diastolic heart failure Compression fracture s/p kyphoplasty ([**10/2154**]) Hypothyroidism Osteoarthritis Osteoporosis Chronic renal insufficiency (baseline Cr 1.3) Probable Alzheimer's dementia (mild) T10 compression fracture s/p vertebroplasty in [**10/2154**] Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with tylenol only Incisions: Sternal - healing well, no erythema or drainage 1+ Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr [**First Name (STitle) **] [**2155-3-17**] at 1:00 pm [**Hospital Ward Name **] 2A Cardiologist:Dr. [**Last Name (STitle) **] [**3-19**] Wed @ 11:00 am [**Hospital1 18**] [**Location (un) 2788**] office Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) **] in [**2-25**] weeks [**Telephone/Fax (1) 4775**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Labs: PT/INR for Coumadin ?????? indication Afib Goal INR 2-2.5 First draw day after discharge; *** please arrange for coumadin f/u with PCP [**Name9 (PRE) 3306**] prior to discharge from rehab ph #[**Telephone/Fax (1) 4775**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2155-2-20**]

[ "428.33", "427.31", "V58.61", "458.29", "244.9", "585.9", "733.00", "403.90", "424.1", "428.0", "584.9", "416.8" ]

icd9cm

[ [ [] ] ]

[ "35.21", "88.56", "37.23", "39.61" ]

icd9pcs

[ [ [] ] ]

9200, 9272

4546, 6096

282, 396

9669, 9840

2847, 4523

10764, 11682

1857, 2062

7628, 9177

9293, 9648

6122, 7605

9864, 10741

2077, 2828

227, 244

424, 1143

1165, 1613

1629, 1841

30,876

149,972

24862

Discharge summary

report

Admission Date: [**2191-9-28**] Discharge Date: [**2191-10-1**] Date of Birth: [**2136-4-10**] Sex: M Service: MEDICINE Allergies: Propafenone Attending:[**Doctor First Name 1402**] Chief Complaint: Atrial Fibrillation, s/p pulmonary vein ablation Major Surgical or Invasive Procedure: Atrial Fibrillation ablation, pulmonary vein isolation History of Present Illness: 55M Jehovah??????s Witness with a-fib who presented for an elective a-fib ablation and developed a pericardial effusion association with transient hypotension during the procedure. Mr. [**Known lastname 62558**] carries an 8 yr history of AF, undergoing a previous failed ablation procedure in [**1-18**]. He is symptomatic almost daily; most recently he was anticoagulated on coumadin and beta blockade. He was admitted for elective repeat a-fib ablation. After all 4 pulmonary veins were identified and the ablations were carried out successfully, the BP dropped to 68 systolic and there arose concern for acute tamponade. Protamine 15 IV was given x2 to reverse the heparin. Bedside echo was performed which showed pericardial effusion although without evidence of tamponade. Mr. [**Known lastname 62558**] was monitored in the CCU for hemodynamic changes and tamponade physiology. . 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. All of the other review of systems were negative. . Cardiac review of systems is notable for palpitations, fatigue, dyspnea as per HPI. There is the absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, syncope or presyncope. Past Medical History: Atrial fibrillation Hematuria in the setting of an elevated INR [**2189**] Cellulitus [**9-18**] Social History: Married and works as a house painter and has 5 children. Wife will accompany him to the procedure. Patient is a Jehovah??????s Witness and does not accept blood products. 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: VS: T 97.9 BP 118/77 HR 75 RR 13 100 O2 % on 2L Gen: WDWN middle aged male in NAD, resp or otherwise. Oriented x3. Mood, affect appropriate. Pleasant. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with JVP of cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No S4, no S3. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No crackles, wheeze, rhonchi. Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: No c/c/e. femoral sheaths in place Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Pertinent Results: [**2191-9-28**] 07:25AM BLOOD WBC-6.9 RBC-4.88 Hgb-15.7 Hct-45.1 MCV-92 MCH-32.2* MCHC-34.8 RDW-13.5 Plt Ct-268 [**2191-9-30**] 05:38AM BLOOD WBC-10.5 RBC-3.56* Hgb-11.6* Hct-33.2* MCV-93 MCH-32.6* MCHC-35.0 RDW-13.4 Plt Ct-152 [**2191-9-30**] 09:15PM BLOOD WBC-11.3* RBC-3.53* Hgb-11.5* Hct-32.9* MCV-93 MCH-32.5* MCHC-34.9 RDW-13.3 Plt Ct-158 [**2191-10-1**] 07:50AM BLOOD WBC-9.5 RBC-3.61* Hgb-11.7* Hct-33.8* MCV-94 MCH-32.3* MCHC-34.5 RDW-13.4 Plt Ct-172 [**2191-9-28**] 07:25AM BLOOD Glucose-101 UreaN-22* Creat-1.1 Na-138 K-7.0* Cl-101 HCO3-28 AnGap-16 [**2191-10-1**] 10:39AM URINE Blood-SM Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-8.0 Leuks-NEG . ECHO [**9-28**] Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There is a small circumferential pericardial effusion without evidence of hemodynamic compromise. . ECHO [**9-30**] Indication: Pericardial effusion. Height: (in) 70 Weight (lb): 183 BSA (m2): 2.01 m2 BP (mm Hg): 123/60 HR (bpm): 94 Status: Inpatient Date/Time: [**2191-9-30**] at 08:43 Test: Portable TTE (Complete) Doppler: Limited Doppler and color Doppler Contrast: None Tape Number: 2007W000-0:00 Test Location: West CCU Technical Quality: Adequate REFERRING DOCTOR: DR. [**First Name8 (NamePattern2) 251**] [**First Name8 (NamePattern2) 640**] [**Last Name (NamePattern1) **] INTERPRETATION: Findings: This study was compared to the prior study of [**2191-9-29**]. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal IVC diameter (1.5-2.5cm) with >50% decrease during respiration (estimated RAP 5-10 mmHg). LEFT VENTRICLE: Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. PERICARDIUM: Small pericardial effusion. No echocardiographic signs of tamponade. Conclusions: The estimated right atrial pressure is 5-10 mmHg. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. Brief Hospital Course: 55M Jehovah??????s Witness with a-fib who presented for an elective a-fib ablation and developed a pericardial effusion association with transient hypotension during the procedure. . Brief hospital course is divided by problem: . 1) Atrial fibrillation The isolation procedure was successful. Afterwards the patient remained in normal sinus rhythm except for frequent premature atrial contractions. Metoprolol was titrated up for antiarrhythmic effect. He was discharged on a lower dose than previous to admission: 50 mg toprol q AM and 25 mg toprol q PM. Coumadin was resumed to prevent thrombosis and stroke subsequent to intracardiac ablation. An INR will be checked on Mon [**10-3**] before his outpt cardiology appt. . 2) Pericardial effusion During the end of the ablation procedure the patient was noted to be hypotensive out of proportion to the isoproterenol infusion and reactive tachycardia. A swan was placed intra-procedure which did not show diastolic equalization of RA /RV / or PA pressures, however an echo was performed which showed a pericardial effusion. He was transferred to the unit for observation. No evidence for pericardial tamponade was noted and within 2 days the effusion began to decrease in size. The decision was made to not withdraw the remaining pericardial fluid. An echo will be performed Monday [**10-3**] as follow up before outpatient cardiology appt. . 3) Pericarditis The night of the procedure Mr. [**Known lastname 62558**] noted positional chest discomfort. EKG initially showed no changes but then revealed PR depression and diffuse ST elevation c/w pericarditis. Low grade temperatures were also reported with Tm of 101.6 F. NSAIDS were not provided given the need for myocyte repair/ healing subsequent to the ablation. Morphone and tylenol were provided and by day 3 the pain had almost completely resolved. . After the ablation procedure, he remained hemodynamically stable. He did have low temperatures which trended down durin the hospitalization. His home dose of Toprol was lowered to 50 q AM and 25 q PM. Coumadin was also reinitiated and an INR will be checked as well as an echocardiogram prior to his next appointment. Medications on Admission: Toprol XL 100mg [**Hospital1 **] Coumadin 1.5mg 5 days per week, 1mg 1 day per week, 2mg 1 day per week, last dose satuday [**9-24**] Vitamin C 500mg daily Vitamin E 400 IU daily Magnesium and potassium 400mg daily Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Warfarin 1 mg Tablet Sig: 1.5 Tablets PO once a day: resume your coumadin dose as it was before hospitalization; 1.5 mg 5 days a week, 1mg 1 day a week, 2 mg 1 day a week. Disp:*45 Tablet(s)* Refills:*2* 3. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO QAM (once a day (in the morning)). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 4. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO QPM (once a day (in the evening)). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 5. Outpatient Lab Work INR check 6. Echocardiogram Echocardiogram, to evaluate pericardial effusion Discharge Disposition: Home Discharge Diagnosis: Pericarditis Pericardial effusion Atrial Fibrillation Discharge Condition: good Discharge Instructions: You were admitted to the hospital for ablation of atrial fibrillation. You were monitored in the cardiac care unit afterwards for low blood pressure in the setting of fluid surrounding your heart. Afterwards you also had pericarditis (inflammation of the fluid and tissue surrounding the heart) which was treated with tylenol for pain. You should continue to take coumadin (warfarin) to thin your blood. You will need your blood checked (INR) by monday for your appointment with Dr. [**Last Name (STitle) 12246**]. You should also continue toprol XL, but at a new dose. Take 50 mg Toprol Xl in the AM and 25 mg Toprol Xl in the PM. Followup Instructions: Get your INR checked and get an echocardiogram on Monday [**10-3**] for your appointment with Dr. [**Last Name (STitle) 12246**]. Call Dr.[**Last Name (un) 62559**] office first thing Monday morning to schedule both the Echo and INR check.

[ "997.1", "427.31", "458.29", "285.1", "423.9" ]

icd9cm

[ [ [] ] ]

[ "37.34" ]

icd9pcs

[ [ [] ] ]

8531, 8537

5262, 7454

323, 380

8635, 8642

3225, 5239

9328, 9572

2283, 2365

7719, 8508

8558, 8614

7480, 7696

8666, 9305

2380, 3206

234, 285

408, 1851

1873, 1971

1987, 2267

25,869

122,998

26748

Discharge summary

report

Admission Date: [**2150-3-31**] Discharge Date: [**2150-4-6**] Date of Birth: [**2093-10-11**] Sex: M Service: SURGERY Allergies: Niacin / Shellfish / Wasp Venom Attending:[**First Name3 (LF) 4111**] Chief Complaint: 56 M recently found to have a tumor in the antrum of his stomach Major Surgical or Invasive Procedure: Laparoscopic resection and esophagogastroscopy. History of Present Illness: This gentleman has had bleeding from his stomach. He initially presented to an outside hospital with a hematocrit of 15. EGD here at [**Hospital1 18**] c/w tumor near the antrum. Pathology at that time was unclear - [**Name2 (NI) **] vs. neuroendocrine tumor. Past Medical History: A Fib (on coumadin) Asthma HTN obesity Social History: quit smoking many years ago Family History: non-contributory Physical Exam: 97.9 65 135/55 15 98% 3L 6'8" 400lbs A&0 x 3 clear bilaterally irreg irreg no MRG abd obese, soft, non-distended, epigastrium +TTP lap sites c/d/i ext no c/c/e Pertinent Results: [**2150-3-31**] 03:29PM BLOOD WBC-15.0*# RBC-5.01 Hgb-11.9* Hct-37.3* MCV-74* MCH-23.8* MCHC-32.0 RDW-19.5* Plt Ct-291 [**2150-4-1**] 06:25AM BLOOD WBC-12.2* RBC-4.67 Hgb-11.2* Hct-35.1* MCV-75* MCH-23.9* MCHC-31.8 RDW-19.4* Plt Ct-267 [**2150-4-2**] 01:20PM BLOOD WBC-8.9 RBC-4.72 Hgb-11.8* Hct-35.3* MCV-75* MCH-25.1* MCHC-33.5 RDW-19.2* Plt Ct-259 [**2150-4-3**] 06:37AM BLOOD WBC-8.6 RBC-5.35 Hgb-12.5* Hct-40.4 MCV-75* MCH-23.4* MCHC-31.1 RDW-18.9* Plt Ct-286 [**2150-4-4**] 12:46AM BLOOD WBC-10.7 RBC-4.46* Hgb-10.8* Hct-32.8* MCV-74* MCH-24.1* MCHC-32.7 RDW-18.5* Plt Ct-289 [**2150-3-31**] 03:29PM BLOOD Glucose-136* UreaN-8 Creat-0.9 Na-141 K-3.8 Cl-104 HCO3-25 AnGap-16 [**2150-4-1**] 06:25AM BLOOD Glucose-130* UreaN-7 Creat-0.8 Na-142 K-4.2 Cl-106 HCO3-28 AnGap-12 [**2150-4-2**] 01:20PM BLOOD Glucose-109* UreaN-9 Creat-0.7 Na-142 K-3.7 Cl-105 HCO3-25 AnGap-16 [**2150-4-3**] 06:37AM BLOOD Glucose-104 UreaN-8 Creat-0.8 Na-138 K-4.6 Cl-103 HCO3-19* AnGap-21* [**2150-4-3**] 12:55PM BLOOD Glucose-120* UreaN-8 Creat-0.6 Na-140 K-3.6 Cl-103 HCO3-27 AnGap-14 [**2150-4-4**] 12:46AM BLOOD Glucose-136* UreaN-10 Creat-0.9 Na-139 K-3.7 Cl-102 HCO3-25 AnGap-16 [**2150-4-4**] 08:14PM BLOOD Glucose-105 UreaN-10 Creat-0.9 Na-139 K-3.6 Cl-102 HCO3-25 AnGap-16 Brief Hospital Course: The patient was taken to the operating room on [**2150-3-31**] for a laparoscopic resection of gastric mass. Postoperatively he was extubated in the PACU in stable condition. On POD #1 , he developed [**8-9**] left sided chest pain and shortness of breath after using his Bipap machine. EKG was in AFIB with HR in the seventies. He was ruled out for MI by enzymes. CTA of his chest was negative for PE. Amp/Gent/Flagyl were started empirically. A upper GI swallow study was negative and his diet was advnaced. Overnight on [**2150-4-2**] his blood pressure was elevated to 200/116 for which he was transfered to the ICU where his pressures were stabilized on a nitroglycerin drip. He was subsquently switched to a Labetalol drip, his pressures were controlled and he was transitioned to PO labetalol 200 PO BID. In addition, his Toprol XL was discontinued and hydrochlorothiazide was added to make his regimen. He was seen by cardiology and an echocardiogram was obtained left ventricle - Ejection Fraction: 65% to 75% . CTA was again reviewed which showed a normal caliber of the aorta with no sign of dissection. On [**2150-4-4**] he was transfered back to the floor. House officer was paged in the evening of [**2150-4-4**] for a reported run of non-sustained V-tach. Telemetry strips were reviewed with cardiology and were thought to likely represent artifact although non-sustained vtach could not be excluded. He was considered safe for discharge from a cardiac stand-point. On [**2151-4-5**] he was ambulating, his pain was improving, and he was tolerating a regular diet. On [**2150-4-6**] he was sent home and he will follow up in Dr.[**Name (NI) 6275**] clinic to review the pathology from his operation. Medications on Admission: Protonix 40mg' Zyrtec 20mg'' Benedryl 10mg prn Albuterol 2 puffs prn Singulair 10mg' Digoxin 0.375mg' Lisinopril 20 mg' Toprol XL 75mg' Flovent 220'' Discharge Medications: Labetalol HCl 200 mg PO BID HOLD SBP < 110 HR < 55 Lisinopril 20 mg PO DAILY hold SBP < 110 Albuterol [**12-1**] PUFF IH Q6H Montelukast Sodium 10 mg PO DAILY Digoxin 0.375 mg PO DAILY Hold for HR<55 Pantoprazole 40 mg PO Q24H Docusate Sodium 100 mg PO BID Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **] Tamsulosin HCl 0.4 mg PO HS Hydrocodone-Acetaminophen [**12-1**] TAB PO Q4-6H:PRN Please give for mod-severe pain. Please limit total tylenol dose to 3gm/day Warfarin 3 mg PO HS Hydrochlorothiazide 25 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: gastric mass s/p laparoscopic resection Discharge Condition: stable Discharge Instructions: [**Name8 (MD) **] M.D. for fevers, chills, redness or drainage from incision sites, severe abdominal pain, chest pain, shortness of breath, nausea/vomitting, questions or concerns. Followup Instructions: Follow-up with Dr. [**Last Name (STitle) 957**] in [**12-1**] weeks please call clinic to schedule ([**Telephone/Fax (1) 57851**]. Please follow-up with primary care provider [**Last Name (NamePattern4) **] 1 week for management of INR / coumadin dose. Completed by:[**2150-4-6**]

[ "401.9", "151.2", "493.90", "241.1", "427.31", "V58.61", "278.01" ]

icd9cm

[ [ [] ] ]

[ "43.42", "45.13", "38.91" ]

icd9pcs

[ [ [] ] ]

4790, 4796

2322, 4038

356, 406

4879, 4887

1034, 2299

5116, 5399

820, 838

4239, 4767

4817, 4858

4064, 4216

4911, 5093

853, 1015

252, 318

434, 695

717, 758

774, 804

82,086

111,187

40001

Discharge summary

report

Admission Date: [**2152-5-25**] Discharge Date: [**2152-5-29**] Date of Birth: [**2127-1-27**] Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 8250**] Chief Complaint: scheduled c/s for complete posterior placenta previa Major Surgical or Invasive Procedure: Primary lower transverse c-section for posterior previa, ICU admission, transfusion blood products. History of Present Illness: Ms. [**Known lastname 1255**] is a 25yo G1P0 at 37+2WGA by LMP ([**2151-9-7**]) presents to L&D for a scheduled c/s for complete posterior placenta previa. Patient trnsferred her care from [**Country 651**] at 24 weeks. Prior to that she reported a normal pregnancy. Pregnancy review: Dating: [**Last Name (un) **] [**2152-6-13**] by LMP ([**2151-9-7**]) c/w 2nd tri US Prepregnancy weight: 128 Exposures: No TB exposures. No pets. No sick contacts. *) [**Name2 (NI) **] - AB+/Abs-/RI/RPRNR/VZI/HBsAg-/HCV-/HIV-/GC-/CT- / GBS positive - normal 2h GTT *) Ultrasound - FFS 25wks nl anatomy, complete previa 4cm over os - [**4-12**]: 1676g 46th% BPP [**9-4**], AFI 9.7cm, cephalic; complete previa - [**5-9**]: [**11-6**] BPP - [**5-16**] ATU EFW: 2918g, 55% *) Screening - Normal hemoglobin electrophoresis *) Issues 1. Previa - Growth/placenta scans in ATU q3 weeks - [**5-16**]: placenta is 1.3cm away from the os - [**5-23**]: complete previa 2. Anemia - iron/colace rx, on PNV as well 3. Transfer of care from [**Country 651**] - Do not have records, probably not necessary at this point (pt says they were faxed from [**Country 651**] by her husband) Genetic risk factors/ethnicity: - Born in [**Country 651**] of Chinese background; no known chromosomal problems/birth defects in family - FOB's family Chinese, no known chromosomal problems/birth defects Past Medical History: -Obstetrical History: G1 current -Gynecological History: LMP [**2151-9-7**]. No abnormal Paps. No STIs. No known fibroids. Regular menses, q 30-31 days [**Hospital 87972**] Medical History: denies -Past Surgical History: denies Social History: Lives with her father. Graduated from BU law school. Husband in [**Name2 (NI) 651**], coming to US and buying [**Last Name (un) **] nearby. Family History: Pt denied family hx of Down syndrome, neural tube defects, thalassemias, Huntingtons dz, mental retardation. Physical Exam: Physical Exam: A&O, NAD RRR, CTAB No thyromegaly or neck mass Abd soft, NT, gravid Ext NT NE Pertinent Results: [**2152-5-27**] 07:15AM BLOOD WBC-9.3 RBC-2.66* Hgb-8.7* Hct-24.7* MCV-93 MCH-32.9* MCHC-35.4* RDW-14.3 Plt Ct-218 [**2152-5-26**] 03:29PM BLOOD WBC-17.5* RBC-2.89* Hgb-9.5* Hct-26.7* MCV-92 MCH-32.8* MCHC-35.6* RDW-14.3 Plt Ct-219 [**2152-5-26**] 04:50AM BLOOD WBC-14.7* RBC-2.79* Hgb-9.1* Hct-25.2* MCV-90 MCH-32.6* MCHC-36.1* RDW-14.2 Plt Ct-186 [**2152-5-25**] 02:01PM BLOOD WBC-14.2* RBC-2.04* Hgb-6.9* Hct-19.4* MCV-95 MCH-33.8* MCHC-35.6* RDW-13.1 Plt Ct-198 [**2152-5-25**] 11:17AM BLOOD WBC-19.6*# RBC-2.47* Hgb-8.3* Hct-23.7* MCV-96 MCH-33.4* MCHC-34.9 RDW-13.0 Plt Ct-240# [**2152-5-25**] 10:00AM BLOOD WBC-9.1 RBC-3.13* Hgb-10.6* Hct-29.8* MCV-95 MCH-33.8* MCHC-35.5* RDW-12.7 Plt Ct-159 [**2152-5-25**] 06:21AM BLOOD WBC-9.9 RBC-3.75* Hgb-12.3 Hct-35.0* MCV-93 MCH-32.8* MCHC-35.2* RDW-13.0 Plt Ct-251 . [**2152-5-26**] 04:50AM BLOOD PT-12.5 PTT-25.5 INR(PT)-1.1 [**2152-5-25**] 09:54PM BLOOD PT-12.4 PTT-23.3 INR(PT)-1.0 [**2152-5-25**] 02:01PM BLOOD PT-12.7 PTT-24.8 INR(PT)-1.1 [**2152-5-25**] 11:17AM BLOOD PT-13.3 PTT-31.8 INR(PT)-1.1 [**2152-5-25**] 10:00AM BLOOD PT-12.4 PTT-31.0 INR(PT)-1.0 . [**2152-5-26**] 04:50AM BLOOD Fibrino-412* [**2152-5-25**] 09:54PM BLOOD Fibrino-384 [**2152-5-25**] 02:01PM BLOOD Fibrino-280# [**2152-5-25**] 11:17AM BLOOD Fibrino-173 [**2152-5-25**] 10:00AM BLOOD Fibrino-220 . [**2152-5-26**] 04:50AM BLOOD Glucose-68* UreaN-10 Creat-0.7 Na-136 K-3.7 Cl-105 HCO3-23 AnGap-12 [**2152-5-25**] 09:54PM BLOOD Glucose-108* UreaN-8 Creat-0.6 Na-139 K-3.3 Cl-104 HCO3-27 AnGap-11 [**2152-5-25**] 02:01PM BLOOD Glucose-94 UreaN-9 Creat-0.5 Na-141 K-3.5 Cl-107 HCO3-28 AnGap-10 [**2152-5-25**] 11:22AM BLOOD Na-139 K-4.3 Cl-109* . [**2152-5-25**] 02:01PM BLOOD LD(LDH)-429* TotBili-0.3 . [**2152-5-26**] 04:50AM BLOOD Calcium-8.0* Phos-3.4 Mg-1.9 [**2152-5-25**] 09:54PM BLOOD Mg-2.1 [**2152-5-25**] 02:01PM BLOOD Calcium-7.7* Phos-4.0 Mg-1.6 [**2152-5-25**] 11:22AM BLOOD Albumin-2.6* Calcium-7.1* Mg-1.5* [**2152-5-25**] 02:01PM BLOOD Hapto-48 . [**2152-5-25**] 02:13PM BLOOD Type-ART Temp-36.6 pO2-148* pCO2-52* pH-7.32* calTCO2-28 Base XS-0 [**2152-5-25**] 02:13PM BLOOD Lactate-1.7 Brief Hospital Course: Ms.[**Known lastname 1255**] presented for L&D at 37 weeks and 2 days gestational age for a planned cesarean delivery given complete posterior placenta previa. The patient had previously been counseled about risk of potential accreta as well as the risk of hemorrhage. She also understood the risk of prematurity, which was outweighed by the risk of labor/hemorhage. The patient was typed and crossed for 2 units, and the blood was available on labor and delivery at the time of the cesarean section. Her surgery was complicated by uterine atony after delivery and hemorrhage, EBL for the surgery was approximately [**2141**] cc. Pt received uterotonics and was transfused 2 units of PRBC, 4 units FFP, 2 units of PLT, and 2 units of cryo. [**Year (4 digits) **] were trended to ensure pt's stability. Please see Dr[**Doctor Last Name 87973**] operative for details of the surgery. Pt was then transferred to the ICU after the surgery for intense monitoring given fluid shifts. Pt was extubated on the evening of post-op day#0. Pt was transferred out of the ICU on POD#1 and received routine post-op/postpartum care. Pt spiked a fever, and was likely due to endometritis. She was treated with Ampicillin/gentamicin/Clindamycin for 48 hrs afebrile. Pt was started on iron supplement for post-op anemia. Pt recovered well and was discharged on post-operative day #4 in stable condition: afebrile, able to eat regular food, under adequate pain control with oral medications, and ambulating and urinating without difficulty. Medications on Admission: Calcium + vit D, PNV, Iron Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for Constipation. Disp:*60 Capsule(s)* Refills:*2* 2. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Pain: take medication with food. Disp:*60 Tablet(s)* Refills:*0* 3. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 4. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for Pain. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: primary cesarean section Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory Discharge Instructions: Nothing in the vagina for 6 weeks (No sex, douching, tampons) No heavy lifting for 6 weeks No driving while taking narcotics Do not take more than 4000mg acetaminophen (APAP) in 24 hrs Do not take more than 2400mg ibuprofen in 24 hrs Please call if you develop shortness of breath, dizziness, palpitations, fever of 101 or above, abdominal pain, increased redness or drainage from your incision, nausea/vomiting, heavy vaginal bleeding, or any other concerns. Followup Instructions: -Postpartum appointment: Dr.[**Last Name (STitle) **] [**2152-7-4**] at 10:15 AM. If you need to change this appointment, please call [**Telephone/Fax (1) 2664**]. Completed by:[**2152-5-31**]

[ "615.9", "V27.0", "666.12", "285.1", "648.22", "615.0", "641.01", "692.9", "276.61", "670.12" ]

icd9cm

[ [ [] ] ]

[ "75.8", "75.52", "74.1" ]

icd9pcs

[ [ [] ] ]

6862, 6868

4684, 6212

370, 472

6937, 6937

2531, 4661

7557, 7752

2291, 2402

6290, 6839

6889, 6916

6238, 6267

7073, 7534

2108, 2117

2432, 2512

278, 332

500, 1865

6952, 7049

1887, 2085

2133, 2275

24,317

100,689

18131

Discharge summary

report

Admission Date: [**2122-5-28**] Discharge Date: [**2122-6-8**] Date of Birth: [**2047-4-9**] Sex: M Service: MEDICINE Allergies: Diovan Attending:[**First Name3 (LF) 3984**] Chief Complaint: Fever and malaise Major Surgical or Invasive Procedure: bronchoscopy [**5-29**] History of Present Illness: Mr. [**Known lastname 50155**] is a very pleasant 75 year old man with past medical history significant for MDS-RAEB2 with AML features, wegener's granulomatosis (in remission), CKD stage V on HD. He has recently been on Revlimid therapy but stopped recently due to rash, fatigue, and thrombocytopenia. He presented to outpatient clinic today with one week of increasing fatigue, intermittent fevers, cough with brown sputum, mild frontal headache, left-sided rib pain with coughing, and anorexia. CT chest showed marked increase in previously described areas of consolidation. He was referred for inpatient management. . He reports chronic DOE related to anemia, he has poor PO intake but increased gas. His rash has resolved, his lower extremity edema has resolved with hemodialysis. He denies orthopnea, abdominal pain, diarrhea, constipation, change in urine, bleeding, increased bruising. Past Medical History: Past Medical History: - MDS RAEB-2/AML overlap initiated treatment with lenalidomide [**2122-3-5**] - Essential Thrombocytosis with Jak2V617F mutation - ANCA + Vascultitis/Wegener's granulomatosis - Stage IV CKD re: GN; treated with Cytoxan. - Pulmonary artery hypertension - PFO/ASD with right-to-left shunting - Hyperparathyroidism s/p resection - HTN - Gout. - Glaucoma. - Osteopenia. Social History: married, lives with his wife. [**Name (NI) **] has 3 children (2 daughters and one son). He currently works part time in an antique shop, and used to work as a land surveyor. He served in the Korean war.Prior smoker, quit over 20 yrs ago. No drinking, illicits. Family History: Father: heart disease, CVA, died from liver cancer Mother: died from heart attack in 80s Physical Exam: . GEN: Comfortable VITALS: 102.5, 140/80 80 92% RA -> 98% when encourage to breath. HEENT: Edentulous maxilla, poor dentition with caries mandible. Soft, no LADts COR: S1 and S2, no murmurs. CHEST: Clear to auscultation bilaterally. Musical rhonchi on inspiration. tenderness over 5th ribs in mid-axillary line. ABD: Soft, non-tender, + spleen tip EXT: No edema, mild atrophy. SKIN: Warm, dry. NEURO: Alert, oriented, normal attention. . Pertinent Results: [**2122-5-28**] 06:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.011 [**2122-5-28**] 06:00PM URINE BLOOD-SM NITRITE-NEG PROTEIN-300 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [**2122-5-28**] 06:00PM URINE RBC-2 WBC-1 BACTERIA-FEW YEAST-NONE EPI-1 [**2122-5-28**] 06:00PM URINE MUCOUS-RARE [**2122-5-28**] 04:31PM UREA N-62* CREAT-4.8* SODIUM-136 POTASSIUM-3.7 CHLORIDE-95* TOTAL CO2-25 ANION GAP-20 [**2122-5-28**] 04:31PM ALT(SGPT)-19 AST(SGOT)-30 LD(LDH)-311* ALK PHOS-121 TOT BILI-0.3 [**2122-5-28**] 04:31PM CALCIUM-7.2* PHOSPHATE-3.4 MAGNESIUM-1.8 [**2122-5-28**] 04:31PM WBC-3.5* RBC-2.44* HGB-7.3* HCT-20.7* MCV-85 MCH-30.1 MCHC-35.5* RDW-15.2 [**2122-5-28**] 04:31PM NEUTS-80* BANDS-0 LYMPHS-12* MONOS-8 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2122-5-28**] 04:31PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2122-5-28**] 04:31PM PLT SMR-VERY LOW PLT COUNT-22* [**2122-5-27**] 11:00AM UREA N-56* CREAT-4.6* [**2122-5-27**] 11:00AM estGFR-Using this [**2122-5-27**] 11:00AM WBC-3.1* RBC-2.68* HGB-8.2* HCT-22.8* MCV-85 MCH-30.5 MCHC-35.9* RDW-15.1 [**2122-5-27**] 11:00AM NEUTS-76* BANDS-1 LYMPHS-14* MONOS-5 EOS-3 BASOS-1 ATYPS-0 METAS-0 MYELOS-0 [**2122-5-27**] 11:00AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+ [**2122-5-27**] 11:00AM PLT SMR-VERY LOW PLT COUNT-30* [**2122-5-27**] 11:00AM GRAN CT-2387 [**2122-5-27**] CT CHEST IMPRESSION: 1. Multiple pulmonary consolidations as described, most of them are either new or significantly increased since [**2122-3-18**]. Similar, but smaller areas of consolidation have been seen back in [**2115-9-22**]. The differential diagnosis would include recurrence of known Wegener vasculitis, in particular given the presence of areas of ground-glass surrounding the areas of consolidation that might be consistent with hemorrhage. The septal thickening surrounding the areas of consolidation might be consistent with clearance of the hemorrhage by the lymphatic system and lymphatic engourgment. The other consideration would include opportunistic infection such as invasive aspergillosis given the known immunosuppressed status of the patient. 2. Splenomegaly, unchanged. Vascular calcifications. Partially imaged horseshoe kidney. 3. Extensive degenerative changes of the thoracic spine. Asymmetric sclerosis within the medial head of the left clavicle most likely consistent with degenerative disease or arthritis or SAPHO. 4. Dilated pulmonary arteries, consistent with pulmonary hypertension, unchanged since [**2122-3-18**], and slightly progressed since [**2115-9-22**] (4.5 cm). 5. Upper chest/lower neck calcifications, 5:19, most likely representing prior surgery and given the known parathyroid adenoma most likely related to that reason. [**2122-6-6**] CT Chest 1. Progression of dominant expansile consolidative opacity since the prior CT in the left upper lobe with some residual areas that remain partly aerated, evolving substantially over two weeks, referring to radiographs. Major differential considerations include an expansile consolidation associated with pyogenic infection or hemorrhage. Given immunosuppresion, atypical sources of infection including fungal etiologies could also be considered. The density is intermediate, so while hemorrhage may represent a substantial component, specific areas of hematoma are not definable. 2. Progression of left upper lobe opacity noted in the background of resolving mass-like opacities in the right lung and left lower lobe. 2. New interval moderate pericardial effusion. 3. Moderate stable cardiomegaly. 4. Enlarged pulmonary artery consistent with pulmonary hypertension. Brief Hospital Course: Course on the Onc Floor: Mr [**Known lastname 50155**] was on [**2122-5-27**] admitted patient with history of Wegener's granulomatosis, MDS/AML, recently on Revlimid therapy, pancytopenia, and poor functional status, presented on with malaise, fever, and acute on chronic changes to his chest CT with increased size and number of areas of consolidation. Given complex history, the differential was broad, and included regular and opportunistic infections, recurrent vasculititis, malignancy, and/or hemorrhage. The case was discussed his oncologist, Dr. [**Last Name (STitle) 6944**], who has also been in contact with his pulmonologist, Dr. [**Last Name (STitle) 2168**]. The plan was to begin broad spectrum antibiotic coverage and to check blood, sputum, and urine cultures. His hemodialysis was continued M, W, F. On [**2122-6-4**] pt developed increasing respiratory distress, progressive CXR consolidation and had continued hemoptysis. ICU Course: Mr. [**Known lastname 50155**] was admitted to the [**Hospital Ward Name 332**] ICU on [**2122-6-4**] for worsening respiratory status and increased oxygen requirements. At admission, patient had been desaturating on low flow NC to mid 80s at times. He was placed on shovel mask and then 70% FM today with sats recovering to high 90s. Etiology was thought to be worse underlying infectious process in lungs with some additional edema as CXR showed worse LUL infiltrate and effusions. Pt was started on broad spectrum antibiotics with vanco, cefepime (later changed to zosyn), voriconazole, and levaquin. For his stage IV CKD secondary to WG pt was continued MWF hemodialysis. He was making very small amounts of urine at baseline # MDS: Pt was transfusion dependent with ongoing thrombocytopenias and severe anemia. He has known AML transformation with last bone marrow just few months ago with 15% blasts. He also had an older history of essential throbocytosis as well. CBCs were followed [**Hospital1 **]. Platelet transfusions were given for platelet counts <50 and PRBCs were given for HCT <21. . #Wegener's: Unclear whether patient was having a wegener's flare. He had been in remission for WG since [**2114**], although he has advancing stage IV renal disease felt to be from WG. His immunosuppression also made a WG flare less likely. On [**6-6**] a repeat CT showed large lung lesions compressing mediastinum with a large pericardial effusion, left pleural effusion, large heart thought to be due to infection vs wegeners w/ hemorrhage. On [**6-7**], Mr. [**Known lastname 50155**] was coded and was intubated and on pressors. Interventional pulmonary, CT surgery and interventional radiology were contact[**Name (NI) **] about a biopsy of the lung mass. Given his thrombocytopenia, risk of bleeding and poor functional status, it was felt that a biopsy carried a high risk of morbidity and mortality. The procedure and the patient's prognosis was explained to the family and they decided to withdraw care. Mr. [**Known lastname 50155**] was extubated on [**2122-6-8**] and passed away at 3:45 pm. His family was comforted and consoled. They declined a autopsy but agreed to a post-mortem bronchoscopy to biopsy the lung mass found on CT. Medications on Admission: Metoprolol Tartrate 50 mg PO/NG [**Hospital1 **] [**5-28**] @ [**2045**] View Lorazepam 0.5 mg PO/NG Q8H:PRN anxiety [**5-28**] @ [**2045**] View Citalopram Hydrobromide 10 mg PO/NG DAILY [**5-28**] @ [**2045**] View Calcitriol 0.25 mcg PO DAILY [**5-28**] @ [**2045**] View Allopurinol 100 mg PO/NG EVERY OTHER DAY [**5-28**] @ [**2045**] View Vitamin B Complex -- TAKES INTERMITTENTLY Calcium Citrate 1500 mg PO DAILY Sodium Bicarbonate 650 mg PO BID Nifedipine SR 60 mg PO QD Discharge Medications: patient deceased Discharge Disposition: Expired Discharge Diagnosis: patient deceased Discharge Condition: patient deceased Discharge Instructions: patient deceased Followup Instructions: patient deceased [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]

[ "446.4", "585.6", "784.7", "284.1", "423.9", "733.90", "518.81", "427.31", "511.9", "786.3", "275.41", "518.3", "518.0", "274.9", "205.00", "787.91", "416.8", "V45.11", "403.91" ]

icd9cm

[ [ [] ] ]

[ "33.24", "39.95", "99.04", "99.05", "99.71" ]

icd9pcs

[ [ [] ] ]

10136, 10145

6347, 9560

283, 308

10205, 10223

2521, 6324

10288, 10433

1940, 2031

10095, 10113

10166, 10184

9586, 10072

10247, 10265

2046, 2502

226, 245

336, 1232

1276, 1644

1660, 1924

21,015

180,668

6111

Discharge summary

report

Admission Date: [**2184-2-7**] Discharge Date: [**2184-2-22**] Date of Birth: [**2133-11-4**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2777**] Chief Complaint: Cool lower extremity, dehydration Major Surgical or Invasive Procedure: [**2184-2-8**] bilateral thrombectomies [**2184-2-8**] bilateral B/l fasciotomy [**2184-2-10**] Diagnostic Angiogram [**2184-2-16**] R BKA / L fasciotomy closure [**2184-2-18**] Angioplasty of L CFA and angioplasty of L fem-AT bpg History of Present Illness: This is a 50 year old gentleman with a past medical history of L fem-AT bypass with PTFE graft [**12-28**], Left common femoral artery to above-knee popliteal artery bypass graft '[**79**], Right common femoral artery to above-knee popliteal artery bypass graft with 8 mm ringed PTFE '[**77**], kidney transplant in '[**75**], pancreas transplant '[**77**], pancreas explant '[**82**], now presents with acute onset of mental status changes, hypotension, and B/L cool extremities. The patient had a recent prostate biopsy on [**2-5**], was in his usual state of health on [**2-6**] AM, experienced nausea and vomitting the remainder of [**2-6**], and on the morning of admission, was unresponsive. The patient was started on a heparin gtt at OSH and was Med-flighted to [**Hospital1 18**]. The patient was hypotensive enroute, had 2.5L IVF, and was started on levophed. Besides the vomitting on [**2-6**], there were no reports of fever/chills, rest pain, or evidence of claudication. The patient did injure his right third toe and took Percocet for the pain. The patient is on ASA and Plavix, which has been held for recent colonoscopy and prostate biopsy. Past Medical History: 1)CABG x 3 '[**75**] 2)Living related kidney transplant coplicated by wound exploration '[**75**] 4)Cadaveric pancreas transplant '[**77**] 5)L CEA '[**77**] ([**Doctor Last Name **]), 6)Right common femoral artery to above-knee popliteal artery bypass graft with 8 mm ringed PTFE '[**77**] 7)Right second toe amputation '[**77**] 8)Cataracts '[**78**] 9)R wrist '[**78**] 10)Left common femoral artery to above-knee popliteal artery bypass graft with 8-mm ringed PTFE '[**79**] 11)Repair of incisional hernia '[**81**] 12)L fem-AT bypass with PTFE graft [**12-28**] 13)Pancreas explant '[**82**] 14)Vitrectomy '[**73**] 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: VS: T: 100.2 HR: 97 BP: 167/52 (0.9 mcg/min Levophed) 25 100% FM GEN: combative, non-verbal HEENT: AT/NC, no icterus HEART: RRR CHEST: CTA B/L ABD: soft, NT, ND, kidney graft palpated in RLQ EXT: warm thighs B/L, cool calves B/L, cold feet B/L, B/L surgical scars (well-healed), R. second toe amp, R. third toe with circumferential eccymosis, calves mottled B/L, >4 second capillary refill B/L feet, patient spontaneously moves B/L feet, calves soft B/L, no edema PULSE: DP PT [**Name (NI) **] Fem Rad L - - - 2+ 2+ R - - - 2+ 2+ NEURO: non-verbal, moves all 4 extremities Pertinent Results: Labs on admission: [**2184-2-7**] 12:20PM BLOOD WBC-8.9 RBC-3.80* Hgb-11.4* Hct-34.3* MCV-90 MCH-30.0 MCHC-33.3 RDW-14.0 Plt Ct-139* [**2184-2-7**] 12:20PM BLOOD Neuts-90* Bands-5 Lymphs-3* Monos-1* Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2184-2-7**] 12:20PM BLOOD PT-14.9* PTT-108.9* INR(PT)-1.3* [**2184-2-7**] 12:20PM BLOOD Glucose-137* UreaN-57* Creat-3.7*# Na-140 K-5.8* Cl-106 HCO3-21* AnGap-19 [**2184-2-7**] 12:20PM BLOOD CK(CPK)-113 [**2184-2-7**] 05:49PM BLOOD Lipase-7 [**2184-2-7**] 12:20PM BLOOD CK-MB-2 [**2184-2-7**] 12:20PM BLOOD cTropnT-<0.01 [**2184-2-7**] 05:49PM BLOOD CK-MB-2 cTropnT-<0.01 [**2184-2-8**] 03:07AM BLOOD CK-MB-3 cTropnT-<0.01 [**2184-2-7**] 05:49PM BLOOD Albumin-3.5 Calcium-8.5 Phos-1.6*# Mg-1.7 [**2184-2-7**] 08:15PM BLOOD Type-ART Temp-38.4 Rates-20/ Tidal V-550 PEEP-12 FiO2-80 pO2-301* pCO2-39 pH-7.42 calTCO2-26 Base XS-1 AADO2-253 REQ O2-48 -ASSIST/CON Intubat-INTUBATED [**2184-2-7**] 12:29PM BLOOD Lactate-3.0* . Labs prior to discharge: [**2184-2-22**] 08:00AM BLOOD WBC-8.5 RBC-2.78* Hgb-8.3* Hct-24.8* MCV-89 MCH-30.0 MCHC-33.6 RDW-14.7 Plt Ct-823* [**2184-2-22**] 08:00AM BLOOD PT-16.3* PTT-30.4 INR(PT)-1.5* [**2184-2-22**] 08:00AM BLOOD Glucose-164* UreaN-26* Creat-1.6* Na-129* K-4.5 Cl-94* HCO3-24 AnGap-16 [**2184-2-22**] 08:00AM BLOOD Mg-2.1 [**2184-2-21**] 08:10AM BLOOD tacroFK-4.6* [**2184-2-22**] 08:00AM BLOOD tacroFK-PND Imaging: CT head noncont: negative CTA torso [**2-7**]: 1. Thrombosis of the right femoral-popliteal, and left femoral-anterior tibial grafts with minimal reconstitution at the level of the tibioperoneal trunks bilaterally via collaterals. The profunda arteries are patent bilaterally. 2. Unchanged plaque/thrombus within the SMA which attenuate the vessel, however, not significantly changed since [**2183-2-18**]. No evidence of bowel ischemia. 3. Unremarkable right lower quadrant renal transplant. 4. Anterior mediastinal soft tissue which may represent thymic rebound. Close interval followup is recommended. 5. Bibasilar atelectasis. Art duplex u/s [**2-13**]: Widely patent left common femoral to popliteal bypass graft. Monophasic waveforms indicate presence of some baseline underlying ischemia of the left lower extremity distal to the popliteal artery. CXR [**2-20**]: Left lower lobe atelectasis significantly improved. Left pleural effusion cleared. No new consolidation. Brief Hospital Course: Summary of major hospital events: HD #1. Upon arrival on [**2184-2-7**] the patient was critically ill with an elevated potassium and an acute renal failure. The patient was admitted to the intensive care unit after a CT angiogram showed that the left profunda was widely opened, but his femoral anterior tibial artery bypass was occluded. He did have distal flow. On the right side he had a small clot in the proximal profunda with good distal flow and flow in the leg. On exam the patient initially had cool legs which were mottled, but as his blood pressure began to resolve, the only cool part of his legs were the feet below the ankles. He had no signals. He had palpable femorals only. Extensive discussions were held with the family and the decision was made to observe on heparin and try to resuscitate him to get him in a more stable condition for the operating room. His initial CK was 110. Over the course of the evening, the patient began to do better and had controlled blood sugars with a potassium in the normal range and his creatinine came down to the 2 range. His CK started to rise and his feet did not improve, so he was taken urgently to the operating room on HD #2. HD #2. On [**2184-2-8**] he underwent bilateral graft thrombectomies, bilateral leg fasciotomies, right common femoral atherectomy with bovine pericardial patch angioplasty, and angiogram demonstrating no flow through the right femoral-popliteal bypass graft with insufficient runoff through the right popliteal supplied by the right profunda. HD #4. On [**2184-2-10**] he had an right lower extremity angiogram via the left brachial artery showing showing a patent profunda with branches supplying a small peroneal artery with no outflow. Based on these findings we concluded that he will most likely require a below-knee amputation in the near future. HD#10: Patient underwent a R BKA. Please see Dr.[**Name (NI) 23935**] operative note for details. Patient tolerated the procedure well, transferred to the PACU and then to VICU. APS was consulted. Dilaudid PCA and ketamine drip was started post op and continued to POD4. Pain medication transitioned to PO ms contin and dilaudid on POD4. Pain controlled prior to discharge. Diet was advanced. Pt consulted to assist in strength training and mobility. HD#12: Patient underwent angioplasty of left common femoral artery and angioplasty of left femoral to anterior tibial bypass graft. Received perioperative HCO3 infusion. Pt tolerated the procedure well, transferred to PACU and then to VICU in stable condition. Again, diet was advanced and pain controlled with first ketamine drip and IV PCA and then po dilaudid MS contin. Hospital course summary by systems: Neuro: Please see above for details. Acute pain service was consulted. Started on ketamine drip and dilaudid PCA. PO ms contin and dilaudid controlling pain reasonably well prior to discharge. Patient is comfortable. Strongly recommend that he follow up with chronic pain service for continued evaluation and treatment. CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. Routine beta blockade and statin therapy was continued. Plavix was continued. No symptoms or signs of ACS, negative set of cardiac enzymes started on admission. Pulmonary: The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout this hospitalization. CXR on [**2-20**] showed improvement of left lower lobe atelectasis and resolution of pleural effusion. No s/s of PE during stay. GI/GU: Pt is s/p renal kidney tx on prograft and predinose. Renal tranplant service actively followed patient. Creatine was closly monitored. Tacrolimus levels were routinely monitored. Tacro dosing was recently changed from 1.5 [**Hospital1 **] to 2 [**Hospital1 **] on [**2-20**]. He should continue on this regimen until he follows up with renal as an outpatient. Renal agrees with discharge to rehab, and does not have any active issues requiring medical management at this time. Labs should be closely followed while at rehab. On [**2-20**] his foley was removed. Patient subsequently was voiding with good u/o but did have relatively high PVR volumes ranging from 300-600cc. He was asymptomatic. It was decided to hold off on inserting a foley at this time, but his PVRs and signs of worsening urinary retention should be closely monitored at rehab. FEN: The patient's diet was advanced when appropriate, which was tolerated well following multiple procedures. The patient's intake and output were closely monitored, and IVF were adjusted when necessary. The patient's electrolytes were routinely followed during this hospitalization, and repleted when necessary. Patient had mild hyponatremia likely from pain induced SIADH per the renal transplant medical team. All infusions were changed to only NS solutions. His sodium stabilized in low 130s and high 120s prior to discharge. ID: The patient's white blood count and fever curves were closely watched for signs of infection. Patient was dignosed with UTI by ciprofloxicin-sensitive enterobacter. Treated by full 7 day course. Subsequent urine culture showed no growth. Patient received routine perioperative antibiotics. Patient was started on keflex [**2-21**] for some mild new erythema around stump suture line. Recommend 7 day course of keflex. Endocrine: The patient's blood sugar was monitored throughout this stay; insulin dosing was adjusted accordingly. [**Last Name (un) **] was contact[**Name (NI) **]. Please see medication list for insulin regimen prior to discharge. Hematology: The patient's complete blood count was examined routinely; no transfusions were required during this stay. Hct was stable in mid 20s priors to discharge. He was asymptomic with stable VSS prior to discharge. Patient was anticoagulated with heparin drip, often requiring up to [**2174**] u/hr to reach therapeutic PTT levels. Patient was switched to therapeutic lovenox (80mg [**Hospital1 **]) on [**2-20**]. 7.5mg of coumadin also started on [**2-20**]. Five mg of coumadin given on [**2-21**]. INR prior to discharge 1.5. We recommend 2.5mg coumadin for his [**2184-2-22**] pm dose. INR goal [**12-23**]. Prophylaxis: See hematology. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, pt was straight cathed for urinary retention which will need to be followed up on at rehab for possible foley placement, and pain was controlled reasonably well. Discharge Medications: 1. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 7 days. Disp:*28 Capsule(s)* Refills:*0* 2. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 7. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for Anxiety. 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO Q8H (every 8 hours). 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 14. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous [**Hospital1 **] (2 times a day). 15. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q8H (every 8 hours). 17. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). 18. Hydromorphone 4 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 19. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 doses. Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital of [**Location (un) **] & Islands - [**Location (un) 6251**] Discharge Diagnosis: Bilatetal occluded bypass grafts (pre-op) Fluid deficit HTN DM hyponatremia PVD Discharge Condition: Stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOLLOWING BELOW OR ABOVE KNEE AMPUTATION . 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. . PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS: . Redness in or drainage from your leg wound(s) . . Watch for signs and symptoms of infection. These are: a fever greater than 101 degrees, chills, increased redness, or pus draining from the incision site. If you experience any of these or bleeding at the incision site, CALL THE DOCTOR. . 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 [**Location (un) 1106**] 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 Followup Instructions: Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2184-3-2**] 10:40 Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2184-3-4**] 8:00 Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2184-3-4**] 9:00 Patient should make an appointment with chronic pain service for managment of chronic pain. Needs apt MS in 4 weeks. Completed by:[**2184-2-22**]

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icd9cm

[ [ [] ] ]

[ "84.15", "86.59", "39.50", "96.04", "83.14", "39.49", "88.48", "88.47", "96.71", "00.41" ]

icd9pcs

[ [ [] ] ]

14045, 14157

5695, 12385

347, 580

14281, 14290

3296, 3301

19698, 20203

2597, 2619

12408, 14022

14178, 14260

14314, 16058

2634, 3277

274, 309

16070, 18998

19021, 19675

608, 1776

3315, 5672

1798, 2426

2442, 2581

24,364

124,692

22511

Discharge summary

report

Admission Date: [**2108-9-17**] Discharge Date: [**2108-9-22**] Date of Birth: [**2056-2-14**] Sex: M Service: ENT Allergies: Bactrim Attending:[**First Name3 (LF) 7729**] Chief Complaint: Right oral mass Major Surgical or Invasive Procedure: Excision of right mandibular mass History of Present Illness: This is a 52- year old gentlman with history of HIV and AIDS admitted with a rapidly growing oral mass on the right side concerning for lymphoma vs. kaposi's vs. SCC. The mass was first noticed on prior hospitalization, while he was aggressively being treated for refractory CD4 count. Past Medical History: AIDs (CD4 13, VL 363) diagnosed with HIV in [**2092**], hemochromatosis, hemorroids, HBV Social History: Lives alone in an apartment on the [**Location (un) 448**] in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 669**]. Has brother and 2 sons in the area who are supportive. Former teamster who worked setting up expos. Divorced. Family History: h/o ETOH abuse with siblings and sons Physical Exam: alert and oriented x 3 RRR, no mrg CTAB S/NT/ND +bs incision CDI wit stitches visible. No erethema, minimal edema. LE: no edema, +SCD's. Pertinent Results: [**2108-9-20**] 04:34AM BLOOD Neuts-81* Bands-0 Lymphs-14* Monos-4 Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2108-9-21**] 07:40AM BLOOD Glucose-141* UreaN-19 Creat-0.7 Na-139 K-4.3 Cl-109* HCO3-23 AnGap-11 [**2108-9-21**] 07:40AM BLOOD ALT-36 AST-36 LD(LDH)-144 AlkPhos-101 TotBili-1.7* [**2108-9-21**] 07:40AM BLOOD Albumin-3.4 Calcium-8.7 Phos-3.4 Mg-2.3 Brief Hospital Course: This is a 52 year old man with HIV/AIDS noted on prior hospitalization to have a rapidly growing Right oral mass concerning for Kaposi's sarcoma. Patient underwent uncomplicated excisional biopsy of right mandibular alveolar ridge tumor with primary closure as described in operative report. Patient's initial post-operative course was noteable for difficulty swallowing. The dysphagia was originally thought to be secondary to incisional pain, however, the patient's pain continued to persist. A speech/swallow evaluation was obtained on POD#2, which revealed aspiration, for which the patient was made strictly NPO. Patient was also noted to have facial cellulitis. FOE at that time revealed bilateral AE fold edema, right more than left, with epiglottis thickening and effacement of the right piriform. Patient was transferred to ICU for continuous telemetry and oxygen monitoring. ID was consulted for increased antibiotic coverage, and unasyn was started. Steroids were also begun to decrease edema. Blood cultures were obtained, and were still pending at discharge. By POD#3, edema was decreased. A repeat swallow study on POD#3 noted patient was able to tolerate ground solids, and patient was started on thin liquids, ground solids, and po meds. ID recommendations with regards to HAART, prophylactic antibiotics, and other HIV/AIDS medications were all instituted. Serial FOE's while patient was in the ICU revealed resolution of edema and patient was transferred to floor. On POD#4, patient did have symptoms of frequent, loose stools, for which c.diff assays were sent. C.diff results were pending at discharge, however symptoms had resolved with trial of imodium. By POD#5, patient's pain was controlled on oral pain meds, he was ambulating well, and tolerating ground solid diet without symptoms of dysphagia or aspiration. Per ID recs, patient was discharged on 14 day course of augmentin. Patient was discharged home with instructions to contact ENT team if symptoms of loose bowel movements returned. Patient will follow up with both Dr. [**Last Name (STitle) 1837**] and infectious disease doctor. Discharge Medications: 1. Amoxicillin-Pot Clavulanate 875-125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 weeks. Disp:*28 Tablet(s)* Refills:*0* 2. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 3. Atazanavir Sulfate 150 mg Capsule Sig: Two (2) Capsule PO QD (once a day). 4. Prochlorperazine 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for nausea. 5. Dapsone 100 mg Tablet Sig: One (1) Tablet PO QD (once a day). 6. Loperamide HCl 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed for diarrhea. 7. Mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO QD (once a day). 9. Trazodone HCl 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 10. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4-6H (every 4 to 6 hours) as needed for pain. 11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed for Temp>101.5, pain. 12. Methylprednisolone 4 mg Tablet Sig: One (1) Tablet PO SEE INSTRUCTIONS () for 6 days. 13. Azithromycin 600 mg Tablet Sig: Two (2) Tablet PO QFRIDAY (). 14. Leucovorin Calcium 25 mg Tablet Sig: One (1) Tablet PO QFRIDAY (). 15. Pyrimethamine 25 mg Tablet Sig: Two (2) Tablet PO QFRIDAY (). 16. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for thrush. 17. Megestrol Acetate 40 mg Tablet Sig: Ten (10) Tablet PO QID (4 times a day). 18. Truvada 200-300 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Right oral cavity mass Discharge Condition: Good Discharge Instructions: Rinse mouth with saline before and after meals. If your loose bowel movements persist or you have associated abdominal pain, call the ENT resident on-call. Followup Instructions: Follow-up with Dr. [**Last Name (STitle) 1837**] in 1 week. Follow-up with your Infectious Diseases doctor [**First Name (Titles) 3**] [**Last Name (Titles) 1988**]. Completed by:[**2108-9-22**]

[ "054.2", "070.32", "263.9", "682.0", "042", "E878.8", "998.59" ]

icd9cm

[ [ [] ] ]

[ "24.4" ]

icd9pcs

[ [ [] ] ]

5335, 5341

1607, 3739

279, 315

5408, 5414

1227, 1584

5618, 5815

1015, 1054

3762, 5312

5362, 5387

5438, 5595

1069, 1208

224, 241

343, 631

653, 743

759, 999

23,924

189,701

48836

Discharge summary

report

Admission Date: [**2183-5-21**] Discharge Date: [**2183-7-17**] Date of Birth: [**2108-10-24**] Sex: F Service: MEDICINE Allergies: Celebrex / Nsaids / Morphine Attending:[**First Name3 (LF) 3913**] Chief Complaint: ??????Shortness of breath?????? and pancytopenia Major Surgical or Invasive Procedure: 1. Open Cholecystectomy 2. Leukemia induction 3. Central line placement History of Present Illness: This is a 74 year-old woman with a history of breast and colon cancer, hypertension, hypercholesterolemia, and anemia (Hct 31-33), who presented to her PCP at [**Name9 (PRE) 191**] with shortness of breath, was put on supplemental oxygen, and then referred to the ED. Of note, patient has a recent history of nose bleeds for two months associated with dizziness and sweating that was diagnosed as a sinus infection on [**5-7**]. Her PCP treated her with a course of Amoxicillin that developed into diarrhea and abdominal cramps. Patient consulted her NP[**Company 2316**] who said it was okay to discontinue her antibiotic. Shortly after, she developed this two-week episode of dyspnea. . Patient complains of dyspnea on exertion for the past couple of weeks that is associated with chest tightness, dizziness, and lightheadedness. She feels weak, barely being able to walk from her chair to her kitchen. After walking up the stairs to her bedroom, she feels like ??????plopping into bed?????? because she is so exhausted. She experiences a dry cough, chest tightness, and heart palpitations with walking but denies radiating chest pain or dyspnea at rest. Patient has developed a low grade fever of 100.0F that is easily abated with Tylenol. She denies dehydration, maintaining adequate fluid intake. Otherwise, patient denies history of asthma/COPD, orthopnea/PND, MI, hemoptysis, hematemesis, N/V, melena/BRBPR, hematuria, edema, or falls. Patient made an appointment with her PCP today, but upon getting off the elevator, she felt that she was ??????mustering all her strength to keep from passing out.?????? Her PCP put her on supplemental oxygen and referred her to the ED for further evaluation. . Hospital course: In the ED, patient had a low grade fever of 100.4. Her labs revealed a 15-point Hct drop and she was transfused 2 U PRBCs. Patient was transferred to the floor saturating at 98% on 2L and feeling more comfortable, denying shortness of breath. Past Medical History: 1. Breast cancer ?????? diagnosed in [**2174**] and treated by right mastectomy, chemo and XRT; she continues to be followed by her oncologist, Dr. [**Last Name (STitle) 2036**], for annual check-ups. Treated with AC 2. Colorectal cancer ?????? diagnosed in [**2153**], s/p colectomy 3. Hypertension 4. Hypercholesterolemia 5. Anemia ?????? chronic Hct (31-33) 6. GERD 7. Osteoarthritis ?????? Low back pain . Allergies/Intolerance: Celebrex ?????? causes stomach irritation,diarrhea NSAIDS Statins ?????? muscle aches, headaches Social History: Social History: Patient??????s father is from [**Name (NI) 6257**]/[**Country 3587**] and her mother is Indian/Irish. She lives in [**Location 669**] in a community home (cooperative), and her 30 year-old son resides with her. She is the mother of 8 children with several grandchildren. She is independent, performing all her ADL??????s and IDL??????s. She has a significant 60 pack-year tobacco history and denies alcohol or IVDU. Her [**Doctor First Name **] heritage plays an important role in her life, serving as a Sunday School teacher. Family History: Father ?????? MI (88yo) Father??????s side ?????? MI, htn, DM, asthma Physical Exam: PE: Tm 100.4 Tc 99.6 HR 90 BP 140/80 RR 14 O2 100% RA Wt 82.9 kgs General: Well nourished, appearing stated age, in no acute distress, breathing comfortably, speaking in full sentences, not using accessory muscles. Head: Normocephalic/atraumatic. Eyes: PERRL, EOMI, sclera anicteric. No conjunctival pallor. Ears: Tympanic membranes clear with light reflex. Mouth: Moist mucous membranes. Clear oropharynx. Top dentures. Neck: Supple with normal range of motion. No thyromegaly. No lymphadenopathy. Lungs: Clear to auscultation bilaterally. No wheezing, rhonci, or rales. + right mastectomy CV: Regular rate and rhythm, no murmur. Normal S1/S2. Normal PMI. No carotid bruits or jugular venous distension. Abdomen: Soft, nontender, normoactive bowel sounds, no masses, no organomegaly. DRE: FOBT negative. Back: No costovertebral angle tenderness. Extremities: No edema, cyanosis, or clubbing. Good dorsalis pedis pulses. . Neurologic Exam: Mental Status: Alert & Ox3, cooperative, attentive; fluent, non-dysarthric speech.. Cranial Nerves: I- not tested. II-XII intact. Motor: Normal bulk and tone, no fasciculations, tremor or pronator drift. Strength: [**4-11**] throughout. Sensation: Intact to light touch, temperature (cold), and vibration sense. Reflexes: 2+ throughout. Toes were downgoing bilaterally. Coordination: Normal on finger-nose-finger, finger tapping, rapid alternating movements. Gait: Not tested. Pertinent Results: Labs on Admission ([**2183-5-21**] 01:40PM): WBC-1.9* RBC-1.61*# HGB-5.9*# HCT-16.4*# MCV-102* MCH-36.5* MCHC-35.9* RDW-18.1* RET AUT-0.6* GRAN CT-390* NEUTS-12* BANDS-4 LYMPHS-46* MONOS-6 EOS-0 BASOS-0 ATYPS-0 METAS-2* MYELOS-0 BLASTS-30* PT-12.9 PTT-23.7 INR(PT)-1.1 PLT SMR-VERY LOW PLT COUNT-30*# LPLT-2+ HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-2+ MACROCYT-1+ MICROCYT-1+ POLYCHROM-OCCASIONAL OVALOCYT-1+ TEARDROP-OCCASIONAL LD(LDH)-298* TOT BILI-0.2 GLUCOSE-107* UREA N-16 CREAT-0.8 SODIUM-132* POTASSIUM-2.9* CHLORIDE-97 TOTAL CO2-23 ANION GAP-15 ANC Values: 390 on [**5-21**] -> 10 on [**6-10**] -> 130 on [**6-20**] -> 560 on [**7-4**] -> 1020 on [**7-13**] -> 1390 on [**7-15**] -> 720 on [**7-17**]; . . STUDIES: 1. CXR [**5-21**]: No pneumonia. 2. BONE MARROW BIOPSY ([**5-22**]): DIAGNOSIS: Acute myelogenous leukemia (see note). Note: cytogenetic studies revealed that 20 of 20 cell analyzed have trisomy 11. Trisomy 11 is frequently associated with internal tandem duplications of the MLL (ALL-1) gene. MICROSCOPIC DESCRIPTION PERIPHERAL SMEAR Smear quality is acceptable. Red cells show anisopoikilocytosis, and include microcytes and pre-dacrocytes. WBC count is decreased. Differential shows: 18% segmented neutrophils, 37% lymphocytes, 45% blasts. Many of the neutrophils are hypolobated and hypogranular. Platelet count appears decreased; rare giant forms are present. ASPIRATE SMEARS The aspirate material is adequate for evaluation. M:E ratio is 30:1. Myeloid cells appear increased, comprised primarily of blasts and microblasts, with moderately nucleoplasm, large prominent nucleoli, and some with Auer rods. . Erythroid maturation cannot be assessed due to paucity of erythroid precursors. Megakaryocytes are present in markedly decreased numbers. Differential shows: Blasts 60%, Promyelocytes 3%, Myelocytes 17%, Metamyelocytes 5%, Bands/Neutrophils 5%, Plasma cells 2%, Lymphocytes 5%, Erythroid 3%. . BIOPSY SLIDES The core biopsy contains periosteum on both ends indicating that it represents a tangential biopsy of the subcortical marrow space, which is frequently hypocellular and not representative. The marrow space is comprised of fat and stromal cells and is devoid of maturing hematopoietic elements. Marrow clot section is not submitted. Touch prep is not submitted. . 3. ECHOCARDIOGRAM ([**5-23**]): IMPRESSION: Preserved global and regional biventricular systolic function. Minimal aortic stenosis. Mild mitral regurgitation. Pulmonary artery systolic hypertension. . 4. CT SINUS ([**5-26**]) IMPRESSION: No evidence of acute sinusitis. . 5. CT ABDOMEN/PELVIS ([**6-24**]): IMPRESSION: -A. Multiple gallstones as well as gallbladder thickening and possible stranding around the gallbladder. This represents acute cholecystitis. These findings were conveyed to the clinical team (Dr. [**Last Name (STitle) **]. If indicated, ultrasound or nuclear medicine gallbladder scan could be performed. -B. Ill-definition and stranding around the head of the pancreas could represent pancreatitis. However, at this point, the amylase and lipase are normal. -C. Small fat-containing ventral hernia (image 2, 29). -D. Mild thickening of the sigmoid colon and rectum with stranding around it likely representing mild colitis. . 6. ECHOCARDIOGRAM ([**7-2**]): Compared with the findings of the prior study (images reviewed) of [**2183-5-23**], there is now a small pericardial effusion. The left ventricular ejection fraction is now somewhat reduced. . 7. MRI HEAD ([**7-9**]): Sagittal T1 and axial T1 images were obtained through the brain. Further imaging was not performed as the patient declined completion of the examination. The gadolinium portion of the examination was not performed. IMPRESSION: Limited examination of the brain with pre-contrast T1-weighted images only performed. No overt evidence of acute intracranial hemorrhage or hydrocephalus. Diffuse marrow space signal abnormality likely represents marrow replacement and may be related to patient's AML. . 8. CXR ([**7-9**]): IMPRESSION: No pneumonia. Stable bilateral pleural effusions. . 9. PLAIN FILM HIPS, BILATERAL ([**7-17**]): 1. Mild-to-moderate degenerative changes of right hip and moderate-to-severe degenerative changes of left hip. No acute fracture or osseous lesions. . Brief Hospital Course: Ms. [**Known lastname 15063**] is a 74-year-old woman with a history of breast cancer s/p mastectomy, radiation and chemotherapy; colon cancer s/p hemicolectomy; and HTN who initially presented with SOB and was found to have pancytopenia (WBC 1.6, Hct 16.4, Plt 30) with a subsequent bone marrow biopsy consistent with AML. Her hospital course for this admission is as follows: . 1. AML. She initially presented with SOB and pancytopenia (WBC 1.6, Hct 16.4, Plt 30, ANC were 390) to the medicine team on admission. Peripheral smear showed 30% blasts. Given this finding, hem/onc service was consulted. After evaluation, patient was transferred from the medicine service to the BMT service. A bone marrow aspiration showed Acute Myeloid Leukemia with trisomy 11. . On admission to BMT, allopurinol was started. After explaining different therapeutic options and the risk involved, patient decided to go for chemotherapy with MEC. A central line was placed on [**2183-5-27**], although it had to be repositioned by IR on [**2183-5-28**] before before use. Echocardiogram was done that showed normal LVEF >55%, minimal aortic stenosis, mild mitral regurgitation and Pulmonary artery systolic hypertension. Induction chemotherapy with MEC was administered per protocol, with Day 0 on [**2183-5-28**]. She was closely monitored for tumor lysis syndrome, but this never developed. Allopurinol was disccontinued on [**2183-6-10**] because of a new rash. The day 14 bone marrow biopsy was not done since it was determined that the results would not change her management. She was treated with GCSF 480mcg SC daily beginning on [**6-11**] and continuing through [**7-15**]. Her ANC response was slow despite GCSF, and in fact, it started coming down again shortly after stopping GCSF; ** this should be followed up in the outpatient follow-up. ** . 2. Neutropenic Fever. She was found to be neutropenic on admission. Given her fever of 100.4 in the ED, cefepime was started. She continued to have temperatures up to 100.5. No source was identified. By [**2183-5-26**], with continued temperatures in this range, vancomycin was initiated to broaden coverage. She also was complaining of sinus congestion and mild frontal headache at that time. CT of the sinus was done which came back negative for sinusitis. All blood cx and urine cultures remained negative. Vancomycin was discontinued after 72 hours and given a lack of other focal signs for infection, it was thought that her fevers might be related to her underlying hematologic malignancy. Throughout her hospital course, she had intermittent low grade fevers. She was started on multiple different abx and would defervesce intermittently. Cefepime was used initially but was switched to meropenem for worsening mucositis; Vanc was used intermittently. Acyclovir was added for a herpetic ulcer in her mouth. Fluconazole was given for approximately one week. Meropenem was discontinued on [**7-4**] for a worsening rash and Cefepime was re-started. Caspo was used for three weeks but was also stopped ([**6-29**]) for worsening rash. Flagyl was started for diarrhea on [**6-24**], but stopped for her rash on [**7-2**]. . 3. Acute cholecystitis. Ms. [**Known lastname 15063**] developed diarrhea on [**6-23**] along with mild upper abdominal pain. A CT showed acute cholecystitis. Surgery was consulted and they performed an open cholecystectomy on [**6-24**] under Dr. [**Last Name (STitle) **]. She tolerated the procedure well and was transferred back to BMT from the SICU on [**6-27**]. Bowel movements began on [**7-1**] and she was advanced to a regular diet. The suture staples were removed on [**7-10**] and the wound healed nicely after that. Her pain was well controlled with oxycodone and acetaminophen. . 4. Rash. A rash developed on [**6-10**], which disappeared after discontinuing ambisome. However, a new rash developed on [**6-27**]; it is presumed that this was a reaction to ibuprofen, which she got in the SICU despite an NSAID allergy. However, the rash continued to worsen over all four extremities. Dermatology recommended starting triamcinolone cream 0.1% [**Hospital1 **], which was done. Caspofungin, Flagyl, and Meropenem were each stopped on [**6-29**], and 28 respectively. The rash gradually began improving and had nearly resolved by the time of discharge. . 5. Mucositis. After her MEC chemo, she developed mucositis. Pain was adequately controlled PCA dilaudid. She was also given Acyclovir for a herpetic ulcer on her right buccal muccosa. Supportive care with Magic mouthwash, Gel [**Last Name (un) **], and viscous lidocaine was given. The PCA was discontinued on [**6-21**] as her pain had decreased and WBC and ANC had increased. . 6. Non gap metabolic acidosis. On hospital day 3, her bicarbonate went down to 18. After reviewing possible causes, it was concluded that it may have been related to her continuous NS. IV fluids were stopped. Slow recovery was obtained. However, given a persistently low bicarb, and a urinary GAP with low K+, it was more likely related to a renal tubular acidosis. However, this resolved over the subsequent week with no further electrolyte abnormalities. . 7. Hyponatremia. This was a euvolemic hyponatremia. Urine osmolality was 364 and plasma osm 268. Given that she was on hydrochlorothiazide and given the potential for SIADH, this medication was discontinued. Betablocker was started for blood pressure control. Her sodium slowly recovered. . 8. GERD. This remained asymptomatic on pantoprazole 40mg PO qday. . 9. SOB. On admission, SOB was secondary to anemia (hct 16.4) admission, which improved after transfussion in the ED. Initial set of enzymes was negative. EKG normal on admission. No evidence of heart failure on physical exam. Further SOB on [**6-15**] was likely due to fluid overload; she got IV lasix 20mg x 1, and albuterol neb. . 10. LE edema. This developed on [**6-20**], with the left greater than the right. A LE Ultrasound was negative for DVT. This slowly resolved as the rash resolved. . 11. Hypertension. This was controlled. As noted above, she was switched from HCTZ 25mg PO to metoprolol 25mg [**Hospital1 **] in the setting of hyponatremia. Nifedipine was started on [**2183-5-30**] for further BP control. . 12. Epistaxis. This was controlled by compression and platelet transfusion. . 13. Hip pain. On the morning of [**7-17**], she awoke with sharp left hip pain. Although there was concern for pathologic fracture or osseous involvement, plain films revealed only degenerative changes consistent with her known osteoarthritis with no acute fracture, dislocation, or osseous lesion. Oxycodone was given for pain. . 14. Anxiety. She was increasingly anxious over the course of her hospitalization. On [**7-15**], she was switched from Ativan to Klonopin 0.5 mg tid. This helped her some, although anxiety remains an issue for her and should be followed as an outpatient. . 15. Access. A central line was placed by surgery on [**2183-5-27**]. It was subsequently changed over a wire on [**2183-5-28**] by IR for proper placement into the IVC. CXR on [**2183-6-4**] for a fever incidentally showed that the central line migrated back to the brachiocephalic vein. However, since she was not getting TPN, we continued to use the line for her other medication. . 16. Code: Full. . . Medications on Admission: Medications on Admission: HCTZ 25mg PO qday Pantoprazole 40mg PO qday Ativan 1 mg PO qhs Tylenol #3 Glucosamine 1 capsule [**Hospital1 **] Discharge Medications: 1. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed. Disp:*30 Tablet(s)* Refills:*0* 2. Nifedipine 10 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). Disp:*90 Capsule(s)* Refills:*2* 3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 4. Clobetasol 0.05 % Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). Disp:*1 tube* Refills:*0* 5. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). Disp:*90 Capsule(s)* Refills:*2* 6. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. Disp:*1 MDI* Refills:*3* 7. [**First Name5 (NamePattern1) 4886**] [**Last Name (NamePattern1) 12106**] Sig: One (1) Miscell. once a day: Dispense 1 [**Last Name (NamePattern1) **], ICD 205. Disp:*1 [**Last Name (NamePattern1) **]* Refills:*0* 8. Aquaphor Ointment Sig: One (1) application Topical three times a day. Disp:*1 tube* Refills:*2* 9. Triamcinolone Acetonide 0.1 % Cream Sig: One (1) application TP Topical twice a day for 2 weeks: to the affected area, avoid face, axilla and groin area . Disp:*1 tube* Refills:*0* 10. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* 11. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. Disp:*5 Tablet(s)* Refills:*0* 12. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO three times a day for 5 days. Disp:*15 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital3 672**] Hospital Discharge Diagnosis: Primary: 1. Acute Myeloid Leukemia, type M2 2. Cholecystitis, now s/p open cholecystectomy Secondary: 1. Osteoarthritis 2. GERD Discharge Condition: Good condition, vital signs stable, discharged to acute rehab facility. Discharge Instructions: You have been evaluated and treated for acute myeloid leukemia (AML), as well as cholecystitis. Please take all medications as directed. Please keep all follow-up appointments. . Call the BMT fellow on call if you develop fever greater than 101 degrees, shortness of breath, pain in the chest, nausea/vomiting, or any other symptom that is concerning to you. Followup Instructions: An appointment will be made for you to see Dr. [**Last Name (un) 5561**] on Thursday, [**7-24**]; you will be contact[**Name (NI) **] with the exact time. . An appointment has been made for you to follow-up with Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 6439**]) on Thursday, [**7-31**], at 3:00 pm. Completed by:[**2183-7-17**]

[ "V45.71", "V45.72", "V17.4", "574.10", "305.1", "996.1", "300.00", "715.95", "V10.05", "530.81", "401.9", "V10.3", "574.00", "E947.8", "784.7", "205.00", "693.0", "588.89", "V18.0", "054.2", "276.1", "272.0" ]

icd9cm

[ [ [] ] ]

[ "99.25", "99.07", "21.00", "38.93", "41.31", "99.05", "51.22", "99.04" ]

icd9pcs

[ [ [] ] ]

18464, 18519

9367, 16701

340, 413

18690, 18764

5064, 9344

19171, 19512

3538, 3610

16891, 18441

18540, 18669

16753, 16868

2163, 2408

18788, 19148

3625, 4548

251, 302

441, 2146

4665, 5045

4580, 4649

4565, 4565

2430, 2962

2994, 3522

18,685

153,280

10503

Discharge summary

report

Admission Date: [**2151-1-1**] Discharge Date: [**2151-1-10**] Date of Birth: [**2099-7-31**] Sex: M Service: PURP [**Doctor First Name 147**] CHIEF COMPLAINT: Abdominal pain. HISTORY OF THE PRESENT ILLNESS: This is a 51-year-old, generally healthy male, who presented to the [**Hospital1 18**] ER with abdominal pain. The patient reports he was generally well until one day prior to admission when he developed some left mid abdominal pain that became more diffuse and intense throughout the afternoon and evening. He had multiple episodes of emesis after the pain started. He was seen by his primary-care physician on the morning of admission and sent to the ER for further evaluation. Review of systems reveals no fevers or chills. The patient was nauseous with some bilious vomiting and the last reported BM one day prior to admission. He denied any bright red blood per rectum or melanic stool. PHYSICAL EXAM: Temperature 98.0, pulse 67, pressure 180/98, respiratory rate 16, saturating at 99 percent on room air. In general, he looks very uncomfortable, holding abdomen and rolling around in bed. HEENT: Pupils equally round and reactive to light and accommodation. No scleral icterus. Oropharynx clear. Chest: Clear to auscultation bilaterally. Cardiovascular: Regular rate and rhythm. Abdomen: No evidence of any scars. He is tender to palpation in the right lower quadrant with no evidence of Rovsing, obturator or psoas sign, no evidence of any abdominal mass. There was no rebound or guarding. Rectal exam revealed tender with palpation to the right, guaiac negative. ADMISSION LABS: Revealed a white count of 20,900, hematocrit 46.3, platelets 252,000. His chemistry panel was unremarkable and LFTs were within normal limits. A CT was performed which revealed a large appendicitis present in the right lower quadrant, measuring 1.4 x 0.9 cm. The appendix appeared to be dilated with an enhancing wall and measured 11 mm in the greatest transverse dimension. This [**Location (un) 1131**] was consistent with an uncomplicated appendicitis. HOSPITAL COURSE: The patient was admitted to the Purple General Surgery Service under Dr. [**Last Name (STitle) 519**] with acute appendicitis. He was taken to the OR as planned where he underwent a laparoscopic appendectomy. For further information of this operation, please see the operative note dictated on this day. His immediate postoperative course was complicated by desaturations in the PACU with concern over a possible aspiration event. The patient was transferred to the Floor in stable condition requiring a fluid bolus of 500 cc. At the time of arrival to the Floor his oxygen saturation was 91 percent on two liters, but later on that night, on postoperative day one, the patient's oxygen saturation deteriorated and his oxygen requirement increased to 5.0 liters nasal cannula where he was saturating 86 percent. A chest x-ray was obtained revealing bilateral lower lobe pneumonias with a possible aspiration event and possible mild fluid overload. The patient was evaluated by the surgical house staff and the decision was made to transfer the patient to the Unit for respiratory distress. He was placed on 100 percent rebreather with improvement in his oxygen saturation to 96 to 98 percent. Additionally 10 mg of Lasix was given for mild fluid overload and an EKG revealed sinus tachycardia, where cardiac enzymes were negative times three. On postoperative day number two the patient remained stable in the ICU where his chest x-ray revealed improved fluid status and persistent bilateral lower lobe infiltrates. Sputum culture was obtained revealing only oral flora. At this time a PCA was started for his abdominal pain which was thought to contribute to bilateral atelectasis. On postoperative day number three the patient's abdomen still appeared to be distended and he was still uncomfortable. His white count had decreased to 14 and his respiratory status had stabilized. The patient was transferred to the Floor later on this day. On postoperative day number four, the patient was evaluated by the night float house staff for persistent abdominal distention and pain. A KUB was obtained revealing a large gastric dilatation and distended loops of small bowel consistent with a postoperative ileus. At this time an NG-tube was placed, with symptomatic relief by the patient. Over the next two ensuing days the NG-tube was continued until postoperative day number seven when the patient finally had a bowel movement and reported passing flatus. At this time his NG-tube was discontinued, sips were started, and meanwhile his oxygen requirement had decreased to 2.0 liters nasal cannula. On postoperative day number eight, the patient was started on clears and his diet was advanced and he was saturating at 98 percent on room air. On postoperative day number nine, the patient tolerated a regular diet in the morning and his respiratory status remained stable. His pain was well-controlled and he continued to ambulate well. The patient was discontinued, discharged home on postoperative day number nine, on Tylenol and Motrin with follow up by Dr. [**Last Name (STitle) 519**] in one week. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: Home. DISCHARGE MEDICATIONS: 1. Tylenol Extra-Strength 500 mg one to two tablets p.o. q.6h. p.r.n. pain. 2. Motrin 600 mg one tablet p.o. q.6h. p.r.n. pain. DISCHARGE INSTRUCTIONS: Diet: Resume a regular diet and activity. No straining or heavy lifting greater than ten pounds until cleared at follow-up appointment. The patient was instructed to call the physician or return to the emergency department if he developed any fevers, chills, temperature greater than 101.5 degrees, redness, swelling, drainage at the surgical site, or if unable to tolerate any food or drinking. FINAL DIAGNOSES: 1. Status post laparoscopic appendectomy. 2. Acute appendicitis. 3. Postoperative ileus. 4. History of low back pain. FOLLOW UP: The patient will follow up with Dr. [**Last Name (STitle) 519**] within two weeks. He was instructed to call his office to schedule this follow-up appointment. These discharge instructions were discussed with the attending and with the surgical team. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. [**MD Number(1) 521**] Dictated By:[**Last Name (NamePattern1) 22434**] MEDQUIST36 D: [**2151-1-10**] 13:03 T: [**2151-1-10**] 13:32 JOB#: [**Job Number 34636**]

[ "997.4", "507.0", "997.3", "518.0", "E849.7", "540.9", "E878.6", "560.1", "737.30" ]

icd9cm

[ [ [] ] ]

[ "47.01", "38.91" ]

icd9pcs

[ [ [] ] ]

5325, 5456

2118, 5241

5481, 5881

946, 1622

5898, 6021

6033, 6567

179, 929

1639, 2100

5266, 5302

14,744

156,156

12380+12412

Discharge summary

report+report

Admission Date: [**2135-1-27**] Discharge Date: [**2135-2-12**] Service: CT SURGERY An addendum will be added to this dictation upon discharge. Please add it to the main dictation summary. HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 38548**] is an 83-year-old woman with a history of hypertension, hypercholesterolemia, who presented with chest pain and abdominal pain. Similar gas pain lasting 10 to 15 minutes which resolved spontaneously. She was visiting her sister in [**Name (NI) 86**]. She herself lives in [**State 108**]. The pain started at dinner and radiated to the back and shoulder as well as coinciding with numbness in the arms. Initial presentation of an electrocardiogram showed some deep inferior ST depressions. She was started on Integrilin and Lovenox and the ST segments improved. PAST MEDICAL HISTORY: Significant for hypertension and hypercholesterolemia and glaucoma. MEDICATIONS AT HOME: Lopid 600 mg twice a day, Plendil 5 mg twice a day, multivitamin pills. ALLERGIES: No known drug allergies. SOCIAL HISTORY: She lives in [**Location 5622**] with her sister. She denied ethanol or tobacco abuse. HOSPITAL COURSE: On the day of admission, [**2135-1-27**], the patient developed increasing pain and had episodes of ventricular tachycardia. Cardiology was consulted, and an emergent catheterization was done, which showed 50% left main disease with 99% left anterior descending disease of the ostium, severe proximal disease of the right coronary artery, 99% of the mid-right coronary artery. She was on an intra-aortic balloon pump at this point, and her creatinine was rising. Th[**Last Name (STitle) 1050**] was taken to the operating room relatively emergently and, on [**2135-1-28**], had a coronary artery bypass graft done x 4, with Dr. [**Last Name (Prefixes) **]. Postoperatively, the chest was open, and she was transferred to the Cardiothoracic Intensive Care Unit in grave condition, with multiple pressor drips. She was started on anti-arrhythmics for her syndromes. After a relatively complex course in the Intensive Care Unit over the next few days, with the patient requiring multiple pressor supports in addition to her intra-aortic balloon pump, as well as multiple drugs for rate control, the patient was taken to the operating room after being stabilized on [**2135-2-1**]. At this point, she had been on multiple antibiotics for her open chest. Postoperatively, after her closure, she was transferred back to the Cardiothoracic Intensive Care Unit and, the next day, her intra-aortic balloon pump was discontinued. On [**2135-2-3**], the patient continued to do well, though it was noted that her creatinine was again rising. At this time, the weaning had begun of her sedation and her pressor support. Cardiology was consulted on [**2135-2-4**] with regards to her atrial fibrillation which had started on [**2135-2-2**], as well as her tachy-brady syndrome which followed. Cardiology agreed to continue the amiodarone and would follow with us. The patient continued on vancomycin, and was now on Levaquin as of [**2135-2-5**]. Her condition was relatively stable, however, remained serious. We were anticoagulating the patient with a heparin drip for her arrhythmia, and we started weaning to extubate. On [**2135-2-7**], the patient was doing well, however, at this point her creatinine had risen back up to 1.9. The patient's medications were adjusted appropriately, and once again EP saw the patient and, at this point, was strongly considering a pacemaker the following week. The patient was transferred to the floor on [**2135-2-8**] after being extubated and weaned off all pressor support. On the floor, her chest tubes were discontinued, yet her wires remained in pending placement of an internal pacemaker. The patient tolerated the discontinuation of the chest tube well, and a subsequent x-ray showed no reaccumulation of the pleural effusion. Concern was raised because of high tube output prior to discontinuation of the chest tubes. The patient's diet was advanced, and EP continued to consult. Physical Therapy was involved with the patient, and felt the patient required rehabilitation stay. On [**2135-2-9**], it was noted that her right leg was a little bit red, and the patient was restarted on vancomycin, which had been discontinued the prior day. We continued her heparinization. Her Foley was discontinued. We were holding her Coumadin until EP placed her internal pacemaker. Speech and Swallow evaluated the patient on [**2135-2-13**], and agreed that the patient had swallowing ability, however, was not presenting with severe dysmotility. The patient may drink sips carefully, and moist solids with thin liquids. The patient is doing well as of [**2135-2-12**], and the final discharge summary addendum will follow. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Name8 (MD) 16758**] MEDQUIST36 D: [**2135-2-12**] 23:20 T: [**2135-2-13**] 00:12 JOB#: [**Job Number 38549**] Admission Date: [**2135-2-14**] Discharge Date: Date of Birth: Sex: F Service: She is being discharged to rehabilitation on [**2135-2-14**] with the following medications: DISCHARGE MEDICATIONS: 1. Aspirin 325 mg q.d. 2. Lopressor 12.5 mg b.i.d. 3. Amiodarone 200 mg once a day. 4. Captopril 50 mg three times a day. 5. Timoptic solution .5% concentration 1 drop to each eye twice a day. 6. Trusopt one drop to each eye b.i.d. 7. .................... one drop each eye q.h.s. 8. Hydralazine 10 mg every 6 hours. 9. Albuterol 2 puffs q.4h, p.r.n. 10. Atrovent 2 puffs q.4h.p.r.n. 11. Vancomycin 750 mg q.36 hours times a week. 12. Levofloxacin 250 mg once a day for one week. 13. Lasix 20 mg once a day. 14. Potassium chloride 20 mEq once a day. 15. Coumadin to keep the INR from 2 to 2.5; dose set at 4 mg this evening. 16. Lovenox 16 mg twice a day until therapeutic. Please monitor her wound healing at rehabilitation. Cardiopulmonary status: Encouraged out of bed ambulation, check INR [**2-15**] as well as for Coumadin dosing. Give her cardiac diet, no heavy lifting, 10 pound limit, removal staples on the 7th of increased, given increased strengthening and endurance. CONDITION ON DISCHARGE: Good. FO[**Last Name (STitle) **]P CARE: The patient is to followup with her PCP and Dr. [**Last Name (Prefixes) **] for all surgical issues only. CONDITION ON DISCHARGE: Good. Incision is clean and dry with no discharge, no click, and no erythema. Leg harvest site on the right side previously slightly cellulitic, is resolving well. Pain is decreased. The patient is being discharged and will followup with us in four weeks. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Name8 (MD) 16758**] MEDQUIST36 D: [**2135-2-14**] 13:51 T: [**2135-2-14**] 13:57 JOB#: [**Job Number 38605**]

[ "707.0", "401.9", "427.1", "414.01", "272.0", "998.59", "410.71", "682.6", "427.31" ]

icd9cm

[ [ [] ] ]

[ "37.22", "37.61", "88.55", "39.61", "99.20", "36.14" ]

icd9pcs

[ [ [] ] ]

5338, 6332

1181, 5315

945, 1057

231, 830

854, 923

1075, 1163

6532, 7050

26,691

165,460

27668

Discharge summary

report

Admission Date: [**2145-5-19**] Discharge Date: [**2145-6-14**] Date of Birth: [**2092-5-19**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5880**] Chief Complaint: s/p Rollover motor vehicle crash Major Surgical or Invasive Procedure: [**5-19**] Bilateral chest tubes; decompressive laparotomy; ICP bolt placement [**2145-5-21**] Abdominal wound closure [**2145-5-27**] ORIF left humerus fracture [**2145-5-28**] Percutaneous Tracheostomy; Scalp advancement and wound closure 7/1306 Percutaneous Gastrostomy placement [**2145-6-14**] s/p Decannulation of tracheostomy History of Present Illness: 55 yo female s/p rollover MVC, restrained rear passenger. Trunk pinned over patient's head with prolonged extrication time. In field patient apneic and was intubated; SBP en route dropped from 117 to 70's. She was taken to an area hospital where found to have scalp laceration which was sutured; right SDH, SAH; frontal contusions; open book pelvis fracture; fractures of left humerus and left 6th rib. She received 4 units blood; bilateral chest tubes placed. She was trnasferredto [**Hospital1 18**] for continued management of her injuries. Past Medical History: None Social History: Married Family History: Noncontributory Physical Exam: VS upon admission to trauma bay: BP 72/palp HR 122 Gen: intubated HEENT: spont eye opening PERRLA 3->2; 6 cm lac forehead Neck: c-collar Back/spine: no stepoffs Chest: bilat chest tubes Cor: tachy Abd: FAST negative Rectum: decreased tone; guaiac negative Extr: LUE deformity Pertinent Results: [**2145-5-19**] 11:34PM LACTATE-3.5* [**2145-5-19**] 09:51PM GLUCOSE-182* UREA N-11 CREAT-0.7 SODIUM-144 POTASSIUM-3.4 CHLORIDE-114* TOTAL CO2-16* ANION GAP-17 [**2145-5-19**] 09:51PM ALT(SGPT)-37 AST(SGOT)-91* CK(CPK)-895* ALK PHOS-43 AMYLASE-122* TOT BILI-0.3 [**2145-5-19**] 09:51PM CK-MB-21* MB INDX-2.3 cTropnT-0.13* [**2145-5-19**] 09:51PM ALBUMIN-2.5* CALCIUM-5.4* PHOSPHATE-4.4 MAGNESIUM-0.9* [**2145-5-19**] 09:51PM WBC-5.4# RBC-4.70# HGB-14.1# HCT-40.7# MCV-87 MCH-29.9 MCHC-34.5 RDW-13.9 [**2145-5-19**] 09:51PM PLT COUNT-24* [**2145-5-19**] 09:51PM PT-17.3* PTT-37.5* INR(PT)-1.6* [**2145-5-19**] 09:51PM FIBRINOGE-230# CT HEAD W/O CONTRAST Reason: eval ich, mass effect [**Hospital 93**] MEDICAL CONDITION: 56 year old woman with MVC, known skull fx, humeral fx, open pelvic fx REASON FOR THIS EXAMINATION: eval ich, mass effect CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 56-year-old in motor vehicle accident with known skull fracture and multiple other fractures, assess for intracranial hemorrhage. TECHNIQUE: MDCT images of the brain without IV contrast. No prior studies. FINDINGS: Numerous intraparenchymal contusions are seen in the right frontal lobe, superior left frontal lobe, right temporal lobe, and along the region of the right petrous apex. There is a right subdural hematoma extending along the convexity of the frontal and parietal lobes and extending inferiorly along the anterior temporal lobe probably into the middle cranial fossa. Subdural hematoma is also seen extending along the posterior aspect of the falx and over the tentorium. There is a mild degree of subarachnoid hemorrhage, best seen in the interpeduncular fossa and within the interfolial spaces of the cerebellum. Blood is also seen within the Sylvian fissures and in the right temporal [**Doctor Last Name 534**] of the lateral ventricle. Mass effect from the hemorrhages and injury produces compression of the body of the right lateral ventricle and mild shift of midline structures towards the left. Additionally, cerebral sulci and the suprasellar space appear somewhat narrowed. There is a fracture of the left parietal bone, which appears to extend inferiorly into the lambdoid suture on the left, where there is sutural diastasis. Small amount of fluid is seen within the left mastoid air cells and a small amount of air in the deep soft tissues of the upper left neck inferior to the mastoid air cells. Findings are related to the inferior aspect of the fracture extending through the mastoid air cells. High-density fluid is seen in the sphenoid sinus consistent with hemorrhage. There appears to be a somewhat irregular fracture through the clivus. There is a large scalp laceration with a significant hematoma and subcutaneous air seen overlying the left parietal fracture. Soft tissue laceration and skin staples are also seen overlying the right frontal bone, though no frontal bone fracture is seen. There is minimal mucosal thickening within the ethmoid air cells. The patient is intubated, and an OG tube is also seen curling within the posterior oropharynx. IMPRESSION: Multiple cerebral contusions. Subdural hemorrhage extending along the convexity of the right frontoparietal region and probably extending into the middle cranial fossa. Subarachnoid hemorrhage and intraventricular hemorrhage. Narrowing of the suprasellar space is concerning for early cerebral edema. Continued close followup is recommended. Fractures through the left parietal bone extending into lambdoid suture causing diastasis. There is also a fracture of the clivus. Findings were communicated to the ED immediately via the ED dashboard. [**Numeric Identifier 4176**] PERC PLCMT GASTROMY TUBE [**2145-6-4**] 7:23 AM Reason: please assess for percutaneous G-J placement Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 53 year old woman with recent decompressive laparotomy, closure, head injury REASON FOR THIS EXAMINATION: please assess for percutaneous G-J placement INDICATION: Status post MVA, high residuals with orogastric tube, need for nutrition. RADIOLOGISTS: Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) 3175**], the Attending Radiologist, present and supervising the entire procedure. PROCEDURE/FINDINGS: After the risks and benefits of the procedure were discussed with the patient's family, written informed consent was obtained. A preprocedure timeout was performed to confirm patient identity and the procedure to be performed. Utilizing an indwelling NG tube, the stomach was insufflated with air under fluoroscopic guidance. A suitable spot for percutaneous gastrojejunostomy tube placement was then chosen. Under local anesthesia with 1% lidocaine, gastropexy was performed using three T fasteners. Gastric puncture was then performed using an 18-gauge needle advanced into the stomach under fluoroscopic guidance. An 0.035 [**Last Name (un) 7648**] wire was then advanced into the stomach and the wire was then introduced across the pylorus into the duodenum and then into the proximal jejunum. The [**Last Name (un) 7648**] wire was exchanged for an Amplatz wire. The patient's indwelling NJ tube was then removed. The percutaneous tract was then sequentially dilated and a peel- away introducer sheath placed. A 14- French [**Doctor Last Name 9835**] gastrostomy tube was then advanced into the proximal jejunum and the peel- away sheath removed. The retention pigtail loop was formed and positioned in the proximal duodenum. The position of the tube was confirmed and documented with injection of contrast. The catheter was then secured using a flexitrack device. The patient tolerated the procedure well without immediate complications. MEDICATION: Moderate sedation was provided by administering divided doses of fentanyl (100 mcg total) throughout the total intra-service time of 1 hour and 20 minutes during which the patient's hemodynamic parameters were continuously monitored. IMPRESSION: Successful placement of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 9835**] percutaneous gastrojejunostomy tube with the tip in the proximal jejunum. BILAT LOWER EXT VEINS Reason: Edema [**Hospital 93**] MEDICAL CONDITION: 53 year old woman with fever in ICU REASON FOR THIS EXAMINATION: Edema INDICATION: Fever. Edema. COMPARISON: [**2145-6-2**]. [**Doctor Last Name **]-scale and Doppler son[**Name (NI) 867**] of the right and left common femoral, superficial femoral, and popliteal veins were performed. Normal flow, augmentation, compressibility, and waveforms are demonstrated. No intraluminal thrombus is identified. IMPRESSION: No evidence of DVT in the right or left lower extremities. Date: [**2145-6-11**] Signed by [**Last Name (NamePattern4) 57715**] [**Last Name (NamePattern1) 15102**], CCC-SLP on [**2145-6-11**] Affiliation: [**Hospital1 18**] PASSY-MUIR VALVE EVALUATION/DISPENSE HISTORY: Thank you for referring this 53 yo female transferred here [**2145-5-19**] s/p a high speech rollover MVA, in which she was a restrained, rear passenger with prolonged extrication, apneic x2 requiring intubation in the field. The pt had multiple orthopedic and intracranial injuries and was transferred here from OSH for further management. Issues include: open book pelvic fx, left humerus fx, right sacral ala, right pubic bone fx with retroperitoneal and intraperitoneal blood. Head CT revealed: "multiple cortical contusions in both frontal lobes and the right temporal lobe, subdural hemorrhage extending along the convexity of the right frontoparietal lobes and probably extending along the right temporal lobe into the middle cranial fossa, subdural hematoma also over the posterior aspect of the falx, subarachnoid hemorrhage and intraventricular hemorrhage as described, apparent narrowing of the suprasellar space and midline shift concerning for cerebral edema, fractures through the left parietal bone extending into lambdoid suture causing diastasis, a fracture of the clivus, questionable fracture through the left mastoid air cells". Pt has had multiple surgical interventions including: [**2145-5-19**]: exploratory laparotomy for retroperitoneal hematoma with intra- abdominal compartment syndrome, [**Last Name (un) **] bolt placement, percutaneous skeletal traction pin placement and closed reduction of pelvic ring fracture dislocation with manipulation, [**2145-5-24**]: open reduction and internal fixation for right vertical shear pelvic fracture with complete sacral fracture and anterior and posterior ring disruption, [**2145-5-28**] tracheostomy placement. Pt has also had interventions to close open head lacerations. On [**2145-6-4**], a J tube was placed. On [**2145-6-6**] trach mask trials began. We were consulted to evaluate the pt for a Passy-Muir Speaking Valve (PMV) and for swallowing. RN reports the pt has only been minimally responsive and when awake has only been able to move the right side of her body (hand/arm and toes). However, RN indicates that she has frequently been lethargic, and only has intermittent periods of wakefulness. RN has not observed mouthing or attempts at verbal communication. The pt has had some improvement in her secretions, which were previously very thick and yellow, but are no white/clear and thinning out somewhat with aerosol/nebulizer treatments. TRACH TYPE: [**Last Name (LF) 67572**], [**First Name3 (LF) **]-fit, DIC, #7, cuffed, trach tube SECRETIONS / ABILITY TO HANDLE CUFF DEFLATION: Pt had been suctioned by respiratory therapy prior to the evaluation. O2 saturation prior to cuff deflation was at 99% on trach mask, and with cuff deflation and suctioning, decreased to 96%, but increased to 99% within 1 minute. There was only a minimal amount of secretions noted with cuff deflation, and the pt did not demonstrate any s&s discomfort, or secretion interference, distress with cuff deflation. PMV TOLERANCE / VOCAL QUALITY / O2 SATS: The pt was able to tolerate the PMV with O2 saturation at 99%, tracheal pressures between -2 to +7 cm H20 (normal range between -10 to +10 cm H20), and without any evidence of respiratory distress or secretion interference. However, her MS was quite limited during the examination, as the pt was only intermittently/alert awake. After several minutes of stimulation and attempting to rouse the pt, she was able to say "good". Vocal quality was hoarse/breathy with limited volume. No other verbal communication could be elicited. SUMMARY: The pt is able to tolerate the PMV at this time, though her MS, TBI is limiting her ability to engage in verbal communication attempts. Discussed with the RN that for today, we could monitor her O2 saturation, leaving the valve in place to determine if she can tolerate the valve for a period of time, which may encourage her to cough out her mouth, develop increased airflow and sensitivity to the oropharynx, and may 'catch moments in time' when the pt may attempt to communicate verbally. It was noted that when the pt actually spoke, she had very little mouth movement, making the likelihood of lip [**Location (un) 1131**] unfeasible. If, however, she is unable to tolerate the PMV today for a period of time, then the plan can be changed to only place the valve on when family/visitors, and/or staff interactions appear to stimulate the pt. With regards to swallowing, the pt's MS is too depressed/limited at this time to even to attempt to engage the pt in a swallowing assessment. However, we can continue to follow the pt to determine when she may be appropriate for that assessment. RECOMMENDATIONS: PMV: 1. ALWAYS DEFLATE CUFF PRIOR TO PLACING THE PASSY-MUIR VALVE! 2. Monitor O2 Sats / respiration while valve is in place. 3. Do not allow the patient to sleep with the valve in place. 4. If the patient is taking PO's, please deflate the cuff and place the PMV for eating and drinking. 5. PMV wear schedule is up to the discretion of the nurse and/or respiratory therapist. SWALLOWING: 1. Remain NPO with J-tube feeding. 2. Will follow the pt's MS to determine when she may be appropriate for a swallowing assessment. Brief Hospital Course: Patient admitted to the trauma service. Orthopedics, Plastics, Neurosurgery were consulted because of her injuries; and admitted to the Trauma ICU for close monitoring. Neurosurgery placed [**Last Name (un) **] ICP bolt; she was loaded with Dilantin and serial head CT scans were performed. She will follow up with Neurosurgery in [**2-25**] weeks for repeat head imaging. Her Dilantin has been discontinued. Plastics consulted because of her extensive scalp wound; she was eventually taken to the operating room on [**6-9**] for scalp advancement and wound closure; her scalp sutures are to remain in place for 3-4 weeks at which time she will follow up with [**Hospital 3595**] clinic. Bacitracin will need to be applied to scalp wound as directed on page 1. Orthopedics was consulted for her multiple injuries; her pelvic fracture was stabilized with closed reduction and fixation; she was later taken to the operating room on [**2145-5-24**] for ORIF. Her humerus was repaired on [**2145-5-27**]. She remained in the Trauma ICU vented; she was eventually trached and a PEG was placed for nutritional support. Her trach was eventually downsized and removed on [**2145-6-14**]. Her PEG remains in place and she is receiving tube feedings. Nutrition services followed patient during her hospitalization. She did require intermittent intravenous antibiotics for positive sputum and wound cultures; a PICC was placed secondary to poor venous access; this line was removed on [**2145-6-14**]. She is no longer on any antibiotics; most recent WBC on [**6-13**] was 9.5. She was evaluated by Speech and Swallow for Passy Muir valve (see pertinent results section). Physical and Occupational therapy have been consulted and have recommended a rehab for patients with traumatic brain injuries. Discharge Medications: 1. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed). 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. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 4. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours). 5. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 6. Metoprolol Tartrate 50 mg Tablet Sig: 1 [**11-23**] Tablet PO BID (2 times a day): hold for HR <60 and/or SBP <110. 7. Bacitracin-Polymyxin B 500-10,000 unit/g Ointment Sig: One (1) Appl Topical TID (3 times a day): Apply to scalp incision. 8. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4H (every 4 hours) as needed for pain. 9. Colace 150 mg/15 mL Liquid Sig: One (1) PO twice a day: hold for loose stools. 10. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 11. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment Sig: One (1) Appl Rectal PRN (as needed) as needed for hemorrhoidal pain/discomfort. 12. Ranitidine HCl 15 mg/mL Syrup Sig: Ten (10) ML's PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital6 **] Discharge Diagnosis: s/p Rollover Motor Vehicle Crash Right Temporal Subdural Hematoma Subarachnoid Hemorrhage Intraventricular Hemorrhage Right Frontal/temporal Contusions Diffuse Axomal Innury Left Parietal Skull Fracture Right 1st Rib Fracture Left Pneumothorax Open Book Pelvic Fracture Right Sacral Ala Fracture Bilateral Superior/Inferior Rami Fracture Left Humerus Fracture Discharge Condition: Good Discharge Instructions: Plastic Surgery - keep head sutures in place for 3-4 weeks. Apply Bacitracin to head wound three times a day. Followup Instructions: Follow up with Neurosurgery in [**2-25**] weeks; call [**Telephone/Fax (1) 1669**] for an appointment. Inform the office that you will need to have a repeat head CT scan for this appointment. Follow up in [**Hospital 5498**] Clinic in [**12-25**] weeks; call [**Telephone/Fax (1) 1228**] for an appointment. Follow up in [**Hospital 3595**] Clinic in 3 weeks, call [**Telephone/Fax (1) 5343**] for an appointment. Follow up in Trauma Clinic in 4 weeks; call [**Telephone/Fax (1) 6439**] for an appointment. Completed by:[**2145-6-14**]

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13105

Discharge summary

report

Admission Date: [**2108-8-12**] Discharge Date: [**2108-8-31**] Date of Birth: [**2030-8-14**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3967**] Chief Complaint: Weakness Major Surgical or Invasive Procedure: plasmapheresis plasmapheresis catheter insertion Chemotherapy History of Present Illness: Mr. [**Known lastname 40029**] is a 77 year old gentleman with a PMH significant for prostate CA on lupron therapy, GERD, and past afib s/p cardioversion admitted to the [**Hospital Unit Name 153**] for urgent plasmapheresis. The patient states that he has had 10 days of progressive fatigue and weakness such that today he was unable to climb a flight of stairs. He denies any dyspnea, orthopnea, increased LE edema, or PND. He reports an associated non-productive cough, decreased PO intake, urine output, and nausea but no emesis. He also reports chills and night sweats that have occurred since starting lupron. Denies any bruising, hematochezia or melena, dysuria, HA, palpitations, or chest pain. The patient presented to an OSH today, and was noted to have a WBC of 144, creatinine of 2.72, and a TnI of 0.8 with no CK. Of note, the patient had a CBC drawn approximately 3 months ago after a colonoscopy which was "normal." The patient received 162 mg ASA and 60 mg IV lasix and was transferred to [**Hospital1 18**] for further management. . In the [**Hospital1 18**] ED, VS 97.9 116/73 62 95%2L nc. The patient was again noted to have a WBC 160 with 74% other, Cr 2.8, UA 16, TnT 0.17, LDH of 2188, and BNP of [**Numeric Identifier 40030**]. The patient was evaluated by oncology in the ED with a peripheral smear that was consistent with AML. A bone marrow biopsy was also performed in the ED, and the patient was then transferred to the [**Hospital Unit Name 153**] for further monitoring and leukopheresis. . Review of Systems: Positive for acid reflux. As above, otherwise negative. Denies visual changes, hearing changes, swollen glands, sore throat, belly pain, n/v/d, constipation, dysuria, bone pain, leg swelling, orthopnea or PND. Past Medical History: GERD Atrial fibrillation - s/p cardioversion 3+ years ago, not currently anticoagulated OA sciatica - took naproxen a couple of years ago. HTN Hyperlipidemia heart murmur ? AS Social History: Patient lives on [**Location (un) **] with his son, and in [**Name (NI) 108**] in the winter; he is currently engaged. He is retired from the wholesale meat industry, no occupational exposures. No tobacco, etoh, IV, illicit, or herbal drugs. Family History: noncontributory Physical Exam: Admission Physical Exam: Gen: Age appropriate male in NAD HEENT: Perrl, eomi, sclerae anicteric. MMM, OP clear without lesions, exudate, or erythema. CV: Irregular S1+S2, harsh IV/VI systolic murmur throughout the precordium radiating to the carotids. Pulm: CTAB Abd: S/NT/ND +bs Ext: No c/c/e, 1+ dp/pt bilaterally Neuro: AOx3, CN II-XII intact Discharg exam: Gen: Age appropriate male in NAD HEENT: Perrl, eomi, sclerae anicteric. MMM, OP clear without lesions, exudate, or erythema. CV: Irregular S1+S2, harsh IV/VI systolic murmur throughout the precordium radiating to the carotids. Pulm: CTAB Abd: S/NT/ND +bs Ext: No c/c/e, 1+ dp/pt bilaterally Neuro: AOx3, CN II-XII intact skin: petechial rash in dependent areas of body, including buttocks and feet. Pertinent Results: Admission labs: [**2108-8-12**] 03:05PM BLOOD WBC-160.6* RBC-4.04* Hgb-12.0* Hct-35.0* MCV-87 MCH-29.8 MCHC-34.3 Plt Ct-218 Neuts-11* Bands-3 Lymphs-3* Monos-3 Eos-0 Baso-1 Atyps-0 Metas-3* Myelos-2* Promyel-0 Young-0 Blasts-0 Other-74* [**2108-8-12**] 03:05PM BLOOD Glucose-139* UreaN-41* Creat-2.8* Na-141 K-3.8 Cl-108 HCO3-18* AnGap-19 Calcium-9.9 Phos-4.4 Mg-2.3 [**2108-8-12**] PT-16.2* PTT-31.1 INR(PT)-1.4* [**2108-8-13**] PT-21.3* PTT-36.4* INR(PT)-2.0* [**2108-8-12**] Fibrino-299, FDP->1280*, D-Dimer-8314* [**2108-8-12**] ALT-33 AST-70* LD(LDH)-2188* CK(CPK)-52 AlkPhos-136* TotBili-0.5 Albumin-3.9 UricAcd-16.0* [**2108-8-12**] proBNP-[**Numeric Identifier 40030**]* [**2108-8-14**] BLOOD PSA-11.0* Cardiac enzymes: [**2108-8-12**] 03:05PM BLOOD CK(CPK)-54 CK-MB-NotDone cTropnT-0.17* [**2108-8-12**] 09:49PM BLOOD CK(CPK)-114 CK-MB-4 cTropnT-0.21* [**2108-8-13**] 02:55AM BLOOD CK(CPK)-84 CK-MB-4 cTropnT-0.18* Cultures: Blood cultures ([**2108-8-13**]): negative to date URINE CULTURE (Final [**2108-8-15**]): BETA STREPTOCOCCUS GROUP B.10,000-100,000 ORGANISMS/ML.. Imaging/Studies: EKG ([**2108-8-12**]): Atrial fibrillation with moderate ventricular response. Left axis deviation with left anterior fascicular block. Modest non-specific ST-T wave changes. No previous tracing available for comparison. Echo ([**2108-8-13**]): There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is moderately dilated. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is moderate aortic valve stenosis (valve area 1.0-1.2cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Moderate aortic stenosis and symmetric LVH. Normal regional and global biventricular systolic function. Mild pulmonary artery systolic hypertension. Flow cytometry ([**2108-8-12**]): Three color gating is performed (light scatter vs. CD45) to optimize blast yield. Cell marker analysis demonstrates that the majority of the cells isolated from this bone marrow express immature antigens CD34, HLA-DR, myelomonocytic antigens CD33, CD15, CD11c, CD64, CD56, and CD4. They lack B and other T cell associated antigens, are CD10 (cALLa) negative, and are negative for CD13, CD117, CD14, CD41, and Glycophorin. Blast cells comprise 68% of total gated events. In the lymphoid gated events. B cells are scant in number. T cells comprise 77% of lymphoid gated events, express mature lineage antigens, and have a helper-cytotoxic ratio of 2. INTERPRETATION: Immunophenotypic findings consistent with involvement by: Acute myeloid leukemia with monocytic differentiation. Bone marrow aspirate and biopsy ([**2108-8-12**]): DIAGNOSIS: Markedly hypercellular bone marrow with involvement by acute monoblastic leukemia (FAB, M5a). See note. Note: Please correlate with cytogenetic findings. MICROSCOPIC DESCRIPTION Peripheral Blood Smear: The smear is adequate for evaluation. Erythrocytes are normochromic and show very mild anisopoikilocytosis with scattered burr cells. Scattered polychromatophils are also seen. Rare nucleated RBCs (2 per 100 RBCs) are noted. The white blood cell count appears markedly increased. Platelet count appears normal; large forms are seen; giant forms are not present. Differential count shows 12% neutrophils, 6% bands, 1% monocytes, 5% lymphocytes, 2% eosinophils, 0% basophils, 69% monoblasts, 3% myelocytes, 2% metamyelocytes. The blasts are large, have abundant vacuolated cytoplasm with fine granules, high N/C ratio, round to irregular nuclear contours, open chromatin, and prominent nucleoli. Aspirate Smear: The aspirate material is adequate for evaluation. The M:E ratio is 11:1. Erythroid precursors are decreased and include occasional dyspoietic form. Myeloid precursors appear increased and consist primarily of blasts. Megakaryocytes are present in increased numbers; abnormal forms are not seen, but focal clusters are seen. Differential shows: 80% Blasts, <1% Promyelocytes, 2% Myelocytes, <1% Metamyelocytes, 6% Bands/Neutrophils, 0% Plasma cells, 4% Lymphocytes, 8% Erythroid. Clot Section and Biopsy Slides: The biopsy material is adequate for evaluation. Marrow cellularity is estimated at 90%. There is an interstitial infiltrate of immature cells consistent with blasts occurring in sheets occupying 90% of marrow cellularity. There is scant remaining hematopoiesis. Scattered erythroid precursors are noted including forms with dyspoietic maturation with irregular nuclear contours and asymmetric nuclear budding. Maturing myeloids are extremely scant. Megakaryocytes are decreased and appear in focal tight clusters; naked nuclei and hyperchromatic forms are seen. Marrow clot section is not submitted. Touch prep is similar to the core. Bone marrow cytogenetics ([**2108-8-13**]): Specimen Type: BONE MARROW - CYTOGENETICS Lab #: [**Numeric Identifier 40031**] Date and Time Taken: [**2108-8-13**] 10:02 AM Date Processed: [**2108-8-13**] Requesting Physician: [**Name (NI) **],[**Name11 (NameIs) 2295**] [**Name Initial (NameIs) **]. Location: INPATIENT Cell culture was established to provide metaphase cells for chromosome analysis. However, no metaphases were available from this specimen, therefore the cytogenetic analysis could not be performed. Please see results of FISH analysis below. -------------------INTERPHASE FISH ANALYSIS, 100-300 CELLS------------------- FISH evaluation for a MLL rearrangement was performed on nuclei with the LSI MLL Dual Color, Break Apart Probe (Vysis) at 11q23 and is interpreted as ABNORMAL. Rearrangement was observed in 78/100 nuclei, which exceeds the range of a normal hybridization pattern (up to 1%) established for this probe in our laboratory. A MLL rearrangement is found in a subset of cases of ALL and AML, and is associated with oncogenic fusions between MLL and various partner genes. nuc ish(MLLx2)(5'MLL [**9-27**]'MLLx1)[78/100] -------------------INTERPHASE FISH ANALYSIS, 100-300 CELLS------------------- FISH evaluation for a 5q deletion was performed with the Vysis LSI EGR1/D5S23, D5S721 Dual Color Probe ([**Doctor Last Name 7594**] Molecular) for EGR1 at 5q31 and D5S721/D5S23 at 5p15.2 and is interpreted as NORMAL Two EGR1 hybridization signals were observed in 99/100 nuclei examined, which is within the normal range established for this probe in the Cytogenetics Laboratory at [**Hospital1 18**]. Up to 3% of cells in normal samples can show apparent 5q deletion using this probe set. A normal EGR1 FISH finding can result from absence of a 5q deletion, from a 5q deletion that does not involve the region to which this probe hybridizes, or from an insufficient number of neoplastic cells in the specimen. FISH evaluation for a 7q deletion was performed with the Vysis D7S522/CEP7 Dual Color Probe ([**Doctor Last Name 7594**] Molecular) for D7S522 at 7q31 and CEP7 (D7Z1) (chromosome 7 alpha satellite DNA) at 7p11.1-q11.1 and is interpreted as NORMAL. Two D7S522 hybridization signals were observed in 98/100 nuclei, which is within the normal range established for this probe in the Cytogenetics Laboratory at [**Hospital1 18**]. Up to 3% of cells in normal samples can show apparent 7q deletion using this probe set. A normal D7S522 FISH finding can result from the absence of a 7q deletion, from a 7q deletion that does not involve the region to which this probe hybridizes, or from an insufficient number of neoplastic cells in the specimen. FISH evaluation for a 20q deletion was performed with the Vysis LSI D20S108 Probe ([**Doctor Last Name 7594**] Molecular) at 20q12 and is interpreted as NORMAL. Two hybridization signals were observed in 97/100 nuclei examined, which is within the normal range established for this probe in the Cytogenetics Laboratory at [**Hospital1 18**]. Up to 8% of cells in normal samples can show apparent 20q deletion using this probe set. A normal 20q FISH finding can result from absence of a 20q deletion, from a 20q deletion that does not involve the region to which this probe hybridizes, or from an insufficient number of neoplastic cells in the specimen. nuc ish(D5S23,D5S721,EGR1,D7Z1,D7S522,D20S108)x2[100] MLL 5' probe at 11q23 MLL 3' probe at 11q23 D5S23, D5S721 at 5p15.2 EGR1 at 5q31 D7Z1 at 7p11.1-q11.1 D7Z522 at 7q31 D20S108 at 20q12 Discharge labs: [**2108-8-31**] 12:00AM COMPLETE BLOOD COUNT White Blood Cells 2.2* K/uL 4.0 - 11.0 Red Blood Cells 3.15* m/uL 4.6 - 6.2 Hemoglobin 9.3* g/dL 14.0 - 18.0 Hematocrit 26.4* % 40 - 52 MCV 84 fL 82 - 98 MCH 29.5 pg 27 - 32 MCHC 35.2* % 31 - 35 RDW 19.5* % 10.5 - 15.5 DIFFERENTIAL Neutrophils 56.8 % 50 - 70 Lymphocytes 34.5 % 18 - 42 Monocytes 6.2 % 2 - 11 Eosinophils 2.0 % 0 - 4 Basophils 0.4 % 0 - 2 BASIC COAGULATION (PT, PTT, PLT, INR) Platelet Count 18* K/uL 150 - 440 GENERAL URINE INFORMATION Urine Color Straw Urine Appearance Clear Specific Gravity 1.009 1.001 - 1.035 DIPSTICK URINALYSIS Blood SM Nitrite NEG Protein 30 mg/dL Glucose NEG mg/dL Ketone NEG mg/dL Bilirubin NEG mg/dL Urobilinogen NEG mg/dL 0.2 - 1 pH 6.0 units 5 - 8 Leukocytes NEG MICROSCOPIC URINE EXAMINATION RBC 1 #/hpf 0 - 2 WBC 1 #/hpf 0 - 5 Bacteria NONE Yeast NONE Epithelial Cells 0 #/hpf URINE CASTS Urine Casts, Other 1* #/lpf 0 - 0 OTHER URINE FINDINGS Urine Mucous RARE [**2108-8-29**] 9:24 am URINE Source: CVS. **FINAL REPORT [**2108-8-30**]** URINE CULTURE (Final [**2108-8-30**]): NO GROWTH. Brief Hospital Course: A/P: 77M with 2-3 weeks of fatigue, found to have elevated white count, diagnosed with AML s/p decitabine ([**8-18**]). . # AML - The patient presented with a leukocytosis of 160k on [**8-12**] with 74% blasts. Bone marrow biopsy was performed and he was found to have AML, moncytic subtype. The patient was having symptoms concerning for leukostasis such as cardiac demand ischemia with troponin leaks. The patient also received multiple treatments of hydroxyurea. These treatments decreased his WBC into normal range. The patient had symptoms concerning for DIC. In the [**Hospital Unit Name 153**] the patient was transfused with 2 units of FFP and 1 unit of cryo. DIC labs were followed and slowly resolved. The patient also had some symptoms of tumor lysis syndrome. Allopurinol was started and the patient also received Rasburicase, along with IVF with bicarb to a goal urine output of 100 cc/hour. The patient was then transferred to 7 [**Hospital Ward Name 1826**] to receive treatment. The patient's options were discussed and he decided to pursue treatment with Decitabine which he received his first infusion on [**2108-8-18**]. The patient tolerated this well. He received 5 days of Decitabine with a resultant drop in all of his cell lines. He was transfused a total of 5 units PRBCs, 2 units FFP, 2 units platelets and 1 unit of cryo. He received a unit of platelets just prior to discharge and was instructed to follow up in the [**Hospital Ward Name 1826**] 7 outpatient clinic on monday. # Renal insufficiency - The patient had a history of renal insufficiency. He presented with a Creatinine of 2.8 with a baseline of 1.5. The likely etiology was pre-renal due to decreased fluid intake versus tumor lysis syndrome. He was given IVF and his creatinine slowly returned to baseline. . # Infectious disease - The patient spiked fevers when he was undergoing pheresis in the [**Hospital Unit Name 153**]. He was treated with cefepime and vancomycin for broad antibiotic coverage. The patient was transferred to 7 [**Hospital Ward Name 1826**] and was afebrile. Vancomycin was discontinued and Cefepime was continued. His urine from [**8-15**] grew out Beta streptococcus group B. A repeat urine culture from [**8-29**] showed no growth after treatment with cefipime. . # Superficial venous thrombosis - On [**8-20**] the patient noted a tender nodule on his right leg. The patient underwent ultrasound of his lower extremities and was found to have a superficial thrombus with no deep vein thrombosis. The patient was treated with warm compresses and the pain resolved. Pathology report of the lesion showed no evidence of leukemia cutis or sweet's syndrome. . # CV disease - Per past medical records the patient has extensive coronary artery disease. The patient underwent an TTE which showed an EF of 55 percent with moderate aortic stenosis and mitral regurgitation with concentric LVH. The patient was asymptomatic. . # Hypertension - The patient was continued on his home blood pressure medications with good control. During his stay at [**Hospital Ward Name 1826**] 7 however, his blood pressure remained low-normal. His amlodipine and lisinopril was discontinued, and his bp remained stable. He was therefore discharged home on only his metoprolol. . # Petechial rash - the patient had a petechial rash which was noticed on the day of his discharge. The rash was present only in dependent areas of his body, including his feet and buttocks. This rash was thought to be due to his low platelet count. Medications on Admission: Lupron Lisinopril Metoprolol Pravastatin Prilosec Discharge Medications: 1. Metoprolol Tartrate 50 mg Tablet Sig: 0.5 Tablet PO once a day. 2. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary: Acute Myelogenous Leukemia Discharge Condition: Hemodynamically stable, good Discharge Instructions: You were admitted with acute myelogenous leukemia. You received leucopheresis, which is where you have your blood filtered to take out some of the white blood cells from your blood. You also received decitabine, a type of chemotherapy for your leukemia, which you tolerated well. During your admission, we gave you some platelets because they became low because of your chemotherapy. You were discharged home with plans to follow up in the clinic on Monday. . Some medication changes have been made: - Your Procardia has been stopped. Please do not take this until you follow up with your PCP. [**Name Initial (NameIs) **] Your lisinopril has been stopped as well. - Do not take your aspirin, because your platelets are low and taking aspirin can cause you to bleed. . Please take all medications as prescribed. . Please keep all of your follow up appointments. . If you develop shortness of breath, chest pain, bleeding from your nose or mouth or rectum, or bleeding that does not stop after 15 minutes, please call your primary care provider or go to your nearest emergency room. You may also call ([**Telephone/Fax (1) 40032**] to reach the outpatient oncology nursing clinic. Your primary oncologist here at [**Hospital1 **] will be [**Last Name (LF) **],[**First Name3 (LF) **]. You can reach his office at ([**Telephone/Fax (1) 40033**]. When you come to your appointment on monday, please ask the nurses to contact Dr. [**Last Name (STitle) **] to come and see you. Followup Instructions: Please come on monday to the [**Location (un) 436**] of the [**Hospital Ward Name 1826**] building to have your blood counts checked at the date and time below. . Provider: [**Name Initial (NameIs) 455**] 2-HEM ONC 7F HEMATOLOGY/ONCOLOGY-7F Date/Time:[**2108-9-3**] 12:00 telephone: ([**Telephone/Fax (1) 40034**] [**Name6 (MD) **] [**Last Name (NamePattern4) 3974**] MD, [**MD Number(3) 3975**] Completed by:[**2108-9-2**]

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icd9cm

[ [ [] ] ]

[ "41.31", "99.25", "99.71", "38.93", "86.11" ]

icd9pcs

[ [ [] ] ]

17215, 17221

13426, 16959

324, 387

17301, 17332

3456, 3456

18861, 19316

2642, 2659

17060, 17192

17242, 17280

16985, 17037

17356, 18838

12276, 13403

2699, 3437

1955, 2167

4193, 12259

276, 286

415, 1936

3473, 4176

2189, 2367

2383, 2626

26,886

179,346

32196

Discharge summary

report

Admission Date: [**2179-4-3**] Discharge Date: [**2179-4-14**] Date of Birth: [**2114-10-14**] Sex: F Service: CARDIOTHORACIC Allergies: Codeine / Percocet Attending:[**First Name3 (LF) 5790**] Chief Complaint: Bronchotrachealmalcia Major Surgical or Invasive Procedure: [**2179-4-8**] - Flexible bronchoscopy and right thoracotomy with intrathoracic tracheoplasty with mesh, right mainstem and bronchus intermedius bronchoplasty with mesh, and left mainstem bronchoplasty with mesh. [**2179-4-6**] Flexible and rigid bronchoscopy with foreign body (stent) removal. History of Present Illness: Ms. [**Known lastname 174**] is a 64 year-old woman who has had progressive DOE, cough, and recurrent respiratory infections over the past 3 years. She notes that her oxygen saturation has worsened over the past 1 year and she has required supplemental O2. She has had [**5-15**] repiratory infections requiring antibiotics over the past few years. Her coughing episodes were quite bothersome and occurred about 3-6 times per day. She denies orthopnea or tussive syncope, though she does sleep on 2 pillows and uses CPAP at night. She does not report having to have been intubated for respiratory failure. She has been on and off of prednisone over the past 2 years, and she carries a diagnosis of hypersensitivity penumonitis, having recently undergone a VATS R lung biopsy. She was found to have severe, diffuse tracheobronchomalacia. She underwent tracheobronchial silicone Y-stent placement on [**2179-3-11**]. She notes that she has had some difficulty clearing phlegm and annoying cough over the past few days, though her initial freedom from coughing over the first several days post-stenting was remarkable. She quotes her overall improvement in dyspnea at 9 out of 10. She notes that she has even gone up to 5 hours at a stretch without supplemental O2. Past Medical History: OSA hypersensitivity penumonitis, s/p R VATS lung biopsy TBM open chole tonsillectomy appendectomy benign skin lesions removed from neck HTN TBI, residual memory loss Social History: Jehovah's witness non smoker, no EtOH smoke exposure as a child Family History: lung cancer Physical Exam: General: 64 year-old female in no apparent distress HEENT: normocephalic, mucus membranes moist Neck: supple, no lymphadenopathy Card: RRR, normal S1,S2 no murmur/gallop or rub Resp: breath sounds clear, bilaterally GI: bowel sounds positive, abodmen soft non-tender/non-distended Extr: warm no edema Incision: Right thoracotomy site clean/dry/intact Neuro: non-focal Pertinent Results: [**2179-4-11**] WBC-9.5 RBC-3.87* Hgb-10.7* Hct-33.2 Plt Ct-245 [**2179-4-2**] WBC-13.6* RBC-4.55 Hgb-12.3 Hct-37.7 Plt Ct-515* [**2179-4-13**] Glucose-76 UreaN-26* Creat-0.8 Na-141 K-4.1 Cl-100 HCO3-32 [**2179-4-2**] Glucose-106* UreaN-25* Creat-1.0 Na-144 K-4.2 Cl-105 HCO3-27 [**2179-4-8**] TISSUE LOWER RIGHT LOBE WEDGE. GRAM STAIN (Final [**2179-4-8**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Final [**2179-4-11**]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. ACID FAST SMEAR (Final [**2179-4-9**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Pending): FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final [**2179-4-9**]): NO FUNGAL ELEMENTS SEEN. LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. Pathology # SPECIMEN SUBMITTED: FS right lower lobe wedge. Wedge biopsy of lung (right lower lobe): Patchy organizing pneumonitis with features of bronchiolitis obliterans-organizing pneumonia/cryptogenic organizing pneumonia (BOOP/COP). No malignancy identified. Gross: The specimen is received fresh labeled with the patient's name "[**Known firstname 1894**] [**Known lastname 174**]" The medical record number and "frozen section right lower lobe wedge." It measures 5.2 x 4.1 x 1.4 cm and the surface is inked black. The wedge is serially sectioned to reveal a small pale nodule measuring 0.3 x 0.3 x 0.3 cm located 1.4 cm from the stapled margin. A representative sections is frozen for frozen section diagnosis. Frozen section diagnosis by Dr. [**Last Name (STitle) **] is "right lower lobe wedge biopsy; focal organizing pneumonitis, final diagnosis pending permanent section." The frozen section remnant is submitted in A. The remainder of the wedge biopsy is submitted in B-F with remaining nodule in B. [**2180-4-12**] CHEST (PA & LAT) FINDINGS: In comparison with the study of [**3-12**], there is little interval change. Again, there are low lung volumes with elevation of the right hemidiaphragm and atelectatic changes at both bases. No evidence of acute pneumonia. Brief Hospital Course: The patient was admitted on [**2179-4-3**] after presenting to the ED with worsening dyspnea and thick sputum production. She was resumed on bronchodilators, NS nebulizers, Mucomyst, mucinex, CPAP. On [**2179-4-5**] she had pulmonary function test with a 6 min walk prior to removal of Y stent. On [**2179-4-8**] she underwent successful Flexible bronchoscopy and right thoracotomy with intrathoracic tracheoplasty with mesh, right mainstem and bronchus intermedius bronchoplasty with mesh, and left mainstem bronchoplasty with mesh. She was transferred to the SICU for close monitoring, right chest tube to suction. Post operative steroid taper initiated. Perioperative Ancef started. Epidural for pain control, Dilaudid PCA continued. The patient required two boluses for a total of 500 ml, for low blood pressure associated with the epidural. The epidural was split, and a PCA was initiated. On POD #1 she was started on a clear liquid diet, steroid taper, chest tube continued to suction, wound care consult for burn from hot pack. Wound was treated with dry gauze and kerlix wrap then Adaptic following blister rupture. On POD #2 the right chest-tube was removed and her diet was advanced to a full liquid and advanced as she tolerated. On POD #4 the epidural was converted to PO pain medication, the foley was removed and she voided without difficulty. She was seen by physical therapy who deemed her safe for home. She continued to improve, her oxygenation requirements improved with 97% RA saturation at rest and 93-95% with activity. She was discharged to home on POD #6 on RA with home oxygen 1L via nasal cannula as needed. She will follow-up with Dr. [**Last Name (STitle) **] as an outpatient. Medications on Admission: prednisone verapamil lisinopril lexapro neurontin mirtazapine Discharge Medications: 1. Fluticasone 110 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*1 inhaler* Refills:*2* 2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 6. Prednisone 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 2 days. Disp:*4 Tablet(s)* Refills:*0* 7. Verapamil 80 mg Tablet Sig: One (1) Tablet PO twice a day. 8. Gabapentin 800 mg Tablet Sig: Two (2) Tablet PO at bedtime. 9. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [**4-11**] hours as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 10. Albuterol Sulfate 1.25 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed. Discharge Disposition: Home Discharge Diagnosis: Tracheobroncho malacia s/p Tracheoplasty Hypersensitive pneumonitis, HTN/HLD, OSA, Hepatitis, B12 deficiency MVC '[**70**] closed head injury residual short-term memory loss Discharge Condition: Good Discharge Instructions: Please call the office of Dr. [**Last Name (STitle) **] at ([**Telephone/Fax (1) 1504**] if you have a fever greater than 101.5, chills, shortness of breath, chest pain, nausea, vomiting, redness or swelling around your wound site, excessive or purulent drainage from your wound, or any other symptom that should concern you. -Complete Prednisone course -Home Oxygen 1L as needed Goal Saturations > 93% -Narcotics: take stool softners while taking narcotics Followup Instructions: Provider: [**Name10 (NameIs) 1532**] [**Name11 (NameIs) 1533**], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2179-4-22**] 3:30 on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical Center, [**Location (un) **]. Report to the [**Location (un) **] Radiology Department for a Chest X-Ray 45 minutes before your appointment Completed by:[**2179-4-14**]

[ "515", "516.8", "266.2", "V58.65", "327.23", "272.4", "401.9", "519.19" ]

icd9cm

[ [ [] ] ]

[ "31.79", "31.99", "33.48", "33.28" ]

icd9pcs

[ [ [] ] ]

7603, 7609

4821, 6540

307, 605

7827, 7834

2611, 3128

8341, 8717

2195, 2208

6653, 7580

7630, 7806

6566, 6630

7858, 8318

2223, 2592

3335, 4798

3302, 3302

246, 269

633, 1906

3164, 3270

1928, 2097

2113, 2179

50,863

123,233

41359

Discharge summary

report

Admission Date: [**2139-5-19**] Discharge Date: [**2139-6-5**] Date of Birth: [**2064-3-14**] Sex: M Service: SURGERY Allergies: Penicillins Attending:[**Doctor Last Name 19844**] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: [**2139-5-21**] R colectomy w/ primary ileocolonic anastomosis History of Present Illness: 75M with previous history of LGIB in setting of known diverticulosis who presents with dark red lower GI bleed. Patient first noticed profuse and spontaneous "darkish red blood" around 9 am on Tuesday ([**5-19**]). He experienced another 3-4 episodes precipitating visit to ED at 2pm. Reports dizziness with some mild chest pain at the time of his bleeding. He denied any abdominal pain, nausea, vomiting/hematemesis, fever, coughing, or changes in bowel movements. He notes that he did not eat much on the day of presentation, other than some bananas in the morning. Patient denies taking any over the counter medications to ease the bleeding. His last colonoscopy was in [**2133**] and the patient believes he was told that he had diverticulosis. At time of consultation, AFVSS, 2u pRBC without appropriate hematocrit response, CTA without active extravasation, hemodynamically appropriate, GI consultation pending. Past Medical History: MGUS, COPD, Asthma, Epilepsy (with 3-4 "grand-mal seizures" in the past. Most recent was 18 mos ago), Aortic Aneurysm, and Acid Reflux Social History: The patient smokes about 2 pipes/day. He used to smoke about [**5-29**] pipes per day before gradually reducing the amount. He has been smoking for over 40 years. Patient denies alcohol/recreational drug use. The patient is a physicist who used to work for Crystal System before retiring. He is currently separated from his wife. Family History: father, grandfather and great grandfather all died of MI at 52 Physical Exam: On admission: VS: in the ED initially: 98 110 121/80 18 98% on RA Gen: AAOX3, on nonrebreather, but otherwise in NAD< appears very comfortable, speaking in full sentences. HEENT:atraumatic Neck:supple Lungs:cta bilaterally no r/w/r CV:RRR s1s2 no m/r/g Abd.:soft protuberant, nt/nd +bs no HSM no stigmata of chronic liver disease Ext:no erythema or edema Neuro: CNii-xii grossly intact Rectal exam: on presentation to the ED was having bright red blood per rectum On discharge: VS: T 97.9 P 80 BP 107/70 R 20 O2sat 98% RA GEN: A&O, NAD HEENT: Small laceration and echymosis to left foreheard, suture in place. PULM: Breath sounds diminished at RLL, no crackles/wheezes. CV: RRR ABD: Soft, appropriately tender at incision, nondistended. Midline surgical incision open with dry dressing in place. EXTR: 1+ edema bilaterally to LE, no edema upper extremities. Warm, pink and well perfused. Pertinent Results: [**2139-5-19**]: ECG: Sinus tachycardia. Non-specific repolarization abnormalities. Compared to the previous tracing of [**2139-5-14**] the rate has increased. Otherwise, findings are similar. [**2139-5-19**]: CHEST PORT. LINE PLACEMENT IMPRESSION: Right internal jugular central venous catheter tip in the mid SVC. No pneumothorax. [**2139-5-19**] CTA ABD & PELVIS: IMPRESSION: 1. No definite evidence of active extravasation to localize the patient's GI bleeding. Small internal hemorrhoid. Focal area of increased enhancement in proximal transverse colon at hepatic flexure is likely from a contracted bowel segment as it is symmetric. 2. Asymmetric prostate enhancement with prostatic enlargement. Correlate with PSA and physical examination. 3. Diverticulosis without diverticulitis. Cholelithiasis without cholecystitis. 4. Bilateral renal cysts. 5. Moderate-to-severe atherosclerotic disease in the coronary arteries and abdominal aorta and major branches. 6. Sub-4 mm left lower lobe nodule for which follow up in 1 year is only required if high risk for malignancy, [**First Name8 (NamePattern2) **] [**Last Name (un) 8773**] society guidelines [**2139-5-20**] GI BLEEDING STUDY: IMPRESSION: Active large bowel GI bleed originating at the region of the hepatic flexure. [**2139-5-20**]: PROCEDURES: 1. Selective superior mesenteric artery angiogram. 2. Selective inferior mesenteric artery angiogram. 3. Superselective contrast injections of second and third order branches of the middle colic artery. 4. Superselective injections of the three branches of the superior mesenteric artery supplying the sigmoid colon. 5. Sidearm angiogram of the right common femoral artery bifurcation. 6. Hemostasis by deployment of 6 French Angio-Seal closure device. CONCLUSIONS: 1. Selective superior mesenteric artery DSA angiogram, inferior mesenteric DSA angiogram and multiple supraselective DSA injections of the second and third order branches of the superior mesenteric artery disclosed no active arterial bleeding. 2. Hemostasis by deployment of 6 French Angio-Seal closure device in the right common femoral artery. [**2139-5-22**]: ECG: Sinus tachycardia. Premature ventricular complexes. Non-specific repolarization abnormalities. Compared to the previous tracing of [**2139-5-19**] no significant difference. [**2139-5-22**]: ECG: Sinus rhythm. Probable left atrial abnormality. Non-diagnostic Q waves in leads III and aVF. Compared to the previous tracing of [**2139-5-22**] ventricular ectopy is absent [**2139-5-22**]: ECG: Sinus tachycardia with frequent and multifocal ventricular premature beats. Non-specific lateral ST-T wave changes. Compared to tracing #1 ventricular ectopy is seen and lateral ST segment changes are new. Clinical correlation is suggested. TRACING #2 [**2139-5-22**]: CHEST (PORTABLE AP): There are lower lung volumes. Aside from linear atelectasis in the left lower lobe, the lungs are clear. There is no evident pneumothorax or pleural effusion. Cardiac size is top normal and stable [**2139-5-22**]: CHEST (PORTABLE AP): FINDINGS: The right IJ line has been removed. Lung volumes are slightly low. There is mild cardiomegaly and mild pulmonary vascular redistribution. There is volume loss at both bases, but no definite infiltrate. [**2139-5-23**] ECHO: IMPRESSION: Normal regional and global biventricular systolic function. Mild calcific aortic stenosis. Mild mitral regurgitation. Compared with the prior study (images reviewed) of [**2138-10-14**], mild aortic stenosis is seen on the current study. The severity of mitral regurgitation has increased slightly. Pulmonary artery systolic pressures have increased. [**2139-5-23**]: ECG: Sinus rhythm with ventricular premature beats. Compared to tracing #2 the heart rate is slower and lateral ST segment changes are less prominent. TRACING #3 [**2139-5-24**]: CHEST (PORTABLE AP): FINDINGS: There are small bilateral pleural effusions. There continues to be volume loss/infiltrate in the right lower lobe, although there has been some interval partial clearing. Upper lungs are clear. [**2139-5-25**]: ECG Sinus tachycardia with occasional ventricular premature contractions that are multifocal. Compared to previous tracing dated [**2139-5-23**], there is no change. [**2139-5-26**] CT ABD & PELVIS WITH CONTRAST: IMPRESSION: 1. Collection of extraluminal air and fluid adjacent to the anastomotic site and extension of fluid from the site to the pericolic gutter. Findings are concerning for an anastomic leak. Repeat scanning could be considered after oral contrast has passed the anastomosis to evaluate for extraluminal contrast. 2. Cholelithiasis without any evidence of cholecystitis. 3. Extensive diverticular disease in the rectosigmoid colon. 4. Air- and fluid-filled distended small bowel consistent with postoperative ileus. [**2139-5-26**] CT ABD & PELVIS W/O CONTRAST: IMPRESSION: 1. While oral contrast is yet to reach the ileocolic anastomosis there has been an interval increase in the amount of surrounding free intraperitoneal air and extensive mesenteric free fluid which raises the concern for anastomotic leak. Upstream dilatation of the small bowel seen is relatively uniform throughout and may reflect postoperative ileus. 2. Moderate hiatal hernia. [**2139-5-26**] CHEST (PORTABLE AP): IMPRESSION: AP chest compared to [**5-24**], 9:40 a.m.: Tip of the endotracheal tube is in standard position. Nasogastric tube is looped in the mid esophagus and would need to be advanced at least 15 cm to move all the side ports into the stomach. Mild pulmonary vascular congestion is new but there is no pulmonary edema. Focal opacification in the infrahilar right lower lobe has improved since [**5-23**], suspicious for pneumonia. [**2139-5-27**]: ECG Normal sinus rhythm with frequent ventricular premature complexes in couplets. Intra-atrial conduction abnormality. Possible inferior myocardial infarction of indeterminate age. Non-specific diffuse ST segment abnormalities. Compared to the previous tracing of [**2139-5-25**], ventricular premature complexes persist as do the ST segment abnormalities. [**2139-5-27**]: ECG Normal sinus rhythm. Intra-atrial conduction abnormality. Frequent ventricular premature complexes, some in couplets. Non-specific ST segment abnormalities, most marked in the lateral precordial leads. Compared to the previous tracing, there is no significant change. TRACING #2 [**2139-5-27**]: CHEST (PORTABLE AP): Vascular congestion on low lung volumes persist. Residual right lower lobe consolidation has not worsened. Heart size is normal. Pleural effusion is small, on the left if any. Nasogastric tube is still looped in the midesophagus. ET tube in standard placement. [**2139-5-27**]: CHEST PORT. LINE PLACEM IMPRESSION: Right-sided PICC line tip now in the right atrium. It should be pulled back 5 cm for more optimal placement at the cavoatrial junction. [**2139-5-28**]: CHEST (PORTABLE AP): FINDINGS: As compared to the previous radiograph, the nasogastric tube and the right PICC line are still seen. The right PICC line has been pulled back by approximately 2 to 3 cm and its tip now projects over the mid-to-low SVC. In the interval, there has been development of bilateral areas of atelectasis and minimal increase in diameter of the pulmonary vasculature, potentially caused by mild fluid overload. Unchanged moderate cardiomegaly. No parenchymal opacity suggestive of pneumonia. [**2139-5-29**]: CHEST (PORTABLE AP); IMPRESSION: AP chest compared to [**5-27**] through 7. Dependent edema and atelectasis have worsened since [**5-28**]. Moderate cardiomegaly is more pronounced and small bilateral pleural effusions are presumed. Right PIC line passes to the low SVC. [**2139-5-30**]: CHEST (PORTABLE AP): FINDINGS: Comparison is made to prior study from [**2139-5-29**]. There is a right-sided central line with distal lead tip in the distal SVC. There are small bilateral pleural effusions. There is atelectasis at the lung bases. However, the opacity at the right lung base is more apparent and may be due to developing infiltrate. Continued attention to this area is recommended on subsequent exams. There are no pneumothoraces. [**2139-5-31**]: CHEST (PORTABLE AP): FINDINGS: Comparison is made to prior study from [**2139-5-30**]. The right base opacity seen on the prior study is less well seen. There is a persistent left retrocardiac opacity. There are no pneumothoraces. There is a right-sided central venous line with distal lead tip in the distal SVC. There are low lung volumes. There are small bilateral pleural effusions, stable. [**2139-6-3**] CT HEAD W/O CONTRAST: 1. No intracranial hemorrhage or fracture. 2. Age-appropriate global atrophy. 3. Chronic left maxillary sinus inflammatory disease; correlate clinically. [**2139-6-3**] CHEST (PA & LAT): IMPRESSION: Small left greater than right pleural effusions, with improvement in aeration compared with [**5-31**]. [**2139-6-3**] EEG (prelim read): no epileptiform discharges, occasional L posterior slowing, otherwise normal. Labs on admission: [**2139-5-19**] 05:00PM WBC-8.5 RBC-4.53* HGB-10.8* HCT-34.0* MCV-75* MCH-23.9* MCHC-31.7 RDW-18.4* [**2139-5-19**] 05:00PM NEUTS-67.6 LYMPHS-23.5 MONOS-5.0 EOS-2.9 BASOS-1.1 [**2139-5-19**] 05:00PM PLT COUNT-279 [**2139-5-19**] 05:00PM PT-11.1 PTT-25.7 INR(PT)-1.0 [**2139-5-19**] 05:00PM GLUCOSE-95 UREA N-19 CREAT-1.0 SODIUM-137 POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-25 ANION GAP-15 [**2139-5-19**] 10:44PM HCT-32.7* Labs at discharge: [**2139-6-4**] 04:44AM BLOOD WBC-10.7 RBC-3.55* Hgb-9.6* Hct-30.2* MCV-85 MCH-27.1 MCHC-31.8 RDW-19.6* Plt Ct-564* [**2139-6-4**] 04:44AM BLOOD Glucose-93 UreaN-8 Creat-0.6 Na-131* K-4.7 Cl-98 HCO3-31 AnGap-7* [**2139-6-4**] 04:44AM BLOOD Calcium-7.8* Phos-2.5* Mg-1.8 [**2139-6-3**] 01:45AM BLOOD Prolact-13 Brief Hospital Course: Pt is a 75 year-old with history of seizure disorder, COPD, GERD, abdominal aortic aneurysm, presenting with multiple episodes of painless BRBPR and admitted on [**2139-5-19**] under the medical service. Medical course is as follows: Patient was initially transferred to MICU for management of GI Bleed. Patient underwent CTA evening of admission which did not localize bleed. Surgery and GI consulted on patient and recommended bleeding scan should patient rebleed. Patient received one unit of pRBCs in ED and one additional until of pRBCs on arrival to ICU. Patient's bleeding stopped the evening he arrived to ICU ([**5-19**]) and he remained hemodynamically stable overnight. On the morning of [**5-20**], patient started having BRBPR and systolic BP dropped to 80s. He went for bleeding scan which localized bleeding to hepatic flexure. Patient went to angio for embolization, but could not be embolized. He was transferred to surgical service for right hemicolectomy with primary anastamosis overnight into [**5-21**]. Post-operatively, he was observed in the surgical ICU and was transferred out to the floor a few hours later in the morning hemodynamically stable. On the floor pain management was difficult to achieve. He failed to pass flatus initially believed to be caused by opiate use, which was also contributing to delirium. Over the course of the following days he failed to advance his bowel function, had increasing distension and pain, to the point that on a repeat CT scan was done on [**5-26**] which was highly suspicious for a leak at the anastamosis. He was then transferred back to the ICU on [**2139-5-26**] due to increasing abdominal distention, pain and worsening confusion. He was subsequently taken back to the OR that same day for revision and creation of a diverting loop ileostomy. Please see Dr.[**Name (NI) 1863**] operative note for additional details. His post-operative course, by system: Neuro: He was extubated one day after the takeback. He was initially placed on a dPCA and then intermittent IV then PO dilaudid and tylenol. He did show initial confusion/delerium in the postoperative period, agitated and combative at times and striking the nurse. Psych consult was obtained recommending haldol for agitation. His confusion gradually improved and by [**5-31**], day of transfer to the floor, he was markedly improved, AAOx3 and no longer combative/agitated. However, following transfer to the floor, the patient was triggered for hallucinations after receiving intravenous hydromorphone. Overnight, he again became agitated and combative requiring bilateral wrist restraints; hydromorphone usage minimized. Geriatric consulted was obtained who recommended standing oxycodone dosing and seroquel qhs, which was started on [**6-2**]. However, his confusion and agitation continued and overnight on [**5-21**] he sustained a fall while trying to get out of bed on his own to use the urinal. Pt struck his head and had a small laceration but no LOC. A head CT was obtained with was negative for any acute injury. On [**6-3**] his medications were again changed and he was started on tramadol for nonnarcotic pain management and zyprexa for agitation. A neurology consult was also obtained at that time who recommended an EEG which was performed which was negative. Neurology felt the patient was stable from their perspective to be discharged to rehab and recommended follow up in one month with Dr. [**Last Name (STitle) 623**], the patients primary neurologist. His home keppra was continued throughout his hospitalization. Psychiatry was consulted during his hospital course for given his delirium. At the time of discharge it was concluded that the was ongoing slow resolution of delirium, likely secondary to complex medical comorbities, including malnutrition, pain, post-op status, and anemia. His agitation and confusion seemed to be much improved. CV: His troponins were trended perioperatively peaking and stabilizing at 0.20. He did not have EKG changes suggesting infarct and was hemodynamically stable. Cardiology was asked to reassess and recommended continuing current management with metoprolol given presumed demand ishemia. He was continued on aspirin 81. Resp: Extubated postop. Showed signs of fluid overload (crackles on exam) and was therefore diuresed with furosemide intermittently to good effect. Satting in the mid to high 90s on 3LNC on transfer to floor. Diuresis with prn furosemide was continued and his supplemental oxygen was weaned, with oxygen saturations remaining in the mid to upper 90's on room air. Incentive spirometry and pulmonary toileting were encouraged, prn albuterol sulfate per patient's home regimen was continued. Patients lung sounds remained diminished at right lower lobe but chest xray on [**6-3**] showed improvement in prior pleural effusions. GI: Ileostomy looked slighly dusky immediately post-operatively but improved. He had ostomy output two days after his takeback/diverting ileostomy and was progressed to sips then clears, and ultimately to a regular diet on [**6-1**] which he tolerated without difficulty. GU: Foley catheter. UOP was good and accentuated with the use of lasix to diurese (see resp section above). His foley was removed on [**6-1**] at which time he voided without difficulty. ON [**6-2**] he was noted to have urinary frequency and a u/a was obtained which was negative. Again on [**6-5**] he complained of dysuria and a u/a was negative. He was voiding adequate amounts of concentrated yellow urine. Heme: He was transfused 2 units of PRBC on [**2139-5-29**] for a Hct that was trending down (23.3) in the setting of known demand ischemia. His post-transfusion Hct responded appropriately (30) and remained stable throughout the remainder of his hospital course. ID: Maintained on cipro/flagyl post-operatively for 14 days. Afebrile but wound showed some slight drainage 2-3 days from the takeback with increasing erythema and WBC increasing to 13.9 then 11.1 (from [**7-30**]). A few staples were removed in the area of increased drainage on [**2139-5-31**] and packed with gauze with [**Hospital1 **] dressing changes. However, on [**6-2**] his wound showed continued errythema with induration and all staples were removed and the wound was opened to allow drainage. [**Hospital1 **] dry dressing changes were performed, with plan for patient to return to [**Hospital 2536**] clinic 1 week from discharge for possible vac placement. Musk: Physical therapy was consulted to evaluate the patient's mobility postoperatively who recommended discharge to rehab when the patient was medically cleared. On [**2139-6-5**] Mr. [**Known lastname 90043**] is afebrile and hemodynamically stable. He is tolerating a regular diet and having output via his ileostomy. His delirium is improving and he is neurologically stable. He is being discharged to rehab with ACS follow up as well as neurology follow up in place. Medications on Admission: albuterol sulfate 90 mcg QID PRN sob/wheezing ipratropium bromide 17 mcg HFA 1 puff Q4 - 6 hrs PRN sob/wheezing levetiracetam 500 mg [**Hospital1 **] aspirin 81 mg daily latanoprost 0.005 % 1 drop qHS ferrous sulfate 300 mg [**Hospital1 **] omeprazole 20 mg [**Hospital1 **] Discharge Medications: 1. multivitamin Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 2. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler [**Hospital1 **]: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for wheezing. 3. ipratropium bromide 17 mcg/actuation HFA Aerosol Inhaler [**Hospital1 **]: Two (2) Puff Inhalation QID (4 times a day). 4. metoprolol tartrate 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 5. levetiracetam 500 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID (2 times a day). 6. aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO DAILY (Daily). 7. omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 8. latanoprost 0.005 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic HS (at bedtime). 9. acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q6H (every 6 hours). 10. olanzapine 2.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 11. olanzapine 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at bedtime). 12. metronidazole 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q8H (every 8 hours) for 5 days: Total 14 day course [**Date range (1) 90047**]. 13. ciprofloxacin 500 mg Tablet [**Date range (1) **]: One (1) Tablet PO Q12H (every 12 hours) for 5 days: Total 14 day course [**Date range (1) 90047**]. 14. nystatin 100,000 unit/mL Suspension [**Date range (1) **]: Five (5) ML PO QID (4 times a day). 15. tramadol 50 mg Tablet [**Date range (1) **]: One (1) Tablet PO QID (4 times a day). 16. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Location (un) 246**] Nursing Center - [**Location (un) 246**] Discharge Diagnosis: Right colonic bleed and severe pancolonic diverticulosis. Anastomotic leak. 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 with lower gastrointestinal bleeding from diverticulosis. You subsequently underwent a right colectomy and were recovering in the hospital and developed abdominal pain related to an anastamotic leak. This required a second operation resulting in creation of and ileostomy. Again, you recovered in the hospital, received teaching for ileostomy care, and are now preparing for discharge to rehab with the following instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**4-30**] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: Dressing changes will be performed by the nurses at the rehab. When you come back to your clinic appointment we will likely place a wound vac to help your incision heal, depending on how the incision looks at that time. *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment, but you may shower. Monitoring Ostomy output/Prevention of Dehydration: *Keep well hydrated. *Replace fluid loss from ostomy daily. *Avoid only drinking plain water. Include Gatorade and/or other vitamin drinks to replace fluid. *Try to maintain ostomy output between 1000mL to 1500mL per day. *If Ostomy output >1 liter, take 4mg of Imodium, repeat 2mg with each episode of loose stool. Do not exceed 16mg/24 hours. Followup Instructions: Department: GENERAL SURGERY/[**Hospital Unit Name 2193**] When: FRIDAY [**2139-6-12**] at 8:30 AM With: ACUTE CARE CLINIC/ Dr [**Last Name (STitle) 853**] Phone:[**Telephone/Fax (1) 90048**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage We are working on a follow up appt with Dr. [**Last Name (STitle) 5560**] in the 1 month. You will be called at rehab with the appointment. If you have not heard or have questions, please call [**Telephone/Fax (1) 7773**]. Completed by:[**2139-6-5**]

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icd9cm

[ [ [] ] ]

[ "46.01", "45.73", "54.59", "45.79", "45.62", "88.47" ]

icd9pcs

[ [ [] ] ]

21818, 21909

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280, 344

22029, 22029

2815, 11959

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176,702

6224

Discharge summary

report

Admission Date: [**2153-10-3**] Discharge Date: [**2153-10-8**] Date of Birth: [**2095-9-17**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 4358**] Chief Complaint: diabetic ketoacidosis Major Surgical or Invasive Procedure: None History of Present Illness: Mr [**Known lastname 6818**] is a pleasant 58M with diabetes x 30yrs, CAD sp MI and stents x2, who was brought to the ED today by his wife for poor po intake x weeks, dizziness and weakness for 4 days. The patient is unable to recount much of the history but states that he was fed up with his medications and and thought they were too expensive so stopped taking all of them several months ago. Denies fevers, cp, sob, abdom pain, N/V, dysuria, endorses polyuria and polyphasia. Per his wife, he has had intermittent abd pain, and decreased appetite, did not go to work on tuesday because of fatigue. She also states that he had two falls recently but does not know if he hit his head. In the ED, inital vitals were 96.1 111 93/60 16 100%. Labs were notable for a bicarb of 5, lactate of 7.1, gap of 42. Lipase was elevated at 210. Gas showed pH of 6.97 12 151. Trops were negative, WBC elevated to 11.2. He was given 4 L IVF, 7 units insulin, and started on 7 u/hr drip, given 40 kcl. Lactate improved to 5.0 with fluids. CXR was unremarkable. EKG was performed and showed sinus tach, TWI and ST depressions inferolaterally. Head CT was performed for unclear reasons, likely AMS. . On the floor, pt states he is thirsty, but otherwise denies symptomatology. Specifically no abd pain, CP, SOB. . Review of sytems: (+) Per HPI, polyuria, polydipsia, constipation. (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea or abdominal pain. No recent change in bowel habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: DM, diagnosed in [**2119**] CAD s/p MI with multiple stents placed 10 yrs ago Depression Social History: Lives with wife. [**Name (NI) **] 2 grown children, ages 24 and 28. Works as a custodian at a school. No tob, etoh, illicits. Family History: mother with diabetes. Denies any family hx of malignancy, heart disease. Physical Exam: Vitals: T:97.6 BP:166/77 P:101 R:20 O2:100% RA General: aao x 3 but somnolent, no acute distress HEENT: Sclera anicteric, MM dry, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi 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 Neuro: A&Ox3, CNII-XII intact, sensation and strength grossly intact in all extremities Pertinent Results: Admission labs: [**2153-10-3**] 09:30PM WBC-11.2*# RBC-6.07 HGB-17.4 HCT-53.2* MCV-88# MCH-28.7 MCHC-32.8 RDW-12.8 [**2153-10-3**] 09:30PM NEUTS-90.1* LYMPHS-5.9* MONOS-3.7 EOS-0.1 BASOS-0.1 [**2153-10-3**] 09:30PM PLT COUNT-331 [**2153-10-3**] 09:30PM PT-11.9 PTT-21.2* INR(PT)-1.0 [**2153-10-3**] 09:30PM GLUCOSE-714* UREA N-52* CREAT-3.2*# SODIUM-132* POTASSIUM-5.1 CHLORIDE-85* TOTAL CO2-5* ANION GAP-47* [**2153-10-3**] 09:30PM ALT(SGPT)-27 AST(SGOT)-25 LD(LDH)-205 ALK PHOS-110 TOT BILI-0.4 [**2153-10-3**] 09:30PM LIPASE-210* [**2153-10-3**] 09:30PM cTropnT-<0.01 [**2153-10-3**] 09:38PM GLUCOSE-GREATER TH LACTATE-7.1* K+-5.1 [**2153-10-3**] 10:19PM PO2-151* PCO2-12* PH-6.97* TOTAL CO2-3* BASE XS--28 [**2153-10-3**] 11:15PM GLUCOSE-484* UREA N-46* CREAT-2.4* SODIUM-137 POTASSIUM-4.4 CHLORIDE-98 TOTAL CO2-6* ANION GAP-37* Chemistry trend: [**2153-10-3**] 09:30PM BLOOD Glucose-714* UreaN-52* Creat-3.2*# Na-132* K-5.1 Cl-85* HCO3-5* AnGap-47* [**2153-10-3**] 11:15PM BLOOD Glucose-484* UreaN-46* Creat-2.4* Na-137 K-4.4 Cl-98 HCO3-6* AnGap-37* [**2153-10-4**] 03:01AM BLOOD Glucose-268* UreaN-42* Creat-2.1* Na-133 K-4.4 Cl-101 HCO3-9* AnGap-27* [**2153-10-4**] 10:59AM BLOOD Glucose-137* UreaN-30* Creat-1.7* Na-136 K-3.6 Cl-106 HCO3-18* AnGap-16 [**2153-10-4**] 03:20PM BLOOD Glucose-210* UreaN-26* Creat-1.5* Na-136 K-4.0 Cl-105 HCO3-15* AnGap-20 [**2153-10-4**] 01:30PM URINE Blood-SM Nitrite-NEG Protein-30 Glucose-300 Ketone-40 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG Discharge labs: [**2153-10-8**] 05:55AM BLOOD WBC-4.7 RBC-4.37* Hgb-12.8* Hct-35.2* MCV-81* MCH-29.3 MCHC-36.4* RDW-12.5 Plt Ct-195 [**2153-10-8**] 05:55AM BLOOD Glucose-69* UreaN-16 Creat-1.0 Na-141 K-4.1 Cl-103 HCO3-31 AnGap-11 Micro: [**10-4**] Urine culture negative [**10-3**] Blood cultures pending (negative at time of d/c) Imaging: [**10-3**] EKG: Sinus tachycardia. Diffuse T wave inversions in the inferior and anterolateral leads. There is a suggestion of left ventricular hypertrophy, although the voltage criteria are not met. Abnormal tracing. Compared to the previous tracing sinus tachycardia is new and the T wave and ST segment abnormalities are new. The prior tracing was recorded on [**2140-4-23**]. [**10-3**] CXR: IMPRESSION: No acute cardiac or pulmonary process. [**10-3**] CT Head: IMPRESSION: Carotid arterial atherosclerotic calcifications. Otherwise normal study. [**10-4**] EKG: Normal sinus rhythm. Diffuse non-specific ST segment abnormalities. Abnormal tracing. Compared to the previous tracing sinus tachycardia is no longer present and the T wave inversions are much less marked. Brief Hospital Course: Pleasant 58 yo gentleman admitted for DKA in the setting of medication non-compliance and found to have major depression requiring inpatient psychiatric stay. # Diabetic ketoacidosis: Patient arrived with large gap in the ED. He had a severe metabolic acidosis with arterial pH 6.97, bicarb 5, from both ketoacidosis and lactic acidosis. He was started on fluids and insulin drip in ED. No infectious source was found, but patient had been off of all of his medications. Lactate improved rapidly with rehydration. He had aggressive K+ and fluid repletion with Q4hr labs and venous pH monitoring. When his anion gap improved, he was taken off of the regular insuling drip and transitioned to 27 units of lantus with a humalog sliding scale. He was discharged back on his home lantus regimen of 54 units with reduced sliding scale given his poor appetite and low PO intake. # ST depressions: While tachycardic, no symptoms of ACS, two sets of troponins were negative. Likely due to fixed defect in setting of tachycardia. He may benefit from an exercise stress test as an outpatient. # Acute renal failure: Creatinine up to 3.2 from baseline 1.1 to 1.2. Likely pre-renal in the setting of severe dehydration from DKA, as his creatinine improved quickly with rehydration. # Depression: Likely contributing to med non-complicance. Pt denies depression currently but wife states he has been acting depressed at home. Found to be severely depressed by our social worker and then sectioned by psychiatry to require inpatient treatment. Medications on Admission: Pt has not been taking any meds x 2 months. - [**Company 4916**] [**Hospital1 **], MA med list: #. Lantus 54units SC qhs (last [**7-5**]) #. Novolog - 20units @ breakfast, 18units @ lunch/snack, 36units @ dinner (last [**7-5**]) #. Isosorbide mononitrate 60mg PO daily (last [**3-5**]) #. Amlodipine 10mg PO daily (last [**3-5**]) #. Clonidine 0.1mg PO BID (last [**3-5**]) #. Simvastatin 80mg PO daily (last [**11-3**]) --- additional meds on Atrius records: #. Lisinopril 20mg PO daily #. Atenolol 100mg PO Daily #. Mirtazapine 15mg PO qhs #. MVI 1tab PO daily Discharge Medications: 1. insulin glargine 100 unit/mL Solution Sig: Fifty Four (54) units Subcutaneous at bedtime. 2. Humalog sliding scale Please continue the attached Humalog insulin sliding scale. 3. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 5. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. 9. Cepacol Sore Throat 15-3.6 mg Lozenge Sig: One (1) lozenge Mucous membrane twice a day as needed for sore throat. Discharge Disposition: Extended Care Facility: [**Hospital **] hospital Discharge Diagnosis: Diabetic ketoacidosis Major depressive disorder 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 with very high blood sugars after stopping all of your medications including your insulin. You had a condition called diabetic ketoacidosis which improved with fluids and insulin treatment. We restarted your other home medications as well. We felt you were depressed and you will be transferred to a facility to help focus on your mood. The following changes were made to your medications: 1. Adjusted your sliding scale as attached as you are not eating much food right now. Please discuss adjusting this scale with your doctors once [**Name5 (PTitle) **] get out of the hospital and your appetite improves. 2. Reduced your simvastatin dose to 20mg daily as it can intereact with your blood pressure medication amlodipine. 3. Stopped your mirtazapine while psychiatry is figuring out a different medication regimen for you. 4. Stopped your clonidine as your blood pressure was controlled without it. Followup Instructions: Please follow-up with your PCP after discharge from your psychiatric facility.

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8668, 8719

5717, 7254

326, 333

8811, 8811

3062, 3062

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361, 1672

5384, 5694

3078, 4573

8826, 8938

2103, 2193

2209, 2339

57,412

137,917

35131

Discharge summary

report

Admission Date: [**2128-11-9**] Discharge Date: [**2128-12-9**] Date of Birth: [**2053-9-20**] Sex: F Service: SURGERY Allergies: Penicillins / Reglan Attending:[**First Name3 (LF) 1556**] Chief Complaint: Ischemic bowel Major Surgical or Invasive Procedure: [**2128-11-9**] - 1. Extended right colectomy. 2. Right hepatic laceration treated with an argon beam coagulation and packing. 3. A [**Location (un) 5701**] bag closure. [**2128-11-10**] - 1. Reopening of abdomen. 2. Argon beam coagulation of liver laceration. 3. [**Location (un) 5701**] bag closure of the abdomen. [**2128-11-13**] - 1. Reopening of abdomen. 2. Cholecystectomy. 3. Ileostomy. 4. Removal of Port-A-Cath. History of Present Illness: 75F with scleroderma, gastric dysmotility, receiving chronic parenteral nutrition transferred from [**Hospital **] hospital after presenting with fevers and chills. During her hospitalization there, she became hypotensive. She was started on Dopamine and aggressively volume resuscitated, receiving 5L prior to transfer. While here, she has continued to be hypotensive and has received an additional 2L of IVF. Her pressor requirement has increased, as she now is requiring Levophed and Dopamine to maintain SBP >90. Her ostomy output is now bloody. She reports not feeling well this weekend. Last night she began having fevers and chills. She denies any chest pain or shortness of breath. She denies any dysuria or hematuria. She has diarrhea at baseline, which has not changed in volume of late. She does have a R-sided port in place, which she has had for the last 6 months to receive TPN. She denies any drainage or erythema around the port site. She does not receive any nutrition orally. Past Medical History: Scleroderma Gastric dysmotility L colectomy and end transverse colostomy for presumed sigmoid volvulus R-sided port-a-cath for TPN Gastostomy h/o C. difficile colitis prior prolonged hospitalization for ? sepsis Social History: Lives at home, has an aide that comes in daily. She is a former smoker, quitting 8 months ago. Rare EtOH. She denies drug use. She has one daughter and 5 grandchildren. Family History: Non-contributory to current situation. Physical Exam: PE: 96.8 104 95/67 (on 0.21 of Levo and 5 of Dopamine) 20 100% on 6L NAD. A&Ox3. Ill-appearing. Anicteric. Tacky mucosal membranes. Trachea midline. No JVD, TM, or LAD. Tachycardic. Regular. Diminished bases. Fair aeration. Soft. Distended. Hypoactive BS. NT. Dark/black blood in ostomy bad. Stoma edematous/ischemic. Gastrostomy w/ benign, clear output. Clammy extremities. Cyanotic digits. Moving all 4. Pertinent Results: [**2128-11-9**] 11:10AM PT-20.7* PTT-55.7* INR(PT)-1.9* [**2128-11-9**] 11:10AM WBC-16.7* RBC-3.42* HGB-10.7* HCT-32.7* MCV-96 MCH-31.3 MCHC-32.8 RDW-15.4 [**2128-11-9**] 11:10AM ALT(SGPT)-64* AST(SGOT)-193* CK(CPK)-335* ALK PHOS-173* TOT BILI-3.1* [**2128-11-9**] 11:10AM GLUCOSE-71 UREA N-25* CREAT-1.1 SODIUM-145 POTASSIUM-3.7 CHLORIDE-119* TOTAL CO2-10* ANION GAP-20 [**2128-11-9**] 11:20AM GLUCOSE-69* LACTATE-5.5* NA+-145 K+-3.8 CL--122* TCO2-10* [**11-9**] CT AP: Extensive circumferential bowel wall thickening extending from the colostomy affecting mainly the right colon, highly concerning for ischemic bowel, with small amount of extraluminal air. Infection and inflammatory processes are much less likely. Brief Hospital Course: Operations/Procedures: [**2128-11-9**]: TO OR 1. Extended right colectomy. 2. Right hepatic laceration treated with an argon beam coagulation and packing. 3. A [**Location (un) 5701**] bag closure. [**2128-11-10**]; TO OR 1. Reopening of abdomen. 2. Argon beam coagulation of liver laceration. 3. [**Location (un) 5701**] bag closure of the abdomen. [**2128-11-13**]: To OR 1. Reopening of abdomen. 2. Cholecystectomy. 3. Ileostomy. 4. Removal of Port-A-Cath. [**2128-12-7**] Tunneled R Central line (double lumen) Placed by IR. Brief Hospital Course: Pt was promptly taken to the operating room for an extended right colectomy for ischemic colitis. [**Location (un) 5701**] bag was placed to close the abdomen with the intention of taking the pt back to the OR for a 2nd look. The following day, the pt was taken back to the OR. The small bowel appeared to be viable. There was oozing from a hepatic laceration and argon beam coagulation was performed. Post-operatively, the pt remained critically ill. On [**11-13**] she went back to the operating room with ? sepsis. Currently patient is stable, white count has normalized. She will be discharged to a rehabilitation facility with trach, g-tube, ileostomy and foley. VAC changes to abdomen will be done q 3 days. Medications on Admission: Lyrica 150'', Keppra 250', Prevacid 30', Iron 325', Flagyl 250' x4d Discharge Medications: 1. Insulin Regular Human 100 unit/mL Solution [**Month/Year (2) **]: per sliding scale ml Injection ASDIR (AS DIRECTED). 2. Miconazole Nitrate 2 % Powder [**Month/Year (2) **]: One (1) Appl Topical QID (4 times a day) as needed for skin folds. 3. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 4. Pregabalin 75 mg Capsule [**Last Name (STitle) **]: Two (2) Capsule PO BID (2 times a day). 5. Escitalopram 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 6. Levothyroxine 25 mcg Tablet [**Last Name (STitle) **]: 1.5 Tablets PO DAILY (Daily). 7. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times a day). 8. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1) ml Injection [**Hospital1 **] (2 times a day). 9. Outpatient Lab Work Please follow LFT's, amylase and lipase, and when trending down add fat back to TPN 10. TPN See additional sheet with current TPN 11. Sodium Chloride 0.9 % 0.9 % Solution [**Hospital1 **]: Ten (10) ML Injection PRN (as needed) as needed for line flush. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Primary Diagnosis: Ischemic bowel Secondary Diagnosis: Sepsis Discharge Condition: Stable Discharge Instructions: Please call your doctor or return to the emergency room if you have any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] on [**12-31**], Friday at 2:15. [**Hospital Ward Name 23**] Building [**Location (un) 470**]. Completed by:[**2128-12-8**]

[ "995.91", "518.81", "038.9", "574.10", "998.2", "999.31", "276.52", "557.0", "V44.3", "710.1", "998.11", "276.2" ]

icd9cm

[ [ [] ] ]

[ "96.72", "96.04", "86.05", "51.22", "50.61", "33.22", "45.73", "38.93", "54.12", "99.15", "86.22", "46.21", "33.21", "31.1" ]

icd9pcs

[ [ [] ] ]

6020, 6092

3985, 4707

295, 720

6198, 6207

2672, 3402

7041, 7218

2185, 2226

4825, 5997

6113, 6113

4733, 4802

6231, 7018

2241, 2653

241, 257

748, 1747

6168, 6177

6132, 6147

1769, 1982

1998, 2169

66,656

122,179

39837

Discharge summary

report

Admission Date: [**2136-1-4**] Discharge Date: [**2136-1-15**] Date of Birth: [**2053-9-4**] Sex: M Service: SURGERY Allergies: Azithromycin / Shellfish Derived Attending:[**First Name3 (LF) 2836**] Chief Complaint: Transfer from OSH for managment of a failed attempt at ERCP for stent placement complicated by perforation with extraluminal retroperitoneal air on post procedure CT scan. Major Surgical or Invasive Procedure: [**2136-1-12**] ERCP [**2136-1-12**] angiogram, coiled gastroduodenal artery History of Present Illness: 82M with h/o asymptomatic hemochromatosis being treated with routine phlebotomy as well as presumed Z-PAK associated autoimmune hepatitis on prednisone x 3 mos, transfered from OSH s/p failed attempt at ERCP for stent placement 9 days ago and with findigs of extraluminal retroperitoneal air on post procedure CT scan. Pt was started on Z-PAK three months ago for URI. He developed jaundice and dark urine 4-5 days upon starting the antibiotics. Was hospitalized for jaundice with a bilirubin of 15-18. CBD was found to be about 9mm with mild intrahepatic biliary dilatation. A liver biopsy was consistent with large duct obstruction with features of chronicity, with presence of inflammatory cells. In light of recent azithromycin and [**Doctor First Name **] of 1:160 with a nucleolar pattern, the patient was discharged on prednisone 40 qDay and scheduled for weekly follow-ups for monitoring. By [**Month (only) 462**], the patient's bilirubin had improved to 3. On [**12-20**], an ERCP was performed with needle knife sphincterotomy and balloon dilatation. After ths procedure patient resumed his prednisone and was also started on Azathioprine 50mg qDay which the patient took for 4 days. The bilirubin was found to be 4.9 on [**12-26**] and another ERCP was attempted for stent placement. The CBD could not be located and a stent was not placed. Apparent retroperitoneal air was noted, which was confirmed by CT-scan. The patient reports an approximate 25 lb weight loss over last 3 months since beginning of jaundice. (182->158) Reports loss of appetite and swelling in cheeks since starting the prednisone, as well as some mild exacerbation of GERD, with increased . He has had increased urinary frequency and urgency since onset of jaundice. Patient reports needing to start insulin within past week in the setting of no prior diagnosis of diabetes, though he mentions his PCP was following his blood sugar due to borderline values. The patient denies pain, nausea, vomiting, pruritis, changes in bowel habits. Denies fevers, chills. Past Medical History: PMH: -CAD s/p stentx2 placement 3 years ago. Asymptomatic since then. -HTN -Hemochromatosis diagnosed 10 yrs ago by routine labwork, asymptomatic, now beig treated with phlebotomy q 2 mos. -Basal cell carcinoma on nose and R temple area s/p removal; undergoes routine freeze treatments with dermatologist, though he has missed appointments recently. Possible new lesion on lower lip. -Hypercholesterolemia PSH: ERCP x 2 Social History: -Smoked 1 pack per day x 30 years, stopped 30 yrs ago. -Drank 2-3 beers nightly x 50 years, stopped 17 years ago. -Denies illicit drug use. Family History: non-contributory Physical Exam: PE: patient does not have vital signs gen: patient is cool to touch, he is non-responsive, motionless CV: no pulse, no heart beat pulm: no respirations Pertinent Results: [**2136-1-4**] 07:05AM BLOOD WBC-8.8 RBC-3.39* Hgb-11.1* Hct-33.4* MCV-99* MCH-32.9* MCHC-33.4 RDW-20.4* Plt Ct-178 [**2136-1-5**] 09:35AM BLOOD WBC-6.2 RBC-3.38* Hgb-11.3* Hct-33.1* MCV-98 MCH-33.3* MCHC-34.0 RDW-20.5* Plt Ct-184 [**2136-1-6**] 05:14AM BLOOD WBC-7.5 RBC-3.10* Hgb-10.2* Hct-30.9* MCV-100* MCH-32.9* MCHC-33.0 RDW-20.1* Plt Ct-186 [**2136-1-8**] 04:57AM BLOOD WBC-5.5 RBC-2.70* Hgb-9.1* Hct-28.1* MCV-104* MCH-33.6* MCHC-32.3 RDW-20.5* Plt Ct-166 [**2136-1-10**] 04:08AM BLOOD WBC-6.6 RBC-2.85* Hgb-9.9* Hct-29.5* MCV-104* MCH-34.8* MCHC-33.6 RDW-21.1* Plt Ct-147* [**2136-1-12**] 06:59AM BLOOD WBC-7.1 RBC-2.69* Hgb-9.1* Hct-28.0* MCV-104* MCH-34.0* MCHC-32.6 RDW-21.7* Plt Ct-177 [**2136-1-12**] 11:23AM BLOOD Hct-22.7* [**2136-1-12**] 10:12PM BLOOD WBC-5.2 RBC-2.12* Hgb-7.0* Hct-20.9* MCV-98 MCH-33.0* MCHC-33.6 RDW-21.4* Plt Ct-97* [**2136-1-13**] 02:17AM BLOOD WBC-6.5 RBC-2.88*# Hgb-9.8*# Hct-26.5*# MCV-92 MCH-33.9* MCHC-36.8* RDW-19.9* Plt Ct-100* [**2136-1-13**] 04:53AM BLOOD WBC-5.7 RBC-2.47* Hgb-8.2* Hct-23.2* MCV-94 MCH-33.3* MCHC-35.4* RDW-20.6* Plt Ct-87* [**2136-1-13**] 09:15AM BLOOD WBC-7.6 RBC-3.50*# Hgb-11.3*# Hct-31.4*# MCV-90 MCH-32.4* MCHC-36.1* RDW-19.3* Plt Ct-121* [**2136-1-13**] 12:42PM BLOOD WBC-8.4 RBC-3.30* Hgb-10.6* Hct-29.5* MCV-89 MCH-32.1* MCHC-35.9* RDW-19.3* Plt Ct-156 [**2136-1-13**] 03:25PM BLOOD WBC-8.9 RBC-2.93* Hgb-9.5* Hct-26.6* MCV-91 MCH-32.5* MCHC-35.8* RDW-19.5* Plt Ct-156 [**2136-1-5**] 09:35AM BLOOD Plt Ct-184 [**2136-1-5**] 02:39PM BLOOD PT-17.6* INR(PT)-1.6* [**2136-1-6**] 05:14AM BLOOD PT-18.3* INR(PT)-1.7* [**2136-1-7**] 05:54AM BLOOD PT-18.1* INR(PT)-1.6* [**2136-1-8**] 04:57AM BLOOD PT-18.5* INR(PT)-1.7* [**2136-1-8**] 04:57AM BLOOD Plt Ct-166 [**2136-1-10**] 04:08AM BLOOD Plt Ct-147* [**2136-1-11**] 05:12AM BLOOD PT-18.3* INR(PT)-1.7* [**2136-1-12**] 06:59AM BLOOD PT-18.0* PTT-65.4* INR(PT)-1.6* [**2136-1-12**] 06:59AM BLOOD Plt Ct-177 [**2136-1-12**] 10:12PM BLOOD Plt Smr-LOW Plt Ct-97* [**2136-1-13**] 02:17AM BLOOD PT-16.5* INR(PT)-1.5* [**2136-1-13**] 04:53AM BLOOD PT-17.2* PTT-49.5* INR(PT)-1.5* [**2136-1-13**] 04:53AM BLOOD Plt Ct-87* [**2136-1-13**] 09:15AM BLOOD PT-15.6* INR(PT)-1.4* [**2136-1-13**] 09:15AM BLOOD Plt Ct-121* [**2136-1-13**] 12:42PM BLOOD Plt Ct-156 [**2136-1-13**] 03:25PM BLOOD Plt Ct-156 [**2136-1-13**] 05:48PM BLOOD PT-16.8* PTT-31.8 INR(PT)-1.5* [**2136-1-4**] 07:05AM BLOOD Glucose-177* UreaN-19 Creat-0.6 Na-135 K-4.4 Cl-98 HCO3-30 AnGap-11 [**2136-1-5**] 05:15AM BLOOD Glucose-186* UreaN-13 Creat-0.6 Na-135 K-3.3 Cl-97 HCO3-29 AnGap-12 [**2136-1-6**] 05:14AM BLOOD Glucose-69* UreaN-14 Creat-0.5 Na-135 K-2.5* Cl-98 HCO3-32 AnGap-8 [**2136-1-7**] 05:54AM BLOOD Glucose-156* UreaN-21* Creat-0.6 Na-143 K-3.0* Cl-107 HCO3-29 AnGap-10 [**2136-1-8**] 12:03AM BLOOD Na-144 K-3.8 Cl-112* [**2136-1-8**] 04:57AM BLOOD Glucose-202* UreaN-24* Creat-0.6 Na-145 K-4.1 Cl-113* HCO3-28 AnGap-8 [**2136-1-10**] 04:08AM BLOOD Glucose-86 UreaN-22* Creat-0.6 Na-144 K-3.6 Cl-110* HCO3-29 AnGap-9 [**2136-1-12**] 06:59AM BLOOD Glucose-186* UreaN-28* Creat-0.7 Na-138 K-4.4 Cl-106 HCO3-21* AnGap-15 [**2136-1-12**] 10:12PM BLOOD Glucose-390* UreaN-22* Creat-0.4* Na-134 K-4.9 Cl-105 HCO3-27 AnGap-7* [**2136-1-13**] 02:17AM BLOOD Na-138 K-3.8 Cl-107 [**2136-1-13**] 04:53AM BLOOD Glucose-554* UreaN-19 Creat-0.4* Na-126* K-3.4 Cl-96 HCO3-24 AnGap-9 [**2136-1-13**] 09:15AM BLOOD Glucose-155* UreaN-20 Creat-0.5 Na-136 K-4.7 Cl-107 HCO3-26 AnGap-8 [**2136-1-5**] 05:15AM BLOOD ALT-153* AST-166* AlkPhos-544* TotBili-20.1* [**2136-1-5**] 12:02PM BLOOD ALT-161* AST-151* AlkPhos-557* TotBili-19.8* [**2136-1-6**] 05:14AM BLOOD ALT-130* AST-109* LD(LDH)-217 AlkPhos-470* TotBili-15.5* [**2136-1-7**] 05:54AM BLOOD ALT-109* AST-85* LD(LDH)-243 AlkPhos-397* TotBili-13.0* [**2136-1-8**] 04:57AM BLOOD ALT-93* AST-83* LD(LDH)-220 AlkPhos-349* TotBili-10.7* [**2136-1-9**] 05:04AM BLOOD ALT-105* AST-127* LD(LDH)-274* AlkPhos-373* Amylase-86 TotBili-12.0* DirBili-8.4* IndBili-3.6 [**2136-1-9**] 01:00PM BLOOD TotBili-11.8* [**2136-1-10**] 04:08AM BLOOD ALT-108* AST-140* AlkPhos-395* TotBili-11.8* [**2136-1-11**] 05:12AM BLOOD ALT-104* AST-157* LD(LDH)-296* AlkPhos-415* Amylase-213* TotBili-12.0* DirBili-9.0* IndBili-3.0 [**2136-1-12**] 06:59AM BLOOD ALT-108* AST-174* LD(LDH)-334* AlkPhos-512* TotBili-14.1* DirBili-11.4* IndBili-2.7 [**2136-1-13**] 09:15AM BLOOD ALT-73* AST-134* LD(LDH)-232 AlkPhos-319* TotBili-15.7* [**2136-1-4**] 07:05AM BLOOD calTIBC-194* Ferritn-220 TRF-149* [**2136-1-9**] 05:04AM BLOOD calTIBC-147* VitB12-1612* Folate-12.3 Ferritn-325 TRF-113* [**2136-1-4**] 07:05AM BLOOD Triglyc-150* [**2136-1-5**] 05:15AM BLOOD IgG-487* IgM-31* imaging: [**2136-1-5**] MRCP 1. Biliary dilatation with mild pancreatic duct dilatation. Features are more in keeping with an ampullary stricture. A small stone is noted in the distal CBD (possibly causing recurrent inflammation and stricturing). A small tumor cannot be excluded. 2. Extensive retroperitoneal and pericardial air related to the recent perforation. [**2136-1-8**] UGI to look for possible duodenal perforation Limited upper GI study tailored for evaluation of the duodenum demonstrates no evidence of contrast extravasation. Residual, retroperitoneal free air outlines retroperitoneal structures in the right abdomen. [**2136-1-12**] angiogram to look for a source of upper GI bleed - no active extravasation, embolization of GDA [**2136-1-12**] ERCP Active bleeding from the peri-ampulla region was seen. There was a clear arterial, pulsating vessel identified near the ampulla. Local thermal therapy was not applied due to significant edema preventing clear visualization of the bleeding site and recent perforation. Brief Hospital Course: Patient was admitted from the OSH for managment of his autoimmune hepatitis that developed several months ago, hemachromatosis and now perforation of the duodenum that happened while ERCP was performed at the OSH. Patient was hemodynamically stable on transfer. He was made NPO with IVF. He was managed conservatively. After a negative UGI leak study, he was started slowely on a diet as he was completely asymptomatic. He tolerated diet well. His bilirubin initially decreased. We elected to monitor him rather than persue biliary tree decompression. Patient did not have any infectious disease issues. He was not any antibiotics. On [**1-12**] patient was found in the bathroom on morning rounds. There was blood on the floor and toilet bowl. He was having a GI bleed. This was the first time that it has been noticed. His hematocrit was carfully monitored and he received blood transfusion as needed to keep his hematocrit greater than 25. He had an ERCP procedure performed on the same day which showed active bleed from the prior sphincterotomy site. Due to inflammatory changes and being post-perforation, it was not safely able to be treated endoscopically. Post-ERCP, his hematocrit continued to drop and he was then taken to the angiogram suite. No active extravasation was found. The gastroduodenal artery was coiled as it was the most likely source of the bleed. Post-procedure patient was admitted to the [**Hospital Unit Name 153**]. He required more transfusions. On [**1-13**] in the afternoon, when it was suggested that patient may need to have another imaging study performed. The patient, with his family's support, decided to make the patient comforrt measures only. The supportive care began and patient passed away approximately 28 hours later. Per family and nursing staff patient passed away at 01:05 am on [**2136-1-15**]. Medications on Admission: Atenolol 50 [**Hospital1 **], Lisinopril 5 [**Hospital1 **], Magnesium 400 qDay AM, Simvastatin 40 qDay PM, Prednisone 40 qDay Discharge Disposition: Expired Discharge Diagnosis: patient passed away most likely from cardiopulmonary arrest secondary to hemorrhage Discharge Condition: patient passed away Discharge Instructions: patient passed away Followup Instructions: patient passed away Completed by:[**2136-1-15**]

[ "578.9", "E879.8", "V10.83", "V45.82", "272.0", "401.9", "427.5", "276.1", "V15.82", "414.01", "998.2", "275.03", "998.11", "285.1", "571.42" ]

icd9cm

[ [ [] ] ]

[ "38.93", "99.15", "99.29", "88.47", "45.13" ]

icd9pcs

[ [ [] ] ]

11204, 11213

9174, 11026

463, 541

11340, 11361

3443, 9151

11429, 11479

3238, 3256

11234, 11319

11052, 11181

11385, 11406

3271, 3424

251, 425

569, 2618

2640, 3064

3080, 3222

64,361

178,426

42899

Discharge summary

report

Admission Date: [**2181-2-17**] Discharge Date: [**2181-2-21**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2291**] Chief Complaint: frequent suctioning Major Surgical or Invasive Procedure: None History of Present Illness: 88 year old female with recent acute on chronic left SDH, recent SAH s/p coiling of right PCA artery aneurysm, hydrocephalus with VP shunt, acute respiratory failure secondary to large thoracic mass (benign thyroid nodule) requiring trach, severe dysphagia with PEG placement, ?GI bleed, DVT with IVC filter placement transferred from OSH for anemia and admitted to MICU for increasing respiratory secretions. . Patient had been at [**Hospital3 **] prior to transfer and per report patient noted to have Hct 23.8 and concern for GI bleed and was sent to OSH for blood transfusion. There VS: 100.4 114/66 80 94% RA. There was question of allergic rxn (?seizures) to blood in the past so OHS transferred her to [**Hospital1 18**]. Prior to transfer patient had CXR with concern for a RLL pneumonia. Given 750mg of levoquin. . In the ED, initial VS were 100 98 106/54 26 94%. 18g and 20g were placed for access. Exam notable for rectal exam: no stool in the vault, very trace guiac + effluent. Pulmonary exam with coarse breath sounds bilaterally, scattered rhonchi, pink secretions from trache collar. Patient received PR tylenol for temp of 100.8. Abx were not continued as suspicion for PNA low. . On arrival to the MICU, patient comfortable without complaint with cough, SOB, CP. . Of note, anemnia/dark tarry stools has been chronic issue and per previous DC summaries patient with recent EGD and C-scope wnl. Previously, initial positive guaiac tests thought secondary due to manipulation of her PEG tube, . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: Subarachnoid hemorrhage s/p coiling of R PCA aneurysm Hydrocephalus s/p VP shunt Respiratory failure requiring trach placement Thoracic mass: biopsied - benign thyroid nodule Hyperthyroidism with goiter Anemia - prior black stools with no source found from EGD/c-scope Deep vein thrombosis s/p IVC filter Hypertension Atrial fibrillation Social History: Originally from [**Country 13622**] Republic, Spanish-speaking. Prior to her prolonged hospitalization in [**Month (only) 1096**] she was living with her daughter and granddaughter and was very independent. Currently she is at [**Hospital3 **]. She walks with a cane or walker at baseline. No history of tobacco or alcohol use. Family History: CAD Physical Exam: Admission Physical: General: Alert, oriented, no acute distress, comfortable, pleasant, breathing comfortably on trach mask HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Rhonchorus breath sounds bilaterally, no wheezes, rales Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: non-focal, moving all four extremities with sensation intact Pertinent Results: LABS: Admission Labs: [**2181-2-17**] 12:55AM BLOOD WBC-8.0# RBC-2.80* Hgb-8.7* Hct-25.4* MCV-91 MCH-31.2 MCHC-34.5 RDW-16.2* Plt Ct-475* [**2181-2-17**] 12:55AM BLOOD Neuts-77.2* Lymphs-11.9* Monos-5.8 Eos-4.6* Baso-0.4 [**2181-2-17**] 12:55AM BLOOD PT-12.4 PTT-30.5 INR(PT)-1.1 [**2181-2-17**] 12:55AM BLOOD Ret Aut-3.9* [**2181-2-17**] 12:55AM BLOOD Glucose-119* UreaN-25* Creat-1.0 Na-139 K-4.6 Cl-102 HCO3-28 AnGap-14 [**2181-2-17**] 12:55AM BLOOD ALT-12 AST-15 LD(LDH)-147 AlkPhos-77 TotBili-0.3 [**2181-2-17**] 06:42AM BLOOD Calcium-9.2 Phos-4.0 Mg-1.8 Iron-15* [**2181-2-17**] 12:55AM BLOOD Hapto-330* [**2181-2-17**] 06:42AM BLOOD calTIBC-250* Ferritn-41 TRF-192* Discharge Labs: Thyroid function tests: [**2181-2-19**] 06:40AM BLOOD T3-65* Free T4-1.5 [**2181-2-19**] 06:40AM BLOOD TSH-0.34 MICRO: [**2181-2-17**] URINE CULTURE-FINAL negative [**2181-2-17**] MRSA SCREEN-FINAL negative [**2181-2-17**] Blood Culture, Routine-PENDING EMERGENCY [**Hospital1 **] [**2181-2-17**] Blood Culture, Routine-PENDING STUDIES: CXR [**2181-2-17**]: IMPRESSION: 1. Grossly stable thyroid goiter causing widening of the right paratracheal stripe. 2. Unchanged elevation of the right hemidiaphragm and bibasilar atelectasis. 3. No evidence of pneumonia or acute pulmonary edema. Brief Hospital Course: 88 year old female with recent acute on chronic left SDH, recent SAH s/p coiling of right PCA artery aneurysm, hydrocephalus with VP shunt, acute respiratory failure secondary to large thoracic mass (benign thyroid nodule) requiring trach, severe dysphagia with PEG placement, ?GI bleed transferred from OSH for anemia and admitted to initially to the MICU for increasing respiratory secretions. She was stable for transfer to the medicine floor within one day. ACTIVE ISSUES BY PROBLEM: # Respiratory secretions: On arrival to MICU, patient's secretions were minimal and she had no signs of respiratory distress. Initial concern for ?PNA vs tracheitis however patient without leukocytosis or fevers (except initial temp of 100, no recurrence). CXR without focal infiltrate. Previous sputum cultures have grown pseudomonas; however this likely represents colonization rather than infection, so it was felt that repeat sputum cultures would not be helpful in this clinical setting. Antibiotics were not started. Secretions appear to be coming from both oropharyngeal and pulmonary sources, however they are clear and she is able to expectorate them extremely well on her own. She was seen by the Interventional Pulmonary team, who had no further recommendations or plans for interventions at this time. Pt was continued on trach mask and required suctioning every 6-8 hours. Guaifenesin and saline nebs were initiated to help break up the thickened sputum. This regimen, along with albuterol, should be continued at her rehab facility. # Normocytic Anemia: Likely due to a very slow lower GI bleed. Admission HCT 25.4, with baseline HCT ~28-30. Exam in ED guaiac + but without overt melena or BRBPR. Previous GI work-up with unrevealing EGD (documented in [**11-27**] operative note) and reportedly normal colonoscopy at [**Hospital3 **] in [**2176**]. PEG lavage on arrival to the MICU guaiac negative. Previous vitamin B12, folate wnl. Iron studies suggested iron deficiency anemia, for which she was continued on her iron supplementation. She was transfused one unit PRBC's for Hct 22 with appropriate response to 25. After transfer to the medicine floor, hct continued to remain stable. She did have more dark brown guaiac positive stools. It is likely that she has a very slow GI bleed that is causing her anemia, more likely lower rather than upper GI given the guaiac negative PEG lavage. As this appears to be a chronic issue that is relatively stable, it is recommended that she continue to have her hemoglobin/hematocrit followed and could have a repeat colonoscopy for further work up, however will defer to her PCP or the rehab medical director for further management. # Dysphagia: Secondary to esophageal narrowing by large thyroid mass and difficulty swallowing (noted to have likely aspirations in the past). PEG tube in place. Initially held tube feeds in the setting of possible GI bleed, however these were restarted on hospital day 2 with no issues. Speech and swallow consult was obtained, however they deferred further evaluation to her speech therapist at [**Hospital3 **], as they have been working with her for 3 months now on this issue. She remained NPO and on tube feeds for her stay in the hospital. # Substernal goiter, hyperthyroidism: TFTs sent while inpatient, which appear improved (however less reliable in acute illness): TSH 0.34, freeT4 1.5, and T3 65. ENT team was notified of her admission and requested an appointment be made for her with Dr. [**Last Name (STitle) 1837**] for evaluation for resection of thyroid mass. This appointment will be on ###, after which the ENT, IP, neurology, and endocrine teams will need to decide on the best future course of action. CHRONIC INACTIVE ISSUES: # DVT s/p filter placement: placed on heparin SC # Seizure disorder: Continued keppra, with prn Ativan. # Hyperthyroidism: Continued methimazole. # History of Atrial Fibrillation. CHADS 2. Anticoagulated with ASA. TRANSITION OF CARE ISSUES: - Resp secretions: will need suctioning at least every [**5-25**] hours, continue with saline nebs, albuterol/ipratropium nebs, and guaifenesin - Goiter, Hyperthyroidism: appears to be in euthyroid state now, may now be a surgical candidate. Has ENT appt with Dr. [**Last Name (STitle) 1837**] for surgical eval, after which ENT, IP, neurology, and endocrine teams will decide on the best future course of action for removal of thyroid mass - Anemia: slow GI bleed most likely, should have hemoglobin/hematocrit checked 2x/weekly. Transfuse for hct <21, hemodynamic instability, or symptoms. - Dysphagia: should continue to work with speech/swallow therapist at [**Hospital1 **] to determine when it may be safe to try PO nutrition again. - FULL CODE this admission Medications on Admission: 1. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 2. levetiracetam 750 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO twice a day. 3. lorazepam 0.5 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO Q6H (every 6 hours) as needed for mouth movements. 4. docusate sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One Hundred (100) mg PO BID (2 times a day). 5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Last Name (STitle) **]: One (1) neb Inhalation Q6H (every 6 hours) as needed for shortness of breath, wheezing. 6. methimazole 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). 7. senna 8.8 mg/5 mL Syrup [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day) as needed for constipation . 8. acetaminophen 500 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO every six (6) hours as needed for pain. 9. heparin (porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1) ml Injection three times a day: for DVT prophylaxis. 10. aspirin 325 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: One (1) Tablet, Delayed Release (E.C.) PO once a day: Please do not start taking until [**2181-1-28**]. . 11. Ferrous Sulfate 300mg PO BID 12. Latanoprost 0.005% 1drop each eye qhs 13. Solumedrol IV 40mg q12hr (never received at [**Hospital1 **], not continued during this hospitalizations) Discharge Medications: 1. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 2. lorazepam 0.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO every six (6) hours as needed for for mouth movements. 3. docusate sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One Hundred (100) mg PO BID (2 times a day). 4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Last Name (STitle) **]: One (1) neb inhalation Inhalation Q6H (every 6 hours) as needed for sob, wheezing. 5. methimazole 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). 6. senna 8.8 mg/5 mL Syrup [**Last Name (STitle) **]: Five (5) ml PO twice a day as needed for constipation. 7. acetaminophen 500 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO every six (6) hours as needed for pain. 8. aspirin 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 9. ferrous sulfate 300 mg (60 mg iron)/5 mL Liquid [**Last Name (STitle) **]: Three Hundred (300) mg PO BID (2 times a day). 10. latanoprost 0.005 % Drops [**Last Name (STitle) **]: One (1) Drop(s) each eye Ophthalmic HS (at bedtime). 11. levetiracetam 100 mg/mL Solution [**Last Name (STitle) **]: 1500 (1500) mg PO BID (2 times a day). 12. guaifenesin 100 mg/5 mL Syrup [**Last Name (STitle) **]: Ten (10) ML PO Q6H (every 6 hours). 13. sodium chloride 3 % Solution for Nebulization [**Last Name (STitle) **]: Fifteen (15) ML(s) (1 nebulization) Inhalation Q6H (every 6 hours). 14. ipratropium bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) neb Inhalation Q6H (every 6 hours) as needed for sob, wheezing . 15. heparin (porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1) injection (5000 units) Injection three times a day: Can discontinue if patient is able to ambulate 3x daily. Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 8957**] Discharge Diagnosis: Primary diagnoses: Chronic respiratory failure Dysphagia Anemia likely secondary to slow gastrointestinal bleed Substernal goiter Hyperthyroidism Secondary diagnoses: Deep vein thrombosis Seizure disorder Atrial fibrillation Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. [**Known lastname **], You were admitted to the hospital for increased respiratory secretions and low blood counts. We did blood tests and xrays, and we do not believe that you have have a lung infection. The increased secretion is partly due to the benign thyroid mass and difficulty swallowing. Your low blood counts are likely coming from a very small and very slow bleed in your intestines. You got 1 unit of blood and your blood counts have been very stable. Your doctor may decided if you should have a colonoscopy as an outpatient for further evaluation. Changes made to your medications: START guaifenesin 10 ml every 6 hours START saline nebulizations every 6 hours START ipratropium nebulizations every 6 hours as needed for shortness of breath or wheezing It was a pleasure to take care of you at [**Hospital1 **]! Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) **] M Location: GREATER [**Hospital1 **] FAMILY HEALTH CENTER Address: [**Location (un) **], [**Hospital1 **],[**Numeric Identifier 66038**] Phone: [**Telephone/Fax (1) 82128**] Please discuss with the staff at the facility a follow up appointment with your PCP when you are ready for discharge. We are working on a follow up appointment in Otolaryngology with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1837**] for your hospitalization. You must follow up within 1 week of discharge. The office will contact you at the facility with the appointment information. If you have not heard within 2 business days please call the office at [**Telephone/Fax (1) 41**]. Department: RADIOLOGY When: THURSDAY [**2181-3-1**] at 2:00 PM With: CAT SCAN [**Telephone/Fax (1) 327**] Building: CC CLINICAL CENTER [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: NEUROSURGERY When: THURSDAY [**2181-3-1**] at 2:45 PM With: [**Name6 (MD) **] [**Last Name (NamePattern4) 7746**], MD [**Telephone/Fax (1) 3666**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: NEUROLOGY When: WEDNESDAY [**2181-3-28**] 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 Department: INTERVENTIONAL PULMONARY When: TUESDAY [**2181-4-3**] at 9:00 AM With: [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Building: DE [**Hospital1 **] BUILDING ([**Hospital Ward Name **] COMPLEX), [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name 23**] Garage Department: ENDOCRINOLOGY When: TUESDAY [**2181-4-3**] at 11:20 AM With: [**First Name11 (Name Pattern1) 1409**] [**Last Name (NamePattern4) 91212**], MD [**Telephone/Fax (1) 1803**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name **] Garage

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icd9cm

[ [ [] ] ]

[ "96.6" ]

icd9pcs

[ [ [] ] ]

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272, 279

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2664, 2994

10,491

171,876

29458

Discharge summary

report

Admission Date: [**2185-1-10**] Discharge Date: [**2185-1-14**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1556**] Chief Complaint: s/p Motor vehicle crash Major Surgical or Invasive Procedure: None History of Present Illness: 88 yo female, rear seat passenger, restrained, s/p motor vehicle crash. No reported LOC. Transported to [**Hospital1 18**] for continued trauma care. Past Medical History: Hypertension Hypercholesterolemia Social History: Lives alone Denies tobacco, EtOH Family History: Noncontributory Pertinent Results: [**2185-1-10**] 07:07PM GLUCOSE-135* LACTATE-2.1* NA+-138 K+-3.7 CL--96* TCO2-29 [**2185-1-10**] 07:01PM UREA N-20 CREAT-0.9 [**2185-1-10**] 07:01PM PLT COUNT-324 [**2185-1-10**] 07:01PM PT-13.7* PTT-21.5* INR(PT)-1.2* CHEST (PORTABLE AP) [**2185-1-11**] 5:04 AM CHEST (PORTABLE AP) Reason: Eval. for PTX [**Hospital 93**] MEDICAL CONDITION: 88 year old woman with multiple rib fx. bilat. and R tiny PTX seen on CT REASON FOR THIS EXAMINATION: Eval. for PTX AP CHEST 5:30 A.M., [**1-11**]. HISTORY: Multiple rib fractures and tiny pneumothorax. IMPRESSION: AP chest compared to [**1-10**]: There is persistent widening of the upper mediastinum on both sides of the trachea. Some of this could be due to fat deposition, but possibility of hematoma is significant and needs to be evaluated by chest CT scanning. Leftward mediastinal shift inferiorly is explained by left lower lobe atelectasis. Heart size is top normal. [**Month (only) 116**] be small bilateral pleural effusion. Multiple rib fractures are seen on both sides of the chest posterolaterally in the upper right and along most of the left lateral and posterolateral ribs inferiorly. Right clavicle fracture shows at least 2-1/2 cm of proximal override. CT C-SPINE W/O CONTRAST Reason: WITH RECONS PLEASE. Eval multiple c-spine fx. seen on OSH CT [**Hospital 93**] MEDICAL CONDITION: 88 year old woman s/p MVC REASON FOR THIS EXAMINATION: WITH RECONS PLEASE. Eval multiple c-spine fx. seen on OSH CT CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 88-year-old female status post motor vehicle accident with C- spine fractures seen at outside hospital. COMPARISON: Outside hospital CT scan dated [**2185-1-10**] at 15:28. TECHNIQUE: MDCT imaging of the cervical spine was performed without intravenous contrast. Coronal and sagittal reformatted images were obtained. CT C-SPINE WITHOUT INTRAVENOUS CONTRAST: There is no prevertebral soft tissue swelling. The bones are diffusely osteopenic. Multiple minimally displaced fractures are seen along the posterior elements of C2 through C6. At the C5 and C6 levels, comminuted fractures extend anteriorly and bilaterally into the lamina. No additional fractures are seen. The odontoid process is intact. There is no evidence of dislocation. Minimal loss verterbal body height from C3 through C6 is likely degenerative. There is narrowing of the intervertebral disc space, most prominently at C6/7, with a small cyst at the C6 inferior endplate. Posterior osteophytes at multiple levels, most prominently from C3 through C6 cause mild narrowing of the spinal canal. Comminuted fractures are noted along the medial right clavicle, and left sternoclavicular junction. There is a comminuted fracture through the anterior aspect of the right first rib. The surrounding soft tissues demonstrate multiple right-sided thyroid nodules. IMPRESSION: 1. Multilevel comminuted fractures through the posterior elements extending from C3 through C6. No evidence of malalignment or dislocation. Given the location of the fractures, MRI is recommended to evluate for potential ligamentous instabililty. 2. Bilateral clavicular, and right first rib fracture. 3. Multilevel degenerative disease as described above. 4. Multiple right-sided thyroid nodules. Followup ultrasound is recommended for further evaluation when the patient's symptoms stabilize. Brief Hospital Course: She was admitted to the Trauma service and transferred to the Trauma ICU for close monitoring given her multiple rib fractures. Neurosurgery was initially consulted because of her spine injuries; these were non-operative. She was placed in a hard cervical collar which will need to be worn for 6 weeks. Follow up with Dr. [**Last Name (STitle) 548**] at that time for further CT imaging. Orthopedic surgery was consulted for right clavicle fracture; this injury was also non-operative. It was recommended that she remain non-weight bearing in that extremity. She will need to wear a sling and follow up in 2 weeks time with Dr. [**Last Name (STitle) 1005**]. Because of her rib fractures there were some pain control concerns on behalf of the patient. She initially was reluctant to take any narcotics and so was placed on around the clock Tylenol. When it became evident that she was unable to take effective deep breaths as demonstrated by low oxygen saturations in the mid 80's she was placed on scheduled Oxycodone 2.5 mg q 6h; the dose was started low given her age and petite size. Physical and Occupational therapy were consulted and have recommend home PT services. she will also require skilled nursing at home for cardiopulmonary assessment. Medications on Admission: HCTZ ASA Atenolol Discharge Medications: 1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 5. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for constipation. 6. Hydrochlorothiazide 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO twice a day. 8. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO three times a day. 9. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day): Apply to leg wounds. 10. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*45 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital3 3765**] Home Care Discharge Diagnosis: s/p Motor vehicle crash C3-5 spinous process fracture C5-6 Bilateral lamina fracture Right clavicle fracture Sternal fracture w/ small retrosternal hematoma Bilat rib fractures left [**6-13**], right [**2-13**] Discharge Condition: Stable Discharge Instructions: You must continue to wear your cervical (neck) collar for the next 8 weeks. DO NOT bear any weight on your right arm because of your clavicle ([**Last Name (un) **] bone) fracture. Return to the Emergency room if your develop any fevers, chills, headache, dizziness, chest pain, shortness of breath, abdominal pain, nausea, vomiting, diarrhea, weakness, tingling, numbness in any of your extremties and/or any other symptoms that are concerning to you. Followup Instructions: Follow up with Dr. [**Last Name (STitle) 1005**], Orthopedics, in 2 weeks. Call [**Telephone/Fax (1) 1228**] for an appointment. Follow up with Dr. [**Last Name (STitle) **], Neurosurgery, in 8 weeks. Call [**Telephone/Fax (1) 1669**] for an appointment. Inform the office that you will need a repeat CT scan of your cervical spine fr this appointment. Follow up in Trauma Clinic in 2 weeks, call [**Telephone/Fax (1) 6429**] for an appointment. Follow up with your primary doctor in [**2-9**] weeks. Completed by:[**2185-1-14**]

[ "862.29", "241.1", "272.0", "401.9", "807.2", "805.08", "810.01", "E812.1", "860.0", "807.08" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6324, 6385

4027, 5283

285, 292

6640, 6649

630, 948

7152, 7687

594, 611

5353, 6301

1995, 2021

6406, 6619

5309, 5328

6673, 7129

222, 247

2050, 4004

320, 471

493, 528

544, 578

80,858

123,510

38288

Discharge summary

report

Admission Date: [**2175-8-19**] Discharge Date: [**2175-9-15**] Date of Birth: [**2124-2-28**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7591**] Chief Complaint: Sore throat, coryza symptoms Major Surgical or Invasive Procedure: PICC placement Bone Marrow Biopsy History of Present Illness: 51 yo male presents with 1 week history of sore throat and URI type symptoms. He presented to an OSH where he was noted to have leukocytosis (WBC >70K) and given concern for hematologic malignancy, he was transferred here for further care. . In the ED, initial vitals were: 98.2, 98, 138/67, 20, 94%. Hematology evaluated the patient, and a peripheral smear was consistent with likely AML. Bone marrow biopsy was performed, and the patient was then initiated on leukopheresis prior to admission. In the ED, he also received 3 gm hydroxyuria, allopurinol, bicarb, as well as levofloxacin for ? PNA on his CXR. . Currently, the patient feels better. He reports brownish productive sputum. He saw his PCP on Wednesday, and since his lungs were clear, he was told to continue on his OTC coricidin. His symptoms continued to worsen which is why he presented to the ED. He states he's also had nightsweats for the last week. . On ROS, he denies fevers, chills, weight change, visual changes, headaches, nausea, vomiting, abdominal pain, constipation, BRBPR, melena, dysuria, hematuria, frequency, urgency, numbness, weakness, orthopnea, PND, or lower extremity edema. He does report some increased dyspnea this past week as well as a few episodes of diarrhea. Past Medical History: Hypertension Seasonal Allergies Social History: Occasional ETOH. Previous smoker, none now (25pk/yr) quit 4 yrs ago. No illicit drug use (prior use of marijuana)- no h/o IVDU. Family History: First cousin with leukemia Physical Exam: VITALS: 101.0 124/72 85 20 96%1L GENERAL: WDWN male, NAD, appears comfortable HEENT: NCAT, no cervical adenopathy; mucous membranes slightly dry CV: RRR, no M/R/G LUNGS: few coarse BS in R base, otherwise clear without wheezes rales or rhonci ABDOMEN: soft, obese, non tender. normal BS. could not appreaciate HSM due to body habitus EXTREMITIES: no C/C/E SKIN: no rash; few petecechiae around neck NEURO: CN 2-12 grossly intact; [**6-14**] prox/distal strength BUE/BLE extremities. no clonus. PSYCH: A/O x 3; mood and affect appropriate LYMPH: no cervical, suprclavicular, or axillary lymphadenopathy appreciated At discharge: same as above except: HEENT: MM moist SKIN: resolving maculopapular rash w/ excoriations on trunk, single suture at site of skin biopsy on L side of abdomen; minimal petechiae on B/L ankles Pertinent Results: Admission Labs: [**2175-8-19**] 06:15PM WBC-70.2* RBC-3.90* HGB-13.6* HCT-36.5* MCV-94 MCH-34.8* MCHC-37.2* RDW-15.2 [**2175-8-19**] 06:15PM NEUTS-4* BANDS-0 LYMPHS-8* MONOS-5 EOS-1 BASOS-0 ATYPS-0 METAS-1* MYELOS-1* NUC RBCS-1* OTHER-80* [**2175-8-19**] 06:15PM PT-14.4* PTT-24.4 INR(PT)-1.2* [**2175-8-19**] 06:15PM GLUCOSE-152* LACTATE-3.1* NA+-137 K+-3.1* CL--92* TCO2-29 [**2175-8-19**] 06:15PM GLUCOSE-159* UREA N-13 CREAT-1.3* SODIUM-137 POTASSIUM-2.8* CHLORIDE-94* TOTAL CO2-26 ANION GAP-20 . Discharge Labs: . Imaging: ECHO [**2175-8-21**] The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened. There is no valvular aortic stenosis. The increased transaortic velocity is likely related to high cardiac output. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. . Cytogenetics [**2175-8-21**] PML at 15q22 RARA at 17q21.1 ETO at 8q22 AML1 at 21q22 CBFB 5' at 16q22 CBFB 3' at 16q22 . CXR [**2175-8-21**]: IMPRESSIONS: Unchanged bibasilar opacities. . CT Chest [**2175-8-24**] IMPRESSIONS: 1. Diffuse right pleural thickening with sparing of the medial pleural surface together with tiny right pleural effusion likely account for the CXR appearance. Together with shift of the mediastinum towards the right, fibrothorax is a possibility, especially if the patient has had prior pleural disease. Comparison with older imaging may be helpful in establishing chronicity. Otherwise, follow up CT in 3 months may be helpful to ensure stability. 2. Diffuse ground-glass attenuation of the lungs with smooth septal thickening can be seen in hydrostatic edema, but also in atypical infections such as viral or pneumocystis pneumonia. 3. Borderline enlarged mediastinal and hilar lymph nodes may be reactive but attention at follow up CT suggested. 4. Splenomegaly with splenic infarct. 5. Possible left renal hypodensity, which may represent either renal lesion or renal infarct. This could be evaluated by renal US if warranted clinically. . CT sinus [**2175-8-26**] IMPRESSION: 1. Mucosal thickening involving maxillary sinuses and sphenoid sinus, consistent with mucosal sinus disease. 2. No evidence of soft tissue infection or osseous erosion. . CXR [**2175-9-8**] Cardiac size is normal. Bibasilar opacity is new on the left, could be atelectasis but superimposed infection cannot be totally excluded. There is no pneumothorax or pleural effusion. Right central catheters remain in place. . CXR [**2175-9-10**] Cardiomediastinal contours are normal. Aside from minimal atelectasis in the right base, the lungs are clear. Opacity in the left lower lobe is no longer visualized. There is no evidence of pneumonia, pneumothorax or pleural effusions. Moderate degenerative changes are in the thoracic spine. Two right central catheters remain in place. . [**9-11**] SKIN BIOPSY PATHOLOGY REPORT: Superficial dermal hemorrhage associated with small vessel thrombi and superficial to mid dermal perivascular lymphocytic infiltrate (see microscopic description and comment). No herpes virus identified (routine and immunostains). Microscopic description. Sections show intact epidermis with occasional dyskeratotic cells. No vesiculation is identified in the multiple tissue levels examined. There is an area of red blood cell extravasation in the superficial dermis which is associated with thrombi in small vessels. No vasculitis is seen. In addition, there is relatively [**Name2 (NI) 15410**] superficial to mid dermal perivascular and predominantly lymphocytic infiltrate, with some admixed histiocytes. No herpes virus cytopathic effect is seen on routine stains. No immunoreactivity for herpes simplex or varicella zoster is seen on specific immunostains. No bacterial or fungal organisms are identified on Gram or GMS stains, respectively. Comment. No infectious agents are identified in this sample on routine or infectious stains, and specifically, no herpes viral cytopathic effect is seen. If there is continuing clinical concern for herpes virus, culture may prove more sensitive than tissue based stains. The combined findings of apparently localized superficial dermal hemorrhage, small vessel thrombi and perivascular mononuclear cell infiltration are unusual and are not specifically diagnostic in this biopsy. The histologic differential diagnosis includes trauma, an adjacent lesion or excoriation, a hypersensitivity reaction, and possibly an occlusive vasculopathy. Clinical correlation is necessary Brief Hospital Course: The patient is a 51-year-old man with newly diagnosed AML who was hospitalized to undergo 7+3 induction 1. AML Patient underwent 7+3 induction and tolerated the chemotherapy well. On [**2175-9-1**], the patient's bone marrow demonstrated "Markedly hypocellular marrow with chemoablation effects. No morphological evidence of residual leukemia is seen." Pt. underwent repeat bone marrow biopsy on day of discharge ([**2175-9-15**]) w/ aspirate taken but unable to obtain core sample. Acyclovir started for prophylaxis. . 2. Febrile neutropenia Following a fever on [**2175-8-20**], the patient was started on cefepime on [**2175-8-21**] and vancomycin on [**2175-8-23**]. Micafungin and levofloxacin were added on [**2175-8-25**] after CT chest showed ground glass attentuation. He was also ordered for CT sinus (pt uses fluticasone at home). The patient developed a non-pruritic maculopapular rash on his upper right arm. Derm was consulted, since rash appeared concomitantly with fever, and were very much convinced that the rash is a drug rash. For pruritus treatment, Derm recommended clobetasone. Cefepime was changed to meropenem on [**2175-8-26**] due to likely drug hypersensitivity. The patient also has an intertriginous rash on his right groin; has miconazole powder to use. On [**9-1**], with the patient having more itching and rash, meropenem was switched to aztreonam and flagyl. On [**2175-9-7**], the patient again began to have fevers. CXR showed perhaps a new opacity at base of left lung. Patient was continued on an antibiotic regimen of aztreonam, flagyl, vancomycin, and micafungin. Repeat CXR showed no evidence of PNA. His fevers resolved on this regimen and flagyl, vancomycin, micafungin d/c'ed on [**2175-9-14**]. Aztreonam d/c'ed on [**2175-9-15**]. ANC improved from 0 to 2647 on day of discharge. . 3. Rash, likely hypersensitivity reaction to drug Patient has maculopapular rash that developed on extremities and torso. Cefepime and meropenem were both stopped following outbreak of rashes. Patient received sarna and diphenhydramine for pruritus. The rash persisted after discontinuation of antibiotics and derm was consulted for possible viral etiologies. A punch biopsy was obtained and sent for pathology which showed superficial dermal hemorrhage associated with small vessel thrombi and superficial to mid dermal perivascular lymphocytic infiltrate with no evidence of HSV or VZV. The patient had a suture at the site of biopsy in place at time of discharge with instructions to remove around [**9-26**]. He was discharged with Sarna and clobetasol creams prn. . -f/u w/ Dr. [**Last Name (STitle) 410**] in clinic on [**2175-9-19**] at 11am -f/u BM aspirate results -Skin biopsy suture should be removed around [**9-26**] Medications on Admission: HCTZ 25 mg daily Fluticasone nasal spray Discharge Medications: 1. Sarna Anti-Itch 0.5-0.5 % Lotion Sig: One (1) application Topical four times a day as needed for itching. Disp:*1 bottle* Refills:*0* 2. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). Disp:*90 Tablet(s)* Refills:*0* 3. Clobetasol 0.05 % Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). Disp:*1 tube* Refills:*0* 4. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) puff each nostril Nasal once a day. 5. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain for 20 doses. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: PRIMARY: Acute myelogenous leukemia SECONDARY: Neutropenic fever Rash, likely in reaction to cefepime 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 with a sore throat and symptoms of an upper respiratory infection. You were found to have a high white blood cell count and were diagnosed with acute myelogenous leukemia. You had multiple bone marrow biopsies. You underwent induction chemotherapy which you tolerated well. Your counts went down as expected and you developed a fever which was treated with antibiotics. Your fevers resolved and your counts have gone back up. You also developed a rash which may have been related to antibiotics and it was determined that there was no virus causing the rash. The rash improved prior to discharge. . Some of your medications were changed during this admission: START Acyclovir START Oxycodone as needed for pain . You should continue to take your other home medications as prescribed. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 3749**], MD Phone:[**Telephone/Fax (1) 3241**] Date/Time:[**2175-9-19**] 11:00 [**Hospital Ward Name **] [**Location (un) **]

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icd9cm

[ [ [] ] ]

[ "99.72", "41.31", "99.25", "86.11", "38.93" ]

icd9pcs

[ [ [] ] ]

11406, 11412

7871, 10635

344, 380

11559, 11559

2778, 2778

12552, 12755

1890, 1918

10726, 11383

11433, 11538

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1933, 2554

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276, 306

408, 1671

2794, 3289

11574, 11686

1693, 1727

1743, 1874

67,032

133,972

17399

Discharge summary

report

Admission Date: [**2108-6-7**] Discharge Date: [**2108-6-22**] Date of Birth: [**2031-1-16**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3043**] Chief Complaint: Fever, respiratory distress Major Surgical or Invasive Procedure: None History of Present Illness: 77 year-old woman with a medical history of HTN, DM, CKD, who was transferred to the ED from [**Hospital1 100**]-MACU for fever to 102. She recently had a prolonged stay at [**Hospital1 **]-[**Location (un) 620**]. She was previously independent until [**2108-5-17**], when she was found down in her apt in feces for an unclear amount of time (max 1-1/2 days). She was initially unresponsive and hypothermic and after being warmed she was conscious but incoherent. Her blood cultures from [**5-17**] grew pneumococcus (4/4 bottles) and MRSA ([**1-16**] bottles). Subsequent Cx ([**5-20**], [**5-21**], [**6-2**]) were negative. Sputum Cx on [**5-17**] grew MRSA and Pneumococcus; subsequently sputum grew MRSA on [**5-22**]. She was treated with a two and a half week course of Vanco for the MRSA. Vanco levels were mainly [**10-26**] over her treatment course. It is unclear for how long she was treated with ceftriaxone but she was not discharged on it, so max of two and a half weeks. TTE on [**5-18**] and [**5-23**] were without endocarditis. Given her respiratory distress and acid base status she was intubated in [**5-22**] and extubated on [**6-2**]. She was given frequent nebs and placed on a steroid taper. She also was found to have rhabdomyolysis from being down for an unclear time. Her CK trended from 3396 to 168 ([**5-23**]). She was treated with fluids. Her creatinine was also elevated during the last admit. She was given aggressive IV hydration (also for rhabdo) and although her Cr initially improved it trended up again to 4.1. She became volume overloaded and developed anasarca and thus underwent 4 sessions of HD. Her last HD sessoin was on [**6-4**] and her Cr was 2.4. Given her change in mental status a CT Head was done which was unrevealing. Neuro was consulted and felt it was a metabolic encephalopathy. An MRI was limited by motion, but did not reveal anything and an EEG did not show a seizure focus. Her mental status improved with resolution of her PNA and HD but she was still not oriented or able to verbalize. Per report from the patient's sons, her NGT was pulled out last pm, unclear if TF were running at the time. Then, the morning of admission, the patient was found to have a fever of 100.8 and was tachypneic with an O2 sat of around 87% on 2L NC (per ED report, not noted in transfer paperwork). She was therefore transported to the ED for further assessment. In the ED, initial vs were: 102 76 190/70 30 100 on NRB. Her labs were notable for WBC count of 11, Cr of 2.4, Na of 148. An ABG was done on NRB: 7.43/44/150. Patient was given Vanco, Zosyn, Levoflaoxacin. On the floor, the patient is non-conversant, but is occasionally able to nod appropriately. She is having occasional myoclonic jerking. She is on a NRB and appears to be in no acute distress. Review of systems: Unable to obtain. Denies pain. Past Medical History: Diabetes mellitus x 10 years Hypertension Hyperlipidemia Chronic obstructive pulmonary disease Spinal stenosis Lower extremity claudication Hypothyroid Chronic kidney disease stage III Social History: Prior to [**2108-5-17**] [**Location (un) 620**] admit she was living alone, independent and functional with all her ADLs. She was still driving. She was independent of her shopping, accounting, cooking and cleaning her house. She did not have any memory problems. She had difficulty walking long distances secondary to her neuropathy. She did not walk with a walker or cane. After her admit she was discharged to [**Hospital1 100**]-MACU Tob: few cigs per day. She first started when she was a teenager. She used to smoke a pack per day. EtOH: she drank alcohol socially. No rec drug use. She was a homemaker at first but then went back as an administrator at the treasury and retired in her sixties. HSG. Health-care Proxy: [**First Name8 (NamePattern2) **] [**Known lastname 48652**] (oldest son) NEXT OF [**Doctor First Name **]: [**Last Name (LF) **], [**First Name3 (LF) **], PHONE: [**Telephone/Fax (1) 48653**] Family History: Her mother lived to be 98 and died of natural causes. Her father died of ?MI in his 60s. One brother died in his early 60s from an MI. Her other brother died of pancreatic cancer at age 76. Physical Exam: Exam when transferred out of ICU T 99.7, BP 149/58, HR 71, RR 13, 98% on non-rebreather General Appearance: Well nourished, No acute distress Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal) Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial pulse: not assessed), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles : at bases, R>>L) Abdominal: Soft, Tender: throughout Skin: Warm Neurologic: Attentive Pertinent Results: Admission labs: [**2108-6-7**] WBC-11.1* RBC-3.56* Hgb-9.7* Hct-32.0* MCV-90 RDW-18.9* Plt Ct-212 Neuts-94.9* Lymphs-3.1* Monos-1.5* Eos-0.3 Baso-0.2 PT-12.7 PTT-26.8 INR(PT)-1.1 Glucose-363* UreaN-96* Creat-2.4* Na-148* K-3.8 Cl-108 HCO3-30 AnGap-14 ALT-59* AST-30 LD(LDH)-472* AlkPhos-60 TotBili-0.6 Lipase-112* Albumin-2.6* Calcium-8.1* Phos-4.9* Mg-2.3 Triglyc-170* Type-ART pO2-150* pCO2-44 pH-7.43 calTCO2-30 Base XS-4 Intubat-NOT INTUBA Lactate-1.2 [**2108-6-7**] URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.011 Blood-MOD Nitrite-NEG Protein-30 Glucose->1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-MOD RBC-2 WBC-26* Bacteri-FEW Yeast-MANY Epi-1 [**2108-6-9**] 08:59AM BLOOD Vanco-17.3 MICRO: [**6-7**] BCx: STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE SET ONLY [**6-7**] UCx: YEAST. >100,000 ORGANISMS/ML [**6-7**] ULegionella: negative [**6-8**] Lyme serology: negative [**6-8**] Catheter tip Cx: negative [**6-9**] C. diff: negative [**6-9**] BCx: negative STUDIES: [**6-7**] ECG: Normal sinus rhythm. RSR' pattern in leads V1-V3 with a QRS duration of 116 milliseconds. Moderate baseline artifact but there is T wave flattening in leads V3-V5. Compared to the previous tracing of [**2107-12-14**] this non-specific T wave change is new. There is no other diagnostic interval change. Intervals Axes Rate PR QRS QT/QTc P QRS T 63 146 116 442/447 46 12 55 [**6-7**] CXR: Left lower lung opacity may represent atelectasis although pneumonia cannot be ruled out; small bilateral pleural effusions. [**6-7**] LENIs: No evidence of deep venous thrombosis in the bilateral lower extremities. [**6-8**] TTE: Mild mitral regurgitation with normal valve morphology. Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Pulmonary artrery systolic hypertension. No valvular pathology or discrete vegetation seen. [**6-8**] CT Chest (prelim): 1. Alveolar pattern of lung disease in right subpleural lung zone compatible with infectious process. As far it can be shown on a non-contrast examination, there is no evidence of associated empyema. Bibasilar atelectasis. 2. Nodular opacity is unchanged in size since examination from [**2103**], though has increased in density, and based on this observation, malignancy cannot be excluded and delayed biopsy should be performed after treatment of acute condition. 3. Relative distention of the gallbladder since prior examination with associated cholelithiasis. Correlation with ultrasound is recommended to exclude the possibility of cholecystitis. 4. Low-attenuation lesion within the right thyroid lobe, likely nodule, and this can be correlated clinically, and if further evaluation is deemed necessary, a thyroid ultrasound on a non-emergent basis can be considered. [**6-8**] RUQ U/S: Distended gallbladder with intraluminal sludge and gallstones without definite evidence of acute cholecystitis. If clinical concern remains nuclear medicine hepatobiliary scan could be performed. [**6-9**] CXR, portable: Heart is mildly enlarged. Aorta is calcified. There is patchy focal density in the right mid lung zone, which may represent aspiration or pneumonia. There is also left lower lobe atelectasis or infiltrate. Findings are about the same as the prior study. There is mild underlying interstitial disease, may represent mild congestive failure. [**6-12**] CXR, portable: The feeding tube is again seen and unchanged and within the fundus of the stomach. There is unchanged cardiomegaly. There is a left retrocardiac opacity. Small bilateral effusions are again seen. There is mild atelectasis of the right mid lung field. Overall, these findings are unchanged. Brief Hospital Course: 77 year-old woman recently discharged from [**Location (un) 620**] ([**6-4**]) for pneumonia/sepsis who presents from rehab with fevers and respiratory distress. She spiked a fever following the removal of her NG feeding tube which may have caused aspiration pneumonitis v. pneumonia. It is possible that her previous pneumonia may have been incompletely treated. Admission CXR had LLL infiltrate and possible RLL infiltrate. Other possible etiologies were thought to be wound infection, bacteremia, endocarditis, C. diff infection. One set of blood cultures did grow coagulase negative Staph. She was initially treated with Vancomycin, Piperacillin/Tazobactam, and Levofloxacin. Her antibiotics were narrowed to Vancomycin alone on [**6-9**], given her prior known infection with strep pneumo and MRSA. TTE was negative for valvular pathology. Aside from Urine with yeast, no other cultures were positive. The patient was stable to transfer to the floor. On the floor, the patient's mental status was more alert. She was able to engage in some mild conversation. Each day on the floor, the patient would have one or more episodes of acute respiratory distress that was attributed to secretions that blocked the airway. Suctioning and good nursing care usually was able to bring the patient back to her recent baseline. The lack of meaningful physical improvement and seeing the type of interventions that are required to suction secretions led to a family meeting where goals of care were discussed. 3 of the patient's 4 sons were able to meet. There consensus is that the patient should only receive care that will add to her comfort. They decided that a clogged NG feeding tube should not be replaced so as to not subject the patient to another somewhat uncomfortable procedure. The family ultimately decided to transition the patient to hospice care. She was made comfort measures only, and she passed away on [**2108-6-22**]. PROBLEM LIST # Fever: aspiration pneumonitis vs transient bacteremia. One set of blood cultures revealed coagulase negative Staph. Antibiotics were narrowed to just Vancomycin (10-day course) which would cover both Staph and Strep. CXR does not look worse. # Respiratory distress: Difficult to determine how hypoxic she was based on nursing home notes. SpO2 was 82% on RA in the ED, then 100% on NRB. She has COPD and per her sons she was on O2 at baseline (unclear how much). CT findings as above. She was started on antibiotic therapy for pneumonia as above. She was also continued on her steroid taper. Repeat CXR showed no obvious worsening throughout the hospitalization. With her COPD at baseline, her pulmonary function likely took a big hit during her 3-wk bout of PNA at the OSH. # COPD: The patient was treated with steroids, nebulizers, antibiotics, and supplemental oxygen. Now only on steroids and nebulizers. # Altered mental status/Delirium: Per family, patient's mental status improved slowly during her stay in the [**Hospital Unit Name 153**]. Possible etiologies for delirium were felt to include infection, fevers, uremia, hypernatremia, CVA. Now that patient has started receiving as needed morhphine and ativan, the mental status is a bit less attentive and less alert. # CKD: Had 4 sessions of HD at [**Location (un) 620**] due to severe [**Last Name (un) **], now with adequate urine output and off HD. Creatinine progressively decreased to <2.0. # Diabetes: On low dose Lantus and sliding scale insulin. Increase as PO intake increases. # Hypertension: On IV hydralazine and metoprolol. Can consider Clonidine patch or crushed PO meds if taking some POs. # Hypothyroidism: Synthroid PO vs IV. # Nutrition/Fluids: IV fluids low rate, POs as tolerated. Speech and swallow recommends pureed diet and nectar-thickened liquids. Reassess as pt's mental status and physical condition improves. # DVT Prophylaxis: Heparin subcutaneous # CODE STATUS: The patient's DNR/DNI status was confirmed with her HCP (son [**Doctor Last Name **] on [**6-7**]. Medications on Admission: Prior to [**5-15**]: Alendronate 70 mg Tablet weekly Amlodipine 7.5 mg Tablet daily Calcitriol 0.25 mcg daily Epoetin Alfa [Procrit] Fluticasone-Salmeterol 250 mcg-50 mcg/Dose 1 puff daily Gabapentin 300 mg daily Hydrocodone-Acetaminophen 5 mg-500 mg Q12 prn pain Levothyroxine 25 mcg daily Lisinopril 20 mg daily Aspirin 81 mg daily NPH Insulin Human Recomb [Humulin N] 16 U [**Hospital1 **] Insulin Aspart Sliding scale . Medications from rehab: Omeprazole solution 20 mg daily Norvasc 10 mg daily Aspirin 81 mg daily Levoxyl 25 mcg daily Ipratropium nebs TID Albuterol nebs TID Brovana nebs b.i.d. (per DC summary, not listed in NH meds) Pulmicort nebs 0.5% b.i.d. (per DC summary, not listed in NH meds) Lantus 70 units daily (per DC summary, not listed in NH meds) Heparin subcu 5000 units daily Prednisone 30 mg daily tapering down by 10 mg every 3 days then off Metoprolol 25 mg t.i.d. Epogen injection q.2 weeks Lasix 40 mg every other day (per DC summary, though not listed in NH meds) NG tube with Nepro tube feeds at a goal of 33 mL/h Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired

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icd9cm

[ [ [] ] ]

[ "96.6", "38.93" ]

icd9pcs

[ [ [] ] ]

14022, 14031

8899, 12926

342, 348

14082, 14091

5161, 5161

14147, 14157

4424, 4615

14052, 14061

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4630, 5142

3230, 3263

275, 304

376, 3211

5177, 8876

3285, 3471

3487, 4408

22,289

117,597

2421

Discharge summary

report

Admission Date: [**2109-7-12**] Discharge Date: [**2109-7-18**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1936**] Chief Complaint: Hematemesis Major Surgical or Invasive Procedure: Endoscopy [**2109-7-15**] History of Present Illness: Admission information and pertinent hospital course: 84 year old male c DM, HTN, OA, afib not on coumadin, CKD stage IV, Chronic CHF recently discharged [**Date range (1) 12474**] for R ankle pain (resolved on own, no etiology) and mild heart failure exacerbation, is readmitted on [**7-12**] for Chest pain. While in ED, had episodes of hematemesis, thus was admitted to MICU. As for chest pain: Pt reports experiencing a sharp, stabbing, left sided CP started [**7-12**] am, on/off since that day. Reproducible on exam. EKG unremarkable. Trops negative. Pain is better today. Thought to be musculoskeletal with possible GI component. As for episode of hematemesis. Has chronic anemia, but recent admission his hgb was lower than baseline ([**7-20**]) to 6.5, hemeoccult neg, no obvious bleeding, got 2U. had no GI complaints, was told to follow up. This admission, initially no GI complaints other than chest pain. No melena, no further hematemesis. NGL was performed in ER, and per report showed old blood that cleared after 700 cc's. He was started on IV PPI and transfered to MICU, where per notes, another NGL done, still old blood, but easily cleared. NGT removed [**1-12**] nausea/discomfort. Seen by GI. hgb and vitals have been stable, thus EGD defered to [**7-15**] am. Over past couple days, has c/o intermitted periumbilical/epigastric pain, but that has also resolved by time of transfer to floor. He is tolerating clears. Of note, pt with hematemesis approx 1 year ago. EGD at that time showed some gastritis in the antrum. He was prescribed high dose PPI. Also, while in ER, initially CXR with possible RLL PNA, started on levaquin, no fevers/white count/cough. Past Medical History: PMH: CHF, nonischemi, systolic EF per echo [**11-17**] 45%, diastolic dysfunction. Etiology, ?HTN (Echo '[**03**] only 30%prox LCx, otw normal) HTN c mod LVH dyslipidemia Afib-not on coumadin CKD IV, baseline 2.6-2.9, sees Dr. [**Last Name (STitle) 4883**] Anemia, normocytic, AoCKD likely Ex Tobacco user DM, on insulin, hgb A1c 8.4 OA CaP s/p prostatectomy Urinary incontinence Gastritis, EGD [**2107**] (p/w hematemesis) on PPI Social History: Lives with daughter and [**Name2 (NI) 802**]. Wife just passed away end of [**6-18**]. Quit smoking 4 years ago but smoked [**12-12**] PPD for 40 years. Drank 1 shot of whiskey everyday in the past. No drugs. Family History: no CAD, no cancers Physical Exam: PHYSICAL EXAM on ICU admission/transfer: Vitals: BP 112/63, HR 80 Gen: NAD, A & O x3 HEENT: No oropharyngeal erythema or exudate. CV: RRR. No m/r/g. LUNGS: CTAB ABD: +BS. Minimal tenderness slightly below umbilicus, ND Recta: Brown, guaiac negative stool in rectal vault. EXT: No c/c/e. Discharge Exam: ============== Vitals: 98.6 96-104/56-68 95%RA Pain: 0/10 Access: PIV Gen: pleasant, nad, walking around HEENT: o/p clear, mmm Neck: JVD 7cm at 45deg CV: irreg irreg, [**1-16**] SM LSB Resp: CTAB with bibasilar crackles, stable, no wheezing Abd; soft, nontender, +BS Ext; no edema Neuro: A&OX3, nonfocal Skin: no changes psych: pleasant Pertinent Results: See below for 24hour Labs: interpretation: creat up from 2.9-->3.3-->3.1-->2.9 today BUN stable 45-55 Hgb around 10. Other labs: Trops X2 unremarkable (0.08, 0.07), proBNP of 2312, and urinalysis unremarkalbe. Blood cultures were also sent, ntd. . . Imaging/results: . Echo: There is moderate symmetric left ventricular hypertrophy with normal cavity size and moderate global hypokinesis (LVEF =30-35%). The estimated cardiac index is borderline low (2.2L/min/m2). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The right ventricular free wall is hypertrophied. The right ventricular cavity is mildly dilated with moderate global free wall hypokinesis. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [**2108-12-7**], biventricular systolic function is more depressed. The estimated pulmonary artery systolic pressure is higher. These findings are suggestive of an infiltrative process (e.g., amyloid). . . EGD: normal esophagus, antral erythema and friability, antral/fundus erosions, angioectasia, first part of duodenum ECG [**7-12**]: Afib, good vent rate, frequent PVCs vs aberrantly conducted beats. . . Chest x-ray [**7-12**]:new RLL possible infiltrate XRAY repeated [**7-13**] and [**7-14**] NO infiltrate *has nonspecific RUL nodule, need f/u CT in few months (last [**4-18**]) . . Echo: [**11-17**]: EF 45%, mod cLVH, no WMA Cath '[**03**]: normal except 30% prox LCx. . Brief Hospital Course: ASSESSEMENT AND PLAN: 84year old male with a history of NICM and chronic HF, CKD stage IV, DM on insulin, afib off coumadin, gastritis, admitted to MICU [**7-12**] with chest pain and hematemesis, transfered to Gen Med [**7-14**]. Underwent EGD, revealing gastritis, no further bleeding. Protonix increased to [**Hospital1 **] for 4weeks, then back to qd. Aspirin changed to EC 162mg qd. While on Med service, Low BP (80-90SBP) and rising creatine limiting diuresis and NS holding coreg/valsartan. Echo repeated, EF 35%, PE c/w volume overload still, pt asymptomatic for low BP, thus meds reintroduced. Now is stable once again on home cardiac regimen. Doing well, ready for discharge home today. UGIB/hematemesis X1: h/o gastritis. hematemesis in ED and NGL with old blood, but hgb here has been stable. No further bleeding. -EGD with gastritis c friable mucosa/erosions, no ulcers. Bx for H.pylori sent (note, neg serologies in past) -will place on on protonix [**Hospital1 **] X4weeks, then back to qd -appreciate GI recs, also started on carafate -should be on EC [**Hospital1 **], no NSAIDs . . Chronic heart failure: NICM, systolic HF EF 45% 12/07, also has diastolic dysfunction. Currently appears euvolemic to slightly hypervolemi (though has slight crackles, elevated jvd, elevated BNP). Unfortunately, fluid removal is limited by CKD. Echo repeated [**7-16**] showing global drop in EF 35% (was 45% 12/07, 35% 6/07). -did well on lasix 120mg [**Hospital1 **] yesterday, creat stable today. Will continue at this dose and coreg 3.125mg [**Hospital1 **] and valsartan 40mg qd (tolerated all three yesterday). He will have f/u Dr. [**First Name (STitle) 437**], cards, on [**7-23**], at which time her creat should be rechecked. -Also of note, echo suggestive of infiltrative process such as amyloidosis, which can be seen in CKD patients. However, not sure if further w/u would be of any significancea at this age. . . CKD stage IV: creat baseline 2.6-2.9. Again, tricky situation in setting of fluid overload, will need to find regimen that keeps him more or less euvolemic with stable creatinine. Electrolytes otw stable. -he seems to be doing well with lasix 120mg [**Hospital1 **], cont this dose with outpt follow up -cont Calcitriol for hyperpara -cont Fe supp for AoCKD, consider epo as outpt, defer to Dr. [**Last Name (STitle) 7473**] [**Name (STitle) 12475**] dose meds, avoid nephrotoxins, monitor uop . . Periumbilical pain/epigastric pain: LFTs with elevated alk phos and lipase. However symptoms resolved, tolerated clears -RUQ US unremarkable, symptoms resolved. . Chest pain, atypical. Reproducible and ?GI related vs volume related. ruled out with trops, unremarkable EKG, no sig CAD (cath essentially normal [**2103**], except 30% prox LAD), so less concern for ischemia. -follow for now, has essentially resolved. tylenol prn . . Diabetes- Levemir=>Glargine here -cont 45U qdinner -cont SSI . . Atrial fibrillation - Rate well-controlled off coreg currenlty. - unclear whether coumadin has been addressed but not issue currently in setting of erosive gastritis. Can be readdressed after 6weeks of high dose PPI [**Hospital1 **]. EC [**Hospital1 **] on discharge until f/u PCP or cards . . Right-upper lobe opacity - Persistent from [**2109-4-21**]. Will need repeat Chest CT in [**2-14**] months. -Need to notify PCP to [**Name9 (PRE) 702**] after discharge. . . Urinary incontinence - Continue imipramine, though has not helped, will discuss with PCP. . . Dyslipidemia: atorva 10, [**Name9 (PRE) **] EC 81 to be resumed in next couple days . . Geriatric Care: recent death of wife, pt is grieving. Also has MMP and 4hosp in past 6months. -appreciate social work help, he is set up VNA services for medications, home PT, nutrition consult. Fortunately, pt lives with daughter, who is involved in his care -med reconciliation to d/c unneccesary meds . . FEN/proph: HLIV, monitor lytes, cardiac/diabetic diet as tolerated, no AC, encourage ambulation TEDs/SCDs, PPI PO BID as above, bowel regimen, PT/OT following . . Dispo/code: Full code. discharge home today in good condition. f/u is set with renal, PCP, [**Name10 (NameIs) 2086**] NP. POA is daughter,[**Name (NI) 12469**] [**Telephone/Fax (1) 12470**], is updated by myself, social worker, and nursing staff. She will pick patient up at 6pm. Medications on Admission: MEDS: 1. Aspirin 162mg 2. Atorvastatin 10 mg 3. Valsartan 40mg daily 4. Carvedilol 3.125 [**Hospital1 **] 5. KlorCon 20mEq daily 6. Furosemide 120 mg [**Hospital1 **] 7. Flonase [**Hospital1 **] 8. Levemir insulin 45 units at supper 9. Pantoprazole 40 mg 10. Imipramine HCl 10 mg HS 11. Calcitriol 0.25 mcg daily 12. Iron 325 mg daily 13. Colace 100 mg [**Hospital1 **] 14. Senna Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day: x four weeks then daily. [**Hospital1 **]:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). [**Hospital1 **]:*120 Tablet(s)* Refills:*0* 3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO twice a day. [**Hospital1 **]:*60 Tablet(s)* Refills:*2* 4. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). [**Hospital1 **]:*qs Capsule(s)* Refills:*2* 5. Imipramine HCl 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). [**Hospital1 **]:*qs Tablet(s)* Refills:*2* 6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Hospital1 **]:*qs Tablet(s)* Refills:*2* 7. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). [**Hospital1 **]:*qs Tablet, Delayed Release (E.C.)(s)* Refills:*2* 8. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). [**Hospital1 **]:*60 Tablet(s)* Refills:*2* 9. Valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Hospital1 **]:*qs Tablet(s)* Refills:*2* 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): for constipation. Hold for diarrhea. [**Hospital1 **]:*60 Tablet(s)* Refills:*2* 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO HS (at bedtime): for constipation. [**Hospital1 **]:*qs Capsule(s)* Refills:*2* 12. Furosemide 80 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). [**Hospital1 **]:*120 Tablet(s)* Refills:*2* 13. Klor-Con 10 10 mEq Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO at bedtime. [**Hospital1 **]:*qs Tablet Sustained Release(s)* Refills:*2* 14. Flonase 50 mcg/Actuation Spray, Suspension Sig: [**12-12**] Nasal twice a day. [**Month/Day (2) **]:*qs bottle* Refills:*2* 15. Levemir 100 unit/mL Solution Sig: 45U Subcutaneous once a day. [**Month/Day (2) **]:*qs qs* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Hematemesis, GAstritis, anemia chronic heart failure Discharge Condition: Good Discharge Instructions: Call your doctor if you have fevers, worsening shortness of breath, chest pain, weight gain. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet, no canned foods. Fluid Restriction: 1.5L per day Your medications are the same, except, you aspirin should be enteric coated. Your protonix is increased to twice a day. your iron should be twice a day. Followup Instructions: Geriatric Consult: Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2109-7-22**] 3:00 Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2109-10-21**] 11:30 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2109-7-23**] 11:00 Provider: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 62**] Date/Time:[**2109-7-23**] 2:00--Cardiology, Dr.[**Name (NI) 3536**] nurse practioner

[ "285.21", "585.4", "272.4", "V58.67", "425.4", "V10.46", "250.00", "403.90", "428.0", "788.30", "535.51", "428.42", "427.31", "518.89" ]

icd9cm

[ [ [] ] ]

[ "45.16" ]

icd9pcs

[ [ [] ] ]

11858, 11915

5070, 9402

275, 303

12012, 12019

3406, 3525

12465, 13138

2707, 2727

9833, 11835

11936, 11991

9428, 9810

384, 2010

12043, 12442

2742, 3031

3047, 3387

223, 237

331, 367

2032, 2464

2480, 2691

3537, 5047

8,331

142,243

48036

Discharge summary

report

Admission Date: [**2128-12-23**] Discharge Date: [**2129-1-3**] Date of Birth: [**2065-12-2**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 783**] Chief Complaint: SOB Major Surgical or Invasive Procedure: intubation ([**Date range (3) 101313**]) History of Present Illness: 63 you M with PMHx of COPD on home O2, Hep C, hx of aflutter 5 yrs ago who presents with cough, rhinorrhea, sore throat since [**Holiday **]. Over the past 2 weeks, he c/o fevers to 101 (3d ago), chills, myalgias, increasing productive cough, increasing SOB. She states he gets bronchitis qyr and got the flu vaccine this yr. He also c/o diarrhea x 2 weeks for which he took immodium and his diarrhea subsequently stopped [**3-15**] d ago. He went to his PCP where CXR showed PNA and he was given combivent/albuterol/solumedrol 125 mg IV x 1. He had OSH labs which were significant for BNP of 77.1. He was transferred to [**Hospital1 18**] for further care. Here, his initial temp was 99.5 with O2 sat of 79% on RA. He was started on 100% NRB and was noted to have increased lethargy. He was then given 40 IV lasix (unclear reasons), [**Name (NI) **], CTX 1g iv x 1, albuterol nebs and ABG showed 7.27/95/140. Thus started on CPAP 10/5/0.6 and given 0.5 mg IV ativan and now MICU consulted. Intubated [**12-24**] for hypercarbic respiratory failure (7.26/103/66/48). Requires home O2 (3L rest, 4L walking) and takes nebs as needed. Not on tiotropium. Reports no EtOH since [**2128-12-11**]. No prior EtOH withdrawl seizures or DTs. Last cigarette 3 months ago. Taking nicotine replaceement (patch). Past Medical History: COPD HCV A-flutter s/p CV, reate controlled, no coumadin for fall precaution (EtOH) EtOH abuse CAD s/p inferior MI Cor pulmonale Social History: lives at home with wife. has 2 sons. not smoking presently on nicotine replacement. Last cigarette 3 months ago. (+) alcohol. (-) illicit drug use. He has significant occupational risk for lung disease, inhaled metal dust and asbestos as a construction worker on power plants. Family History: noncontrib Physical Exam: VS: t99.8, 110/80, p111, r23, 96% on BIPAP 10/5/60% gen: sedated, on CPAP, not easily arousable heent: pinpoint pupils, op not examined as on bipap chest: decreased BS left base, diffuse wheezes bilaterally Cor: s1/s2, tachycardic, no s3 no murmur, JVP flat abd: soft, nt/nd, noabs ext: no c/c/e neuro: mae Pertinent Results: LABS ON DISCHARGE: WBC-7.6 Hgb-12.8* Hct-38.3* MCV-97 Plt Ct-185 neut 88%, band 0%, lymph 8% INR 1.1, albumin 3.8 ALT 40, AST 39, Tbili 1 Glucose-87 UreaN-25* Creat-0.6 Na-144 K-3.6 Cl-101 HCO3-39* AnGap-8 Calcium-9.0 Phos-4.2 Mg-2.3 CK 154, 107, 77 TnT <0.01 x3 Digoxin 0.7 ABG: 7.27/95/140 on 100% nonrebreather 7.31/87/71 (intubated) 7.38/72/81 (extubated on 3L n/c) MICRO: Sputum ([**2128-12-27**]): GRAM STAIN (Final [**2128-12-27**]): <10 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. QUALITY OF SPECIMEN CANNOT BE ASSESSED. RESPIRATORY CULTURE (Final [**2128-12-29**]): RARE GROWTH OROPHARYNGEAL FLORA. Sputum ([**2128-12-24**]): GRAM STAIN (Final [**2128-12-24**]): >25 PMNs and <10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND SINGLY. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S). RESPIRATORY CULTURE (Final [**2128-12-26**]): SPARSE GROWTH OROPHARYNGEAL FLORA. MOLD. 1 COLONY ON 1 PLATE. Sputum ([**2128-12-23**]): GRAM STAIN (Final [**2128-12-23**]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. RESPIRATORY CULTURE (Final [**2128-12-25**]): MODERATE GROWTH OROPHARYNGEAL FLORA. NEISSERIA MENINGITIDIS. HEAVY GROWTH. BETA-LACTAMASE NEGATIVE: PRESUMPTIVELY SENSITIVE TO PENICILLIN. Legionella Urinary Antigen (Final [**2128-12-25**]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. Influenza DFA ([**2128-12-23**]): NEGATIVE for influenza A and B Influenza viral cx no isolate at time of discharge Blood Cx X1 SET([**2128-12-23**]): NO GROWTH IMAGING: CXR ([**2128-12-23**]): IMPRESSION: Mild increased opacities within the retrocardiac left lower lobe. A repeat PA and lateral is recommended to exclude pneumonia CXR ([**2128-12-24**]): AP bedside chest. The heart is normal in size without vascular congestion, consolidations, or effusions. Right CP angle not imaged. Since exam one day previous, the equivocal process in the left lower lobe behind the heart is no longer identified. No overt evidence of emphysema on current exam. CXR ([**2128-12-30**]): There has been considerable improvement in the appearance of the chest since [**2128-12-29**]. IMPRESSION: There are no acute changes. CARDIAC: TTE ([**2128-12-24**]): LA 3.6x4.8cm RA 5cm LV septum 1 cm E/A ratio 1 E wave decel 265ms LVEF 55% with no WMA (though suboptimal study) Dilated RV Brief Hospital Course: 63 y/o man with severe COPD and LLQ pneumonia admitted to MICU for hypercapnic respiratory failure requiring intubation. Hospital course outlined by problem [**Name (NI) 101314**]: ## RESPIRATORY FAILURE: Etiology due to LLL pneumonia with COPD exacerbation. He was started on CPAP with little benefit and required intubation for worsening hypercapnia, respiratory distress, and somnolence. He was continued on IV steroids then transitioned to a PO steroid taper. Sedation was accomplished with midaz and fentanyl drip. He was started on azithromycin and ceftrizxone for coverage of community acquired oragansims, however when he failed to improve, he was transitioned to levaquin and ceftriaxone for more appropriate coverage of a possible pseudomonas nosocomial pneumonia. Sputum cultures grew oral flora and on one occasion Neiseria meningitis. He is a carrier for N. meningitis which does not warrant treatment, however the ceftrizxone would cover this organism. His MICU course was complicated by a brief episode of hypotension that was felt to be related to hypovolemia (increased insensible losses from respiratory distress) and not felt to be related to sepsis. He was volume resuscitated with good results and required a total of 7 liters IVF in the MICU. He was extubated on [**2128-12-30**] with a postextubation ABG of 7.38/72/81 with a HCO3=40. O2 sats were 91-95% on 3 liters n/c. He is a CO2 retainer and should be kept at O2 sats of 90-94%. Standing atrovent and albuterol nebulizers and fluticasone were continued. Echo showed evidence of RV failure in the absence of LV failure consistent with cor pulmonale from his COPD. He was encouraged to continue his effort toward smoking cessation. He was d/c on nicotine replacment therapy (patch). HE WILL NEED A TOTAL OF 4 MORE DAYS OF PREDNISONE FOR HIS RAPID TAPER. He was started on Tiotropium and after 24 hours of loading the drug, his Atrovent was stopped. His Advair was increased to 500/50 1 puff [**Hospital1 **]. Unfortunately at the end of his stay, he was exposed to a roomate who tested positive for INFLUENZA A. Given his poor pulmonary reserve, he was started on prophylactic amantadine 100mg [**Hospital1 **] x10days. Nasopharyngeal aspirate was performed; the results of his DFA and viral cultures are pending and will need to be followed up by his primary care physician, [**Name10 (NameIs) 7470**] if he develops any flu-like symptoms. ##CAD: The patient had no active coronary ischemia, however his EKG was notable for inferior Q waves suggestive of a prior inferior wall MI. Transthoracic echo did not show an inferior wall motion abnormality however the study was of suboptimal quality. He was started on an ACEI and aspirin. He was continued on a statin. He is taking a CCB for rate control of a-flutter, however he is not taking an beta blocker. This should be considered once his COPD is back to baseline for secondary prevention of ACS and decreased mortality benefit. It is suggested that he be started on an ACEI, beta blocker, and increased statin (if LDL is >100) for longterm management of his CAD. ##Heart failure: He had evidence of RV failure in the absence of LV failure most consistent with Cor Pulmonale from his sevre COPD. He was hypovolemic on presentation to our ED. His lasix was held and he was volume resusitated. He will need to restart his lasix from longterm management of his edema. His COPD was treated as above. ##Sinus tachycardia: Despite improvements in his respiratory function, he continued to be tachycardic. ECG confirmed sinus tachycardia and not recurrence of atrial flutter. He was not hypoxic and demonstrated no other signs/symptoms of DVT or PE (no fever, chest pain, leg pain/edema, breathing was improved with COPD managment). Given that his verapamil was discontinued abruptly in the ICU it was felt that it was due to rebound tachycardia. He was restarted on his CCB prior to discharge and his heart rate decreased accordingly. He is being discharged on a higher dose of verapamil 200mg SR qd and HIS BLOOD PRESSURE AND HEART RATE WILL NEED TO BE CHECKED. ##Alcoholism: The patient's last alcohol consumption was 1/105, more than one week prior to admission. He had received a benzo drip for sedation while intubated and then was loaded on valium. Except for a sinus tachycardia (felt to be related to his CCB rebound tachycardia), he demeonstrated no signs/symptoms of withdrawl. Medications on Admission: Verapamil CR 180mg qd lasix 20mg po qd Kcl 10mEq qd flovent 220mcg [**Hospital1 **] albuterol 2 puffs qid atroven 2 puffs qid digitec 0.25mcg qd Discharge Medications: 1. Prednisone 10 mg Tablets, Dose Pack Sig: see below Tablets, Dose Pack PO once a day for 7 days: 2 tablets daily on [**12-12**] 1 tablet daily on [**12-14**]. Disp:*qs Tablets, Dose Pack(s)* Refills:*0* 2. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 4. Potassium Chloride 10 mEq Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day. 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours): continue until 1 week after stopping steroids. Disp:*15 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 7. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). 8. Digoxin 50 mcg Capsule Sig: .5 Capsule PO once a day. 9. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1) Inhalation twice a day. Disp:*3 qs* Refills:*6* 10. Verapamil HCl 200 mg Cap, 24HR Sust Release Pellets Sig: One (1) Cap, 24HR Sust Release Pellets PO once a day. Disp:*30 Cap, 24HR Sust Release Pellets(s)* Refills:*2* 11. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation four times a day. 12. Amantadine HCl 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 10 days. Capsule(s) Discharge Disposition: Home Discharge Diagnosis: Primary: 1. Respiratory Failure. 2. Acute Exacerbation of COPD. 3. Paroxysmal Atrial Flutter. 4. Congestive Heart Failure. 5. ETOH Withdrawal. Secondary: 1. 02 Dependent COPD. 2. Alcohol Dependence. 3. Cor Pulmonale. 4. Hepatitis C. Discharge Condition: stable to home on baseline O2 requirement with services Discharge Instructions: if you devleop fever, worsening trouble breathing, , generalized body aches (like you're coming down with the flu) then contact your physician or call 911. wear a mask when interacting with young children or people older than 65y/o until you know that you don't have influenza. Call [**Telephone/Fax (1) 2756**] and ask to speak with the laboratory. Ask them what your results are. Talk to your physician about the use of tiotropium Followup Instructions: Contact your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Name (STitle) **], to schedule a follow up visit within 1 week of your hospital discharge, phone: ([**Telephone/Fax (1) 101315**] [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]

[ "428.0", "276.0", "491.21", "303.90", "276.5", "291.81", "V01.79", "416.9", "427.32", "486", "070.70", "518.81" ]

icd9cm

[ [ [] ] ]

[ "96.6", "96.04", "96.72", "93.90" ]

icd9pcs

[ [ [] ] ]

11252, 11258

5162, 9619

318, 360

11535, 11592

2512, 2512

12077, 12428

2158, 2170

9814, 11229

11279, 11514

9645, 9791

11616, 12054

2185, 2493

275, 280

2531, 5139

388, 1693

1715, 1845

1861, 2142

47,827

192,193

43296

Discharge summary

report

Admission Date: [**2197-1-18**] Discharge Date: [**2197-1-31**] Date of Birth: [**2117-10-12**] Sex: M Service: NEUROSURGERY Allergies: Aspirin Attending:[**First Name3 (LF) 2724**] Chief Complaint: WOUND DRAINAGE Major Surgical or Invasive Procedure: wound washout x 2 TEE blood transfusions History of Present Illness: HPI:79M recently discharged to rehab from the neurosurgery service. He had a thoracic instrumented fusion with pedicle screws and iliac crest bone graft on [**2197-1-11**]. The patient was extubated the following day and his CT scan showed proper placement of hardware. The patient was sent to rehab on [**1-16**]. He is back in the ER today with an elevated WBC and reportedly has had purulent drainage from the wound. The patient reports that he is in pain but that it is not any worse today compared with the last few days. He reports that it is difficult for him to lie flat in the bed. The patient has been participating in physical therapy at rehab. He has no new weakness, numbness, tingling. He has no bowel or bladder changes, no SOB, or chest pain. Past Medical History: PMHx:HTN,dislipidemia,TIA, ankylosing spondylitis, sleep apnea, BPH s/p prostatectomy and removal of colon polyps. Social History: Social Hx:lives alone in [**Hospital3 4634**] Family History: Family Hx: widowed with 6 children Physical Exam: PHYSICAL EXAM: T:99.3 BP:137/72 HR:105 RR:18 O2Sats:96% RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils:PERRL EOMs-intact Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Motor: D B T WE WF IP Q H AT [**Last Name (un) 938**] G R 5 5 5 5 5 5- 5 5 5 5 5 L 5 5 5 5 5 5 5 5 5 5 5 Sensation: Intact to light touch, propioception bilaterally. Propioception intact Toes downgoing bilaterally Dressing changed: Wound had serosanguanous drainage. Dressing had some purulent drainage as well. Pertinent Results: 1/28/09Labs: Na 138 Cl 100 BUN 19 Glu 147 K 4.4 CO2 29 Cr 0.8 WBC 20.9 Hgb 10.3 Hct 29.4 Plts 546 N:92.7 L:3.8 M:2.5 E:0.9 Bas:0.1 Brief Hospital Course: Pt was admitted to the hospital and went to OR for wound washout with placement of VAC dressing. He was seen by ID and started on antibxs and cultures followed. His vanco trough and creatinine were also followed and adjustments to vancomycin made - he will need weekly labs while on antibiotics - estimated course - 6 weeks at minimum. VAC dressing was removed [**1-21**]. He returned to the OR for second washout [**1-26**] and closed primarily. He had drain placed which was removed on POD#4. The wound was clean and dry. His hematocrit was followed and he received transfusion [**1-30**] for hematocrit of 23 which came up to 28. His motor exam remained full. He worked with PT/OT and was recommended for rehab. Medications on Admission: simvastatin metoprolol lidoderm patch Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed. 6. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 7. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 10. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. 11. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 13. Insulin Lispro 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR (AS DIRECTED). 14. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 16. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) Intravenous Q 24H (Every 24 Hours). 17. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: Wound infection Bacteremia post op anemia of blood loss ankylosing spondylitis Discharge Condition: NEUROLOGICALLY STABLE Discharge Instructions: DISCHARGE INSTRUCTIONS FOR SPINE CASES ?????? Do not smoke ?????? Keep wound clean / No tub baths or pools until seen in follow up/ take daily showers ?????? No pulling up, lifting> 10 lbs., excessive bending or twisting for two weeks then increase as tolerated. ?????? Limit your use of stairs to 2-3 times per day ?????? Have your incision checked daily for signs of infection ?????? Take pain medication as instructed; you may find it best if taken in the a.m. when you wake for morning stiffness and before bed for sleeping discomfort ?????? Do not take any anti-inflammatory medications such as Motrin, Advil, aspirin, Ibuprofen etc. for 3 months. ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? Pain that is continually increasing or not relieved by pain medicine ?????? Any weakness, numbness, tingling in your extremities ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F ?????? Any change in your bowel or bladder habits You will need to stay on vancomycin IV until seen in follow up with ID - please have weekly labs: CBC with diff, BUN,Creatinine, ESR, CRP and vanco trough and have results faxed to Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 432**] Followup Instructions: PLEASE HAVE YOUR SUTURES REMOVED AT REHAB [**2-9**] OR RETURN TO THE OFFICE IF NEEDED PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR. [**Last Name (STitle) **] TO BE SEEN IN 6 WEEKS. YOU WILL NEED XRAYS PRIOR TO YOUR APPOINTMENT Please follow up with ID: [**First Name4 (NamePattern1) 8495**] [**Last Name (NamePattern1) 8496**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2197-3-9**] 10:00AM Completed by:[**2197-1-31**]

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icd9cm

[ [ [] ] ]

[ "03.4", "77.69", "86.74", "88.72", "86.04", "38.93" ]

icd9pcs

[ [ [] ] ]

4779, 4876

2389, 3112

288, 331

4999, 5023

2216, 2366

6555, 7012

1337, 1373

3200, 4756

4897, 4978

3138, 3177

5047, 6532

1403, 1649

234, 250

359, 1119

1664, 2197

1141, 1257

1273, 1321

8,389

122,962

53724

Discharge summary

report

Admission Date: [**2111-11-15**] Discharge Date: [**2111-11-22**] Date of Birth: [**2047-3-13**] Sex: M Service: MEDICINE Allergies: Plavix / Dofetilide / Ace Inhibitors Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: s/p fall Major Surgical or Invasive Procedure: central venous line anesthesia History of Present Illness: Mr. [**Known lastname 75926**] is a 63 yo M with history of HTN, DM, hypercholesterolemia and CAD s/p CABG who presented to the ED after a mechanical fall. He was walking into his kitchen, slipped on a bag and fell on his left thigh. He did not have any loss of consciousness, chest pain, shortness of breath, dizziness or lightheadedness either preceding or following the event. He believes he hit the left side of his head. He banged on the floor of his apt to alert his son who lives below him. He had L thigh pain, no other pain. His son called EMS. The pain is severely exacerbated with minimal movement. He denies any recent illness. . ROS: He denies any fevers, chills, or night sweats, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies constipation, diarrhea. . Cardiac review of systems is notable for increased LE edema over the past two weeks, which he attributes to dietary indiscretion. He has been cutting back on salt in his diet and noted some improvement in the edema. He also has DOE. At baseline he is able to walk [**4-12**] blocks without dyspnea. No change in functional status recently. Negative for chest pain, paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope or presyncope. Last episode of CP was > 6 months ago. . ED Course: Vital signs were T97.6, BP98/69, HR76, RR18, O2sat 95% on RA. CXR was unremarkable. Femur film showed femoral neck fracture. He was seen by ortho in the ED. He is admitted to medicine due to complicated cardiac history. . Of note, the patient suffered from a head injury ([**5-14**]) which resulted in a subdural hematoma. He suffered seizures from this and was started on anticonvulsants. He self d/c'd this medication and has not suffered from any seizures since that time. However, he is not currently on anticoagulation for his atrial fibrillation. Prior to restarting he will need to be cleared by neurology. Past Medical History: 1. CAD: s/p CABG in [**2098**] (LIMA to LAD, SVG to OM1, SVG to PDA) -[**2109**] echo: EF 20%, MR [**First Name (Titles) **] [**Last Name (Titles) **] -[**12-11**] stress: negative, though stopped [**1-9**] fatigue; Pacemaker/[**Month/Day (2) 3941**], in BiV [**Month/Day (2) 3941**] placed in [**12-11**] for low EF -[**12/2102**] cath: stenting of the proximal SVG-RCA lesion, angio-jet thrombectomy of the thrombotic occlusion SVG-OM graft, stenting of the mid-graft and ostial graft SVG-OM lesions -[**10/2102**] cath: done for recurrent angina showed severe native vessel disease, a patent LIMA with a 40% stenosis in the LAD distal to the touchdown, a proximal 50% stenosis in the SVG to RCA, and a mid 50% stenosis in the SVG to the OM branch. -[**2098**]: Coronary artery bypass graft x 3,including one arterial and two saphenous vein anastomoses, left internal mammary artery to the left anterior descending coronary artery, saphenous vein graft to first obtuse marginal, saphenous vein graft to posterior descending coronary artery. 2. Type II diabetes mellitus. 3. Hypertension. 4. Hypercholesterolemia 5. CRI 6. BiV [**Year (4 digits) 3941**] placed in [**12-11**] for low EF, generator changed (DDD 45-120) on [**2110-2-7**] 7. Enterococcal bacteremia- of unclear origin [**4-12**] 8. Afib- not currently on anticoagulation 9. Subdural hematoma - followed by neurology, on keppra ppx Social History: Denies smoking. He drinks 3 alcoholic beverages/year. Lives alone in an apt above his son's. There is no history of alcohol abuse. Family History: Father died at 59 years with diabetic complications. Mother died at 77 years. She had a coronary artery bypass graft in her mid 50s. Brother had a coronary artery bypass graft at the age of 53. Physical Exam: Vitals: T 97.4, BP 102/64, HR 70, RR 20, O2sat 96% on 2L. Gen: Disheveled male in moderate distress secondary to pain. NCAT. Lying very still in bed. HEENT: Clear OP, MMM, poor dentition, EOMI, PERRL NECK: Supple, No LAD, No JVD on exam (pt lying flat) CV: RR, NL rate. distant S1, S2. HSM distant, non radiating LUNGS: Clear anteriorly and laterally ABD: Soft, NT, ND. NL BS. No HSM EXT: LLE shortened and externally rotated, neurovascularly intact with intact DP and PT pulses. Normal sensation. Moving toes spontaneously. Tenderness to palpation along posterior left thigh. 2+ edema bilaterally. SKIN: Chronic venous stasis changes NEURO: A&Ox3. Appropriate. 5/5 strength bilateral upper extremities. LE not tested as pt in acute pain during time of examination. Sensation of b/l LE intact. PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: LABS: TFTs: TSH 5.6 FT4 1.6 T3 159 . MICRO: Urine [**2111-11-15**]: UA negative; UCx MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. . CT Head [**2111-11-15**]: There is no acute intracranial hemorrhage, edema, shift of normal midline structures or hydrocephalus. The appearance of chronic left parietal infarction. There is extensive mucosal thickening involving right maxillary sinus. The rest of imaged paranasal sinuses and mastoid air cells are well aerated.IMPRESSION: No acute intracranial hemorrhage. . XR femur, pelvis [**2111-11-15**]: There is a left femoral neck fracture with proximal displacement of the distal fracture fragment as well as varus angulation of the fracture fragment. There are extensive vascular calcifications. IMPRESSION: Left femoral neck fracture. . ECG [**2111-11-15**]: Tracing shows irregular ventricular pacing with capture. Compared to prior tracing of [**2111-5-25**] atrial pacing is no longer seen. Ventricular pacing now appears irregular raising the possibity of intercurrent development of atrial fibrillation and suggesting, if so, that pacemaker should be reprogrammed. Suggest clinical correlation and repeat tracing. . CT head/neck [**2111-11-17**]: No C-spine fx. No ICH. No acute process. Brief Hospital Course: 64 year old man with MMP including severe ischemic cardiomyopathy, DM2, CKD admitted with left hip fracture, then PEA arrest following anesthesia induction, minimally responsive since then and eventually made CMO on [**2111-11-21**] after extubation and change of code status to DNR/DNI to comfort measures only. On [**11-22**] he died at 05:50 of cardiopulmonary arrest, immediate cause s/p PEA arrest on [**11-16**]. . 1. s/p pulseless arrest, neurologic status: Event most likely due to pre-load dependence secondary to significant cardiomyopathy exacerbated by induction of general anesthesia. Cycled cardiac enzymes. Peaked at 0.1. Down to 0.06. CT head and CT cspine neg for C-spine injury or bleed. Pt transiently required levophed gtt. Extubated [**11-21**] as above, then CMO since persistently minimally responsive with suspected major neurological damage since event. . 2. Respiratory failure: initially intubated s/p PEA arrest. Kept on AC, then PSV until successfully extubated on [**2111-11-21**] but still only minimally responsive. DNR/DNI since then in agreement with family, followed by CMO status. . 3. Fever: Pt spiked intermittently. [**Month (only) 116**] have been due to infection, however, more likely due to CNS ischemia. Pan-cultured [**11-17**], [**11-18**], [**11-21**]. NGTD. Made CMO on [**11-21**]. . 4. Hip fracture - with femoral neck fracture. Made CMO on [**11-21**]. Pain was controlled with morphine drip. . 5. DM: insulin sliding scale, added basal. . 6. F/E/N: IVF. Repleted lytes PRN. Started tube feeds following nutrition recs. . 7. PPx: Bowel regimen, PPI, sq Heparin until made CMO on [**11-21**] . 8. Access: RIJ until [**11-21**], PIV . Medications on Admission: MEDICATIONS: (compiled by PCP, [**Name10 (NameIs) 3545**] med list) Atorvastatin 40 mg QD Amiodarone 200 mg QD Coreg 6.25 [**Hospital1 **] Bumex 2 mg [**Hospital1 **] NTG 0.6 SL PRN Keppra 1000 [**Hospital1 **] Folic acid 1mg daiy Trevental 400 [**Hospital1 **] zantac 150 in PM and 75 in AM levothyroxine 0.75 daily lorazepam 0.5 QHS PRN Cloracon 10mEq daily Humalog ASA 325 daily Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Cardiopulmonary Arrest . coronary artery disease congestive heart failure diabetes (insulin dependent) history of subdural hematoma left hip fracture Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

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icd9cm

[ [ [] ] ]

[ "96.04", "96.72" ]

icd9pcs

[ [ [] ] ]

8505, 8514

6357, 8044

315, 348

8708, 8718

5043, 6334

8774, 8921

3952, 4148

8476, 8482

8535, 8687

8070, 8453

8742, 8751

4163, 5024

267, 277

376, 2368

2390, 3788

3804, 3936

4,064

143,431

43374+58607

Discharge summary

report+addendum

Admission Date: [**2139-10-6**] Discharge Date: [**2139-10-9**] Date of Birth: [**2093-5-6**] Sex: M Service: HISTORY OF PRESENT ILLNESS: This is a 46-year-old African-American male patient who is well known to the Medical Intensive Care Unit team from a recent lengthy admission, who was discharged the morning prior to this readmission to [**Hospital6 13846**] facility. The patient had been in the Medical Intensive Care Unit for treatment of multiple medical problems from [**8-28**] to [**2139-10-6**]. Events during that hospital stay included treatment for respiratory failure, renal insufficiency of unclear etiology (dialysis dependent), lower extremity bilateral elephantiasis and enterococcal bacteremia, herpes zoster infection, pulmonary hypertension, and upper gastrointestinal bleed. The patient was ultimately stabilized and had a tracheostomy placed on [**9-15**] for failure to wean from the ventilator. A PEG tube was also placed, but the patient was able to take p.o. by the time of previous discharge. Of note, the patient also had known diastolic and right-sided heart failure with an ejection fraction of greater than 55%, and dilated right ventricle. According to the Emergency Medical Service records and report, as well as the Emergency Room Department, and a written record from [**Hospital3 672**], the patient was transported to [**Hospital3 672**] on the afternoon of this admission, was conversant and stable until transferred to flat bed from ambulance stretcher. On transfer, the patient apparently suffered an acute respiratory decompensation, and Emergency Medical Service staff was unable to ventilate him. A large mucous plug was subsequently removed from the tracheostomy insert and respirations were restarted successfully; although the patient became acutely bradycardic and a cardiac arrest code was called. According to the physician notes, the patient was unresponsive from the time of the respiratory distress, and the patient was pulseless when a code was called. The patient was found to be in pulseless electrical activity, and cardiopulmonary resuscitation was begun. The patient then received epinephrine times 1 mg and atropine times 1 mg and converted to ventricular tachycardia which normalized to pulsatile sinus tachycardia. An arterial blood gas was done and found to be 7.107/80/72 on 87% oxygen saturation. The patient never regained responsiveness and was noted to have total left-sided hemiparesis, doll's eyes, and purposeless right-sided movements. The patient was immediately transferred back to [**Hospital1 69**] for readmission and evaluation. In the Emergency Room the patient was unresponsive with arbitrary right-sided arm movements and withdrew to pain on the right lower extremity only. There was no sign of verbal communication or auditory understanding. PAST MEDICAL HISTORY: 1. Obesity. 2. Obstructive sleep apnea. 3. Status post tracheostomy. 4. Hypertension. 5. Pulmonary hypertension. 6. Chronic obstructive pulmonary disease. 7. Cor pulmonale. 8. Chronic renal insufficiency, on hemodialysis. 9. Lower extremity venous ulcers. 10. Dilated right ventricle and right heart failure. 11. Status post upper gastrointestinal bleed. 12. Lower extremity edema/elephantiasis. 13. Status post enterococcal bacteremia. 14. Herpes zoster. 15. Gastric ulcer. ALLERGIES: The patient is allergic to KEFLEX and OXACILLIN. FAMILY HISTORY: The patient has a history of cerebrovascular accidents in his brother and his sister. SOCIAL HISTORY: The patient has a history of remote cocaine and marijuana. The patient quit 10 years ago. The patient also has a 15-pack-year history of tobacco use. The patient is married and lives with his wife previously. MEDICATIONS ON ADMISSION: Please see previous Discharge Summary from [**2139-10-6**]. PHYSICAL EXAMINATION ON ADMISSION: The patient was afebrile, pulse of 75, blood pressure of 122/53, respirations of 19, oxygen saturation 96% on 50% tracheostomy mask. Generally, the patient had purposeless movement of the right upper extremity, in respiratory distress, wide opened injected sclerae. HEENT was significant for dry blood in the oropharynx, tracheostomy was in place and working properly, bilateral injected sclerae, doll's eyes. Lungs revealed he had decreased breath sounds throughout with coarse breath sounds throughout, with some expiratory wheezes diffusely. Heart was tachycardic without an murmur, rubs or gallops. The abdomen was soft, obese, and nontender. Extremities was significant for 3 to 4+ pitting edema bilaterally which was unchanged from previous discharge secondary to elephantiasis. Neurologically, the patient withdrew to pain only on the right lower extremity. Right upper extremity with purposeless movements. The patient did not move his left upper or lower extremity. Of note, the patient was known to not be able to move the left shoulder. LABORATORY DATA ON ADMISSION: He had a white blood cell count of 8, hematocrit of 33.4, platelets of 208. Sodium of 139, potassium of 4.4, chloride of 103, bicarbonate of 20, BUN of 44, creatinine of 3.4, glucose of 124. Calcium was 8.4, phosphorous 5.2, magnesium 2. Creatine kinase #1 was 31. Creatine kinases #2 and #3 were also flat. Troponin was negative. HOSPITAL COURSE: This is a 46-year-old male patient recently discharged after a prolonged Medical Intensive Care Unit stay for multiple medical problems; now re-presenting to the Emergency Room after a respiratory failure and pulseless electrical activity arrest with cardioversion, and neural changes consistent with a possible new cerebrovascular accident. 1. NEUROLOGY: The patient's left-sided weakness was likely secondary to an anoxic brain injury given history of mucous plug and desaturation. Throughout this hospital stay the patient began to regain function in the extremities. At the time of discharge, the patient was able to lift the left lower extremity against gravity and against some resistance; although, it is still weak compared to the right side. The patient had a grasp on the left upper extremity and was able to minimally move his left upper extremity. The patient had no deficits on the right side. A Neurology consultation was obtained for further evaluation of this possible stroke. They also felt that it was consistent an anoxic brain injury and likely area would include the right parietal region. A head CT was obtained while the patient was in the hospital to further evaluate the location of possible cerebrovascular accident. The head CT was pending at the time of this dictation, and an addendum will be dictated as soon as the results are known. 2. CARDIOVASCULAR: The patient was also being ruled out for a myocardial infarction on this hospital admission. Creatine kinases times three as well as troponin were flat. The patient was effectively ruled out. The patient's blood pressure was stable throughout and did not require any additional pressors. The patient did have some bradycardic episodes during dialysis which was consistent with his history of bradycardia during dialysis. Electrocardiograms obtained at this time just showed sinus bradycardia. The patient was asymptomatic with these bradycardic episodes. The patient had no acute changes on the electrocardiogram. An electrocardiogram obtained at this hospital was consistent with previous electrocardiograms. 3. PULMONARY: The patient had a tracheostomy in place and it was functioning well. The patient was kept on a 50% tracheostomy mask ventilation assist control. The tidal volume was 700, respirations of 12, FIO2 of 50%, and a PEEP of 5. The patient's arterial blood gases were done throughout the hospital stay, and last arterial blood gas was 7.39/40/182 and significantly improved. The patient will need routine tracheostomy care and suctioning as needed as the patient had increased secretions while in the hospital. 4. INFECTIOUS DISEASE: Question of possible tracheobronchitis given increased secretions. A chest x-ray was obtained during this hospital stay which showed possible congestive heart failure, but no signs of a pneumonia. Antibiotics were initially held but given the increased secretions, the patient was started on levofloxacin for possible tracheobronchitis. Cultures obtained of the sputum showed 3+ gram-positive rods which were most consistent with oropharyngeal flora. The patient will need to be continued on levofloxacin for a total of seven days. The patient also had a history of herpes zoster and was on intravenous acyclovir. The patient was given intravenous acyclovir until [**10-10**] on hemodialysis days. The patient was afebrile throughout this hospital stay but did have one low-grade fever of 100.8. White count has been stable. 5. RENAL: The patient was on chronic hemodialysis which was started during previous hospital admission. The patient has been receiving Nephrocaps as well as Epogen at hemodialysis and received one hemodialysis treatment this recent hospital admission on the day prior to discharge. 6. CODE STATUS: Code status on this admission was re-addressed with the wife, and the patient is still full code. MEDICATIONS ON DISCHARGE: 1. Estar-Gel. 2. Hibiclens soaks. 3. Epogen 10,000 units three times a week at hemodialysis. 4. Colace 100 mg p.o. b.i.d. 5. Senna 2 tablets p.o. q.d. 6. Nephrocaps 1 tablet p.o. q.d. 7. Domeboro soaks for the zoster. 8. Protonix 40 mg p.o. q.d. 9. Heparin 5000 units subcutaneous t.i.d. 10. Lotrimin cream to the feet b.i.d. 11. Bacitracin to the left lower extremity ulcer b.i.d. 12. Flovent 110 mg 6 puffs b.i.d. 13. Erythromycin ointment to the eye b.i.d. 14. Acyclovir 600 mg p.o. q.d. during hemodialysis; last dose to be given on [**10-10**]. 15. Clonidine 0.2 mg p.o. t.i.d. 16. Hydralazine 50 mg p.o. q.i.d. 17. Isordil 20 mg p.o. t.i.d. 18. Dulcolax 10 mg p.r.n. 19. Tylenol p.r.n. 20. Combivent meter-dosed inhaler 2 puffs q.6h. p.r.n. 21. Tylenol No. 3 one to two tablets for pain q.4h. p.r.n. 22. Levofloxacin 250 mg p.o. times six additional days. CONDITION AT DISCHARGE: The patient was stable at the time of discharge. DISCHARGE STATUS: The patient was to be discharged to [**Hospital6 **] where the patient will receive additional hemodialysis treatments as well as management of ventilation. DISCHARGE INSTRUCTIONS: Of note, please suction tracheostomy secretions routinely as the patient has had increased secretions on this admission and is at risk for plugging up the tracheostomy which is what apparently happened previously. The patient will requiring days of levofloxacin for a total of a 7-day course, and acyclovir can be stopped on [**10-10**]. The patient should be on contact precautions until then. DISCHARGE DIAGNOSES: Respiratory failure with associated possible cardiac arrest, status post mucous plus in tracheostomy. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 5587**] Dictated By:[**Name8 (MD) 2402**] MEDQUIST36 D: [**2139-10-8**] 16:31 T: [**2139-10-8**] 15:45 JOB#: [**Job Number 93366**] Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 14713**] Admission Date: [**2139-10-6**] Discharge Date: [**2139-10-9**] Date of Birth: [**2093-5-6**] Sex: M Service: ADDENDUM: The results of the head computerized tomography scan had been obtained. There is no sign of any acute hemorrhage or any acute changes. There is no sign of mass effect or any air in [**Doctor Last Name **]/white matter differentiation. There is an increased area of attenuation in the anterior aspect of the left frontoparietal cortex which is most likely a calcified meningioma or a calcified dural plaque and unchanged from a previous computerized tomography scan in [**2136**]. The results of the head computerized tomography scan do not change any of the management of this patient in the future. Please see previous dictation for further recommendations. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6293**], M.D. [**MD Number(1) 2609**] Dictated By:[**Name8 (MD) 6831**] MEDQUIST36 D: [**2139-10-8**] 16:37 T: [**2139-10-8**] 17:14 JOB#: [**Job Number 14714**]

[ "427.89", "496", "780.57", "V44.0", "V45.1", "585", "348.1", "518.81", "428.0" ]

icd9cm

[ [ [] ] ]

[ "96.71", "39.95" ]

icd9pcs

[ [ [] ] ]

3460, 3547

10864, 12441

9273, 10176

3804, 3886

5343, 9246

10443, 10841

10191, 10418

155, 2859

4988, 5325

2882, 3443

3564, 3777

5,071

120,208

6617+55771

Discharge summary

report+addendum

Admission Date: [**2175-7-9**] Discharge Date: [**2175-7-21**] Date of Birth: [**2094-6-28**] Sex: M Service: MEDICINE Allergies: Penicillins / Codeine / Iodine Attending:[**Last Name (NamePattern1) 9662**] Chief Complaint: SOB, hypotension Major Surgical or Invasive Procedure: NONE History of Present Illness: Chief Complaint: SOB Reason for MICU transfer: hypotension 81 year old male with h/o CHF (EF 20%), CAD s/p CABG in [**2166**], afib on warfarin, VT s/p [**Year (4 digits) 3941**] placement, GI bleed secondary to ?NSAID use, peripheral [**Year (4 digits) 1106**] disease s/p right SFA stent last week, ?dementia, presented with SOB. In the ED, initial VS were: 08:02 0 97.8 83 92/74 18 98%. He triggered for BP 60s. Physical exam was notable for red blood on rectal examination. Labs were notable for Hct 26 (at discharge [**7-3**] was 27.5), INR 2, Cr 1.9 (baseline 1.5). Also trop 0.61 with ECG showing no changes by report. BNP 5900, Lactate 2.8. Patient was started on peripheral dopa but was tachy to 130s and switched changed to peripheral norepinephrine. On arrival to the MICU, patient is comfortable and conversant. He [**Month/Year (2) **] any pain and has no acute complaints. His norepinephrine was decreased from .1 to 0.6 mcg/kg/hr. There was initial concern for upper GI bleed. Pt reports dark brown stools with drops of blood at home, and reports state 1x 500cc melanotic stool in the MICU. GI was [**Month/Year (2) 4221**], and stool was dark red, more consistent with lower GI/diverticular bleed. EGD was not performed because of high risk cardiac status and higher suspicion for lower GI bleed. Baseline HCT 27-28, on admission HCT 26, rec'd 1U PRBCs, now 29, stable since admission. Pt has a complex cardiac history and severe peripheral [**Month/Year (2) 1106**] disease. He has afib on warfarin. Had SFA stent placed last week, started plavix. Also started 10 day course of TMP/SMZ post-procedure. Also has [**Month/Year (2) 19874**], with EF 20%, mitral and tricuspid regurgitation, and RV dysfunction, on [**2175-7-10**] TTE. Cardiology [**Year (4 digits) 4221**], no acute intervention recommended. Pt will require lifetime anti-platelet therapy. Per [**Year (4 digits) 1106**] surgery, plavix 30 days followed by aspirin for life. He has CAD s/p CABG x 4 in [**2-/2166**], and VT s/p dual-chamber [**Year (4 digits) 3941**] placement. On admission troponin 0.61 --> 0.47 --> 0.56. Unsure of patient's baseline MS. [**First Name (Titles) **] [**Last Name (Titles) **] [**7-11**], became combative, tried to leave. Touched base with daughter and health care proxy, [**Name (NI) **], see social history for details. Does not understand reason for admission or circumstances that brought him to the hospital. ROS negative except as per HPI. Past Medical History: # Diabetes # Hyperlipidemia # Hypertension # Peripheral [**Name (NI) 1106**] disease with chronic LE ulcers # s/p resection of R 1st MT joint [**2-/2166**] # s/p R BK [**Doctor Last Name **] -DP w/nrsvg [**4-11**] # s/p plasty of bpg [**4-13**] # s/p agram [**3-14**] # arteriogram [**12-18**] # [**2174-2-10**] R 3rd toe debrid by podiatry # [**2174-2-8**] right BK [**Doctor Last Name **] to PT bypass w/ NRSVG # [**Last Name (LF) 19874**], [**First Name3 (LF) **] 20% (echo [**7-9**]) # CAD s/p CABG x 4 in [**2-/2166**] # VT s/p dual-chamber [**Year (4 digits) 3941**] placement # Atrial fibrillation on warfarin Social History: Married, has 6 children. [**Year (4 digits) 4273**] tobacco. Quit EtOH 25 years ago. [**Year (4 digits) 4273**] illicits. Lives alone at [**Doctor Last Name 406**] Estates [**Location (un) 8608**] retirement community. Has occasional nursing help. Manages his own finances. Per daughter, he usually has fair understanding of his medical conditions, but has had a few episodes of confusion; he was found confused and wandering on previous admission Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION EXAM: Vitals: T:97.3 BP:106/65 P:73 R: 18 O2:93% RA General: Alert, oriented x 1.5 (to self, knows he's in a hospital), no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP approximately 10cm, no LAD CV: In a-fib, regular rate, 2/6 systolic murmur loudest at RUSB, no rubs or gallops Lungs: Bibasilar crackles Abdomen: soft, non-tender, non-distended, bowel sounds present/ hyperactive, no organomegaly GU: foley Ext: warm, well perfused, dopplerable pulses by report, no clubbing, cyanosis, 2+ edema up to knees bilaterally Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact DISCHARGE EXAM: VS: T 97.7, BP 95-115/45-60, P 60-90, R 18, Sat 94-98% RA General: Sitting in chair in no acute distress, alert&oriented x3, answers questions appropriately HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP 7cm, +hepatojugular reflux, no LAD CV: Regular rate and rhythm, normal S1 + S2, 3/6 systolic murmur heard best at apex, no rubs or gallops Lungs: Mild bibasilar rales. No wheezes or rhonchi. Abdomen: soft, non-tender, non-distended, bowel sounds present no organomegaly Ext: warm, well perfused, dopplerable pulses by report, no clubbing, cyanosis, 2+ edema up to mid shin bilaterally, right foot bandaged, left foot with 2-3 cm erosion on left, dry, non-erythematous Neuro: CNII-XII grossly intact, 5/5 strength upper/lower extremities, grossly normal sensation, gait deferred, finger-to-nose intact Pertinent Results: ADMISSION LABS: [**2175-7-10**] 11:58AM BLOOD Hct-27.4* [**2175-7-10**] 02:40AM BLOOD WBC-9.0 RBC-3.67* Hgb-7.8* Hct-26.8* MCV-73* MCH-21.2* MCHC-29.1* RDW-24.1* Plt Ct-364 [**2175-7-9**] 02:01PM BLOOD Hct-28.6* [**2175-7-9**] 08:30AM BLOOD WBC-6.0 RBC-3.63* Hgb-7.3* Hct-26.0* MCV-72* MCH-20.2* MCHC-28.1* RDW-23.0* Plt Ct-357 [**2175-7-10**] 02:40AM BLOOD PT-18.6* INR(PT)-1.8* [**2175-7-9**] 08:30AM BLOOD PT-21.6* PTT-32.8 INR(PT)-2.1* [**2175-7-10**] 02:40AM BLOOD Glucose-107* UreaN-23* Creat-1.6* Na-139 K-3.8 Cl-103 HCO3-26 AnGap-14 [**2175-7-9**] 08:30AM BLOOD Glucose-135* UreaN-27* Creat-1.9* Na-138 K-3.6 Cl-99 HCO3-23 AnGap-20 [**2175-7-10**] 02:40AM BLOOD CK(CPK)-32* [**2175-7-9**] 02:01PM BLOOD CK(CPK)-45* [**2175-7-10**] 02:40AM BLOOD CK-MB-2 cTropnT-0.56* [**2175-7-9**] 02:01PM BLOOD CK-MB-3 cTropnT-0.47* [**2175-7-9**] 08:30AM BLOOD cTropnT-0.61* proBNP-5904* [**2175-7-9**] 02:01PM BLOOD Calcium-8.4 Phos-3.5 Mg-1.9 [**2175-7-9**] 08:36AM BLOOD Lactate-2.8* K-3.3 RELEVANT LABS: [**2175-7-12**] 03:25AM BLOOD WBC-7.4 RBC-3.92* Hgb-8.7* Hct-29.3* MCV-75* MCH-22.3* MCHC-29.8* RDW-24.9* Plt Ct-287 [**2175-7-13**] 08:00AM BLOOD WBC-8.8 RBC-4.22* Hgb-9.4* Hct-32.4* MCV-77* MCH-22.4* MCHC-29.2* RDW-25.6* Plt Ct-294 [**2175-7-13**] 09:40PM BLOOD WBC-7.7 RBC-3.70* Hgb-8.4* Hct-28.6* MCV-77* MCH-22.6* MCHC-29.3* RDW-26.1* Plt Ct-258 [**2175-7-13**] 09:40PM BLOOD PT-19.8* PTT-31.0 INR(PT)-1.9* [**2175-7-13**] 08:00AM BLOOD PT-19.7* PTT-31.0 INR(PT)-1.9* [**2175-7-11**] 01:50AM BLOOD Glucose-74 UreaN-19 Creat-1.4* Na-140 K-3.7 Cl-104 HCO3-25 AnGap-15 [**2175-7-12**] 03:25AM BLOOD Glucose-100 UreaN-22* Creat-1.7* Na-137 K-4.2 Cl-101 HCO3-25 AnGap-15 [**2175-7-13**] 08:00AM BLOOD Glucose-142* UreaN-24* Creat-1.7* Na-136 K-3.8 Cl-97 HCO3-25 AnGap-18 DISCHARGE LABS: [**2175-7-14**] 08:00AM BLOOD WBC-6.7 RBC-3.65* Hgb-8.1* Hct-28.2* MCV-77* MCH-22.1* MCHC-28.6* RDW-26.1* Plt Ct-253 [**2175-7-14**] 01:39PM BLOOD PT-19.7* PTT-31.4 INR(PT)-1.9* [**2175-7-14**] 08:00AM BLOOD Glucose-87 UreaN-27* Creat-1.6* Na-138 K-3.6 Cl-101 HCO3-26 AnGap-15 Brief Hospital Course: 81 year old male with h/o [**Month/Day/Year 19874**] (EF 20%), CAD s/p CABG, peripheral [**Month/Day/Year 1106**] disease s/p SFA stent, diabetes, presented with hypotension, now hemodynamically stable, no evidence of active bleed. # Shock: Yet unclear why he became hypotensive. Cardiogenic cause most likely given significant history. Echo reveals decreased wall motion compared to [**2-18**]. Hypovolemia secondary to GI bleed less likely as there is no clear evidence of significant GI bleed (see below). Sepsis is less likely as pt has been afebrile and improved without antibiotics. Pt required pressors briefly, but weaned off and now stable with SBPs in 100-110s, on his home BP regimen. # GI bleed?: Most likely a slow lower GI / diverticular bleed. s/p 1U PRBCs ([**7-9**]) appropriate increase in HCT (26 to 28.8). Had evidence of moderate diverticuli ([**2-19**]), downtrending HCT starting in [**5-20**]. No active bleeding during hospitalization. EGD not indicated at this time given high cardiac risk and lower clinical suspicion for upper GI bleed (however, last EGD [**2-19**] showed moderate gastritis, duodenal ulcer). Received omeprazole 40mg [**Hospital1 **]. Will have follow-up with GI Dr. [**First Name4 (NamePattern1) 25294**] [**Last Name (NamePattern1) 174**]. # Peripheral [**Last Name (NamePattern1) 1106**] disease s/p stent with right LE ulcer. Warfarin and Clopidogrel were briefly held given fear of GI bleed. Restarted Warfarin and Clopidogrel. ******Patient will need lifetime antiplatelet rx: per [**Last Name (NamePattern1) 1106**] & GI recs, will continue with warfarin & plavix for 30 days, then go back to warfarin & aspirin***** Wound care nurse [**First Name (Titles) **] [**Last Name (Titles) 4221**], and gave recommendations for management of foot ulcers. Pt completed post-procedural antibiotics prophylaxis with trimethoprim/sulfamethoxazole on [**7-13**]. # Altered MS: Delirium vs. baseline dementia. Pt received haldol once in the [**Month/Day (1) **] for episode of agitation. Touched base with family to reassess baseline mental status, and he seems to have baseline confusion. Would try to avoid haldol in the future for moderately elevated QTc = 480. # [**Month/Day (1) 19874**] (EF 20%): worsened from [**2-/2174**] echo, cardiology evaluated, may have had a new coronary event undetected in nursing home, no acute intervention warranted. Continued his home metoprolol, torsemide, lisinopril. Will follow-up with Dr. [**Last Name (STitle) 25295**] in cardiology. # CAD s/p CABG with Troponinemia: EKGs unremarkable, echo revealed worsening wall motion abnormality, but no acute coronary event; continue medical management # [**Last Name (un) **] on CKD (Cr 1.7, baseline 1.3-1.5): [**Month (only) 116**] be an element of hypoxic injury following shock episode, also a component of drug-related injury on TMP/SMZ - Renally dose medications - Daily Chem 7 - Encourage po hydration [**Hospital **] MEDICAL CONDITIONS: # Atrial fibrillation: CHADS2 = 4 = 8.5% chance of stroke per year. Continue warfarin. INR = 1.9 on d/c. # Hypertension: Not an active issue, currently controlled on home regimen # Diabetes: - Hold metformin, SSI while in house # Anemia: HCT 29.3; s/p 1U PRBCs, stable since admission; baseline HCT 26-28, microcytic - MCV 75; likely iron-deficiency anemia in the setting of recent slow GI bleed. [**Month (only) 116**] have decreased production due to CKD. - Continue home iron supplement, consider increasing - Fe, ferretin, TIBC normal Transitional Issues: # Pt must have LIFETIME antiplatelet therapy because he has right lower extremity stent. Continue warfarin AND clopidogrel for 30 days, then continue warfarin and aspirin thereafter for life. PCP [**Name Initial (PRE) 23491**]. # Please follow up creatinine / renal function in approximately 1 week, with PCP # [**Name10 (NameIs) **] gastroenterology follow-up for question of lower gastrointestinal bleed, given repeated blood in stools, iron deficiency anemia # Cardiology follow-up with Dr. [**Last Name (STitle) 25295**] # Consider starting spironolactone given mortality benefit for severe [**Last Name (STitle) 19874**] Medications on Admission: 1. Metoprolol Succinate XL 25 mg PO DAILY 3. MetFORMIN (Glucophage) 850 mg PO BID 4. Acetaminophen 650 mg PO Q6H:PRN pain 5. Aspirin 325 mg PO DAILY 6. Bisacodyl 10 mg PO/PR DAILY:PRN constipation RX *bisacodyl 5 mg 1 Tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 7. Clopidogrel 75 mg PO DAILY Start: in am for the recommended duration 8. Ferrous Sulfate 325 mg PO BID 9. Torsemide 20 mg PO BID 10. Omeprazole 40 mg PO BID 11. Pravastatin 40 mg PO DAILY 12. Docusate Sodium 100 mg PO BID RX *Colace 100 mg 1 Capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 13. Warfarin 2 mg PO DAILY16 follow your INR with Dr. [**Last Name (STitle) 25293**] 14. Lisinopril 5 mg PO DAILY 15. Nitroglycerin SL 0.3 mg SL PRN chest pain 16. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 10 Days RX *Bactrim DS 800 mg-160 mg 1 Tablet(s) by mouth twice a day Disp #*20 Tablet Refills:*0 Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Bisacodyl 10 mg PO DAILY:PRN constipation 3. Clopidogrel 75 mg PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Ferrous Sulfate 325 mg PO BID 6. Torsemide 20 mg PO BID 7. Warfarin 2 mg PO DAILY16 8. Atorvastatin 80 mg PO DAILY RX *atorvastatin 80 mg 1 Tablet(s) by mouth daily Disp #*30 Capsule Refills:*3 9. Lisinopril 5 mg PO DAILY 10. MetFORMIN (Glucophage) 850 mg PO BID 11. Metoprolol Succinate XL 25 mg PO DAILY 12. Nitroglycerin SL 0.3 mg SL PRN chest pain 13. Omeprazole 40 mg PO BID Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - [**Location (un) 550**] Discharge Diagnosis: PRIMARY DIAGNOSIS: Hypotension SECONDARY DIAGNOSIS: Anemia, Diabetes, Hypertension, Peripheral [**Location (un) 1106**] disease, Coronary artery disease, Congestive heart failure, Atrial fibrillation Discharge Condition: stable Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 25280**], It was a pleasure being involved in your care during your recent hospitalization. You were admitted because your blood pressure dropped significantly, and you required medications to help your blood pressure. We were concerned that you were bleeding from your gastrointestinal tract because there was blood in your stool, and your blood counts were low. You received a blood transfusion and your blood went back up. Recently, you had a stent placed to open up the vessels in your right leg. Because of this, you will need to take blood thinners for the rest of your life, to prevent the stent from clotting up and cutting off the circulation from your leg. Your heart does not pump as well as a healthy heart. Please weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. TRANSITIONAL ISSUES: #Patient requires LIFETIME anti-platelet therapy because of right lower extremity stent, PCP informed [**Name Initial (PRE) **] Warfarin + Plavix 30 days - Warfarin + Aspirin thereafter Followup Instructions: PCP: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], within 1-2 weeks Department: DIV. OF GASTROENTEROLOGY When: WEDNESDAY [**2175-7-26**] at 11:30 AM With: [**First Name4 (NamePattern1) 1386**] [**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: CARDIAC SERVICES When: THURSDAY [**2175-8-3**] at 3:00 PM With: DEVICE CLINIC [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: THURSDAY [**2175-8-3**] at 3:20 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2175-7-14**] Name: [**Known lastname 4298**],[**Known firstname **] Unit No: [**Numeric Identifier 4299**] Admission Date: [**2175-7-9**] Discharge Date: [**2175-7-21**] Date of Birth: [**2094-6-28**] Sex: M Service: MEDICINE Allergies: Penicillins / Codeine / Iodine Attending:[**First Name3 (LF) 1775**] Addendum: Mr. [**Known lastname **] continued to have BP in the 100/50 range and metoprolol 25mg was occasionally held for SBP <100. He had intermittent episodes of non-sustained ventricular tachycardia, during which time he was asymptomatic. Mr. [**Known lastname **] also continued to be intermittently delerious and was evaluated by geriatric psychiatry, who recommended zyprexa 2-5mg qHS prn and setting adjustment re-orient patient. Mr. [**Known lastname **] on [**2175-7-19**] was noticed to have a melanotic stool, without a HCT drop. GI evaluated him, and indicated that given his recent NSTEMI, he was high risk for a GI procedure. He should be re-evaluated in the future for possible further GI intervention to assess source of GI bleed. Chief Complaint: Hypotension Major Surgical or Invasive Procedure: Blood transfusion (2 Units) History of Present Illness: Reason for MICU transfer: hypotension requiring pressors 81 year old male with h/o CHF (EF 20%), CAD s/p CABG in [**2166**], afib on warfarin, VT s/p ICD placement, GI bleed secondary to ?NSAID use, peripheral vascular disease s/p right SFA stent last week, ?dementia, presented with SOB. In the ED, initial VS were: 08:02 0 97.8 83 92/74 18 98%. He triggered for BP 60s. Physical exam was notable for red blood on rectal examination. Labs were notable for Hct 26 (at discharge [**7-3**] was 27.5), INR 2, Cr 1.9 (baseline 1.5). Also trop 0.61 with ECG showing no changes by report. BNP 5900, Lactate 2.8. Patient was started on peripheral dopa but was tachy to 130s and switched changed to peripheral norepinephrine. On arrival to the MICU, patient is comfortable and conversant. He denies any pain and has no acute complaints. His norepinephrine was decreased from .1 to 0.6 mcg/kg/hr. There was initial concern for upper GI bleed. Pt reports dark brown stools with drops of blood at home, and reports state 1x 500cc melanotic stool in the MICU. GI was [**Month/Year (2) 4317**], and stool was dark red, more consistent with lower GI/diverticular bleed. EGD was not performed because of high risk cardiac status and higher suspicion for lower GI bleed. Baseline HCT 27-28, on admission HCT 26, rec'd 1U PRBCs, now 29, stable since admission. Pt has a complex cardiac history and severe peripheral vascular disease. He has afib on warfarin. Had SFA stent placed last week, started plavix. Also started 10 day course of TMP/SMZ post-procedure. Also has [**Month/Year (2) 4318**], with EF 20%, mitral and tricuspid regurgitation, and RV dysfunction, on [**2175-7-10**] TTE. Cardiology [**Year (4 digits) 4317**], no acute intervention recommended. Pt will require lifetime anti-platelet therapy. Per vascular surgery, plavix 30 days followed by aspirin for life. He has CAD s/p CABG x 4 in [**2-/2166**], and VT s/p dual-chamber ICD placement. On admission troponin 0.61 --> 0.47 --> 0.56. Unsure of patient's baseline MS. [**First Name (Titles) **] [**Last Name (Titles) **] [**7-11**], became combative, tried to leave. Touched base with daughter and health care proxy, [**Name (NI) **], see social history for details. Does not understand reason for admission or circumstances that brought him to the hospital. ROS negative except as per HPI. Past Medical History: # Diabetes # Hyperlipidemia # Hypertension # Peripheral vascular disease with chronic LE ulcers # s/p resection of R 1st MT joint [**2-/2166**] # s/p R BK [**Doctor Last Name **] -DP w/nrsvg [**4-11**] # s/p plasty of bpg [**4-13**] # s/p agram [**3-14**] # arteriogram [**12-18**] # [**2174-2-10**] R 3rd toe debrid by podiatry # [**2174-2-8**] right BK [**Doctor Last Name **] to PT bypass w/ NRSVG # [**Last Name (LF) 4318**], [**First Name3 (LF) **] 20% (echo [**7-9**]) # CAD s/p CABG x 4 in [**2-/2166**] # VT s/p dual-chamber ICD placement # Atrial fibrillation on warfarin Social History: Married, has 6 children. Denies tobacco. Quit EtOH 25 years ago. Denies illicits. Lives alone at [**Doctor Last Name 4319**] Estates [**Location (un) 4320**] retirement community. Has occasional nursing help. Manages his own finances. Per daughter, he usually has fair understanding of his medical conditions, but has had a few episodes of confusion; he was found confused and wandering on previous admission Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: Admission PE: O: 98.0 94-108/53-64 HR: 60-78 RR: 18 O: 90-98%RA I: 900 O: 450+ General: Lying in no acute distress, answers questions appropriately HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI CV: Regular rate and rhythm, normal S1 + S2, 3/6 systolic murmur heard best at apex, no rubs or gallops Lungs: Mild bibasilar rales. No wheezes or rhonchi. Abdomen: soft, non-tender, non-distended, bowel sounds present no organomegaly Ext: warm, well perfused, dopplerable pulses by report, no clubbing, cyanosis, 1+ edema up to mid shin bilaterally, right foot bandaged, left foot with 2-3 cm erosion on left, dry, non-erythematous, small ulceration lateral right knee Neuro: CNII-XII grossly intact, 5/5 strength upper/lower extremities, grossly normal sensation, AAOx2 (person, place) Discharge physical exam: VS: Tm 98.3, BP 104/59, P 71, R 19, 100% on RA, FSG 126 General: Lying in no acute distress, answers questions appropriately HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI CV: Regular rate and rhythm, normal S1 + S2, 3/6 systolic murmur heard best at apex, no rubs or gallops Lungs: Mild bibasilar rales. No wheezes or rhonchi. Abdomen: soft, non-tender, non-distended, bowel sounds present no organomegaly Ext: warm, well perfused, no clubbing, cyanosis, no edema, R leg clean stage II ulcer, R buttocks hypoigmented lesions (not dermatomal distribution, not tender). Neuro: CNII-XII grossly intact, 5/5 strength upper/lower extremities, grossly normal sensation, AAOx2 (person, place) Pertinent Results: Admission Labs: [**2175-7-9**] 08:30AM BLOOD WBC-6.0 RBC-3.63* Hgb-7.3* Hct-26.0* MCV-72* MCH-20.2* MCHC-28.1* RDW-23.0* Plt Ct-357 [**2175-7-9**] 08:30AM BLOOD Neuts-67.4 Lymphs-25.7 Monos-6.0 Eos-0.4 Baso-0.5 [**2175-7-9**] 08:30AM BLOOD PT-21.6* PTT-32.8 INR(PT)-2.1* [**2175-7-9**] 08:30AM BLOOD Glucose-135* UreaN-27* Creat-1.9* Na-138 K-3.6 Cl-99 HCO3-23 AnGap-20 [**2175-7-9**] 02:01PM BLOOD Glucose-146* UreaN-26* Creat-1.8* Na-140 K-3.3 Cl-101 HCO3-24 AnGap-18 [**2175-7-9**] 02:01PM BLOOD CK(CPK)-45* [**2175-7-9**] 08:30AM BLOOD cTropnT-0.61* proBNP-5904* [**2175-7-9**] 02:01PM BLOOD CK-MB-3 cTropnT-0.47* [**2175-7-9**] 02:01PM BLOOD Calcium-8.4 Phos-3.5 Mg-1.9 [**2175-7-9**] 08:36AM BLOOD Comment-GREEN TOP [**2175-7-9**] 08:36AM BLOOD Lactate-2.8* K-3.3 Relevant Labs: [**2175-7-9**] 08:30AM BLOOD WBC-6.0 RBC-3.63* Hgb-7.3* Hct-26.0* MCV-72* MCH-20.2* MCHC-28.1* RDW-23.0* Plt Ct-357 [**2175-7-10**] 11:58AM BLOOD Hct-27.4* [**2175-7-13**] 08:00AM BLOOD WBC-8.8 RBC-4.22* Hgb-9.4* Hct-32.4* MCV-77* MCH-22.4* MCHC-29.2* RDW-25.6* Plt Ct-294 [**2175-7-14**] 09:10PM BLOOD Hct-30.4* [**2175-7-17**] 07:50AM BLOOD WBC-8.4 RBC-3.64* Hgb-8.6* Hct-28.6* MCV-78* MCH-23.6* MCHC-30.2* RDW-24.6* Plt Ct-250 [**2175-7-18**] 07:55AM BLOOD WBC-8.1 RBC-4.01* Hgb-9.4* Hct-31.7* MCV-79* MCH-23.3* MCHC-29.5* RDW-24.9* Plt Ct-249 [**2175-7-17**] 02:31AM BLOOD Hct-28.5* [**2175-7-17**] 07:50AM BLOOD WBC-8.4 RBC-3.64* Hgb-8.6* Hct-28.6* MCV-78* MCH-23.6* MCHC-30.2* RDW-24.6* Plt Ct-250 [**2175-7-18**] 07:55AM BLOOD WBC-8.1 RBC-4.01* Hgb-9.4* Hct-31.7* MCV-79* MCH-23.3* MCHC-29.5* RDW-24.9* Plt Ct-249 [**2175-7-19**] 08:03AM BLOOD WBC-8.4 RBC-4.24* Hgb-9.9* Hct-33.9* MCV-80* MCH-23.3* MCHC-29.1* RDW-24.9* Plt Ct-207 [**2175-7-19**] 09:50PM BLOOD Hct-33.8* [**2175-7-20**] 08:05AM BLOOD WBC-7.8 RBC-4.32* Hgb-10.0* Hct-34.8* MCV-81* MCH-23.2* MCHC-28.8* RDW-24.6* Plt Ct-270 [**2175-7-21**] 07:50AM BLOOD WBC-7.8 RBC-4.39* Hgb-10.3* Hct-35.5* MCV-81* MCH-23.4* MCHC-29.0* RDW-24.5* Plt Ct-226 [**2175-7-9**] 08:30AM BLOOD Glucose-135* UreaN-27* Creat-1.9* Na-138 K-3.6 Cl-99 HCO3-23 AnGap-20 [**2175-7-13**] 08:00AM BLOOD Glucose-142* UreaN-24* Creat-1.7* Na-136 K-3.8 Cl-97 HCO3-25 AnGap-18 [**2175-7-15**] 07:25AM BLOOD Glucose-134* UreaN-24* Creat-1.6* Na-137 K-3.8 Cl-101 HCO3-28 AnGap-12 [**2175-7-16**] 07:00AM BLOOD Glucose-84 UreaN-25* Creat-1.5* Na-136 K-3.8 Cl-101 HCO3-26 AnGap-13 [**2175-7-17**] 07:50AM BLOOD Glucose-103* UreaN-22* Creat-1.4* Na-138 K-3.4 Cl-100 HCO3-29 AnGap-12 [**2175-7-18**] 07:55AM BLOOD Glucose-81 UreaN-22* Creat-1.2 Na-138 K-3.3 Cl-99 HCO3-29 AnGap-13 [**2175-7-19**] 08:03AM BLOOD Glucose-111* UreaN-24* Creat-1.3* Na-139 K-3.9 Cl-100 HCO3-31 AnGap-12 [**2175-7-20**] 08:05AM BLOOD Glucose-104* UreaN-24* Creat-1.2 Na-140 K-3.4 Cl-99 HCO3-31 AnGap-13 [**2175-7-21**] 07:50AM BLOOD Glucose-99 UreaN-26* Creat-1.4* Na-140 K-3.6 Cl-98 HCO3-31 AnGap-15 [**2175-7-19**] 08:03AM BLOOD ALT-17 AST-29 AlkPhos-81 [**2175-7-9**] 08:30AM BLOOD cTropnT-0.61* proBNP-5904* [**2175-7-9**] 02:01PM BLOOD CK-MB-3 cTropnT-0.47* [**2175-7-10**] 02:40AM BLOOD CK-MB-2 cTropnT-0.56* [**2175-7-13**] 08:00AM BLOOD calTIBC-285 Ferritn-45 TRF-219 Discharge Labs: [**2175-7-21**] 07:50AM BLOOD WBC-7.8 RBC-4.39* Hgb-10.3* Hct-35.5* MCV-81* MCH-23.4* MCHC-29.0* RDW-24.5* Plt Ct-226 [**2175-7-21**] 07:50AM BLOOD Plt Ct-226 [**2175-7-21**] 07:50AM BLOOD Glucose-99 UreaN-26* Creat-1.4* Na-140 K-3.6 Cl-98 HCO3-31 AnGap-15 [**2175-7-19**] 08:03AM BLOOD ALT-17 AST-29 AlkPhos-81 [**2175-7-21**] 07:50AM BLOOD Calcium-8.7 Phos-3.8 Mg-1.9 Microbiology: [**2175-7-9**] 8:30 am BLOOD CULTURE: Blood Culture, Routine (Final [**2175-7-15**]): NO GROWTH. [**2175-7-9**] 9:35 am BLOOD CULTURE Blood Culture, Routine (Final [**2175-7-15**]): NO GROWTH. [**2175-7-9**] 10:20 am URINE URINE CULTURE (Final [**2175-7-10**]): <10,000 organisms/ml. [**2175-7-9**] 11:41 am MRSA SCREEN Source: Nasal swab. MRSA SCREEN (Final [**2175-7-11**]): No MRSA isolated. [**2175-7-10**] 11:58 am MRSA SCREEN Source: Nasal swab. MRSA SCREEN (Final [**2175-7-12**]): No MRSA isolated. Imaging: EKG [**2175-7-9**]: Atrial demand pacing. Left axis deviation. Inferior wall myocardial infarction, likely old. Poor R wave progression of uncertain significance. Intraventricular conduction delay and diffuse non-specific ST-T wave abnormalities. Compared to tracing #1 more atrial pacing is now seen. Increased R wave in leads V3-V5 may reflect lead placement. Otherwise, no diagnostic change. EKG [**2175-7-9**]: Predominantly sinus rhythm versus ectopic atrial rhythm with atrial premature contractions and one apparently atrial paced beat. Left axis deviation. Prior inferior myocardial infarction. Possible anterior wall myocardial infarction of indeterminate age. Intraventricular conduction defect. Diffuse non-specific ST-T wave abnormalities. Compared to the previous tracing of [**2175-6-29**] atrial fibrillation has been replaced by what appears to be predominantly sinus or ectopic atrial rhythm. ST-T wave abnormalities are less marked in leads V5 and V6. Clinical correlation and repeat tracing are suggested. CXR [**2175-7-9**]: Lungs are well expanded with improved aeration at the left base. Mild-to-moderate cardiomegaly is slightly improved with no appreciable residual pulmonary edema. No pleural effusion or pneumothorax. Pacemaker/defibrillator is in unchanged position. Echo [**2175-7-10**]: Biventricular cavity enlargement with regional and global systolic dysfunction c/w multivessel CAD or other diffuse process. Pulmonary artery hypertension. At least moderate mitral regurgitation. Severe tricuspid regurgitation. Mild-moderate aortic regurgtiation. Dilated ascending aorta. Compared with the prior study (images reviewed) of [**2173-9-17**], the right ventricular cavity is more dilated with more prominent free wall hypokinesis, the severity of TR is increased, and the estimated PA systolic pressure is lower (likely due to progressive RV dysfunction). EKG [**2175-7-14**]: Sinus tachycardia. Incomplete left bundle-branch block. Compared to the previous tracing atrial pacing is no longer seen. Brief Hospital Course: 81 year old male with h/o [**Month/Day/Year 4318**] (EF 20%), CAD s/p CABG, peripheral vascular disease s/p SFA stent, diabetes, presented with hypotension, now hemodynamically stable, no evidence of active bleed. Active Issues: # Shock: Yet unclear why he became hypotensive. Cardiogenic cause most likely given significant history (please see below). GI bleed also likely explanation. Echo revealed decreased wall motion compared to [**2-18**]. Sepsis is less likely as pt has been afebrile and improved without antibiotics. Pt required pressors briefly, but weaned off and now stable with SBPs in 100-110s, on a slightly modified (decreased) home BP regimen (see below). # GI bleed: Most likely a slow lower GI / diverticular bleed. s/p 1U PRBCs ([**7-9**]) appropriate increase in HCT (26 to 28.8). On [**7-17**], HCT was 27.2, received another 1U PRBCs, HCT bumped to 28.5. Had evidence of moderate diverticuli ([**2-19**]) and moderate gastritis/duodenal ulcer on EGD ([**2-19**]), downtrending HCT starting in [**5-20**]. Several reports of BRBPR during hospitalization and melanotic [**Doctor Last Name **] x 1 on [**2175-7-18**]. EGD not indicated at this time given high cardiac risk and lower clinical suspicion for upper GI bleed (however, as mentioned, gastritis, duodenal ulcer on prior EGD). Received omeprazole 40mg [**Hospital1 **]. Will have follow-up with GI Dr. [**First Name4 (NamePattern1) 4321**] [**Last Name (NamePattern1) **]. # Anemia, acute on chronic: Prior to admission baseline HCT 26-28; During hospitalization, received s/p 1U PRBCs in [**Last Name (NamePattern1) **], increased appropriately and remained stable on the floor. [**7-17**] HCT was 27.2, pt received another 1U PRBCs, and HCT increased to 28.5. Had several episodes of BRBPR during hospitalization. Anemia is microcytic - MCV 75; likely iron-deficiency anemia in the setting of recent slow GI bleed (per above, has diverticulosis). [**Month (only) 412**] also have decreased production due to CKD. Iron studies were normal. We continued home iron supplementation. F/U with GI for sources of GI bleeding. # Supraventricular tachycardia - Pt had an episode of SVT on [**7-14**], with HR in the 140s. EKG consistent with atrial tachycardia, no ischemic changes. Resolved with carotid massage, IV metoprolol, additional po metoprolol, and gentle IVF. Given concern for GI bleed, checked HCT, which was 30.4. Home metoprolol 25mg XL was increased to metoprolol 50mg XL. ****HIGH IMPORTANCE**** # Peripheral vascular disease s/p stent with right LE ulcer. Warfarin and Clopidogrel were briefly held given fear of GI bleed. Restarted Warfarin and Clopidogrel. ******Patient will need lifetime antiplatelet rx: per vascular & GI recs, will continue with warfarin & plavix until [**2175-7-28**], then go back to warfarin & aspirin***** Wound care nurse [**First Name (Titles) **] [**Last Name (Titles) 4317**], and gave recommendations for management of foot ulcers. Pt completed post-procedural antibiotics prophylaxis with trimethoprim/sulfamethoxazole on [**7-13**]. # Altered MS: Delirium vs. baseline dementia. Pt received haldol once in the [**Month/Day (1) **] for episode of agitation. Touched base with family to reassess baseline mental status, and he seems to have baseline confusion. Would try to avoid haldol in the future for moderately elevated QTc = 480. # [**Month/Day (1) 4318**] (EF 20%): worsened from [**2-/2174**] echo, cardiology evaluated, may have had a new coronary event undetected in nursing home, no acute intervention warranted. Continued a change in dose of metoprolol (slightly increased), torsemide, lisinopril (lower dose). Will follow-up with Dr. [**Last Name (STitle) 4322**] in cardiology. # CAD s/p CABG with Troponinemia: EKGs unremarkable, echo revealed worsening wall motion abnormality, but no acute coronary event; continue medical management # [**Last Name (un) **] on CKD Cr peaked to 1.7, and returned to baseline 1.3-1.5: [**Month (only) 412**] have been an element of hypoxic injury following shock episode, also a component of drug-related injury on TMP/SMZ (now complete) [**Hospital 4323**] MEDICAL CONDITIONS: # Atrial fibrillation: CHADS2 = 4 = 8.5% chance of stroke per year. Continue anticoagulation as above. INR = 1.8 on d/c. # Hypertension: Not an active issue, currently controlled on home regimen # Diabetes: Held metformin (on SSI in hospital). Will restart on DC. TRANSITIONAL ISSUES: # Pt must have LIFETIME antiplatelet therapy because he has right lower extremity stent. *******Continue warfarin AND clopidogrel until [**2175-7-28**]*******STOP clopidogrel on [**2175-7-28**] and continue warfarin and aspirin thereafter for life********* # Gastroenterology follow-up with Dr. [**Last Name (STitle) **] # Cardiology follow-up with Dr. [**Last Name (STitle) 4322**] # Consider starting spironolactone given mortality benefit for severe [**Last Name (STitle) 4318**] if BP is rising # Please make appointment with patient's PCP [**Name Initial (PRE) **] 1 week after discharge # Please follow up creatinine / renal function in approximately 1 week, with PCP #Lisinopril lowered to 2.5mg po qd in setting of borderline hypotension; please consider increasing back to 5mg when BP improves. #Metoprolol in hospital 12.5mg po tid because of arrhythmia; Please re-evaluate and consider reverting to Metoprolol XL. Medications on Admission: . Information was obtained from . 1. Metoprolol Succinate XL 25 mg PO DAILY 2. MetFORMIN (Glucophage) 850 mg PO BID 3. Acetaminophen 650 mg PO Q6H:PRN pain 4. Aspirin 325 mg PO DAILY 5. Bisacodyl 10 mg PO DAILY:PRN constipation 6. Clopidogrel 75 mg PO DAILY 7. Ferrous Sulfate 325 mg PO BID 8. Torsemide 20 mg PO BID 9. Omeprazole 40 mg PO BID 10. Pravastatin 40 mg PO DAILY 11. Docusate Sodium 100 mg PO BID 12. Warfarin 2 mg PO DAILY16 13. Lisinopril 5 mg PO DAILY 14. Nitroglycerin SL 0.3 mg SL PRN chest pain 15. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 10 Days Until [**7-13**] Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Bisacodyl 10 mg PO DAILY:PRN constipation 3. Clopidogrel 75 mg PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Ferrous Sulfate 325 mg PO BID 6. Torsemide 20 mg PO BID 7. Atorvastatin 80 mg PO DAILY RX *atorvastatin 80 mg 1 Tablet(s) by mouth daily Disp #*30 Capsule Refills:*3 RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 8. MetFORMIN (Glucophage) 850 mg PO BID 9. Nitroglycerin SL 0.3 mg SL PRN chest pain 10. OLANZapine 2-5 mg PO QHS:PRN delerium RX *olanzapine 2.5 mg [**1-9**] tablet(s) by mouth at night Disp #*30 Tablet Refills:*0 11. Pantoprazole 40 mg PO Q12H RX *pantoprazole 40 mg 1 tablet(s) by mouth two times per day Disp #*30 Tablet Refills:*0 12. Warfarin 5 mg PO DAILY16 RX *Coumadin 5 mg 1 tablet(s) by mouth daily Disp #*10 Tablet Refills:*0 13. Metoprolol Tartrate 12.5 mg PO TID hold for SBP <100, HR <55 RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth three times per day Disp #*30 Tablet Refills:*0 14. Lisinopril 2.5 mg PO DAILY RX *lisinopril 2.5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 Discharge Disposition: Extended Care Facility: [**Hospital6 609**] for the Aged - [**Location (un) 1409**] Discharge Diagnosis: PRIMARY DIAGNOSIS: Hypotension SECONDARY DIAGNOSIS: Anemia, Diabetes, Hypertension, Peripheral vascular disease, Coronary artery disease, Congestive heart failure, Atrial fibrillation, gastrointestinal bleeding Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname **], It was a pleasure being involved in your care during your recent hospitalization. You were admitted because your blood pressure dropped significantly, and you required medications to help your blood pressure. We were concerned that you were bleeding from your gastrointestinal tract because there was blood in your stool, and your blood counts were low. You received two blood transfusions and your blood counts went back up. You will need to follow up with your gastroenterologist for further evaluation of causes of bleeding. On [**2175-6-28**], you had a stent placed to open up the vessels in your right leg. Because of this, you will need to take blood thinners for the rest of your life, to prevent the stent from clotting up and cutting off the circulation from your leg. Your heart does not pump as well as a healthy heart. Please weigh yourself every morning, [**Name8 (MD) 233**] MD if weight goes up more than 3 lbs. MEDICATION CHANGES: # Metoprolol XL 25mg daily was changes to Metoprolol 12.5mg po tid because of your fast heart rate # Pravastatin was replaced with atorvastatin 80 mg to more effectively treat your high cholesterol and protect your heart # Your lisinopril dose was lowered from 5mg to 2.5mg because your blood pressure was low. Please ask about increasing the dose back to 5mg once your blood pressure improves. TRANSITIONAL ISSUES: #Patient requires LIFETIME anti-platelet therapy because of right lower extremity stent, placed [**2175-6-28**], PCP informed [**Name Initial (PRE) **] Warfarin + Plavix 30 days [**Date range (1) 4324**]/[**2175**] - Warfarin + Aspirin, [**7-28**]- forever # Cardiology: Worsening cardiac function; episode of atrial tachycardia; consider starting spironolactone # Gastroenterology: Evaluation for cause of lower gastrointestinal bleed sufficient to cause anemia Followup Instructions: Department: DIV. OF GASTROENTEROLOGY When: WEDNESDAY [**2175-7-26**] at 11:30 AM With: [**First Name4 (NamePattern1) 4325**] [**Last Name (NamePattern1) 32**], MD [**Telephone/Fax (1) 1834**] Building: Ra [**Hospital Unit Name 1835**] ([**Hospital Ward Name 1836**]/[**Hospital Ward Name 257**] Complex) [**Location (un) 1830**] Campus: EAST Best Parking: Main Garage Department: CARDIAC SERVICES When: THURSDAY [**2175-8-3**] at 3:00 PM With: DEVICE CLINIC [**Telephone/Fax (1) 337**] Building: SC [**Hospital Ward Name **] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name **] Garage Department: CARDIAC SERVICES When: THURSDAY [**2175-8-3**] at 3:20 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 337**] Building: [**Hospital6 189**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name **] Garage [**First Name11 (Name Pattern1) 1034**] [**Last Name (NamePattern1) 1778**] MD [**MD Number(2) 1779**] Completed by:[**2175-7-23**]

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icd9cm

[ [ [] ] ]

[ "38.91" ]

icd9pcs

[ [ [] ] ]

35903, 35989

28706, 28921

17335, 17365

36246, 36246

22523, 22523

38293, 39375

20860, 20975

34760, 35880

36010, 36010

34143, 34737

36399, 37367

25714, 28683

20990, 21782

4880, 5719

37804, 38270

37387, 37783

17284, 17297

28936, 33163

17393, 19772

36064, 36225

22540, 25698

36030, 36042

36261, 36375

19794, 20411

20427, 20844

21807, 22504

26,632

120,604

14296+14297

Discharge summary

report+report

Admission Date: [**2193-6-9**] Discharge Date: [**2193-6-12**] Date of Birth: [**2123-7-30**] Sex: M Service: CCU CHIEF COMPLAINT: Status post ventricular tachycardia arrest, hypotension and rapid atrial fibrillation. HISTORY OF PRESENT ILLNESS: The patient is a 69-year-old male who was in his usual state of health until the morning of admission, while on the golf course, he felt dizzy, lightheaded, and fell to the ground. EMTs were called and patient was taken to [**Hospital3 24768**]. He was thought to be in ventricular tachycardia, and was given adenosine and shocked. He went into a rapid atrial fibrillation, given diltiazem and Lopressor. Patient developed some hypotension and was started on dopamine. Patient was sent to [**Hospital6 1760**], and in route, he had ventricular tachycardia times two. He was started on a lidocaine drip. When patient arrived, he was on dopamine at 10, lidocaine at 3, without any symptoms. Throughout all of this, the patient had no chest pain, shortness of breath, or palpitations. Of note, patient had one episode of syncope one month ago in a similar situation while golfing. PAST MEDICAL HISTORY: 1. Angioplasty 15 years ago at [**Hospital6 **]. Unknown anatomy. 2. Hypertension. Off medications for 3+ years. 3. High cholesterol. 4. Right shoulder surgery for chronic dislocation. 5. Cataracts three to four years ago. 6. Tonsillectomy. 7. Syncope one month ago. MEDICATIONS: Aspirin 325 mg q.d. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Tobacco one pack per day, alcohol four to five drinks per day. Patient is a retired salesman for GE for ten years. FAMILY HISTORY: Father had an myocardial infarction in his 70s and hypertension. [**Name (NI) **] father and uncles had gastric cancer. PHYSICAL EXAM ON ADMISSION: Blood pressure 105/71. Heart rate 146. Oxygen saturation 96%. General: Patient is a pleasant, obese, white male in no acute distress. Head, eyes, ears, nose and throat: Normocephalic, atraumatic. Pupils equal, round and reactive to light and accommodation. Extraocular movements intact. Oropharynx clear. Neck was obese with no jugular venous distention appreciated. Lungs were clear to auscultation bilaterally. Cardiovascular: Regular rhythm, tachycardic, normal S1, S2, no murmurs, rubs or gallops. Abdomen obese, nontender, nondistended, positive bowel sounds. Extremities: No cyanosis, clubbing or edema. Neurological: Patient alert and oriented times three, moving all extremities. Electrocardiogram showed aflutter with 2:1 block with a rate of 150. Patient's previous electrocardiogram showed ST depressions in I, II, V2 through V5, V6 and a T wave inversion in III, Q in III and atrial fibrillation. Chest x-ray showed cardiomegaly and mild congestive heart failure. LABS ON ADMISSION: White blood cell count 14, hematocrit 48, platelets 241,000, INR 1.3, CK 168, MB of 9, troponin of 3.2. Urinalysis was negative with greater than 300 protein. Sodium 141, potassium 4.4, chloride 104, bicarbonate 24, BUN 22, creatinine 1.2, calcium 10.3, magnesium 1.9, phosphorus 4.0, glucose 142. At outside hospital, CK was 115 and troponin of 0.2. HOSPITAL COURSE: 1. Cardiovascular: The patient on admission had no further ventricular tachycardia on telemetry. He had a CK that peaked at 274, third troponin was 6.8. Patient was sent to the EP Laboratory where he had an AICD placed for inducible ventricular tachycardia. He was continued on Toprol XL 100 for rate control. He had an echocardiogram that showed an ejection fraction of 25% and 3+ mitral regurgitation. Patient then had a Persantine thallium that was negative. He was started on an ACE inhibitor for his low ejection fraction, Zestril 5. Patient was transferred out of the Intensive Care Unit the day following admission after having his AICD placed. He had no further episodes of rapid atrial fibrillation or ventricular tachycardia. DISCHARGE DIAGNOSES: 1. Status post ventricular tachycardia arrest. 2. AICD placement. 3. Left ventricular dysfunction with ejection fraction of 25%. 4. 3+ mitral regurgitation. 5. History of hypertension. DISCHARGE MEDICATIONS: 1. Toprol XL 50. 2. Amiodarone 400 b.i.d. times two weeks, then 400 q.d. times three months, then 200 q.d. 3. Zestril 5 q.d. 4. Aspirin 1 q.d. FOLLOW-UP: Patient will follow-up at the Device Clinic on [**2193-6-19**]. He will also follow-up with Dr. [**Last Name (STitle) **] on [**2193-7-16**] and on [**2193-6-19**], he will have pulmonary function tests for being on the amiodarone. He had LFTs that were within normal limits. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**MD Number(1) 1014**] Dictated By:[**Name8 (MD) 2069**] MEDQUIST36 D: [**2193-8-17**] 19:34 T: [**2193-8-17**] 19:34 JOB#: [**Job Number **] Admission Date: [**2193-6-9**] Discharge Date: [**2193-6-12**] Date of Birth: [**2123-7-30**] Sex: M Service: CCU CHIEF COMPLAINT: Patient is status post ventricular tachycardia arrest, hypotension, rapid atrial fibrillation. HISTORY OF PRESENT ILLNESS: The patient is a 69-year-old gentlemen who was in his usual state of health until the morning of admission, while on the golf course, he felt dizzy, lightheaded, and fell to the ground. EMTs were called. Patient was taken to [**Hospital3 24768**]. Patient was thought to be in ventricular tachycardia, given adenosine, then shocked. Patient then went into rapid atrial fibrillation, and was given diltiazem, Lopressor. Patient had some hypotension with a blood pressure down to the 70s. He was started on peripheral dopamine. Of note, after the first shock, the patient appeared to be in a torsade-like rhythm. He was sent to the [**Hospital6 2018**] and developed ventricular tachycardia times two on his way to [**Hospital6 256**]. INCOMPLETE; CUT OFF [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**MD Number(1) 1014**] Dictated By:[**Name8 (MD) 2069**] MEDQUIST36 D: [**2193-8-17**] 19:30 T: [**2193-8-17**] 19:30 JOB#: [**Job Number 42450**]

[ "427.1", "427.32", "428.0", "414.01", "V45.82", "401.9", "427.5" ]

icd9cm

[ [ [] ] ]

[ "37.94" ]

icd9pcs

[ [ [] ] ]

1677, 1813

3978, 4169

4192, 5024

3212, 3957

5042, 5138

5167, 6192

2841, 3194

1176, 1526

1543, 1660

29,027

131,105

48369

Discharge summary

report

Admission Date: [**2164-5-18**] Discharge Date: [**2164-5-24**] Date of Birth: [**2099-3-16**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2745**] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: right internal jugular central line placement History of Present Illness: This is a 65 y.o. Spanish-speaking male with a h/o paraplegia, large sacral decubitus ulcer, stage IV, s/p recent abx course for osteo who presents from [**Hospital **] clinic with hypotension and chills. . Pt had recently been treated for sacral decub and osteomyelitis for approx 11 weeks with vanco/Zosyn (until [**2164-5-7**]) without resolution (no improvement in his ESR per ID call-in note). He was seen by Plastics on [**2164-5-11**] and wound looked "good" (per PCP [**Name9 (PRE) 7421**] note). He returned today to [**Hospital **] clinic complaining of increased back pain in last 2 weeks. BP 85/60 in the [**Hospital **] clinic (normal BP 130s/70s). Reported also increased dressing changes at nursing home and subjective chills. Of note, pt has also indwelling foley and had been on Vantin for ?UTI [**Date range (1) 101884**]. . In the ED, his initial VS were T99.2, 87, 75/50, 15, 97%RA. He remained hypotensive despite 4L IVF. Lactate was 1.2. WBC 9.2 without left-shift. ESR was 130. CXR unremarkable. UA cloudy and positive for WBC and bacteria. ID was called and it was decided to restart him on Vanc/Zosyn again. Pt received also 10 mg of dexamethasone for presumed relative adrenal insufficiency. R IJ was placed and pt was started on levophed gtt since still hypotensive despite 4L IVF. Of note, trop was 0.17, cards was called. EKG was unremarkable but cards recommended CTA to r/o PE. Pt undergoing CTA prior to admission. . On arrival to the ICU, pt was still on low-dose levophed, mentating fine, with good UOP. . On ROS, pt c/o chills, dysuria, recent flu-like symptoms with cough, sputum (resolving), mild HA x3d (unchanged from prior). Denies CP, SOB, abdominal pain, N/V. Past Medical History: 1. Paraplegia (fell 13 years ago working on construction) 2. Depression 3. Frequent Urinary tract infections 4. GERD 5. Indwelling foley with persistent L sided hydronephrosis (per last DC summary from [**1-/2164**]) 6. Anemia (Hct baseline 28-30) 7. Sacral decubitus, stage IV, with recent osteomyelitis, s/p approximately 11 wks of Vanc/Zosyn (completed [**2164-5-7**]), followed by ID (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**]) Social History: No smoking, no alcohol, no drug use. Currently at rehab. Family History: Mother: no history of MI, CA Father: no history of MI, CA Physical Exam: VS: Temp: 95.4 BP: 113/62 HR: 76 RR: 13 O2sat 98% RA; CVP 3 GEN: pleasant, comfortable, NAD, cachectic HEENT: PERRL, EOMI, anicteric, MM dry, op without lesions, poor dentition NECK: no jvd, supple, RIJ in place. RESP: CTA b/l anteriorly CV: RR, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt EXT: no c/c/e, warm, good pulses SKIN: no rashes/no jaundice. Large sacral decub, stage 4, 5x5 cm but clear margins, no purulent discharge. Also L lateral knee ulcer, 1x1cm with clear margins. NEURO: AAOx3. Moves UE b/l. Paraplegic. Pertinent Results: . 131 96 62 =========== 130 4.9 25 1.2 . CK: 199 MB: 4 Trop 0.17 Ca: 10.1 Mg: 2.4 P: 3.8 ALT: 44 AP: 117 Tbili: 0.2 Alb: 3.4 AST: 31 [**Doctor First Name **]: Lip: 85 . WBC 9.2 Hct 30.1 Plt 377 N:59.1 L:30.3 M:5.5 E:4.3 Bas:0.7 SED-Rate: 130 . PT: 13.3 PTT: 28.8 INR: 1.1 . UA: cloudy, 21-50 WBC, neg nitrite, moderate bacteria . EKG in the ED: NSR @ 79, nl axis, nl itnervals, no acute ST-T wave changes. 3h later EKG with SB at 45 and Rsr' in V1 and V2. . Studies: . [**2164-5-18**] CXR: No acute cardiopulmonary process. . [**2164-5-18**] CTA: No evidence of pulmonary embolism or thoracic aortic dissection. . [**2164-5-19**] MRI L spine: 1. Status post resection of distal sacrum and coccyx with a soft tissue defect in the sacrococcygeal region. 2. The abnormal signal with enhancement of the S4 segment of the coccyx could be due to osteomyelitis. Mild soft tissue changes are seen surrounding the tip S4 segment of the coccyx. 3. No focal abscess is seen near the tip of the coccyx. 4. Slightly increased signal in the medial portion of the right psoas muscle, in its lower portion, could be due to mild inflammation. No abscess seen. 5. Small cysts within the right kidney, with prominence of the right renal collecting system. . [**2164-5-20**] Renal U/S: Grossly unchanged exam with persistent mild-to-moderate left hydronephrosis. Of note the left ureter was not able to be identified on today's exam due to obscuration from bowel gas. No renal or perirenal abscess is identified. Brief Hospital Course: 65 y.o. Spanish-speaking male with a h/o paraplegia, large sacral decubitus ulcer, stage IV, s/p recent abx course for osteo who presented from [**Hospital **] clinic with hypotension and chills. . # Hypotension/sepsis: Hypotension most likely due to sepsis. Given pyuria and history of frequent UTIs, most likely source of infection is from the GU tract. Pt also has sacral decubitus ulcer with recent osteomyelitis s/p abx; but no drainage and clean margins. ESR has been rising from 100 since [**1-31**] to 130 on this admission was concerning for recurrent osteo. Had low baseline cortisol level but bumped appropriately after [**Last Name (un) 104**] stim test, so relative adrenal insufficiency less likely. Hematocrit remained stable, and there was no evidence of active bleeding. The patient also ruled out for MI as noted below. Pt was initially admitted to the MICU on a levophed drip, but this was rapidly weaned off after fluid resuscitation. The patient was then transferred to the floor and remained hemodynamically stable off pressors. Vancomycin and zosyn were continued to treat both UTI (given history of pseudomonas) and skin flora. MRI of the L spine showed findings possibly consistent with recurrent osteo. Wound care nurse and plastic surgery were consulted who did not feel that the wound was changed from baseline and not the source of his sepsis. Renal ultrasound was done to rule out perinephric abscess given the hisotry of recurrent UTIs; this was negative for abscess. Prostate ultrasound was also done to rule out abscess given history of elevated PSA; this showed no evidence of a prostatic abscess or mass. Infectious disease consult followed the patient during his hospital course and recommended an antibiotic course of Zosyn 4.5g q8 to complete a 2 wk course for sepsis from presumed urinary source. A PICC line was placed on [**2164-5-23**] and he was discharged to complete a 14d course (d#5 on day of discharge). . . # Chronic Sacral Decubitus Ulcer: Patient is paraplegic; ulcer is stage 4, with exposed bone. Covered skin flora with vanco as above. Wound care nurse and plastic surgery consult evaluated the patient who did not feel this wound was infected and Vancomycin was discontinued prior to discharge. A follow up appointment was made with plastics clinic to consider a bone biopsy once off antibiotics. . # Positive troponin: Initial cardiac enzymes were elevated in the emergency room, but the patient was asymptomatic. Pt was evaluated by cardiology in the ED. EKG without acute ST changes and CTA without evidence of PE. Serial enzymes trended downward, and the pateint ruled out for MI. Further workup deferred to his PCP. . # Anemia - Recent baseline of 28-30. However, last Hct at rehab from [**5-3**] was 35. Hct remained stable 26-30 during this hospital course with no evidence of active bleeding. . # Elevated PSA: This was checked by urology as an outpatient, and per OMR notes urology was unable to reach the patient to follow up this result (possibly because the patient has been at rehab). Prostate U/S done as above which did not reveal any masses or abscess. Pt will need outpatient urology followup. . # Paraplegia: Has neurogenic bladder, indwelling foley. Foley was changed on arrival due to positive UA. Foley will need to be changed again midway through course of antibiotics. DVT ppx was continued. . # Depression: continued venlafaxine . # DISPO - Full Code. Discharged back to [**Hospital3 2558**] to complete a 2 wk course of Abx as above. Medications on Admission: Prilosec 20 daily Trazodone 50 qHS Tylenol prn Venlafaxine 75 [**Hospital1 **] Senna Colace 100 [**Hospital1 **] MoM 30ml daily prn Bisacodyl prn fleet enema prn Vitamin C [**Hospital1 **] Heparin sc TID Oxycontin 20 qAM / 10 qPM Zinc sulfate 220 mg daily Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Primary Diagnoses: Sepsis, likely from urinary tract infection Chronic stage IV sacral decubitus ulcer . Secondary Diagnoses: paraplegia, anemia Discharge Condition: Stable for discharge back to [**Hospital3 2558**] Discharge Instructions: You were hospitalized with low blood pressure, related to an infection, likely from a bladder infection. You should continue the antibiotics Zosyn for 9 more days. Continue taking all of your other medications as prescribed. Please have your blood drawn 1 week after discharge as instructed below. Please followup with your primary care physician, [**Name10 (NameIs) **] with your infectious disease physician as scheduled below. If you experience fevers, chills, shortness of breath, back pain, abdominal pain, or any other concerning symptoms, please call your doctor or return to the emergency room for evaluation. Followup Instructions: Please make an appointment to followup with your primary care physician. . You have the following appointments already scheduled: Provider: [**Name10 (NameIs) **] SURGERY CLINIC Phone:[**Telephone/Fax (1) 4652**] Date/Time:[**2164-6-8**] 2:00 . Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2164-6-15**] 11:00 Completed by:[**2164-5-23**]

[ "596.54", "593.2", "730.28", "038.9", "707.03", "344.1", "591", "599.0", "285.9", "311", "995.91" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

8681, 8751

4839, 8375

327, 375

8940, 8992

3309, 4816

9662, 10059

2688, 2747

8772, 8877

8401, 8658

9016, 9639

2762, 3290

8898, 8919

276, 289

403, 2109

2131, 2597

2613, 2672

14,350

196,257

42916

Discharge summary

report

Admission Date: [**2146-12-8**] Discharge Date: [**2146-12-8**] Date of Birth: Sex: M Service: TRAUMA Briefly, this is a 30 year-old male found down on the field who was brought to the trauma bay. He became unstable and arrested in the Emergency Room and was worked up for this. A chest x-ray was normal. Pelvic x-ray was normal. Patient had a DPO which was positive for blood. He was hemodynamically unstable, therefore he was rushed to the operating room for an emergent exploratory laparotomy. His belly was distended on his examination prior to going to the operating room. It was unclear at that time his past medical and past surgical history. However, after discussion with the family it was found that the patient was with hepatitis C and HIV positive with cirrhosis. Patient was taken to the operating room for emergent exploratory laparotomy. Please see operative report for further details. At exploratory laparotomy it was found patient had ruptured spleen. He was transferred to the post anesthesia care unit. He was significantly hemodynamically unstable and required significant fluid resuscitation. A discussion was carried out with the family and it was decided this would not go along with the patient's wishes. The patient's mother was [**Name (NI) 653**] and ultimately it was decided the patient would be made CMO. Patient was made CMO on [**2146-12-8**] at 8:30 P.M. and passed away shortly thereafter. The medical examiner was [**Date Range 653**] and the case was reviewed by the medical examiner. Patient's death notification on [**2146-12-8**]. His cause of death was hemorrhage. Patient is discharged on [**2146-12-8**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D. [**MD Number(1) 2214**] Dictated By:[**Last Name (NamePattern4) **] MEDQUIST36 D: [**2147-3-21**] 09:46 T: [**2147-3-21**] 09:45 JOB#: [**Job Number 92622**]

[ "571.5", "865.04", "286.9", "305.91", "042", "789.5", "998.2", "070.51", "427.1" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.71", "38.57", "34.02", "99.04", "96.04", "41.5", "38.86", "54.19" ]

icd9pcs

[ [ [] ] ]

56,661

168,866

48717

Discharge summary

report

Admission Date: [**2179-9-23**] Discharge Date: [**2179-10-5**] Service: MEDICINE Allergies: Penicillins / Lisinopril / Niacin / Meclizine / Ace Inhibitors / Paxil Attending:[**First Name3 (LF) 2290**] Chief Complaint: Black Tarry Stools Major Surgical or Invasive Procedure: Push enteroscopy- [**2179-10-1**] Placement of left nephrostomy tube- [**2179-10-1**] History of Present Illness: Ms. [**Known lastname 38758**] is a 86 y/o woman with recent history of low crit who had swallow study today with GI at [**Hospital3 **] presenting for melena and weakness. The patient reports she has been experiencing melena and weakness for the past 2 weeks in the setting of iron supplementation. The patient also notes experiencing substernal discomfort similar to heartburn which has been occurring for the past week which was different in nature from her baseline heartburn symptoms. She reports the pain occurred with laying down or on exertion, but states the pain was different in that it recurred intermittently in the past week which was different from baselien. The day of presentation, the patient had undergone a capsule endoscopy and got home, noticed 2 episodes of black, tarry stool without any red blood. She again noted weakness, lethargy, and nausea. She denies fevers, chills, vomiting, abd pain or SOB. She presented to the ED. Of note she had a large diverticular bleed in [**Month (only) **] of this year which required 4 transfusions at [**Hospital6 **]. Colonocopy at the time showed diverticuli and EGD showed mild antral gastritis and duodenitis. She had recently been undergoing an outpatient workup for worsening anemia and was due for initiation of aranesp shot tomorrow after having received IV Iron supplementation recently. She denies NSAID use and denies alcohol use. In the ED, initial VS were 98.4 103 125/63 20 100%. Workup was notable for a HCT of 21 (was 22.1 2 days prior, 26.2 one month prior). EKG showed new ST depressions in the inferolateral leads with Troponin of 0.06. Cardiology evaluated the patient and felt that this was likely demand ischemia in the setting of GI bleed. She was given Aspirin 325mg and and Nitroglycerin SL 0.4mg x1 with improvement of her heartburn-like pain. CXR showed possible mild pulm edema, focal calcification R lower lung, likely scarring/atelectasis. She was written for 2 units PRBC in addition to 500cc of a 1L NS bag, a GI cocktail, and Pantoprazole IV x1, and was admitted to the MICU for the management of GI Bleed. VS prior to transfer were 116/64, 107, 17, 98% 2L. On arrival to the MICU, the patient denied symptoms including abdominal pain, nausea/vomiting, chest pain, heartburn, or shortness of breath. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, or palpitations. Denies vomiting, diarrhea, constipation. Denies dysuria, frequency, or urgency. Denies myalgias. Denies rashes or skin changes. Past Medical History: Lower GI Bleed [**Month (only) **]/[**2179-3-9**] at [**Hospital **] Hospital. Thought to be Diverticulosis. Required 4 units of blood. Had colonoscopy with adenoma removed. Normocytic Anemia: thought to be due to CKD/iron def Iron Deficiency: S/P Ferraheme X 2 in [**2179-8-9**] stage 4 CKD thought to be due to hypertension and possibly diabetes. Hypertension hyperlipidemia right knee arthritis gastroesophageal reflux disease mild aortic stenosis mild mitral regurgitation ? mild type 2 diabetes (last A1C 6.2% not on any meds) Social History: Lives alone with sons very supportive. Uses Walker/Wheelchair - Tobacco: Previously smoked, quit over 60 years ago. - Alcohol: Denies Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: 96.7 BP: 122/66 P: 100 R: 22 PO2: 98% 2L NC General: Alert, oriented, no acute distress HEENT: Pupils equal and round, sclera anicteric, MMM Neck: supple CV: Regular rate and rhythm, normal S1/S2, GIII crescendo-decrescendo murmer at RUSB radiating across the precordium, GII holosystolic murmer at the apex, no rubs or gallops Lungs: End inspiratory crackles at bases b/l, no wheezes or ronchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly Rectal: Guiac (+) with Black stool in ED Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . DISCHARGE PHYSICAL EXAM: Pertinent Results: Admission Labs: [**2179-9-22**] 09:10PM WBC-10.1 RBC-2.43* HGB-7.2* HCT-21.0* MCV-86 MCH-29.6 MCHC-34.3 RDW-16.6* [**2179-9-22**] 09:10PM NEUTS-85.6* LYMPHS-10.3* MONOS-3.0 EOS-0.7 BASOS-0.3 [**2179-9-22**] 09:10PM PLT COUNT-241 [**2179-9-22**] 09:10PM FIBRINOGE-453* [**2179-9-22**] 09:10PM CALCIUM-9.0 PHOSPHATE-4.3 MAGNESIUM-1.2* IRON-38 [**2179-9-22**] 09:10PM cTropnT-0.06* [**2179-9-22**] 09:10PM GLUCOSE-132* UREA N-77* CREAT-3.2* SODIUM-142 POTASSIUM-3.7 CHLORIDE-107 TOTAL CO2-19* ANION GAP-20 Reports: . ECG [**9-22**]: Sinus tachycardia and occasional atrial ectopy. Increase in rate as compared with prior tracing of [**2170-5-21**]. There is new ST segment depression in leads I, aVL and V2-V6 consistent with active anterolateral ischemic process, in the context of the increase in rate. Followup and clinical correlation are suggested. . TTE [**9-23**]: Mild symmetric left ventricular hypertrophy. The distal segments are not well seen but the distal inferior, septal and lateral segments are probably hypokinetic. Moderate calcific aortic stenosis. At least moderate mitral regurgitation. Moderate to severe tricuspid regurgitation with at least moderate pulmonary artery systolic hypertension. . CT Abd/Pelvis: [**9-24**]: 1. 6.8 cm abdominal mass, centered anterior/inferior to the aortic bifurcation, abutting small bowel loops anteriorly, and displacing the left ureter and left iliac vessels posteriorly. Given the lack of associated bowel obstruction, this most likely represents small bowel lymphoma. Other etiologies such as a GIST could also be considered. Adenocarcinoma is less likely. 2. Moderate left hydronephrosis and hydroureter, secondary to compression from aforementioned small bowel mass. 3. Small bilateral pleural effusions with associated atelectasis. 4. Sigmoid diverticulosis. 5. Aortic atherosclerosis, with 2.3 cm infrarenal aortic ectasia. 6. Extensive lumbar degenerative change. . RENAL ULTRASOUND:FINDINGS: The right kidney measures 8.3 cm with no evidence of hydronephrosis, stones, or masses within it. Normal vascularity is seen within the right kidney. The left kidney measure 9.5 cm. Moderate to severe hydronephrosis is detected in the left kidney with preservation of the left kidney cortex. No stones or masses are seen within the left kidney. A simple cyst is seen within the upper pole of the left kidney. The simple cyst has not changed from previous examination. The left ureter was followed until its mid portion where it disappeared. The bladder is within normal limits. No jet sign was detected from the left side. IMPRESSION: Moderate to severe hydronephrosis with hydroureter of the proximal and mid ureter. The renal cortex is preserved. . CXR: Portable AP chest radiograph was reviewed on [**2179-9-22**]. Heart size is enlarged. Mediastinal silhouette is unremarkable. Lungs are grossly clear except for minimal bibasilar atelectasis, but no focal consolidation is noted to suggest infectious process. Minimal interstitial changes, most likely chronic cannot be ruled out. . PUSH ENTEROSCOPY: Normal esophagus. Normal stomach. A few small superficial nonbleeding ulcers at duodenal bulb. At the distal jejunum, there was a large malignant appearing ulcerated mass. It was >10 cm in length and involved the entire circumference causing partially obstruction. The scope was able to traverse. There was slight oozing of blood and heme within the mass. Multiple biopsies were taken from the mass with a cold biopsy forceps for histology. It was tattooed with the Indian Ink at both ends. The capsule had passed distally and was seen on fluoroscopy. Otherwise the limited exam of the rest of small intestine was normal. . IR-GUIDED URETRAL STENT PLACEMENT: . Discharge labs: . . Microbiology: . H. PYLROI SEROLOGY: NEGATIVE Brief Hospital Course: 86yoF with history of gastric polyp, recent diverticular bleed, progressive anemia, and CAD presenting for melena, anemia, and demand cardiac ischemia. . #. GI bleed: She presented with black tarry stool and negative [**Last Name (un) **]-gastric lavage in the ED. She had recently had a capsule endoscopy that showed a possible necrotic bleeding mass in the small bowel. She was given 3 units PRBCs with stabilization of her hematocrit in the intensive care unit. She was also placed on an IV PPI. A CT abdomen/pelvis was done that showed a 6.8cm small bowel tumor consistent with malignancy. She remained stable in the MICU with plans to have push enteroscopy for biopsy after transfer to the medicine floor. On the floor, the patient had episodes of melena. She received 2 units of pRBCs on the floor and remained hemodynamically stable through her admission on the medicine floor. The patient underwent push enteroscopy [**2179-10-1**] which showed a malignant mass involving the entire circumference of the distal jejunum causing partially obstruction. A biopsy was obtained; the final pathology report was pending on day of discharge, but prelim results showed poorly differentiated carcinoma, unclear if adenocarcinoma or lymphoid in origin. Oncology has consulted as an inpatient. Just prior to discharge, prelim path results suggested poorly differentiated lymphoma. Oncology has coordinated a PET/CT for staging to be done in the next available slot on [**10-12**] at 2:45. She will f/u on [**10-15**] with Dr. [**Last Name (STitle) 410**] & [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4027**]. Oncology administrative staff have helped to notify her rehab, Colony in [**Last Name (un) 33487**] [**Telephone/Fax (1) 102418**], of these appointments and patient instructions for PET (NPO at least 4 hours before the test). . #. NSTEMI: She had ST depressions in the precordial and lateral leads on EKG and ruled in for NSTEMI. It was felt this was likely demand ischemia in the setting of GI bleed and she was transfused to a hematocrit of 30. Her ST depressions normalized with resolution of her anemia. Serial EKGs were performed that showed stable Q waves in leads III and avF, with T wave inversion in leads V4-V6. Her cardiac enzymes were trended through her admission on the medicine floor. The troponin peaked and then fell; the patient's CK-MB and CK remained flat while on the medicine floor. Cardiology was consulted to determine if the patient needed revascularization given the persistent T wave inversions on EKG. Cardiology recommended no revascularization at the present time, given the presence of the mass in the patient's small bowel and that revascularization would delay work-up of the small bowel mass. The patient was treated medically with beta-blocker, aspirin, and statin. The patient was monitored on telemetry through the admission. She had one episode of 9 beats of non-sustained ventricular tachycardia. Pt had no other significant events on telemetry. . #. Acute on Chronic Renal Failure: She had acute on chronic renal failure with Cr 3.2 and recently 3.4 on [**9-20**] from baseline of 2.4 on [**6-17**]. This was felt to be related to her recent GI bleed and renal hypoperfusion. CT of the abdomen/pelvis showed left hydronephrosis and hydroureter. The patient's creatinine was trended through her admission on the medical floor. The patient's creatinine continued to up-trend through the admission. Urology was called, and they did not feel that stents were warrented in this patient as there is a high risk of stent-failure in patient's with an obstructive mass causing hydroureter/hydronephrosis. Urine was negative for eosinophils and the creatinine was unresponsive to fluid bolus. The patient's worsening kidney function was thought to be due to obstruction presumably from the small bowel mass. Renal ultrasound showed moderate to severe left hydronephrosis with hydroureter of the proximal and mid ureter. The renal cortex was preserved on renal ultrasound. A renal consult was called, and they attributed the patient's worsening renal function to obstruction. The patient underwent nephrostomy tube placement on the left. The patient's serum creatinine trended downward with placement of the nephrostomy tube on the left, which initially had bloody output that cleared to essentially normal urine with trace bloody streaks by discharge. Pt has an appointment later this week with Renal outpatient clinic. . #. Anemia: Patient presented with hematocrit of 26.8. Given that the anemia is normocytic, it is more consistent with acute or subacute blood loss rather than slow, occult blood loss causing iron deficiency and microcytosis. The patient received a total of 5 units of pRBCs. Her hematocrit was trended daily. The patient had a transfusion threshold to transfuse if hematocrit was less than 30 in light of the patient's NSTEMI. On day of discharge, the patient's hematocrit was stable at ~ 29. . #. Aortic Stenosis: History of mild AS (valve area 1.2-1.9cm2) in [**2170**], and Pt has 5/6 systolic murmur now. Repeat TTE on this admission showed worsening of her AS with valve area of 1.0. Cardiology did not feel that intervention was needed. . #. HTN: Her home hydrochlorothiazide, metoprolol, and losartan were initially held in the setting of GI bleed. Upon transfer to the floor, the patient's metoprolol had been restarted. Metoprolol was continued through her admission on the medicine floor. Her blood pressures ranged from 120s -140s / 60s-80s while on the floor on metoprolol. Her Hctz was held, but her losartan was restarted on discharge. . #. HLD: The patient's home atorvastatin was continued through the admission, but the dose was increased in the setting of the patient's NSTEMI per cardiology recommendations. . # Residual Capsule: Prior to admission, the patient underwent capsule endoscopy. The patient had not passed the capsule prior to admission and through the admission. KUB films showed that the capsule was present in the right lower quadrant. The patient was never obstructed through the admission. Push enteroscopy showed that the capsule had passed the area of partial obstruction. Per GI, there is no need to do any further imaging. She will only need a KUB if she develops obstructive symptoms. . #Transition of Care: - Follow-up with Oncology regarding the pathology report from biopsies done at the push enteroscopy. Oncology has coordinated a PET/CT for staging to be done in the next available slot on [**10-12**] at 2:45. She will f/u on [**10-15**] with Dr. [**Last Name (STitle) 410**] & [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4027**]. Oncology administrative staff have helped to notify her rehab, Colony in [**Last Name (un) 33487**] [**Telephone/Fax (1) 102418**], of these appointments and patient instructions for PET (NPO at least 4 hours before the test). . - Follow-up with outpatient nephrologist regarding nephrostomy tube, continuation of aranesp and ferraheme, and chronic kidney disease. They will also help with determining when to restart hydrochlorothiazide and losartan. . - Follow-up with primary care physician regarding [**Name9 (PRE) 18290**] hydrochlorothiazide and losartan in light of Pt's recent acute renal insufficiency. . - Pt was prescribed ARANESP by unknown practitioner. Will need to follow-up w/ heme/onc clinic about this. . Medications on Admission: ATORVASTATIN 10mg PO Daily CITALOPRAM - 20 mg PO Daily FOLIC ACID 1mg PO Daily HYDROCHLOROTHIAZIDE - 25 mg PO Daily LOSARTAN - 100 mg PO Daily METOPROLOL TARTRATE - 50 mg PO BID PANTOPRAZOLE - 80 mg qAM and 40mg qPM ARANESP FERRAHEME FERROUS SULFATE - 325mg PO BID MULTIVITAMIN - PO Daily Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 10. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) packet PO once a day as needed for constipation. 11. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO three times a day: hold for sbp < 90 or HR < 55. 12. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day: Take 2 tabs qam and 1 tab qhs. Tablet, Delayed Release (E.C.)(s) 13. Aranesp (polysorbate) Injection Discharge Disposition: Extended Care Facility: Colony House Nursing & Rehabilitation Center - [**Location (un) 32775**] Discharge Diagnosis: Primary diagnosis: -GI bleed -poorly differentiated small bowel carcinoma Secondary diagnosis: Anemia NSTEMI Hypertension Aortic stenosis Acute on chronic kidney failure Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [**Known lastname 38758**], It was a pleasure taking care of your during your hospitalization at [**Hospital1 69**]. You were admitted with bleeding from your gastrointestinal tract and were found to have a mass in your small bowel. You underwent push enteroscopy to gather tissue samples. The final results from these samples are still not available, but the preliminary results show that you do have a cancer in your small bowel. You spoke with our cancer experts, who will continue to see you as an outpatient. During this hospitalization you also suffered a very small heart attack, known as an NSTEMI, because of anemia (low blood counts) caused by the bleeding abdominal mass. You received blood tranfusions to keep your blood counts stable. Your creatinine also rose through the admission. You were found to have an obstruction in your left kidney preventing the flow of urine, which was causing worsening kidney function. You had a nephrostomy tube placed in the left kidney to help drain urine from this kidney. Please take all medications as prescribed. Please note the following medication changes: *NEW: - aspirin 81mg daily by mouth - senna 1 tab orally twice a day - docusate 100mg orally as needed for constipation - polyethylene glycol 17g orally as needed for constipation *CHANGED: - metoprolol 25mg orally three times a day from metoprolol 50mg orally twice a day - increased the dose of atorvastatin to 80mg daily by mouth *STOPPED: - hydrochlorothiazide 25mg orally daily - losartan 100mg orally daily - pantoprazole 80mg in morning and 40mg in the evening Please keep all follow up appointment as scheduled below. Please arrange with your [**Hospital3 **] facility a hospital follow-up appointment with your primary care doctor. You will also need to have follow-up with an Oncologist regarding the results of the biopsy from the mass in your small bowel. Followup Instructions: Department: WEST [**Hospital 2002**] CLINIC When: TUESDAY [**2179-10-12**] at 4:00 PM With: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. [**Telephone/Fax (1) 721**] Specialty: Nephrology Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8428**], MD Specialty: Internal Medicine Location: [**Hospital1 **] HEALTHCARE - [**State 3753**]GROUP Address: [**State **], [**Apartment Address(1) 3745**], [**Location (un) **],[**Numeric Identifier 809**] Phone: [**Telephone/Fax (1) 2205**] Please discuss making a follow up appointment with Dr. [**Last Name (STitle) 2903**] with the facility when you are ready for discharge. You will need to discuss the results of your testing done while in the hospital. *** You will need to have an appointment schedule with Oncology. A doctor from our Oncology service will call you to schedule a follow-up appointment for you once the pathology results are finalized. Completed by:[**2179-10-7**]

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icd9cm

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icd9pcs

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12894

Discharge summary

report

Admission Date: [**2187-3-30**] Discharge Date: [**2187-4-6**] Date of Birth: [**2131-3-30**] Sex: M Service: MEDICINE Allergies: Benadryl Allergy / AmBisome / Flomax / Tacrolimus Attending:[**Last Name (NamePattern1) 4377**] Chief Complaint: Fever, hypotension Major Surgical or Invasive Procedure: None History of Present Illness: This is a 56 year old male with a history of AML s/p double cord bone marrow transplant over three years ago, COP who presents with one day of sore throat, nose pain/sinus pain, headache, and fever to 103.2 this morning. He also endorses 2 episodes of vomiting (without nausea), cough, chills, and rigors. He was in his usual state of health until last evening when he started to feel unwell, and started experiencing malaise, and headache. This morning things worsened to the point where he was unable to get himself into the car because of fatigue/weakness. He has history of apnea requiring intubation 3 years ago. Also, patient is on 2L home O2 (use with a lot of activity but not at rest) for COP. . He has not ahd any recent history of travel, hiking, or sick contacts. His wife states they had a vacation planned, but haven't done anything recently because he has been unwell. He has chronic arthralgias from GVHD, but they have been well controlled and they have been able to wean his prednisone down to 3mg. He also has had a decrease in his pain requirement and is now only on oxycontin. . Of note prior admission in [**Month (only) **] with fever, malaise, vomiting. He was afebrile during his admission. He was started on cipro for possible GI source and his voriconazole (for aspergillus sinusitis) was discontinued given interaction with Cipro. . In the ED, initial VS were: 100.2 120 109/56 20 94%. CXR with ?LLL infiltrate. Looked dry, IVC collapsible on beside U/S. Started on IVF and ceftx, azithromycin. SBP down to 79, given hydrocort 25mg. With persistent hypotension, broadened with vancomycin and ceftazidime, as well as another hydrocort 75mg. Awaiting oseltamivir. Now on 3rd and 4th L IVF. Pt notes wanting to avoid CVL. Rapid flu negative, nasal swab pending. Labs notable for WBC 11.8, CKD (at baseline), elevated BNP. Currently alert and appropriate, maintaining airway, breathing comfortably. Access is 18g and 20g PIV. Current VS: 90 94/44 12 100,4L. . On the floor, He is lethargic, but appropriate. He wakes to voice, and follows commands appropriately. Answering questions, oriented. Past Medical History: -AML M5B -- S/p idarubicin, Ara-C, mitoxantrone, etoposide and cytarabine -- S/p double cord transplant in [**2184**] -- Prior GVHD, specifically myalgias, arthralgias, Fe overload, peripheral neuropathy -Chemotherapy-associated cardiomyopathy, LVEF 50% -CKD -DM due to prednisone -Hemochromatosis with chronic liver disease -Aspergillus of the sinuses and nares -Sarcoid diagnosed in [**2172**] on intermittent steroids -Hypertension -GERD -Hypercholesterolemia -BOOP in [**2184-3-13**] on occasional home oxygen Social History: Formerly worked as auto mechanic, now disabled secondary to AML and GVHD. Lives with wife and son. Past tobacco use, but non currently. - Tobacco: Prior to AML diagnosis, he was a smoker, but quit 5 years - Alcohol: only very occassionally - Illicits: None Family History: Father- CAD s/p CABG. Type II Diabetes Mother- Type [**Name (NI) **] Diabetes. Multiple paternal uncles with heart disease. 2 siblings in good health. Physical Exam: ON ADMISSION: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry MM, oropharynx clear, unable to see posterior pharynx Neck: supple, JVP not elevated, no LAD Lungs: Crackles bilaterally at the bases to the mid lungs otherwise clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Somewhat distant heart sounds, 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, 2+ pulses, no clubbing or cyanosis, trace edema Neuro: PERRL, EOMI, strength 5/5 . ON DISCHARGE: Stable from admission exam with exception of clear lung exam, and improved hypotension. Pertinent Results: ADMISSION LABS: [**2187-3-30**] 11:30AM BLOOD WBC-11.8* RBC-3.59* Hgb-11.9* Hct-36.1* MCV-101* MCH-33.1* MCHC-32.9 RDW-13.6 Plt Ct-131* [**2187-3-30**] 11:30AM BLOOD Neuts-86* Bands-0 Lymphs-4* Monos-8 Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0 [**2187-3-30**] 11:30AM BLOOD PT-14.6* PTT-28.4 INR(PT)-1.3* [**2187-3-30**] 11:30AM BLOOD Glucose-110* UreaN-43* Creat-2.1* Na-141 K-5.3* Cl-107 HCO3-22 AnGap-17 [**2187-3-30**] 11:30AM BLOOD ALT-23 AST-18 LD(LDH)-145 AlkPhos-199* TotBili-0.3 [**2187-3-30**] 11:30AM BLOOD proBNP-2580* [**2187-3-30**] 11:30AM BLOOD Albumin-4.0 Calcium-8.7 Phos-2.0*# Mg-1.7 [**2187-3-30**] 12:14PM BLOOD Lactate-2.1* [**2187-3-30**] 02:10PM BLOOD Lactate-1.2 . DISCHARGE LABS [**2187-4-6**] 07:40AM BLOOD WBC-6.6 RBC-3.23* Hgb-10.5* Hct-33.4* MCV-103* MCH-32.4* MCHC-31.4 RDW-13.3 Plt Ct-142* [**2187-4-6**] 07:40AM BLOOD Neuts-77.0* Lymphs-7.5* Monos-8.0 Eos-7.3* Baso-0.3 [**2187-4-6**] 07:40AM BLOOD PT-13.8* PTT-28.7 INR(PT)-1.2* [**2187-4-6**] 07:40AM BLOOD Glucose-89 UreaN-14 Creat-1.2 Na-143 K-4.3 Cl-110* HCO3-23 AnGap-14 [**2187-4-6**] 07:40AM BLOOD ALT-49* AST-22 LD(LDH)-131 AlkPhos-140* TotBili-0.2 [**2187-4-6**] 07:40AM BLOOD Calcium-8.3* Phos-3.4 Mg-1.6 . MICRO: Blood culture [**3-30**]: NEG Urine culture [**3-30**]: NEG Respiratory viral screen: NEG CMV viral load: non-detecable Stool culture [**4-2**]: NEG C Diff: NEG x2 Legionella urinary antigen: NEG Aspergilus galactomannan: 0.1 (ref <0.5) C Diff PCR: PENDING ON DISCHARGE . URINE: [**2187-3-30**] 02:45PM URINE Blood-TR Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [**2187-3-30**] 02:45PM URINE RBC-4* WBC-2 Bacteri-FEW Yeast-NONE Epi-<1 [**2187-3-30**] 02:45PM URINE CastHy-3* [**2187-3-30**] 02:45PM URINE AmorphX-FEW [**2187-3-30**] 02:45PM URINE Mucous-RARE [**2187-3-30**] 02:45PM URINE Hours-RANDOM UreaN-608 Na-39 K-73 Cl-47 [**2187-3-30**] 02:45PM URINE Osmolal-453 . CXR [**2187-3-30**]: The cardiac, mediastinal and hilar contours are normal. The pulmonary vascularity is not engorged. Patchy opacity is noted within the left lung base. The right lung is grossly clear. No pleural effusion or pneumothorax is present. There are mild degenerative changes in the thoracic spine. Right-sided rib excrescences are again demonstrated. IMPRESSION: Patchy opacity in left lung base which may be infectious in etiology. Brief Hospital Course: 56 year old male with a h/o AML, CKD, and possible COP, now s/p double cord transplant over three years ago who presents with a 1 day history of fever, cough, malaise, and hypotensive in the ED. . # Fever/Pneumonia: On admission, pt found to have LLL pneumonia likely explaining fevers with leukocytosis to 11.8. Respiratory viral culture, CMV viral load, urine culture, and blood cultures were all negative. Pt was started on vanc/ceftazidime which he tolerated well. Fevers resolved and patient became hemodynamically stable and was transferred to the floor. IV antibiotics were changed to levofloxacin on HOD # 5 and SOB/cough continued to improve. He was discharged on levofloxacin to complete a total 14 day course of antibiotics. He was provided with tesslon perels for his cough on discharge though this had almost entirely improved. . # Hypotension: Pt was hypotensive upon admission to the ICU. He met SIRS criteria with fever and leukocytosis, though was not bacteremic. He was likely dehydrated with poor PO intake in the days leading up to admission, along with possible adrenal insufficiency in setting of chronic steroids. He was fluid resuscitated with 4L NS in the ED and given Hydrocortisone 100 mg IV. He was given antibiotics as above, and his lactate decreased from 2.1 on admission to 1.2 the next day. He was switched back to his home dose of Prednisone 3 mg PO daily. His BP steadily improved and he was restarted on his home Carvedilol 12.5 mg PO BID, which had been held on admission. He remained normotensive upon transfer to the floor and through discharge. . # Diarrhea: Pt developed diarrhea on HOD #5, with up to 5 loose BMs/day. Fecal culture and C. diff negative x2, though C. Diff PCR was sent and pending on discharge. He was started on fluids which were eventually stopped once PO intake improved. He was also started empirically on PO flagyl for C. Diff which he will continue for 14 day course. Diarrhea was much improved on discharge with only 1 episode the morning of discharge. . # AOCRF: Cr was 2.1 on admission (recent baseline of ~2). Was likely a pre-renal state given hypotension and dehydration. Improved with fluids and PO intake to 1.2 on discharge. . # AML S/P double cord transplant: Stable. Continued immunosuppression and treatment of GVHD with Prednisone and Cellcept. . # GERD: Continued home Pantoprazole 40 mg PO daily. . # Follow up issues/Transitional: -Patient set up with follow up with oncologist for 1 week after discharge -C. Diff PCR pending on discharge and should be followed Medications on Admission: acyclovir 400 mg PO TID allopurinol 100 mg PO Daily carvedilol 12.5 mg PO BID escitalopram [Lexapro] 10 mg PO daily furosemide 40 mg PO daily only as needed for weight gain of 3 lbs** He has not used this med in some time gabapentin 300 mg PO TID mycophenolate mofetil [CellCept] 500 mg PO bid nitroglycerin 0.3 mg SL** Has not needed oxycodone 5-10 mg PO Q4-6H prn pain** Not currently requiring oxycontin 10 mg PO BID pantoprazole [Protonix] 40 mg PO daily Colace 100mg PO TID Miralax PRN constipation prednisone 3 mg PO daily Sulfamethoxazole-trimethoprim 800 mg-160 mg PO MWF ascorbic acid [Vitamin C] 500 mg PO daily calcium carbonate 1,000 mg PO daily cholecalciferol (vitamin D3) 2,000 unit PO daily Aspirin 81 mg PO daily loratadine [Claritin] multivitamin with iron-mineral PO daily thiamine HCl 50 mg PO daily Discharge Medications: 1. acyclovir 400 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO Q8H (every 8 hours). 2. allopurinol 100 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY (Daily). 3. escitalopram 10 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY (Daily). 4. furosemide 40 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO once a day as needed for weight gain greater than 3 pounds. 5. gabapentin 300 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO TID (3 times a day). 6. mycophenolate mofetil 500 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO BID (2 times a day). 7. oxycodone 5 mg Tablet [**Month/Day/Year **]: 1-2 Tablets PO every 4-6 hours as needed for pain. 8. OxyContin 10 mg Tablet Extended Release 12 hr [**Month/Day/Year **]: One (1) Tablet Extended Release 12 hr PO twice a day. 9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Month/Day/Year **]: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. docusate sodium 100 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO TID (3 times a day). 11. prednisone 1 mg Tablet [**Month/Day/Year **]: Three (3) Tablet PO DAILY (Daily). 12. sulfamethoxazole-trimethoprim 800-160 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO 3X/WEEK (MO,WE,FR). 13. ascorbic acid 500 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY (Daily). 14. calcium carbonate 200 mg (500 mg) Tablet, Chewable [**Month/Day/Year **]: Two (2) Tablet, Chewable PO DAILY (Daily). 15. cholecalciferol (vitamin D3) 2,000 unit Capsule [**Month/Day/Year **]: One (1) Capsule PO once a day. 16. aspirin 81 mg Tablet, Chewable [**Month/Day/Year **]: One (1) Tablet, Chewable PO DAILY (Daily). 17. loratadine Oral 18. multivitamin with iron-mineral Tablet [**Month/Day/Year **]: One (1) Tablet PO once a day. 19. carvedilol 12.5 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO BID (2 times a day). 20. Miralax 17 gram/dose Powder [**Month/Day/Year **]: One (1) PO once a day as needed for constipation. 21. thiamine HCl 50 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO once a day. 22. benzonatate 100 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO BID (2 times a day) as needed for cough. Disp:*20 Capsule(s)* Refills:*0* 23. levofloxacin 750 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY (Daily) for 3 days: to be completed [**2187-4-9**]. Disp:*3 Tablet(s)* Refills:*0* 24. metronidazole 500 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO Q8H (every 8 hours) for 13 days: to be completed [**2187-4-19**]. Disp:*39 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: -Pneumonia -Antibiotic associated diarrhea Secondary: -History of Acute Myeloid Leukemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname 39623**], You were admitted to the hospital for fevers and weakness. You were found to have a pneumonia on chest XRAY, and were started on IV antibiotics. You spent 1 night in the ICU and then got transferred to the floor. Your pneumonia has improved and you are tolerating oral antibiotics well. You did develop some diarrhea which we feel is likely related to your antibiotics. Your C. diff testing was negative, but we would like to continue your treatment for this given your good response. We made the following changes to your medications: STARTED: Levofloxacin (levoquin) 750mg by mouth once daily to be completed [**2187-4-9**]. STARTED: Metronidazole (flagyl) 500mg by mouth every 8 hours. You should complete your last dose on the evening of [**2187-4-19**] Please note your follow up appointments below. It was a pleasure participating in your care Followup Instructions: Department: [**Date Range **]/BMT When: FRIDAY [**2187-4-13**] at 2:00 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4380**], MD [**Telephone/Fax (1) 3237**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital Ward Name **]/BMT When: FRIDAY [**2187-4-13**] at 2:00 PM With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3310**], PA [**Telephone/Fax (1) 3241**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: WEDNESDAY [**2187-5-2**] at 11:20 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

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icd9pcs

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11534

Discharge summary

report

Admission Date: [**2120-8-5**] Discharge Date: [**2120-8-20**] Date of Birth: [**2038-1-28**] Sex: F Service: MEDICINE Allergies: Biaxin / Morphine / Codeine Attending:[**First Name3 (LF) 106**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Right Internal Jugular Hemodyalysis Line Cardiac Catheterization with stents to LAD and renal artery History of Present Illness: 82 y/o female with HTN, Hyperlipidemia, DM2, PVD, CAD s/p CABG and PTCA/Stent [**2117**] presented to [**Hospital3 7571**]Hospital with one month of worsening dyspnea on exertion with one day of acute worsening dyspnea awakening her from sleep. She denies chest pain. She had no increase in salt intake, no change in meds other than her lasix which had been increased from 80 mg [**Hospital1 **] to 100 mg [**Hospital1 **] in the last two weeks. She also reports black stools this past week, with increasing fatigue, dry cough, paroxysmal nocturnal dyspnea, and generalized weakness. On review of symptoms, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, joint pains, hemoptysis. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. Cardiac review of systems is notable for absence of chest pain, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: Diabetes Dyslipidemia Hypertension CAD S/P CABG [**10-10**] SVG to distal RCA S/P RCA stent PVD S/P Left popliteal artery to dorsalis pedis artery bypass using left basilic arm vein Aotric Stenosis S/P Aortic valve replacement with 21 mm [**Last Name (un) 3843**]-[**Doctor Last Name **] bovine prosthesis Hypothyroidism Renal Stones S/P Right Nephrectomy Possible Epilepsy evaluated by neurology (neurologist is Dr. [**Last Name (STitle) **] 1. CAD s/p CABG [**2113**] (SVG to RCA) and bovine AVR, s/p PTCA with Cypher stent to LAD beyond the graft in [**2116**], s/p PTCA with 3 overlapping cypher stents to RCA in [**6-13**], complicated by ARF and temporal lobe seizures 2. Critical AS with bicuspic valve s/p Bovine AVR in [**2113**] 3. Hyperlipidemia 4. hypertension 5. Depression 6. Diabetes since [**2072**] 7. GERD PSH: 1) Kidney stones removed [**2072**] 2. right nephrectomy secondary to kidney stone [**2087**] 3. Hysterectomy [**2083**] 4. Fibrocystic breast biopsy [**2104**] 5. CABG with valve replacement [**2113**] 6. Left leg bypass [**2114**] 7. Cath with stent [**7-/2117**] 8. Stent [**2118-7-4**] 9. Multiple finger surgeries Social History: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. Daughter lives out of town; son lives in town near mother, but relationship somewhat strained. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: Well appearing elderly female in no distress T 97.5 HR 70 BP 138/74 RR 12 SAT 99%2L NC HEENT: Sclera anicteric NECK: No visible JVP elevation at 30 degrees elevation. Hepatojugular reflex is positive with JVP elevation to about 10cm. CHEST: Crackles at lung bases one quarter way up. HEART: Regular rhythm. Harsh 2/6 systolic murmur without heave or gallop. ABD: Soft, normal active bowel sounds, non tender, no distention. EXT: No piting edema. PULSES: Carotid pulse 2+ b/l without bruits. Femoral pulses 1+b/l without bruit. Pertinent Results: LABORATORY DATA: BUN 76/Cr 2.2 Hct 30 CK 494 CK-MB 19 MBI 3.8 Trop-T 0.78 . CK had a second increase on [**8-8**] up to 427 then trended down to 206 on discharge . Cr was 2.2 on admission, climbed to 5.4 on [**8-9**], then decreased to 1.6 at time of discharge. . EKG demonstrated Lateral ST depressions slightly more pronounced than prior from [**2-14**]. . 2D-ECHOCARDIOGRAM performed in [**2117**] demonstrated: 1. The left atrium is mildly dilated. The left atrium is elongated. 2.There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly decreased (LVEF45-50%). While not well seen there appeared to be basal and mid inferior wall hypokinesis. 3.The aortic valve is not well seen. A bioprosthetic aortic valve prosthesis is present. The transaortic gradient is normal for this prosthesis. No aortic regurgitation is seen. 4.The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. 5.The estimated pulmonary artery systolic pressure is normal. 6.There is no pericardial effusion. . Echo [**2120-8-5**]: The left atrium is elongated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild global left ventricular hypokinesis (LVEF = 40%). Tissue Doppler velocity suggests an increased LVEDP (>18mmHg). Right ventricular chamber size is normal with mild global free wall hypokinesis. The aortic root is mildly dilated at the sinus level. The ascending aorta is moderately dilated. A bioprosthetic aortic valve prosthesis is present. The aortic valve prosthesis appears well seated, with normal leaflet motion and transvalvular gradients. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the report of the prior study (images unavailable for review) of [**2118-7-8**], global left ventricular systolic function is more depressed, the ascending aorta is now moderately dilated (prior 4.2cm ascending on review), mild mitral regurgitation and pulmonary artery systolic hypertension are now identified. . Renal ultrasound [**2120-8-13**]: The patient is status post right nephrectomy. The left kidney measures 11.4 cm. There is again seen a 1.4 cm simple cyst within the left kidney. Arterial waveforms suggestive of a renal artery stenosis in the left kidney identified. . Cardiac Cath [**2120-8-16**]: 1. Selective coronary angiography of this right dominant system demonstrated three vessel coronary artery disease. The mid-LAD had a 95% heavily calcified stenosis, with the proximal stent patent. The LCx demonstrated diffuse distal disease as in previous studies. The distal RCA had a 70% stenosis with proximal stents patent. The SVG was not engaged due to known past total occlusion. The LMCA did not demonstrate any angiographically apparent disease. 2. Selective renal angiography of the left renal artery demonstrated a 90% heavily calcified stenosis. 3. Limited resting hemodynamic measurement revealed an elevated systemic arterial pressure of 167/65 mmHg. 4. Successful stenting of the mid LAD with 3.0 X 8 and 2.5 X 8 overlapping bare metal Mini Vision stents without residual stenosis (see PTCA comments for detail). 5. Successful stenting of the left renal artery with a 5.0 X 18 mm Genesis stent postdilated to 7.0 without residual stenosis of embolization, performed with distal protection device. Brief Hospital Course: 82 y/o female with HTN, Hyperlipidemia, DM2, PVD, CAD admitted with NSTEMI. . 1. NSTEMI: This was initially medically managed in the setting of a slow upper GI bleed. Later, she developed acute renal failure, and catheterization was again delayed out of concern that the dye load would further injure her kidney. Echo demonstrated an EF of 40% and global hypokinesis as described in the results section above. Once it was felt that her renal function was not improving and she was likely to end up on dialysis, a cardiac catheterization was performed. She had bare metal stents placed to her LAD as described in the cath report included. She should be continued on aspirin 325mg ongoing, plavix 75mg for at least one month, and simvastatin 40. Once her renal function has been followed for a couple of weeks and remains stable, it would be recommended to start an ACE inhibitor. . 2. Upper GI bleed: GI was consulted and did not feel that the patient was a candidate for an EGD given her slow bleed. She was transfused packed red cells and monitored; eventually her hematocrit stabilized and she was no longer having dark, guaiac positive bowel movements. By her report, the patient had a colonoscopy in [**2119-9-10**] that was negative. It is advised that her primary care physician follow her hematocrit to make sure that it is stable. GI did not feel that she would require an upper endoscopy as an outpatient. Patient should have follow-up with her PCP to ensure that the colonoscopy was indeed negative. . In addition, H. pylori serology was sent and was found to be positive. Although it was unclear whether the GI bleed was secondary to an ulcer or simple gastritis, the team felt it appropriate to begin therapy for H pylori given the recent bleed. She had an bad reaction to clarithromycin in the past that she was not able to describe, so therapy with Pantoprazole [**Hospital1 **], Amoxicillin [**Hospital1 **], and Levofloxacin was started for a total of a 10 day course. The dosage of these meds was adjusted for her renal function. . 3. Acute renal failure: The patient is s/p right nephrectomy for renal stones many years ago. Her Cr on admission was 2.2, and continued to worsen until it peaked at 5.4 on [**8-9**] and she developed oliguria. Renal was consulted, and it was thought that her renal failure was most likely secondary to hypoperfusion following her NSTEMI. A renal artery ultrasound was suggestive of renal artery stenosis; however, we could not perform confirmatory CT or MRI in the setting of her elevated Cr. A hemodialysis catheter was placed and the patient was receiving ultrafiltration and then hemodialysis. When her urine output remained very poor, it was felt that she was unlikely to recover renal function. She was then taken to cardiac catheterization, at which time her left renal artery was found to have a significant proximal stenosis and was stented. She had rapid improvement of her renal function with almost 1L of urine out the night following her catheterization. Her Cr returned to baseline and she had significantly decreased need for her antihypertensives. Hemodialysis catheter was removed the day prior to discharge. . 4. HTN: Patient had difficult-to-control blood pressure requiring multiple medications. At the time of discharge, her blood pressure medications had been decreased until she was only on Norvasc 2.5 and Metoprolol 12.5 [**Hospital1 **]. Given her recent improvement in renal function, the team was careful to avoid low blood pressures that might hypoperfuse her kidneys. At the time of discharge, this regimen maintained blood pressures between 120 and 140 systolic. She may need to have BP meds titrated in the next several weeks. . 5. CHF, systolic dysfunction: Echo demonstrated EF 40% as described above. Patient initially had difficult to control pulmonary edema with associated respiratory distress. Following renal artery stent placement, her pulmonary edema improved and she was sat'ing well on room air. Of note, she was admitted to the hospital on a home dose of lasix 100mg po BID. By the time of discharge, she was not taking lasix, and it was felt that she should not yet be restarted out of concern it might dehydrate her and damage her kidney. In addition, it was not clear that she would still need such high doses of lasix. Over the next weeks, it will be important to monitor her fluid status and consider restarting lasix. . 6. Hyperlipidemia: patient not taking simvastatin because of chronic pain in legs. She was put on simvastatin 10 and then 40, and appeared to tolerate these doses. . 7. DM2: Her oral glucose agents were held during admission. She was advised to return to her home regimen upon discharge. . 8. Shoulder pain--apparently, patient has a rotator cuff injury in the past. Her pain responded to tylenol. . She had no other active issues during this hospitalization. Her daughter ([**Name (NI) **]) can be contact[**Name (NI) **] with questions at: cell [**Telephone/Fax (1) 36726**]. Home: [**Telephone/Fax (1) 36727**] . Medications on Admission: ASA 325 mg Daily Plavix 75 mg Dialy Simvastatin 10 mg QHS (not taking) Lopressor 50 mg [**Hospital1 **] Lasix 100 mg [**Hospital1 **] Norvasc 2.5 mg Daily Synthroid 50 mcg daily Gluctrol 10 mg [**Hospital1 **] Imdur 120 mg daily Trileptal 150 mg QHS Allopurinol 100 Vitamin D Insulin- Lantus 7 units QPM with humolog sliding scale Celexa 20 mg [**Hospital1 **] Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Oxcarbazepine 150 mg Tablet Sig: One (1) Tablet PO at bedtime. 6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for shoulder pain. 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day for 9 days: Last day to give twice a day is [**8-28**], then continue medication once daily. 9. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Amoxicillin 250 mg Capsule Sig: One (1) Capsule PO twice a day for 9 days: Please give last dose on [**8-28**]. 11. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a day for 9 days: Please give last dose on [**8-28**]. 12. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 13. Glucotrol XL 10 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1) Tab,Sust Rel Osmotic Push 24hr PO twice a day. 14. Lantus 100 unit/mL Solution Sig: number of units needed units Subcutaneous at bedtime: Please return to using the dose of evening lantus you were on before coming to the hospital. 15. Humalog 100 unit/mL Solution Sig: number of units needed units Subcutaneous with meals: Please return to using the sliding scale you were on before coming to the hospital. 16. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day. 17. Vitamin D 400 unit Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Location (un) **] House Discharge Diagnosis: Primary Diagnosis: NSTEMI Secondary Diagnoses: Upper GI bleed, Acute renal failure, diabetes, hypertension Discharge Condition: Patient was improved. She had no chest pain or shortness of breath, and she was no longer having dark bowel movements, hematocrit was stable. Her renal function had returned to a baseline Cr of 1.6 with good urine output. Her vital signs were stable. Discharge Instructions: You were admitted with a heart attack. Initially, we could not perform a cardiac catheterization because you also were bleeding slowly from your stomach. You then developed worsening kidney function. When we eventually were able to perform a cardiac catheterization, you received stents to keep the arteries to your heart open as well as a stent to keep the artery to your kidney open. Your kidney function improved. 1. Please take all medications as prescribed. 2. Please attend all follow-up appointments listed below. 3. Please call your doctor or return to the hospital if you develop chest pain, shortness of breath, blood in your stool, or black, sticky bowel movements, or you develop any other concerning symptom. Followup Instructions: Please see the following doctors within the next month: 1. Dr. [**First Name (STitle) **], your kidney doctor [**First Name8 (NamePattern2) **] [**Last Name (Titles) **], MA 2. Dr. [**Last Name (STitle) 11493**], your heart doctor 3. Your primary care physician Completed by:[**2120-8-20**]

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icd9cm

[ [ [] ] ]

[ "88.45", "00.41", "36.06", "00.47", "39.95", "39.50", "00.66", "39.90", "88.56", "38.95" ]

icd9pcs

[ [ [] ] ]

14363, 14416

7172, 12246

295, 397

14568, 14824

3500, 7149

15598, 15891

2854, 2937

12658, 14340

14437, 14437

12272, 12635

14848, 15575

2952, 3481

14485, 14547

247, 257

425, 1445

14456, 14463

1467, 2617

2633, 2838

13,623

176,071

25384

Discharge summary

report

Admission Date: [**2106-6-30**] Discharge Date: [**2106-7-22**] Date of Birth: [**2044-7-20**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1283**] Chief Complaint: Transfer for carotid stenting and coronary artery bypass grafting Major Surgical or Invasive Procedure: [**2106-7-6**] Three vessel coronary artery bypass grafting utilizing the left internal mammary artery to left anterior descending; vein graft to right coronary artery; vein graft to ramus. [**2106-7-1**] Thoracic aorta, subclavian and carotid angiography with PTA/stenting to right internal carotid artery [**2106-7-7**] Bronchoscopy History of Present Illness: Mr. [**Known lastname 406**] is a 61 year old male with known coronary disease and multiple cardiac risk factors. He had a previous stent placed to his LAD. He also has a history of polymorphic VT and underwent AICD placment back in [**2101**]. On [**6-21**], he experienced a syncopal episode. During his evaluation at an outside hospital, he required defibrillation for several episodes of torsades. Outside cardiac catheterization revealed a 60% left main lesion; LAD had a 80% ostial lesion, and moderate in-stent restenosis; LCX had a 40% stenosis proximally; the RCA was totally occluded; the distal RCA had left-right collaterals. Left ventriculogram showed an akinetic anteroapical wall and basal aneurysm. His LVEF was estimated at 35%. Further evaluation revealed severe carotid disease. A carotid ultrasound showed 99% [**Country **] occlusion, while the [**Doctor First Name 3098**] had an 60-80% stenosis. Based on the above results, he was transferred to [**Hospital1 18**] for further evaluation and treatment. Past Medical History: Coronary artery disease - history of MI and s/p LAD stent, CHF, AAA - s/p vascular stent, PVD - s/p bilateral iliac artery stents, Carotid disease, CRI, HTN, NIDDM, Hyperlipidemia, Polymorphic VT - s/p AICD, Prostate CA - s/p XRT, DJD, Migraine HA Social History: Former smoker, quit approximately 20 years ago. Admits to at least 20 pack year history. Admits to two drinks per night. He is retired and married. Family History: Father died at age 47 of MI. Grandfather died at age 57 of MI. Physical Exam: PE: 97.6, 107/39, 77, 20, 96% on 2L Gen: NAD, lying in bed comfortable HEENT: mmm, o/p clear, bruise under R eye improving CV: RRR, distant hs, -m/r/g PULM: cta b/l; crackles resolved since yesterday ABD: s/nt/nd, +bs Groin: cath sites healing well b/l EXT: +1 pulses in lower ext b/l NEURO: eomi, perrl, CN II-XII intact, 5/5 strength in all 4 ext Brief Hospital Course: On admission, the neurology service was consulted. Due to symptomatology, intravascular carotid stenting was recommended as he was not a candidate for carotid endarterectomy secondary to his cardiac condition. On [**7-1**], PTA and stenting to his right internal carotid artery was successfully performed. The final residual was 10% with normal flow. Angiography at that time was also notable for a 2.5 cm proximal aneurysm of the left subclavian artery. He remained neurologically intact throughout the procedure. He otherwise remained pain free on medical therapy. Given his cerebrovascular disease, his SBP was maintained between 120-160 mmHg. He intermittently required fluid boluses. He remained neurologically intact. No further ventricular arrhythmias were noted. His renal functioned remained relatively stable with creatinine ranging between 1.5 - 1.9. On [**7-6**], Dr. [**Last Name (STitle) 1290**] performed three vessel coronary artery bypass grafting. Following the operation, he was brought to the CSRU. Intravenous Amiodarone was started for ventricular ectopy. On postoperative day one, bronchoscopy was performed for left lower lobe collapse and copious secretions. Given pulmonary secretions, he was empirically started on broad spectrum antibiotics. He remained sedated and intubated for several more days. He was concomitantly noted to have bright red blood per rectum and his hematocrit dropped as low as 23%. He was intermittently transfused with packed red blood cells. A CT scan was obtained which found no evidence of retroperitoneal hematoma and an abdominal ultrasound found no evidence of stent graft leak . General surgery was consulted and anoscopy was performed. This was notable for grade I-II hemorrhoids with friable rectal mucosa. His proctitis was most likely related to prior radiation exposure. Over several days, his rectal bleeding resolved and his hematocrit stablized. Outpatient colonoscopy is recommended. He eventually awoke neurologically intact and was extubated. He was transitioned to oral Amiodarone. He maintained stable hemodynamics and transferred to the SDU on postoperative day six. His ventricular ectopy improved. He remained on antibiotics for persistent thick, yellow secretions. Sputum cultures were sent, all eventually returning negative. His pulmonary status gradually improved with diuresis. By discharge, he continue to have oxygen requirements with a final oxygen saturation of 95 percent on 4 liters nasal cannula. He was subsequently started on Flomax and by discharge was passing urine on his own. He worked daily with physical therapy and made steady progress and was able to walk stairs by discharge. Medications on Admission: Tri-Cor, Effexor, Crestor, Amiodarone, Toprol-XL, Lisinopril, Imdur, Digoxin, Lansoprazole, Aspirin, Plavix Discharge Disposition: Home with Service Facility: [**Location (un) 582**] Of [**Location (un) 620**] Discharge Diagnosis: Coronary artery disease - s/p CABG, CHF, AAA - s/p vascular stent, PVD, Carotid disease - s/p [**Country **] stenting, CRI, HTN, NIDDM, Hyperlipidemia, Polymorphic VT - s/p AICD, Prostate CA, DJD, Proximal aneurysm of left subclavian artery Discharge Condition: Stable, good. Discharge Instructions: Patient may shower. No baths. No creams, lotions, or ointments to incisions. No driving for one month. Lift restrictions - no more than 10 lbs for 10 weeks. Followup Instructions: Cardiac surgeon, Dr. [**Last Name (STitle) 1290**] in 4 weeks Cardiologist, Dr. *** in 2 weeks Local PCP, [**Last Name (NamePattern4) **]. *** in 2 weeks

[ "250.00", "518.0", "458.29", "433.30", "414.01", "600.01", "442.82", "V45.02", "272.0", "569.3" ]

icd9cm

[ [ [] ] ]

[ "36.12", "88.41", "00.61", "39.61", "88.44", "33.24", "00.63", "36.15" ]

icd9pcs

[ [ [] ] ]

5529, 5610

2690, 5371

387, 724

5895, 5910

6115, 6272

2234, 2298

5631, 5874

5397, 5506

5934, 6092

2313, 2667

282, 349

752, 1782

1804, 2053

2069, 2218

8,196

130,974

10944

Discharge summary

report

Admission Date: [**2105-6-18**] Discharge Date: [**2105-7-16**] Date of Birth: [**2034-11-12**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3561**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: None History of Present Illness: 70M Cape-Verdean speaking with h/o DM, HTN, PVD s/p bilateral BKA (Right [**2105-5-13**]) and ESRD s/p LUE fistula [**2105-5-22**], recent admission for altered mental status presents with intermittent CP and SOB x 3 days. The patient is a poor historian. He describes the onset of palpitations 3 days ago, which on further history reports as substernal chest pain. Denies any radiation, SOB, nausea, or diaphoresis. The episode lasted 30-60 min and resolved. He had repeat episodes yesterday and then today when he was brought into the ED by his son. [**Name (NI) **] [**Name2 (NI) **], fever, chills, SOB, HA, nausea/vomiting. Continues to make urine, perhaps slightly increased amount recently but no dysuria. . Of note, the patient was recently admitted ([**Date range (1) 35542**]) for altered mental status thought to be multifactorial from medication confusion/noncompliance, severe hypertension at presentation, and vomiting/minimal po intake; his confusion improved prior to discharge. He also had bilious nausea/vomiting with KUB and CT abdomen/pelvis negative for obstruction that then resolved, hypertensive urgency, and isolated leukocytosis (WBC 17) without obvious signs for infection and therefore not treated. . In the ED, vitals: T 96.0 HR 84 BP 136/58 RR 16 SaO2 86 on RA -> 97% on 4.5L. Noted to be tachypnea intermittently to RR 32. ECG nondiagnostic with LVH with repol changes, worsening ST depressions laterally and positive troponin but normal CK. ABG 7.53/27/58; lactate 1.6; WBC 15.3; BNP [**Numeric Identifier 35543**]. CXR with ?left infiltrate vs. pulmonary edema. Pt received Lasix 20mg IV, ASA 325mg, and Levaquin 500mg PO. He adamantly refused blood cxs prior to antibiotics. Past Medical History: Insulin dependent diabetes mellitus-nephropathy, neuropathy, retinopathy Hypertension Peripheral Vascular disease s/p bilateral BKA Coronary artery disease End stage renal disease BPH Social History: retired engineer, married, lives at home with wife. no [**Name2 (NI) **], etoh, ivdu Family History: noncontributory Physical Exam: T 97.7 HR 72 BP 118/71 RR 22 SaO2 93% on 4.5L General: WDWN, +acc muscle use, speaks in full sentences HEENT: PERRL, EOMi, anicteric sclera, conjunctivae pink Neck: supple, trachea midline, no thyromegaly or masses, no LAD Cardiac: RRR, s1s2 normal, no m/r/g, JVP ~12cm Pulmonary: Bilateral crackles lower [**2-12**] lung fields with decreased BS at the left base and dullness to percussion Abdomen: +BS, soft, nontender, nondistended, no HSM Extremities: warm, bilateral BKAs with stumps c/d/i (staples on left), no edema apparent Neuro: Alert, speech clear and logical, CNII-XII intact, moves all extremities Brief Hospital Course: 70 y/o M with PMHx of DM, CRI, CAD, PVD s/p b/l BKA who was initially admitted on [**2105-6-18**] for NSTEMI and CHF that was later felt to be due to demand ischemia from CHF rather than plaque rupture. While on the floor was refusing lab draws and echocardiogram to assess resolution of NSTEMI. His hospital course was then complicated by 2 embolic strokes on [**6-22**] (R parietal and L frontal lesion) which caused him to become aphasic and develop R sided weakness. He did not receive any thrombolysis, and coumadin was held as felt risk on anticoagulation outwayed the benefits. He has ESRD but not getting dialysis yet as making urine, has a working fistula on R arm. On [**6-28**] he was intubated and transfered to the ICU for Urosepsis. He was treated with Meropenem, extubated, and transfered out of the ICU and back to the medical floor. While in the ICU a double lumen PICC was placed. . On the medical floor a PEG tube was placed and dispo planning was in process until [**2105-7-11**] AM when he was found to be grunting and coughing. At that time Lasix was given for fluid overload and enzymes were cycled. His EKG showed suggestion of anterior STEMI with no reciprocal changes, cardiology evaluated this and felt it was most likely a NSTEMI. They felt that no further intervention was warented. His troponin bumped to 1.49 and then 2.75 without an increase in his MB fraction. He was started on Heparin for anticoagulation. . At 6:30 AM on [**2105-7-12**] a trigger was called for hypoxia and tachypnia. Per the vitals sheet her O2 sat had dropped at 4:30AM to 80s however he was due for transfusion which was started and respiratory status worsened. The blood transfusion was stopped and he was placed on 100% on shovel mask with sats recorded at 86%, he was then placed on NRB with sats up to 97%. He was given 100mg Lasix and 500mg Diurel. He was then transfered to [**Hospital Unit Name 153**] for management of pulmonary edema. . On the evening of [**2105-7-12**] he again developed acute respiratory failure. He was intubated. A family meeting was held [**7-13**], and the decision was made to make the patient DNR, and to not pursue any further escalation of care (no pressors, no dialysis). A seconde family meeting was held on [**7-15**], and the decision was made to make the patient comfort measures only. He was extubated in the evening of [**7-15**]. He died at 0600 on [**2105-7-16**]. His son, [**Name (NI) **], was contact[**Name (NI) **] at the time of death. Medications on Admission: ASA 325mg daily Sodium citrate-citric acid 500-334 30ml tid Sevelamer 800mg tid Docusate 100mg [**Hospital1 **] Senna 8.6mg [**Hospital1 **] Lactulose 30ml tid Lantus 7 units qhs ISS Amlodipine 10mg daily Isosorbide dinitrate 40mg [**Hospital1 **] Simvastatin 20mg daily Lopressor 100mg [**Hospital1 **] Discharge Medications: NA Discharge Disposition: Expired Discharge Diagnosis: Primary: 1. Diastolic Heart Failure. 2. NSTEMI. 3. Acute Embolic Left Frontal and Right Parietal Stroke. 4. Acute Renal Failure Secondary: 1. Chronic Kidney Disease Stage V. 2. Peripheral Vascular Disease. 3. Bilateral BKA. 4. Diabetes Mellitus Type II. 5. Peripheral Neuropathy. 6. S/P LUE fistula [**2105-5-22**] Discharge Condition: NA Discharge Instructions: NA Followup Instructions: NA

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icd9cm

[ [ [] ] ]

[ "96.04", "96.71", "96.72", "96.6", "44.32", "99.04", "38.91", "38.93" ]

icd9pcs

[ [ [] ] ]

5951, 5960

3068, 5569

327, 333

6320, 6324

6375, 6380

2399, 2416

5924, 5928

5981, 6299

5595, 5901

6348, 6352

2431, 3045

277, 289

361, 2072

2094, 2280

2296, 2383

26,105

180,251

18986

Discharge summary

report

Admission Date: [**2155-7-14**] Discharge Date: [**2155-9-1**] Date of Birth: [**2107-11-15**] Sex: M Service: MICU HISTORY OF PRESENT ILLNESS: This is a 47-year-old male with past medical history significant for morbid obesity, diabetes mellitus, prostate cancer status post a radical prostatectomy with perineal approach performed [**2154-11-27**], who was admitted from an outside hospital for persistent shortness of breath and increased oxygen requirements. Since his surgery in [**Month (only) 1096**] he has noted periods of progressive dyspnea. His postsurgical course was complicated by multiple wound infections. The patient's initial complaints included dyspnea, orthopnea, and a sense of chest discomfort. The patient has also been having low-grade fevers. PAST MEDICAL HISTORY: 1. Prostate cancer status post surgery on [**2154-11-27**]. This was a [**Doctor Last Name **] six adenocarcinoma with negative margins. Postsurgical course was complicated by wound infections from perineal approach. 2. Morbid obesity. 3. Questionable history of a bacterial Enterococcal endocarditis. 4. Hypercholesterolemia. 5. Hypertension. 6. Diabetes type 2. 7. Depression/anxiety. ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: This gentleman is married with two children, formerly worked in a scrap metal company. He quit smoking about five years ago, but prior had a five-pack-a-day history for 8-10 years. He denied alcohol use. FAMILY HISTORY: Significant for diabetes and hypertension in his mother. PHYSICAL EXAMINATION: On initial presentation he was a fatigued, obese male speaking in short bursts of sentences. He was on a Venti mask in order to breathe. He was noted to be using his accessory muscles. Initial vital signs were 96.4 temperature, blood pressure 144/66, respiratory rate 30, heart rate 100 and 100% on 15 liter Venti mask. He was normocephalic, atraumatic, with supple neck. It was difficult to appreciate any jugular venous distension secondary to body habitus. He was regular rate and rhythm with S1 and S2 noted. No murmurs were noted but his heart sounds were distant, again secondary to habitus. He was noted to be tachypneic with decreased breath sounds at the bases. He had a soft obese belly with positive bowel sounds. He was noted to have 2+ pitting edema to the knees. LABORATORY DATA: On admission he had a 9.8 white count. His EKG showed only sinus tachycardia with some flattening of T waves but no sign of acute ischemia. His arterial blood gas was 7.45, 47, and 118. Records from the outside hospital indicate that he had received lower extremity Dopplers on [**2155-7-1**], which were negative for DVT. His chest x-ray showed some cardiomegaly and some question of increased pulmonary vascular congestion. He had a VQ scan done earlier on [**2155-6-15**] that showed low probability of embolic disease. He was admitted for progressive shortness of breath which, at the time, was of unclear etiology. It was thought it might have been secondary to congestive heart failure, pneumonia, pulmonary embolism or other source. HOSPITAL COURSE: 1. Cardiovascular: Echocardiogram showed evidence of endocarditis, including a vegetation seen on the right cusp of the aortic valve. It was also noted that he had 4+ mitral regurgitation and 3+ aortic insufficiency. This was presumed to be secondary to his enterococcal bacteremia and represent enterococcal endocarditis. He was on ampicillin at the time. CT surgery as well as cardiology were consulted. He had a catheterization done on [**2155-7-23**] that showed clean coronaries and an elevated left ventricular end-diastolic pressure of 45. The subsequent plan made was for bivalvular replacement. The conditions for surgery initially were for him to remain afebrile with negative cultures for 48 hours. In the meantime, he was started on low-dose captopril 6.25 t.i.d. to reduce afterload to improve cardiac function. On initially starting captopril, he dropped his pressures and required pressors. Surgical planning was complicated by the patient running persistent fevers and running positive blood cultures. Captopril was restarted on [**2155-8-22**] and this time tolerated by the patient with adequate pressures. On [**2155-8-23**] an EKG showed T wave inversions that were new compared with the [**2155-8-4**] comparison, across the precordium. Cardiac enzymes were cycled which showed a troponin of 0.13 and a CK of 100. The elevation of cardiac enzymes prompted a reconsult of cardiology, who felt that the findings were consistent with flipped emboli given the previously negative catheterization. Repeat checks of enzymes showed the CK maintained between 92 and 100 and the troponin did not elevate, it stayed at 0.10 for the subsequent two cycles of enzymes. The patient was started on aspirin, a beta blocker, and was maintained on the ACE inhibitor. Also, attempts at diuresis with combinations of Lasix and Diuril were used to attempt to keep the patient slightly negative. The patient continued to be febrile throughout most of his course in the intensive care unit. CT surgery's criteria for surgery were clearing of his decubitus ulcers and for the patient to become more awake and alert, and improve physical stamina. Therefore, they decided it would be best if he went to a rehabilitation unit once he was stable. The patient has now been afebrile for four days. CT surgery has been contact[**Name (NI) **] periodically to update them on his condition. At the present time they still feel he is a poor surgical risk and have recommended that he go to rehabilitation prior to surgery. 2. Infectious disease: The patient has known enterococcal endocarditis with visualized vegetation on TEE on the valve of the aorta. The patient has also had a history of bacteremia while in the unit. He has had panresistant Klebsiella, positive bacteremia, as well as periodic coagulase-negative staphylococcus bacteremia. He has been followed closely by infectious disease over the seven weeks that he has been in the unit and has had multiple antibiotic switches. He was on ampicillin, gentamicin, and ceftazidime for much of [**Month (only) 216**]. He had CT scan of head, chest, abdomen, and pelvis on [**2155-8-8**] that showed only his pulmonary infiltrates and no sign of other embolic disease. He had a brief bump in his creatinine to 1.4 while on gentamicin and since it was being used for synergy, it was discontinued after a two-week course. Subsequently the creatinine returned to [**Location 213**]. He was placed on imipenem and Cipro for 21 days for his Pseudomonas in the sputum, of which he is about day 19 of 21, and completed a week's worth of vancomycin for the coagulase-negative staphylococcus. He had a PICC line placed and all other lines were removed in an attempt to remove potential sources for infection. He has currently been afebrile for the past four days. 3. Respiratory: The patient initially came in very short of breath and tiring, requiring 15 liter Venti mask. He was electively intubated to facilitate studies including CT Scan and echo to evaluate his orthopnea and respiratory distress. Due to his peristent bacteremia and continued CHF related to his valvular disease he remained intubated and required a tracheostomy on [**2155-8-16**]. For the last several days he has been on a tracheostomy collar doing very well without the ventilatory support. 4. Neurologic: The patient's sedation and pain medication regimens have been lightened over the past several weeks in an attempt to wake him up. As the patient became more alert, it became concerning that he was not moving his right arm very effectively. Repeat CT scan showed no events to indicate embolism or stroke. In the last several days the patient has been visualized using that right hand, but to a lesser extend than the left. He will need physical therapy as well as monitoring of his neurological status as he becomes more alert. 5. Fluids, electrolytes and nutrition/GI: The patient is on continuous tube feeds via a PEG. He required insulin drips for some parts of his intensive care unit stay in order to maintain his sugars at a reasonable rate given his infectious disease status. Over the last several days he has been switched over to Lantus in the evening and sliding scale insulin, with a goal blood sugar of less than 133. 6. Pain/sedation: The patient is currently on a 25 mcg fentanyl patch as well as Klonopin 1 t.i.d. to help control his anxiety issues. He seems to be doing well on this regimen and we feel we have balanced his need to be awake and interactive with the need to control his symptoms. 7. Access: The patient has a right upper extremity PICC line. 8. Code status: Full code. 9. Hematology: The patient had some chronic mild anemia while in the unit, possibly secondary to repeated cultures which have been done nearly daily since his stay, also possibly secondary to his chronic illness. He has been placed on Epogen three times a week. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To a rehabilitation facility. Both [**Hospital1 **] and [**Hospital1 **] have available beds for him and it is undecided yet which he will accept. DISCHARGE DIAGNOSES: 1. Morbid obesity. 2. Prostate cancer status post surgical resection in [**11-25**]. 3. Enterococcal endocarditis with both aortic and mitral regurgitation. 4. History of Klebsiella and coagulase-negative Staphylococcus bacteremia. 5. Depression and anxiety. DISCHARGE MEDICATIONS: 1. Sliding scale regular insulin. 2. Metoprolol 50 mg p.o. b.i.d. 3. Aspirin 81 mg p.o. q.i.d. 4. Lantus 60 units subcutaneous q.h.s. 5. Clonazepam 1 mg p.o. t.i.d. 6. Sertraline 50 mg p.o. q.d. 7. He is on day nine of 10 of ciprofloxacin 400 mg IV q. 12. 8. He is on day 19 of 21 of imipenem 500 mg IV q. 8. 9. Nystatin swish and swallow. 10. Famotidine 20 mg p.o. b.i.d. 11. Epoetin 15,000 units subcutaneous three times a week. 12. Ferrous sulfate 325 mg p.o. t.i.d. 13. Docusate liquid 100 mg p.o. b.i.d. 14. Heparin 5,000 units subcutaneous q. 8 hours. 15. Atrovent nebulizers q. 6 hours. 16. Zinc sulfate 220 mg p.o. q.d. 17. Ascorbic acid 500 mg p.o. b.i.d. 18. Captopril 50 mg p.o. t.i.d. 19. Albuterol nebulizers q. 6 hours p.r.n. 20. ProMod at 85 cc per hour tube feeds, held for residuals over 100 cc. 21. Free water boluses 250 cc per PEG tube q. 6 hours. 22. Bisacodyl p.r.n. 10 mg p.o. p.r. q.d. 23. Lactulose p.r.n. 30 mL p.o. q. 8 hours. 24. Lidocaine p.r.n. 1%, 1.25 mL i.h. q. 6 hours p.r.n. for irritation when he coughs. FOLLOW-UP PLANS: The plan is to change his antibiotics over to ampicillin at the end of the 21-day course of imipenem. His anticipated discharge is today to rehabilitation. We will contact CT surgery to let them know of his progress. Dr. [**Last Name (STitle) 1537**] previously agreed in a family meeting to do a two-week follow up in his clinic after Mr. [**Known lastname 39151**] is discharged. The patient's family has sought out second opinions from several CT surgeons to see if they would be more likely to take this patient to the operating room. [**Known firstname **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 5587**] Dictated By:[**Last Name (NamePattern1) 50708**] MEDQUIST36 D: [**2155-9-1**] 08:07 T: [**2155-9-1**] 08:33 JOB#: [**Job Number 51882**]

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Discharge summary

report

Admission Date: [**2145-5-4**] Discharge Date: [**2145-5-27**] Date of Birth: [**2122-2-7**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Fevers, rigors, rigidity Major Surgical or Invasive Procedure: VP shunt tap Endotrachial intubation and mechanical ventilation History of Present Illness: 23 year old F with rollover MVC in [**12/2144**] and resulting TBI s/p craniectomy who was recently admitted to neurosurgery service in [**2-/2145**] for a cranioplasty. Presenting from rehab with fevers, rigors, and report of myoclonic jerks. Also a report of vomiting. According to rehab records, had dose of Keppra increased approximately 1 week ago. Family notes that patient has not been herself in last several days and was having more frequent shaking episodes. They felt like she was becoming ill and had her sent to ED. . In the ED, initial vs were: T 97.8, HR 92, BP 113/73, RR 16, O2Sat 100%. Shortly after arrival to triage, patient decompensated with increased temp and HR. Patient was felt to be having seizure and was given several pushes of lorazepam IV. Rectal temp shortly into ED course was 103 rectally and climbed to 105 during ED course. Concordant with spike in temp, HR climbed as high as 162, and was reportedly sinus tach. Received 5L NS through ED stay. Patient was cooled with ice and was given acetaminophen. Also felt to be in respiratory distress shortly after spiking a fever and was intubated. Fentanyl and midazolam given for sedation. Initial labs significant for lactate of 4.9 and WBC of 14. U/A showed 54 WBC and many bacteria. CSF was obtained from VP shunt and showed 1 WBC, 1 RBC, nml protein, nml glucose. Patient was given Vancomycin, Ceftriaxone, and Pip/Tazo for empiric treatment of fevers. Neurosurgery was consulted in ED and will follow patient on consult service. Toxicology consult was called in and and they reviewed meds for possible causes of serotonin syndrome or NMS. Prior to transfer to the MICU vitals were: T 101, HR 85, BP 107/58, RR 18, O2Sat 97% intubated. . Review of systems: Unable to obtain given altered mental status Past Medical History: 1) Rollover MVC with resulting traumatic brain injury ([**12/2144**]) - multiple facial fractures 2) s/p craniectomy 3) s/p VP shunt 4) s/p Trach/PEG with reversal of trach Social History: Currently resides at [**Hospital3 **]. Has a very involved and supportive family. Family History: Reviewed and non-contributory Physical Exam: On Admission: VS: T 97.7, HR 84, BP 95/44, RR 18, O2Sat 100% on AC Vt 400, f 18, PEEP 5, FiO2 70% GEN: Sedate, unresponsive, appears comfortable HEENT: Left eye with roving eye movements and left pupil reacts 4mm to 3mm, right eye with pupil fixed and dilated at 6 mm, right slcera edema, right conjunctival serous exudate, non-purulent NECK: Closed stomal scar in site of former tracheostomy PULM: CTAB CARD: RR, nl S1, nl S2, no M/R/G ABD: BS+, soft, NT, ND, slightly tympanic, G-tube in place without surrounding skin breakdown or erythema EXT: BLE with foot plantar flexion and internal rotation SKIN: No rashes or breakdown NEURO: Does not follow simple commands, intermittent increased tone in upper extremities, no rigidity, no clonus . At discharge: GEN: Sleeping, appears comfortable, does not open eyes to voice HEENT: Left pupil 5mm and reactive, right eye with pupil fixed and dilated at 6 mm, does not blink to threat NECK: tracheostomy in place PULM: Clear anteriorally, no wheezes/rales/rhonchi CARD: RR, nl S1, nl S2, no M/R/G ABD: BS+, soft, NT, ND, G-tube in place without surrounding skin breakdown or erythema EXT: BLE with foot plantar flexion and internal rotation SKIN: No rashes or breakdown NEURO: Does not follow simple commands, intermittent increased tone in upper extremities, no posturing Pertinent Results: Admission labs: [**2145-5-4**] 06:15PM BLOOD WBC-14.0*# RBC-4.55# Hgb-12.9# Hct-39.5# MCV-87 MCH-28.4 MCHC-32.8 RDW-16.9* Plt Ct-310 [**2145-5-4**] 06:15PM BLOOD Neuts-60.7 Lymphs-29.8 Monos-7.1 Eos-1.8 Baso-0.6 [**2145-5-5**] 03:39AM BLOOD PT-14.9* PTT-29.9 INR(PT)-1.3* [**2145-5-4**] 06:15PM BLOOD Glucose-111* UreaN-23* Creat-0.7 Na-141 K-4.9 Cl-100 HCO3-26 AnGap-20 [**2145-5-4**] 06:15PM BLOOD ALT-28 AST-30 CK(CPK)-85 AlkPhos-73 TotBili-0.5 [**2145-5-5**] 03:39AM BLOOD Calcium-8.7 Phos-3.3 Mg-1.9 . CSF Studies: [**2145-5-4**] 09:24PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-1* Polys-0 Lymphs-74 Monos-22 Macroph-4 [**2145-5-21**] 02:56PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-1* Polys-0 Lymphs-100 Monos-0 [**2145-5-4**] 09:24PM CEREBROSPINAL FLUID (CSF) TotProt-83* Glucose-71 [**2145-5-21**] 02:56PM CEREBROSPINAL FLUID (CSF) TotProt-59* Glucose-82 . [**2145-5-4**] CXR: IMPRESSION: Mild bibasilar atelectasis in the setting of reduced lung volumes. . [**2145-5-4**] Head CT: 1. Stable extra-axial collection overlying the right cerebral convexity since [**2145-4-9**]. 2. The left frontal subdural collection with small curvi-linear hyperdense component appears similar in attenuation but overall is slightly larger than [**2145-4-9**]. 3. No area of abnormal enhancement. If clinical concern remains high for infection, MRI is a more sensitive exam. . [**2145-5-5**] EEG: IMPRESSION: This is an abnormal continuous EEG, due to consistently lower amplitude activity seen over the right hemisphere, with less high frequency activity and occasional periods of delta slowing, consistent with a large underlying structural lesion involving the cortex on the right. In addition, the presence of mixed diffuse alpha and beta frequency activity, seen best over the left hemisphere throughout most of the tracing is consistent with pharmacologic sedation. The pushbutton event occurring on [**5-5**] at 8:13 pm appears to be clinically and electrographically consistent with shivering. There were no epileptiform features seen. . [**2145-5-10**] MRI: IMPRESSION: 1. Post-traumatic severe encephalomalacia of the right temporal lobe, with ex vacuo dilatation of the temporal [**Doctor Last Name 534**] of the right lateral ventricle. 2. Mild to moderate right frontoparietal encephalomalacia. 3. Right epidural and bilateral subdural hematomas, minimally changed since [**2145-5-4**]. 4. No acute superimposed process. . [**2145-5-16**] MR Pituitary: IMPRESSION: Motion artifact somewhat limits the examination. There is no definite pituitary mass. Lobular contour of the pituitary contents likely is secondary to this motion artifact as well as prominent adjacent pachymeningeal enhancement. There is no mass effect upon the optic chiasm, and the pituitary stalk is midline. . MICROBIOLOGY: [**2145-5-4**] Urine culture: URINE CULTURE (Final [**2145-5-8**]): KLEBSIELLA OXYTOCA. >100,000 ORGANISMS/ML.. Piperacillin/tazobactam sensitivity testing available on request. KLEBSIELLA OXYTOCA. >100,000 ORGANISMS/ML.. 2ND MORPHOLOGY. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML ________________________________________________________ KLEBSIELLA OXYTOCA | KLEBSIELLA OXYTOCA | | AMPICILLIN/SULBACTAM-- <=2 S <=2 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CIPROFLOXACIN---------<=0.25 S <=0.25 S GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S NITROFURANTOIN-------- 64 I 64 I TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S . CSF GRAM STAIN (Final [**2145-5-4**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final [**2145-5-7**]): NO GROWTH. . [**2145-5-5**] Sputum culture/Gram Stain: GRAM STAIN (Final [**2145-5-5**]): [**10-26**] PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. . RESPIRATORY CULTURE (Final [**2145-5-8**]): RARE GROWTH Commensal Respiratory Flora. STAPH AUREUS COAG +. SPARSE GROWTH. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. This isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . GRAM NEGATIVE ROD(S). RARE GROWTH. GRAM NEGATIVE ROD #2. RARE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 1 S OXACILLIN------------- 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S . [**5-10**] Sputum Cx and gram stain: GRAM STAIN (Final [**2145-5-10**]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [**2145-5-13**]): Commensal Respiratory Flora Absent. PSEUDOMONAS AERUGINOSA. MODERATE GROWTH. Piperacillin/Tazobactam sensitivity testing confirmed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. ENTEROBACTER CLOACAE. 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. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | ENTEROBACTER CLOACAE | | AMIKACIN-------------- 16 S CEFEPIME-------------- 8 S 2 S CEFTAZIDIME----------- 4 S =>64 R CEFTRIAXONE----------- 32 I CIPROFLOXACIN--------- =>4 R =>4 R GENTAMICIN------------ =>16 R 4 S MEROPENEM------------- 8 I 1 S PIPERACILLIN/TAZO----- 16 S TOBRAMYCIN------------ =>16 R <=1 S TRIMETHOPRIM/SULFA---- =>16 R . [**2145-5-16**] 2:09 pm SPUTUM Source: Endotracheal. **FINAL REPORT [**2145-5-20**]** GRAM STAIN (Final [**2145-5-16**]): >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2145-5-20**]): RARE GROWTH Commensal Respiratory Flora. ENTEROBACTER CLOACAE. RARE 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. Piperacillin/tazobactam sensitivity testing available on request. PSEUDOMONAS AERUGINOSA. RARE GROWTH. Piperacillin/Tazobactam sensitivity testing confirmed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROBACTER CLOACAE | PSEUDOMONAS AERUGINOSA | | AMIKACIN-------------- 16 S CEFEPIME-------------- 2 S 16 I CEFTAZIDIME----------- =>64 R 4 S CEFTRIAXONE----------- 16 I CIPROFLOXACIN--------- =>4 R =>4 R GENTAMICIN------------ 4 S =>16 R MEROPENEM------------- 4 S 4 S PIPERACILLIN/TAZO----- 16 S TOBRAMYCIN------------ <=1 S =>16 R TRIMETHOPRIM/SULFA---- =>16 R . [**2145-5-22**] 4:25 pm SPUTUM Source: Endotracheal. **FINAL REPORT [**2145-5-26**]** GRAM STAIN (Final [**2145-5-22**]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): YEAST(S). SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final [**2145-5-26**]): RARE GROWTH Commensal Respiratory Flora. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. Piperacillin/Tazobactam sensitivity testing confirmed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. Piperacillin/Tazobactam sensitivity testing confirmed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SECOND MORPHOLOGY. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | PSEUDOMONAS AERUGINOSA | | AMIKACIN-------------- 32 I 16 S CEFEPIME-------------- 8 S 16 I CEFTAZIDIME----------- 4 S 8 S CIPROFLOXACIN--------- =>4 R =>4 R GENTAMICIN------------ =>16 R =>16 R MEROPENEM------------- 4 S =>16 R PIPERACILLIN/TAZO----- 16 S 32 S TOBRAMYCIN------------ =>16 R =>16 R Brief Hospital Course: 23 year old F with rollover MVC in [**12/2144**] and resulting TBI s/p craniectomy who was recently admitted to neurosurgery service in [**2-/2145**] for a cranioplasty. Presents from rehab with fevers and worsening twitching and shaking. Ms. [**Known lastname 1968**] had extended MICU course for central dysautonomia with difficult to control sympathetic storm, respiratory failure, ventilator acquired pneumonia. . #. Central dysautonomia: Patient had presumed seizure [**5-7**] prior to admission. She was intubated in the emergency department for airway protection. It was suspected that patient is susceptible to seizures due to history of TBI and had decreased seizure threshold in setting of infection and fevers. She was admitted to the medical intensive care unit with neurology following patient. She has several days of continuous EEG monitoring that were not consistent with seizures. VP shunt was tapped and was negative for infectious process in CNS. MRI of the head was performed which did not show any acute processes or changes from prior. Patient's symptoms were somewhat controlled while on versed, but with decreased sedation, she had symptoms of hypertension, tachycardia, fever, diaphoresis, pupillatory dilataion, and muscle contraction. Neurology felt that patient's symptoms were secondary to sympathetic storm from central dysautonomia. She was started on a regimen of clonidine, labetolol and bromocriptine to help control these episodes, but had ongoing shaking activity with pyrexia, tachycardia, and hypertension. She was briefly tried on dantrolene which was thought to worsen her fevers and spasticity. Her regimen was eventually adjusted to standing clonidine, bromocriptine, propranolol, and baclofen with relatively good control. She was extubated and a tracheostomy was placed, patient was on trach mask and did not require venting at time of discharge. Per neurology, the prognosis of these episodes is unclear and it may take months for the sympathetic system to downregulate. In the acute setting of the sympathetic storms, morphine, tylenol, or motrin can be tried to control pyrexia and diaphoresis. We are attempting to minimize the use of benzodiazepines. Patient was also continued on her home keppra. She should follow up with the neurologists at rehab as well as her outpatient neurosurgeon for the long-term management of her TBI. Should call Dr. [**Last Name (STitle) 88235**] office to schedule a follow-up appointment for the sympathetic dysfunction. . #. Fevers: Urine culture show klebsiella and sputum cx show enterobacter, pseudomonas and MSSA. CSF sample from VP shunt had only 1 WBC, which is not concerning for CNS infection. Toxicology consulted and does not believe NMS was an issue at this time. Patient had repeated sputum samples which grew pseudomonas and enterobacter. Her initial sample was sensitive to cefepime and she was treated with this for nearly 2 weeks, she also completed a course of vancomycin. A repeat sputum returned pseudomonas with only intermediate sensitivity to cefepime, and greater sensitivity to meropenem. She was changed to meropenem on [**2145-5-24**] but subsequent sputum culture returned resistant to meropenem and sensitive to ceftazidime. She was started on cftazidime on [**2145-5-26**] and should complete a 2-week course (last day [**2145-6-8**]). She is likely colonized with a few different strains of pseudomonas and has bronchiectasis. Though fevers may be in setting of infection, they may also be due to central dysautonomia and patient has ongoing spiking throughout the day sometimes accompanied by tachycardia and hypertension. Episodes are sometimes self-resolved and often require morphine 1-2mg IV, tylenol, or motrin and cooling blanket to break the acute sympathetic storm. . # Traumatic brain injury: pt s/p MVA in [**12/2144**] with subsequent resulting in TBI with baseline non-verbal status and 3-month stay at rehab. Her progress at [**Hospital1 **] has been slow and she continues to have large baseline neurologic deficits. She will be discharged to a MACU from the MICU here and will discuss subsequent placement. She needs ongoing neurorehabilitation and should follow up with her neurosurgeon and the neurology team at [**Hospital 100**] Rehab. Medications on Admission: Medications: *From [**Hospital3 **] Records* 1) Adderall 5 mg daily 2) Akwa tears (polyvinyl alcohol) both eyes QID 3) Atrovent (ipratropium bromide) 0.5 mg neb Q6H PRN: dyspnea 4) Dantrium (dantrolene sodium) 50 mg [**Hospital1 **] 5) Dulcolax (bisacodyl) supp 10 mg PR PRN: constipation 6) Folvit (folic acid) 1 mg daily 7) Fragmin (dalteparin inj) 5000 units subcut daily 8) Ilotycin (erythromycin base oph) 1 application to right eye QID (last day [**5-6**]) 9) Inderal (propranolol) 10 mg Q8H 10) Keppra (levetiracetam) 1000 mg [**Hospital1 **] 11) Lacri-lube ointment both eyes QHS 12) Mycostatin powder (nystatin powder) [**Hospital1 **] PRN: rash 13) Oralbalance PO TID 14) Roxicodone (oxycodone) liquid 5 mg Q4H:PRN pain 15) Sarna lotion TID PRN:redness 16) Sodium chloride neb 3mL inh PRN: coughing 17) Symmetrel Liq (amantadine) 200 mg morning and lunch 18) Tylenol (acetaminophen) 650 mg Q4H PRN:pain 19) Vitamin B-1 100 mg QHS 20) Vitamin C liq 500 mg [**Hospital1 **] 21) Zegerid (omeprazole) 40 mg packet QHS Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) Injection TID (3 times a day). 2. polyethylene glycol 3350 17 gram/dose Powder [**Hospital1 **]: One (1) PO DAILY (Daily). 3. senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 4. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 5. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette [**Last Name (STitle) **]: One (1) Drop Ophthalmic QID (4 times a day). 6. acetaminophen 500 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever, pain. 7. docusate sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One (1) PO BID (2 times a day). 8. bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 9. levetiracetam 100 mg/mL Solution [**Last Name (STitle) **]: [**2134**] ([**2134**]) mg PO Q 12H (Every 12 Hours). 10. miconazole nitrate 2 % Powder [**Year (4 digits) **]: One (1) Appl Topical QID (4 times a day) as needed for RASH. 11. bromocriptine 2.5 mg Tablet [**Year (4 digits) **]: Two (2) Tablet PO TID (3 times a day). 12. gabapentin 300 mg Capsule [**Year (4 digits) **]: Two (2) Capsule PO TID (3 times a day). 13. clonidine 0.1 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO BID (2 times a day). 14. ibuprofen 100 mg/5 mL Suspension [**Year (4 digits) **]: Six Hundred (600) mg PO Q8H (every 8 hours) as needed for fever. 15. propranolol 40 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO QID (4 times a day). 16. baclofen 10 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO TID (3 times a day). 17. morphine 5 mg/mL Solution [**Year (4 digits) **]: 1-2 mg Injection Q2H (every 2 hours) as needed for agitation. 18. ceftazidime 2 gram Recon Soln [**Year (4 digits) **]: One (1) Recon Soln Injection Q8H (every 8 hours): last day = [**2145-6-8**]. Each dose should be infused over 3 hours. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary: Central dysautonomia / sympathetic storms Traumatic brain injury Hospital-community acquired pneumonia Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. [**Known lastname 1968**], You were admitted to [**Hospital1 18**] with seizure-like activity. We performed several tests that did not show seizure activity being generated by your brain. Our neurology team followed you closely and believes that you have sympathetic discharges that cause fevers, fast heart rate, and high blood pressure. We started several medications to help control these episodes though it may take some time for them to subdue. We also found that you had a pneumonia for which you were treated with antibiotics. You had a tracheostomy placed while you were in the hospital, and will be going to a rehabilitation facility for further care. You will follow up with the neurologists there. We made the following changes to your medications: - START baclofen, bromocriptine, propranolol and clonidine to help control your sympathetic storm episodes - CONTINUE ceftazidime for two weeks for treatment of the bacteria in your lungs (last day = [**2145-6-8**] Followup Instructions: Please follow up with the neurologists at your rehab facility and your regular outpatient neurosurgeon. We have placed a call in to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1274**] office and left them a message. You need to follow up with Dr. [**Last Name (STitle) 1274**] within the next month for your hospitalization. The office number is [**Telephone/Fax (1) 8139**]. If you have any questions or concerns please call the office as well. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

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icd9cm

[ [ [] ] ]

[ "96.04", "96.72", "33.23", "31.1", "38.97", "96.6" ]

icd9pcs

[ [ [] ] ]

21555, 21621

14118, 18388

334, 399

21777, 21777

3912, 3912

22965, 23573

2527, 2558

19462, 21532

21642, 21756

18414, 19439

21954, 22697

2573, 2573

3331, 3893

22726, 22942

2168, 2215

270, 296

427, 2149

4893, 14095

3928, 4884

2587, 3317

21792, 21930

2237, 2412

2428, 2511

21,903

118,106

4854

Discharge summary

report

Admission Date: [**2200-8-7**] Discharge Date: [**2200-8-20**] Date of Birth: [**2124-7-27**] Sex: F Service: HISTORY OF PRESENT ILLNESS: This is a 76 year old female who fell down two stairs in a witnessed fall and landed on her right-hand side and struck the right side of her head and was transferred to [**Hospital3 2063**] where a computerized axial tomography scan showed a right parietal subarachnoid hemorrhage. The patient was also found to have an INR of 3.1 and she was given Vitamin K and fresh frozen plasma and transferred to [**Hospital6 256**]. Upon arrival at [**Hospital6 256**] Emergency Room the patient was complaining of a headache and also right hip pain. The patient denied any loss of consciousness, preceding dizziness, palpitations or chest pain prior to the fall. The fall was witnessed. There was no seizure activity. PAST MEDICAL HISTORY: Previous medical history is significant for atrial fibrillation, hypertension, status post aortic valve and mitral valve replacement in [**2198**], status post breast cancer and insulin dependent diabetes mellitus. HOME MEDICATIONS: Coumadin, Insulin, Lasix 40 mg p.o. b.i.d. and Lopressor. ALLERGIES: She has a medical allergy to Procainamide. PHYSICAL EXAMINATION: Temperature 95.6, heartrate 80, blood pressure 175/76 and respirations 18, sating 99% on 2 liters per minute. The patient was alert and oriented times three. She had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2611**] coma scale of 15 and pupils were 3 mm and reactive. Tympanic membranes were clear. The mid face was stable. Trachea was midline. Hard collar was in place. There was no midline cervical tenderness. Heart was irregularly irregular and the rate was well controlled. Breathsounds were equal bilaterally and there was an old median sternotomy scar. Abdomen was soft, nontender. There were positive bowel sounds. Vascular examination was negative. Pelvis was stable and tender on the right hand side. Rectal was heme negative with normal sphincter tone. There was no stepoff in the back and the back was nontender. The right lower extremity was externally rotated and shortened. Distal pulses and sensation was intact in all extremities. LABORATORY DATA: Initial laboratory data work was significant for a hematocrit of 38.5, the patient's urinalysis was normal. INR was 3.1. Her BUN and creatinine were 31 and 1.4 and her glucose was 277. Initial radiology showed chest x-ray normal. Cervical spine series revealed no fracture, no dislocation and the pelvic AP revealed a right intertrochanteric femur fracture. Computerized tomography scan of the head repeated again showed a right parietal subarachnoid hemorrhage. There was no mass or shift. HOSPITAL COURSE: The patient was admitted to the SICU. Orthopedics, Cardiology and Neurosurgery were all consulted regarding the risks of anticoagulating the patient and expanding her subarachnoid hemorrhage, versus leaving her on unanticoagulated and putting her at risk for valve leaflet thrombosis and embolization as a result of her atrial fibrillation. The decision was made to perform open reduction and internal fixation of the right femur fracture while the patient was in an unanticoagulated state for her subarachnoid hemorrhage with the attempt to resume anticoagulation on heparin as soon as possible. She was taken to the Operating Room on hospital day #5 and had her femur surgically fixed. Serial head computerized tomography scans up to this point had revealed an unchanged subarachnoid hemorrhage. Postoperatively the patient exhibited some confusion and magnetic resonance imaging scan/magnetic resonance angiography was obtained that revealed no new hemorrhage, although it was difficult to rule out an embolic event. Her symptoms improved and she was back to her level of baseline mentation over the course of two days. Subsequently it was found that the patient had a urinary tract infection for which she was treated with Levaquin. She has also been consistently anemic throughout her hospital stay. An abdominal computerized tomography scan was performed to rule out any abdominal bleed. She has been guaiac negative throughout her hospital stay and no source of bleeding was able to be found. She was started on Epogen, however, this will take several weeks before the results are seen. In the interim, she has been intermittently transfused with packed red blood cells. Her Coumadin was restarted along with the heparin drip until her INR became therapeutic. She has also had diarrhea for which she has been Clostridium difficile negative repeatedly and has had a normal abdominal examination for which on source of diarrhea could be found. Now that serial hematocrits have been stable and the patient's diarrhea has had good resolution with p.o. Imodium she will be discharged to a rehabilitation facility in which to regain function of her normal daily activities. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D. [**MD Number(1) 2214**] Dictated By:[**Last Name (NamePattern1) 4791**] MEDQUIST36 D: [**2200-8-20**] 14:46 T: [**2200-8-20**] 15:59 JOB#: [**Job Number 20273**]

[ "820.21", "250.00", "599.0", "V43.3", "852.01", "V10.3", "V58.61", "E880.9", "423.1" ]

icd9cm

[ [ [] ] ]

[ "79.35" ]

icd9pcs

[ [ [] ] ]

2781, 5246

1131, 1246

1269, 2763

158, 873

896, 1112

3,145

134,002

15860+56698

Discharge summary

report+addendum

Admission Date: [**2107-10-7**] Discharge Date: [**2107-10-19**] Date of Birth: [**2065-7-27**] Sex: F Service: CHIEF COMPLAINT: Transfer from [**Hospital6 8283**] for epigastric pain, nausea, vomiting, and hypotension, requiring pressors. HISTORY OF PRESENT ILLNESS: This is a 42-year-old female with a history of hepatitis C, alcoholic hepatitis, chronic pancreatitis, narcotic abuse, and gastritis, last hospitalized from [**7-24**] through [**7-27**] at [**Hospital6 4299**] for alcoholic hepatitis and pancreatitis flares, who was transferred from [**Hospital6 8283**] for acute elevation in liver chemistries and hypotension. The patient was in her usual state of health until ten days prior to admission when she developed tooth pain. She initially took Penicillin without relief and was seen at [**Hospital6 8283**] Emergency Room on [**10-1**] where she was found to have a right tooth abscess and was prescribed erythromycin and Percocet. She developed hives with the Erythromycin and returned to the Emergency Room where her treatment was changed to Clindamycin with a prescription of Vicodin prescribed 2 tab q.4 hours. The patient subsequently developed nausea, vomiting, sharp and crampy epigastric pain that was radiating to her back. She discontinued the use of Clindamycin and presented to the Emergency Room with symptoms of nausea, vomiting, pain, and light-headedness. In the Emergency Room at the outside, she was found to be afebrile, tachycardiac with a heart rate of 134, orthostatic, and her exam was notable for scleral icterus, poor dentition, epigastric tenderness, and dry mucous membranes. Her liver chemistries were elevated with an AST of 83, 64, and an ALT of 1272, with an amylase of 40, lipase 17, lactate 9.2, and a potassium of 2.7, creatinine 1.8, and anion gap of approximately 30. She was given Ativan, Dilaudid, intravenous fluids, and placed on pressor drips of Dopamine and Neo-Synephrine. She was also given Vancomycin 1 dose, Levofloxacin 1 dose, and air-flighted to [**Hospital6 1760**] for further evaluation and treatment. PAST MEDICAL HISTORY: 1. Hepatitis C. 2. Alcoholic hepatitis. 3. History of alcohol abuse with withdraw seizures and DTs in the past. 4. History of hypertension. 5. History of chronic pancreatitis. 6. Status post cesarean section and ectopic pregnancies in the past. 7. History of traumatic wrist laceration in the past status post surgical repair with blood transfusions in [**2084**]. MEDICATIONS ON ADMISSION: Clindamycin and Vicodin p.r.n. ALLERGIES: ERYTHROMYCIN CAUSES HIVES, LIBRIUM CAUSES MENTAL STATUS CHANGES ACCORDING TO THE PATIENT. SOCIAL HISTORY: The patient lives with her ex-husband [**Name (NI) 13291**], [**Telephone/Fax (1) 45573**]. She is still legally married to her current husband, although is separated from him. She admits to drinking about one pint to one quart of vodka per day and stated that her last drink was 1?????? days prior to admission. She smokes one pack per day for the past 20-25 years. She admits that she is a former IV and intranasal drug user but stated that the use was somewhere between 1-5 years ago (her story changes throughout her admission). FAMILY HISTORY: Notable for mother who died secondary to complications of diabetes. Father died secondary to complications of coronary artery disease. No family history of liver disease. PHYSICAL EXAMINATION: Vital signs: Temperature 99.8??????, blood pressure 108/64 on Neo-Synephrine and Dopamine. General: she was an obese female. HEENT: Dry mucous membranes. Positive scleral icterus. Poor dentition. Cheek swollen secondary to dental abscess. Pupils constricted. Abdomen: Soft, nondistended, obese. No stigmata of chronic liver disease. Decreased bowel sounds. Tenderness in the epigastrium and left upper quadrant without rebound or voluntary guarding. Unable to percuss liver and spleen size or palpate secondary to subcutaneous fat and tissue. LABORATORY DATA: As above for labs at outside hospital. Labs also notable for a white blood cell count of 13.4, hematocrit 40, platelet count 85; UCG negative; toxicology screen positive for opiates, but negative for acetaminophen; urinalysis positive for 2+ protein, 3+ bilirubin, [**2-1**] fine granular casts. Electrocardiogram with normal axis and normal sinus rhythm. Chest x-ray, PA and lateral, without any acute disease, infiltrates, or failure. Abdominal ultrasound demonstrated fatty infiltration of liver with several small gallbladder polyps and no gallstones. Ultrasound also demonstrated pancreatic calcifications consistent with chronic pancreatitis. HOSPITAL COURSE: 1. Hypotension: The patient remained in the Medical Intensive Care Unit for two days where she was aggressively hydrated, and her pressors were slowly weaned off. Her renal function improved over the course of time from a creatinine of 1.8 to a creatinine of 0.4. She required no more pressors or had no more episodes of hypotension throughout the course of her hospitalization. 2. Infectious disease: The patient had a low-grade fever on admission with a white blood cell count slightly elevated at 10.5. She had two blood cultures from the outside hospital positive for coagulase positive Staphylococcus aureus which was sensitive to Clindamycin. She was started on Clindamycin on [**10-8**] and completed an 11-day course of this medication. She also underwent a 3-day course of Levofloxacin for pyuria; however, she continued to have fever spikes throughout the course of her hospitalization as high as 102-103??????F. Multiple tests were done including CMV, EBV, which were all negative, and surveillance blood cultures on [**10-8**], [**10-12**], [**10-13**], and [**10-17**] were all without any growth to date. Blood cultures were also sent for .................. organisms, and there has been no growth to date of these organisms. Dental films were obtained, given the patient's complaint of dental abscess and demonstrated no abscess or no signs of osteomyelitis. The patient was seen and followed by Oral Surgery, and they felt that the source of her staph bacteremia was unlikely from her dental issues which they felt were more consistent with cellulitis and not an abscess. Transthoracic echocardiography and transesophageal echocardiography were within normal limits and did not demonstrate any vegetations on exam. The patient was begun on Oxacillin as her bacteremia was sensitive to Oxacillin on [**10-11**] and will complete a 14-day course of Oxacillin. She was followed by the Infectious Disease Services while in-house and for the last two days of her hospitalization has been afebrile with normal white blood cell count and no fever spikes. She is transferred with the specific desire that she will continue out her Oxacillin treatment which is 2 g q.4 hours for the next seven days, to complete a 14-day course. 3. GI: The patient presented with acute hepatic toxicity, likely secondary to not only alcohol but acetaminophen toxicity with elevated liver function tests that are also suggestive of ischemic hepatitis. The patient underwent 48 hours of .................. therapy, as well as Vitamin K for three days to bring down her elevated INR of 3.3. She has an ultrasound that demonstrated patent hepatic vasculature, as well as patent portal vein. She did not at any point have any asterixis or signs of hepatic encephalopathy. EGD demonstrated no significant varices, but only some esophagitis. She did have a CT scan that demonstrated some small splenic and gastric varices. She was confirmed to be positive for hepatitis C and negative for hepatitis A and B viruses. While in-house she received hepatitis A vaccine and hepatitis B vaccine. She did during the course of the hospitalization develop diarrhea and C-diff. Cultures were negative times two. The patient thus likely had hepatic toxicity secondary to alcohol and acetominophen, as well as ischemic hepatitis. Her liver chemistries trended back toward normal during the course of her hospitalization and were with an AST of 85 and ALT 84 by the time of discharge. The patient will follow-up with the Liver Clinic at [**Hospital6 256**] for her liver failure. The patient was not willing to speak to addictions specialist at [**Hospital6 2018**] regarding her alcohol abuse. 4. Neurological: The patient received Benzodiazepines per CIWA scale with signs of delirium tremens in the Intensive Care Unit; however, the patient was rapidly titrated off of her benzodiazepines and did not require any for the rest of the course of her admission without any signs of DTs; however, the patient was started on Dilaudid for her abdominal pain and pan secondary to multiple blood draws during the course of her admission, and titration is ensuing for these medications. She is currently on Dilaudid q.6 hours and will continue to titrate back as tolerated. 5. Heme: The patient had a low hematocrit noted during the course of the admission with iron studies demonstrating normal iron but lower TIBC and an elevated MCV. Folate and B12 were within normal limits. 6. Pain: As above, the patient continues to take small Dilaudid for abdominal pain which we will attempt to wean off as tolerated. The patient demonstrates addictive behaviors towards these medications and often becomes angered or tearful when we try to wean them back. The patient also underwent abdominal CT to rule out intra-abdominal source of abscess, splenic infarct, or colitis, which may be contributing to her fever spikes. There was no evidence of splenic or renal pathology. There was no evidence of intra-abdominal abscess or other abnormal fluid collections. There was a diffusely calcified pancreas noted and diffuse fatty infiltration of the liver. There were mild gastroesophageal and splenic varices as described before. DISPOSITION: The patient will be transferred to an outside hospital ([**Hospital6 8283**]) for continuation of her course of antibiotics. Infectious Disease Service recommended one week more of Oxacillin to treat the coag-positive Staphylococcus aureus that was noted on blood cultures at the outside hospital. No obvious source of this infection has been noted to date and may have been a transient bacteremia, but given the status of the patient on admission and her hypotension/sepsis, they recommend one more week of antibiotic treatment. DISCHARGE STATUS: Fair. DISCHARGE DIAGNOSIS: 1. Hepatic toxicity secondary to alcohol and acetaminophen overuse. 2. Ischemic hepatitis. 3. Esophagitis. 4. Narcotic abuse. 5. Alcohol withdraw. 6. Anemia likely satisfactory condition alcohol abuse and myelosuppression. DISCHARGE MEDICATIONS: Oxacillin 2 g q.4 hours, Clotrimazole 1% vaginal creme 1 application q.h.s. for 7 days, Creon 10 mg 2 cap p.o. q.i.d. for her chronic pancreatic insufficiency, Magnesium Oxide 800 mg p.o. t.i.d., please hold for diarrhea, Pantoprazole 40 mg p.o. q.24 hours for gastritis/esophagitis, Calcium Carbonate 500 mg p.o. b.i.d., Folic Acid 1 mg p.o. q.d., Thiamin 100 mg p.o. q.d., Multivitamin 1 q.d. FOLLOW-UP: The patient will follow-up in the Liver Clinic at [**Hospital6 256**] in the future. The patient will follow-up with her primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. DR.[**First Name (STitle) **],[**First Name3 (LF) 734**] 12-944 Dictated By:[**Last Name (NamePattern1) 3864**] MEDQUIST36 D: [**2107-10-18**] 15:03 T: [**2107-10-18**] 15:25 JOB#: [**Job Number 45574**] cc:[**Last Name (STitle) 45575**] Name: [**Known lastname 1028**], [**Known firstname **] [**Last Name (NamePattern1) **] Unit No: [**Numeric Identifier 8367**] Admission Date: [**2107-10-7**] Discharge Date: [**2081-2-24**] Date of Birth: [**2065-7-27**] Sex: F Service: ADDENDUM: The patient was scheduled to be transferred to [**Hospital6 8368**] on [**2107-10-21**]; however, the patient, despite the conditions of her transfer at that time, was offered the opportunity to stay at [**Hospital6 4122**] for the remainder of her IV Oxacillin therapy treatment for her methicillin-sensitive Staphylococcus aureus bacteremia. The patient had a PICC line to receive this; however, was not a candidate for VNA services given her history of IV drug use and was not eligible for rehab transfer given her insurance status. On [**2107-10-22**], the patient requested to leave AMA because she no longer wanted to stay in the hospital. The patient was educated that this is not the standard of care for the MSSA bacteremia and that any other types of treatment would not necessarily completely treat the infection that she had. The patient understood this and decided to leave AMA regardless of this information. She was discharged with her medications and in place of Oxacillin was given by mouth dicloxacillin 500 mg p.o. q.i.d. for the remainder of her therapy for four days. DISCHARGE STATUS: To home. FOLLOW-UP: The patient will follow-up as per the prior dictation. [**First Name11 (Name Pattern1) 27**] [**Last Name (NamePattern1) 28**], M.D. [**MD Number(1) 29**] Dictated By:[**Last Name (NamePattern4) 8369**] MEDQUIST36 D: [**2107-10-24**] 18:22 T: [**2107-10-24**] 16:41 JOB#: [**Job Number 8370**]

[ "571.1", "285.9", "070.54", "038.11", "008.45", "291.0", "401.9", "304.01", "577.1" ]

icd9cm

[ [ [] ] ]

[ "45.13", "88.72", "38.93" ]

icd9pcs

[ [ [] ] ]

3235, 3409

10754, 13395

10500, 10730

2529, 2664

4677, 10479

3432, 4659

150, 262

291, 2102

2125, 2502

2681, 3218

6,098

126,130

44835

Discharge summary

report

Admission Date: [**2108-1-21**] Discharge Date: [**2108-1-22**] Date of Birth: [**2042-9-8**] Sex: M Service: MEDICINE Allergies: Hydralazine / Iodine Attending:[**Last Name (NamePattern1) 293**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: 65 yo m with cad, renal transplant, copd, chf, recent charcot foot wound debridement who presents with acute dysnea, cough, and viral sx x 2d. Of note, has developed left foot erythema, pain x 8 days, had debridement 10 d ago. . In ED, patient was febrile to 102 HR 108, bp 150-170 systolic RR 30's and RA sat of 96%. He was given 80 IV lasix, nebs, nitro drip, and started on bipap. He was briefly started on heparin-with 4000 u bolus- for st depressions in lateral leads (original ekg missing). Cards reviewed EKG though it was demand ischemia and pt was given asa, 1 unit prbcs. . On ROS: admits to right hip and knee pain. Patient says he was taking all his medications as prescribed. Denies N/V/abd pain/dysuria/cp, +sick contact sunday dinner . Of note, Mr. [**Known lastname 95923**] made it clear on this and previous admissions that he would not want to undergo dialysis or endotracheal intubation, and his DNR/DNI status was confirmed. Past Medical History: Multifactoral Iron deficiency (iron def. and CRI) DM2 c/b retinopathy, neuropathy ESRD after angioplasty 10 years ago. On dialysis 5 years and then had CRT in [**2100**] complicated by chronic rejection. Chronic allograft nephropathy with progressive proteinuria and decline in allograft function. S/P 5 years of HD and two AV fistula placements. Now with chronic renal failure with baseline creatinine high 4's HTN COPD (w/o prior PFTs) h/o Wenkebach heart block. Left Charcot foot. Suppurative hydradenitis. Right hip fx s/p ORIF [**2100**]. CAD (patient reports having undergone cath, reports clean coronaries) PUD c/b UGIB Hyperlipidemia. Neurogenic Bladder BPH Aflutter s/p ablation [**2106**], Dr. [**Last Name (STitle) **] Social History: Lives at home alone. Smokes 4 cigarettes/day after breakfast. 50 pack/yr smoking hx. No alcohol or drugs. Born and raised in New [**Location (un) **] City, studied economics at NYU, received a grad degree in economics, worked [**Street Address(1) 95920**] and moved to [**Location (un) 86**]. Has two sons but lives alone. He is close with his family. Has been divorced for a number of years. Family History: Father deceased of an MI at age 74; mother deceased from a [**Name (NI) 4278**] cancer at age 65. Mother also was with breast cancer. One sibling healthy Physical Exam: VS: T 98.4 BP 125/56 P 89 irreg 100% BIPAP--> 4L NC, pulsus <5 GEN: On bipap, speaking in full sentences HEENT: O/P clear NECK: JVP 10-12, no bruits B CV: Distant heart sounds. No rub heard. Nml s1,s2. RESP: Rales bilaterally. Inital wheeze and transmitted upper airway sounds, clears with cough, otherwise, no w/r/r ABD: Obese, soft. NTND. EXT: 1+ edema to shin bilat. Pulses 2+, symmetric. Left foot lesion, stage 2, with surrounding erythema, L Arm AV fistula site: pulse, but no thrill. RECTAL: neg x 4 in ED. Evidence of chronic scarring and surgical changes perirectally. Pertinent Results: [**1-21**] CXR: AP UPRIGHT PORTABLE CHEST X-RAY: The cardiac silhouette is grossly enlarged. The mediastinal contour is normal. There is bilateral hilar fullness. The pulmonary vasculature is engorged and redistributed. There is no pneumothorax. No consolidations or effusions are seen. The right lung base effusion seen on [**2107-11-22**] has resolved. IMPRESSION: Moderate CHF. . [**2108-1-21**] 06:45AM BLOOD WBC-10.2 RBC-2.60*# Hgb-7.0*# Hct-19.6*# MCV-76* MCH-26.8* MCHC-35.5* RDW-19.1* Plt Ct-251 [**2108-1-21**] 06:45AM BLOOD Neuts-91.8* Lymphs-3.7* Monos-3.9 Eos-0.4 Baso-0.2 [**2108-1-21**] 06:45AM BLOOD PT-15.2* PTT-28.5 INR(PT)-1.4* [**2108-1-21**] 06:45AM BLOOD Fibrino-622* [**2108-1-21**] 06:45AM BLOOD Glucose-128* UreaN-109* Creat-5.0*# Na-134 K-4.1 Cl-97 HCO3-16* AnGap-25* [**2108-1-21**] 06:45AM BLOOD Calcium-6.0* Phos-4.0 Mg-1.5* [**2108-1-21**] 06:48AM BLOOD Lactate-1.1 . [**2108-1-22**] 03:55AM BLOOD WBC-10.2 RBC-2.50* Hgb-6.7* Hct-19.6* MCV-78* MCH-26.7* MCHC-34.0 RDW-18.9* Plt Ct-223 [**2108-1-22**] 03:55AM BLOOD Neuts-97.1* Bands-0 Lymphs-1.6* Monos-0.9* Eos-0.3 Baso-0.2 [**2108-1-22**] 03:55AM BLOOD PT-15.5* PTT-30.5 INR(PT)-1.4* [**2108-1-22**] 03:55AM BLOOD Glucose-153* UreaN-115* Creat-5.8* Na-134 K-4.8 Cl-97 HCO3-17* AnGap-25* [**2108-1-22**] 03:55AM BLOOD Calcium-6.0* Phos-6.7*# Mg-1.7 . [**2108-1-21**] 06:45AM BLOOD CK(CPK)-361* CK-MB-7 proBNP-[**Numeric Identifier 95924**]* cTropnT-0.42 [**2108-1-21**] 01:13PM BLOOD CK(CPK)-381* CK-MB-10 MB Indx-2.6 cTropnT-0.51* [**2108-1-22**] 03:55AM BLOOD CK(CPK)-495* CK-MB-8 cTropnT-1.07* . [**2108-1-21**] 07:02AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.012 [**2108-1-21**] 07:02AM URINE Blood-NEG Nitrite-NEG Protein-100 Glucose-NEG Ketone-TR Bilirub-SM Urobiln-NEG pH-5.0 Leuks-NEG [**2108-1-21**] 07:02AM URINE RBC-0 WBC-[**3-12**] Bacteri-MOD Yeast-NONE Epi-0-2 . [**1-21**] and [**1-22**] BCx: No growth [**1-21**] UCx: No growth Brief Hospital Course: History of diastolic dysfxn, presenting with worsening failure, with no diuresis response to 80 IV lasix in ED. Volume overload state most likely due to worsening renal dysfunction as well as hypermetabolic state from foot ulcer/cellulitis. Placed on lasix and nitro drips overnight in ICU, with very little diuresis and laboraory evidence of worsening renal dysfunction. He was maintained on BiPap. Renal and podiatry services were initially consulted, but eventually were deferred due to change in goals of care as below. Mr. [**Known lastname 95923**]' wishes to not undergo dialysis or be endotracheally intubated were confirmed by him. After discussions with Mr. [**Known lastname 95923**], his family, pastor, and primary care physician, [**Name10 (NameIs) **] were in agreement to change the goals of care to focus on comfort. He was placed on a morphine drip to alleviate his dyspnea and, once the remainder of his family arrived, the BiPap was discontinued. He died on [**1-22**] with family at the bedside. There was no post-mortem examination. Medications on Admission: 1. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 2. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Calcitriol 0.25 mcg Capsule Sig: Four (4) Capsule PO DAILY (Daily). 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: Four (4) Tablet, Chewable PO QID (4 times a day). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). 9. Epoetin Alfa 20,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 10. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for anxiety. 11. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed. 12. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 13. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed). 15. Amitriptyline 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 16. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 17. Sodium Bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 18. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4-6H (every 4 to 6 hours) as needed. 19. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO every morning. 20. Lasix 40 mg Tablet Sig: One (1) Tablet PO every evening. 21. medication Insulin as per sliding scale Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: ESRD, heel ulcer, diastolic heart failure Discharge Condition: Deceased Discharge Instructions: None Followup Instructions: None

[ "427.32", "362.01", "428.0", "428.33", "496", "996.81", "250.50", "250.60", "600.00", "403.91", "585.9", "713.5", "707.14", "357.2", "682.7", "596.54" ]

icd9cm

[ [ [] ] ]

[ "99.04" ]

icd9pcs

[ [ [] ] ]

8067, 8076

5208, 6265

295, 302

8162, 8173

3232, 5185

8226, 8234

2461, 2618

8038, 8044

8097, 8141

6291, 8015

8197, 8203

2633, 3213

248, 257

330, 1278

1300, 2032

2048, 2445

41,702

120,860

44727

Discharge summary

report

Admission Date: [**2153-8-30**] Discharge Date: [**2153-9-6**] Date of Birth: [**2112-6-12**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 4095**] Chief Complaint: DKA/hyperglycemia Major Surgical or Invasive Procedure: right internal carotid central line History of Present Illness: Ms. [**Known lastname 13469**] is a 41yo F w/ h/o T2DM, depression and frequent past admissions for DKA/hyperglycemia who presented to the ED w/ SOB, tachycardia and tachypnea and found to have glucose 626. Pt reports poyuria and polydypsia for past few days and often skipping evening dose of insulin due to financial constraints and stress/distractions at home. Pt woke this morning with nausea and one episode of nonbloody nonbilious vomiting, rapid heart rate and feeling of anxiety and rapid heart rate, similar to prior episodes of hyperglycemia. She did not take her morning insulin. Pt also endorses headache, blurry vision which she says is at baseline due to cataracts and dabetic retinopathy, and post-nasal drip due to allergies. She denies fever/chills, productive cough, abdominal pain, change in bowels or sick contacts. Pt has depression treated with Paxel which she has not taken for the past 2 wks after running out of the medication, and reports sleeping more and feeling more depressed lately. She denies current suicidal/homocidal ideals or thoughts of self harm. On arrival to the [**Name (NI) **], pt's VS: T 98.7, HR 128, BP 111/55, RR 20, Sa02 100% on 2L. Blood glucose 626. UA with glucose 1000 and ketones 150. VBG showed pH 6.88, Bicarb 3, Anion gap 39. In the [**Name (NI) **], pt was given a total of 5L NS, 10U insulin boluses x 2 and started on insulin drop at 8U/hr and 2 mg lorazepam due to anxiety and tachypnea/tachycardia. On arrival to the MICU, patient's VS were 98.3 HR 91, BP 109/77, RR 13, Sa02 96% on RA. IVF were switched to D51/2NS + 20mEq KCl as BG 263. Due to inability to get PIV, central line placement was required for blood draws and IVF administration. Past Medical History: DM2 w/moderately severe B nonproliferative diabetic retinopathy HTN Depression- one psych hospitalization in [**2150**] for SI h/o EtOH abuse- never experienced withdrawal sx, no longer drinking Social History: Lives with her brother and 2 children. Currently seeking disability, not employed. Denies tobacco use. Occasional marijuana use, none recently. Hx of prior alcohol abuse, now drinks once weekly. Last drink over one week ago. Denies hx of withdrawal. Family History: Mother with DM2, HTN. No known family history of cancer. Physical Exam: Admission Labs: Vitals: T 98.7, HR 128, BP 111/55, RR 20, Sa02 100% on 2L General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: tachycardic ~110bpm, regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. . Discharge Exam: AVSS Card: s1 s2 no m/r/g otherwise as above Pertinent Results: Admission Labs: [**2153-8-31**] 11:03AM BLOOD Hct-29.9* [**2153-8-31**] 05:41AM BLOOD WBC-7.5 RBC-3.23* Hgb-10.1* Hct-29.7*# MCV-92# MCH-31.4 MCHC-34.1# RDW-16.1* Plt Ct-221 [**2153-8-30**] 05:00PM BLOOD WBC-13.1*# RBC-4.19* Hgb-13.1 Hct-42.7# MCV-102*# MCH-31.3 MCHC-30.7* RDW-15.7* Plt Ct-334 [**2153-8-30**] 05:00PM BLOOD Neuts-82.4* Lymphs-12.1* Monos-5.2 Eos-0.1 Baso-0.2 [**2153-8-31**] 05:41AM BLOOD Plt Ct-221 [**2153-8-30**] 05:00PM BLOOD Plt Ct-334 [**2153-8-31**] 05:41AM BLOOD [**2153-8-31**] 11:03AM BLOOD Glucose-172* UreaN-16 Creat-0.7 Na-138 K-3.9 Cl-116* HCO3-17* AnGap-9 [**2153-8-31**] 05:41AM BLOOD Glucose-79 UreaN-18 Creat-0.7 Na-143 K-3.8 Cl-117* HCO3-17* AnGap-13 [**2153-8-31**] 02:10AM BLOOD Glucose-125* UreaN-19 Creat-0.8 Na-144 K-3.9 Cl-118* HCO3-15* AnGap-15 [**2153-8-30**] 06:55PM BLOOD Glucose-99 UreaN-5* Creat-0.0*# Na-152* K-LESS THAN Cl-GREATER TH HCO3-LESS THAN [**2153-8-30**] 05:00PM BLOOD Glucose-626* UreaN-27* Creat-1.4* Na-139 K-5.9* Cl-97 HCO3-LESS THAN [**2153-8-30**] 05:00PM BLOOD estGFR-Using this [**2153-8-31**] 11:03AM BLOOD Albumin-3.2* Calcium-7.9* Phos-2.8 Mg-2.5 [**2153-8-31**] 05:41AM BLOOD Albumin-3.3* Calcium-7.8* Phos-1.6* Mg-2.8* [**2153-8-31**] 02:10AM BLOOD Albumin-3.4* Calcium-7.6* Phos-1.2*# Mg-1.5* [**2153-8-31**] 05:41AM BLOOD %HbA1c-12.9* eAG-324* [**2153-8-31**] 02:10AM BLOOD Acetone-SMALL Osmolal-305 [**2153-8-31**] 05:57AM BLOOD Type-MIX pH-7.33* [**2153-8-31**] 02:29AM BLOOD Type-MIX pH-7.32* [**2153-8-30**] 10:19PM BLOOD Type-[**Last Name (un) **] pO2-117* pCO2-19* pH-7.21* calTCO2-8* Base XS--18 [**2153-8-30**] 06:59PM BLOOD Type-[**Last Name (un) **] pO2-105 pCO2-7* pH-6.88* calTCO2-1* Base XS--32 Comment-GREEN TOP [**2153-8-30**] 10:19PM BLOOD Glucose-195* Lactate-1.4 Na-142 K-4.3 Cl-119* [**2153-8-30**] 07:09PM BLOOD Lactate-4.2* K-5.3* [**2153-8-31**] 05:57AM BLOOD freeCa-1.20 [**2153-8-31**] 02:29AM BLOOD freeCa-1.16 [**2153-8-30**] 10:19PM BLOOD freeCa-1.16 CXR: IMPRESSION: Tip of the new right internal jugular line ends in the region of the superior cavoatrial junction. Lungs clear. Heart size normal. No pneumothorax, pleural effusion or mediastinal widening. Brief Hospital Course: 41yo F w/ T2DM and frequent admissions for DKA/hyperglycemia presenting with DKA and glucose >500 secondary to medication non-compliance. # Diabetic Ketoacidosis: Patient presented with hyperglycemia, anion gap metabolic acidosis, and ketonuria, likely secondary to DKA in setting of insulin therapy non-adherence. Patient had mild leukocytosis, though no fevers/chills or localizing signs or symptoms of infection. UA not suggestive of UTI, and CXR shows no acute process. EKG similar to priors, and not concerning for ischemia. FSBS has improved on arrival to [**Hospital Unit Name 153**], down from >600 to 315 and 260s on transfer to ICU. Patient was aggressively volume resuscitated with 5L NS in ED, and is currently hemodynamically stable without evidence of significant volume depletion. Glucose came down to wnl and gap closed. Insulin drip was stopped. [**Last Name (un) **] Diabetes was consulted, who recommended re-starting the patient's home regimen of insulin 70/30 25units qam, 20units pm. Urine culture was no growth to date. Given an episode of mild hypoglycemia overnight the patient regimen was adjusted to 70/30 27units QAM and 18 units QPM. For 48hrs prior to discharge the patients blood sugars were well controlled with the exception of one mild hypoglycemic episode to the mid 60s. Prior to discharge the patient regimen was: - 70/30 27units QAM and 18 units QPM - Humalog Sliding Scale QID with her QHS SS only receiving humalog for PM FS of >250. # Anion gap metabolic acidosis: This was secondary to DKA as above, though lactate also elevated (in setting of DKA and volume depletion). Patient denies any ingestions. Had anion gap initially of 39, which has resolved and currently anion gap of 9. # [**Last Name (un) **]: Cr elevated to 1.4 on admission, up from baseline of 0.5-0.7, now back to baseline at 0.7. This was likely secondary to pre-renal azotemia in setting of volume depletion from DKA. Home lisinopril was been held given lower blood pressures, volume depletion and risk of [**Last Name (un) **]. # Leukcytosis: Likely caused by stress response in setting of DKA. No localizing signs/symptoms of infection. UA negative, CXR negative, no fevers/chills. On admission leukocytosis to 13.1 which has resolved to 7.5. # HTN: Pt was restarted on ACEi while in house # Depression: Pt has h/o psychiatric hospitalization in [**2150**] for suicidal ideation. Pt denies SI, HI or thoughts of self harm during current admission, although admits to feeling more depressed and having her anxiety and financial concerns contribute to her medication noncompliance. Social work and psychiatry consulted. Psychiatry found patient to be in major depressive episode and have recommended inpatient psychiatric stay after medically stable. Pt was placed under Section 12, although patient at this time is voluntary and willing for inaptient psychiatric admission. - Paroxetine 20mg was increased to 40mg just prior to discharge to psychiatric facility Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Lisinopril 2.5 mg PO DAILY 2. Humalog 25 Units Breakfast Humalog 20 Units Dinner 3. Paroxetine 20 mg PO DAILY 4. traZODONE 50 mg PO HS:PRN sleep Discharge Medications: 1. 70/30 27 Units Breakfast 70/30 18 Units Dinner Insulin SC Sliding Scale using HUM Insulin 2. Lisinopril 2.5 mg PO DAILY 3. traZODONE 50 mg PO HS:PRN sleep 4. Fluoxetine 40 mg PO DAILY Discharge Disposition: Extended Care Facility: [**Hospital1 69**] - [**Location (un) 86**] Discharge Diagnosis: Primary Diagnosis - Diabetic Ketoacidosis - Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the ICU with diabetic ketoacidosis due to not taking your insulin. You received 7 liters of IV fluid and restarted on your insulin regimen. Please continue to take all of your medications and note the changes that have been made. Followup Instructions: Please follow-up with your PCP and [**Name9 (PRE) **] doctors [**First Name (Titles) **] [**Name5 (PTitle) 15968**] from your psychiatric facility

[ "303.93", "V15.81", "250.12", "300.00", "288.60", "362.06", "V58.67", "493.90", "250.52", "309.81", "584.9", "250.82", "296.33", "276.8", "401.9", "285.9" ]

icd9cm

[ [ [] ] ]

[ "38.97" ]

icd9pcs

[ [ [] ] ]

9143, 9213

5642, 8635

321, 358

9313, 9313

3451, 3451

9738, 9887

2600, 2659

8931, 9120

9234, 9292

8661, 8908

9463, 9715

2674, 2674

3386, 3432

264, 283

386, 2095

3467, 5619

9328, 9439

2117, 2313

2329, 2584

24,905

140,391

2773

Discharge summary

report

Admission Date: [**2192-9-11**] Discharge Date: [**2192-9-21**] Date of Birth: [**2133-7-3**] Sex: F Service: MEDICINE Allergies: Aspirin / Codeine / Penicillins Attending:[**First Name3 (LF) 3624**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: none History of Present Illness: 56 yo AA F, hx DM II, ESRD s/p caveric renal tx [**12-30**] with worsening renal dysfunction over last 2 years (Cr 2.2 -> 3.6). Her transplant course was complicated by rejection AV fistula in [**1-28**], treated with steroids, resolved by [**4-29**] as well as BK nephropathy treated with a decrease in immunosupression. The pt presented to [**Hospital 1474**] Hospital on [**9-8**] with worsening dyspnea and non-productive cough x1 week. Dyspnea associated with SOB, + orthopnea. No CP or palpitations, mild nausea, no vomiting. On presentation she was febrile to 102, although denies any preceding fevers. Her oxygen saturation was 94-97% on 3L NC and she was noted to be tachypneic to 30's. Pt initially treated with solumedrol 125mg IVx1, azithromycin, and nebs. CXR demonstrated bibasilar infiltrates, WBC of 18 with 86% neutrophils. Chest CT on [**9-10**] also showed a LUL opacity. She was initially started on moxifloxacin and vancomycin. On [**9-11**] developed worsened SOB, O2 sat to 84% on 4L NC, placced on 100% on NRB, trial of BiPAP, which she did not tolerate. Prior to d/c, abx were broadened to tigecycline, aztreonam, and caspofungin. Upon arrival, pt states that her breathing feels improved. Her non-rebreather 100% mask was able to be weaned off to 3L NC while settling settling in. She denies any chest pain, significant SOB, nausea, palpitations. She notes that her leg edema is improved compared to baseline. Past Medical History: 1. IDDM 2. HTN 3. Asthma 4. Hx CVA x2 5. S/P cadaveric renal tx [**2189-1-2**], c/b actue rejection w/ AV fistula, BK nephropathy. Social History: lives with niece who helps with care, no etoh, tobacco, or IVDU. Family History: NC Physical Exam: Vitals: Temp: 97.7, HR 71, BP 149/57, O2 sat 98% on 3L NC Gen: elderly female, fairly comfortable appearing, mild use of abdominal resp muslces. HEENT: anicteric, OP dry, no plaques Neck: supple, no LAD, no JVD Resp: bibasilar crackles L>R, no wheezes, good air entry b/l CV: RRR nl s1, s2, no m/r/g Abd: soft, obese, + BS, mild tenderness difusely, no guarding, tx in RLQ non-tender, no bruit. Extr: tr edema, chronic venous stasis changes. Neuro: non-focal Pertinent Results: [**2192-9-12**] 03:33AM BLOOD WBC-12.0* RBC-3.55*# Hgb-10.3*# Hct-32.3*# MCV-91 MCH-29.1 MCHC-31.9 RDW-15.4 Plt Ct-247 [**2192-9-12**] 03:33AM BLOOD Plt Smr-NORMAL Plt Ct-247 [**2192-9-12**] 03:33AM BLOOD PT-12.2 PTT-34.0 INR(PT)-1.0 [**2192-9-12**] 03:33AM BLOOD Glucose-123* UreaN-48* Creat-2.7* Na-142 K-6.2* Cl-117* HCO3-16* AnGap-15 [**2192-9-12**] 03:33AM BLOOD ALT-23 AST-16 LD(LDH)-324* AlkPhos-242* Amylase-26 TotBili-0.3 [**2192-9-12**] 03:33AM BLOOD Lipase-13 [**2192-9-12**] 03:33AM BLOOD proBNP-8055* [**2192-9-12**] 03:33AM BLOOD Albumin-3.9 Calcium-7.4* Phos-2.9 Mg-2.6 [**2192-9-12**] 01:27PM BLOOD calTIBC-181* VitB12-977* Folate-9.3 Ferritn-1143* TRF-139* [**2192-9-12**] 06:04PM BLOOD Osmolal-324* [**2192-9-13**] 03:15PM BLOOD TSH-0.97 [**2192-9-12**] 03:33AM BLOOD FK506-5.4 [**2192-9-12**] 06:04PM BLOOD ALDOSTERONE-Test [**2192-9-12**] 06:04PM BLOOD RENIN-PND [**2192-9-16**] 06:50AM BLOOD Calcium-7.4* Phos-4.7* Mg-1.9 [**2192-9-14**] 05:40AM BLOOD GGT-119* [**2192-9-14**] 05:40AM BLOOD AlkPhos-219* [**2192-9-16**] 06:50AM BLOOD Glucose-62* UreaN-45* Creat-2.6* Na-144 K-5.2* Cl-106 HCO3-26 AnGap-17 [**2192-9-16**] 06:50AM BLOOD Plt Ct-308 [**2192-9-16**] 06:50AM BLOOD WBC-11.1* RBC-4.11* Hgb-11.9* Hct-36.8 MCV-90 MCH-28.9 MCHC-32.2 RDW-15.5 Plt Ct-308 CHEST (PA & LAT) PA and lateral chest radiographs dated [**2192-9-13**], compared to portable AP chest radiograph dated [**2192-9-12**]. On this radiograph, multifocal consolidations are appreciated in the left upper lung, right middle and right lower lung. Mild cardiomegaly is stable. Mediastinal and hilar contours are unremarkable. There are no pleural effusions. Pulmonary vascularity is normal. IMPRESSION: Multifocal areas of consolidation,the right lower lobe areas are concerning for pneumonia. ECHO [**2192-9-12**] There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). There is an abnormal systolic flow contour at rest, but no left ventricular outflow obstruction. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitralregurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. . V/Q scan low probability . [**9-19**] CT chest: As suggested on the prior chest radiographs, there are multiple linear opacities within the lung lobes, right greater than left consistent with atelectasis and/or scarring. There are no focal areas of airspace consolidation, or pleural effusion. The airways are patent to the segmental level bilaterally. There are no pathologically enlarged axillary, hilar, or mediastinal lymph nodes. The heart is normal in size. Atherosclerotic calcifications are seen within the aorta, left anterior descending and right coronary arteries. The aorta and great vessels are normal. There is no pericardial effusion. . ABG on RA after pneumonia: was 7.40/41/54. Brief Hospital Course: 59 yo F hx renal tx presents from OSH, admitted with 1 wk worsening dyspnea, non-productive cough, fever. Transferred after worsening dyspnea despite antibiotic treatment, dyspnea resolved on transfer. Pt. was transferred from ICU soon after admit as dyspnea had resolved. . 1. Dyspnea/Hypoxia- no organism identified in sputum at outside hospital, and a sputum was unable to be obtained here. She was begun on levofloxacin and vancomycin for community acquired pneumonia (started at OSH). PA/LAT CXR showed a multilobar PNA. Her WBC count decreased from around 20 at the OSH to about [**9-6**]; her dyspnea totally resolved however her hypoxia continued. She remained on her home asthma medications although she never showed any signs of obstructive disease on CXR or exam. A trial of diuresis did not improve her hypoxia. An ABG on room air showed 7.40/41/54. At this point the pulmonary consult team consulted and a Chest CT was obtained that showed diffuse scarring versus atelectasis. A V/Q scan showed low-probability for PE. Pulmonary consult felt that her hypoxia was due to shunt physiology and upon reviewing the CT scan felt her abnormal findings were most likely due to atelectasis. She had PFTs directly before discharge, the results of which are still pending. It was additionally recommended that a echocardiogram with bubble study be performed in the future to evaluate for intracardiac shunt. However, the pulmonary team assessing the patient agreed that this was likely a chronic condition and did not need additional extensive inpatient work up and management. However, given PaO2 < 60 and desaturation with ambulation, the patient will require oxygen therapy, 2L NC currently. The patient will require O2 with ambulation, at night, and for O2 sats < 90% at rest. She will continue oxygen therapy and will receive additional pulmonary follow up upon discharge from her upcoming psychiatric admission. . 3. CHF - BNP of 8055, no echo in our system, negative cardiac cath 10 yrs ago. Pt appears clinically euvolemic, had ECHO that showed preserved LVEF, with moderate pulmonary hypertension. She was continued on metoprolol 150 [**Hospital1 **], zocor, lasix 60 [**Hospital1 **]. Her hypoxia did not improve with a trial of diuresis. . 4. Hx of renal transplant - Ms [**Known lastname 13662**] was continued on her home regimen of prednisone 5mg and tacrolimus; her tacrolimus was decreased to 3mg [**Hospital1 **]. Renal function appears stable from previous baseline and immunosuppressive regimen continued. . 5. IDDM - continued PM lantus 15, and Humalog ISS QIDACHS, please see attached sliding scale. . 6. HTN - was continued outpt regimen of metoprolol, amlodipine, with good BP control . 7. suicidality: Ms [**Known lastname 13662**] expressed suicidal intent during this hospitalization which may have been related to anxiety over an oxygen facemask. She has had passive SI in past and episode of attempted klonapin overdose. Psych was consulted and recommended sitter, they started celexa 20mg q day and remeron 7.5mg QHS. It is recommended at this time that the patient receive in patient psych admission for ongoing treatment of her depression. Given her hypoxia is thought to be from chronic underlying lung disease she is medically cleared to receive psychiatric treatment at this time with additional work-up/management as detailed above upon discharge Medications on Admission: Transfer Meds: Tigecycline 50mg IV q12 Aztreonam 1 gm IV q12 Caspofungin 50mg daily Prednisone 5mg daily Prograf 5 mg po BID Protonix 40mg daily Lopressor 150mg [**Hospital1 **] Bactrim DS PO daily vitamin C 500mg daily Zocor 40mg MagO4 400mg TID Amlodipine 10mg daily Lovenox 30mg SQ Lantus 30 Units Ilotycin eye gtt Flovent 110mcg [**Hospital1 **] Xalatan eye qtt Alphagan eye qtt Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 7. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours). 8. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 9. Bacitracin 500 unit/g Ointment Sig: One (1) Appl Ophthalmic DAILY (Daily). 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 11. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO QMOWEFRI (). 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 13. Dorzolamide-Timolol 2-0.5 % Drops Sig: 1-2 Drops Ophthalmic [**Hospital1 **] (2 times a day). 14. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q4H (every 4 hours) as needed for wheezing. 15. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 16. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 17. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 19. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for wheezing. 20. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 21. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 22. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO BID (2 times a day). 23. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 24. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 25. Insulin Glargine 100 unit/mL Solution Sig: as directed Subcutaneous at bedtime. 26. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 27. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO BID (2 times a day). 28. Insulin Lispro (Human) 100 unit/mL Cartridge Sig: as directed Subcutaneous QIDACHS. Discharge Disposition: Extended Care Discharge Diagnosis: Pneumonia s/p renal cadaveric transplant IDDM Asthma Hypertension Discharge Condition: good, ambulating with physical therapy, tolerating POs, satting 98% on 2L Discharge Instructions: Please seek medical attention should you develop shortness of breath, chest pain dizziness, decreased urinary output, or thoughts of hurting yourself or others. . Please take all medications exactly as described. We have decreased your tacrolimus dose to 3mg twice per day. We hae also started you on celexa, which you should also take as directed. You may use remeron for sleep. . Please follow up at the appts. below. You will need to follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 6700**] within 2 weeks. You should also call for an appointment with the pulmonary clinic. Followup Instructions: Your primary care physician [**Last Name (NamePattern4) **] 2 weeks . psychiatry . Provider: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] with [**Hospital1 18**] pulmonology. Please come to the [**Location (un) 1773**] of the [**Hospital Ward Name 23**] building at 8:30 AM on [**10-4**] for a lung test and then go to the seventh floor for a 9am appointment. Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2192-10-4**] 9:00 . Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2193-2-8**] 9:50 [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**] MD [**MD Number(1) 3629**]

[ "486", "428.0", "403.91", "285.21", "493.90", "300.4", "250.80", "276.7", "V42.0", "585.6" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

11971, 11986

5741, 9134

299, 305

12096, 12172

2524, 5718

12832, 13596

2025, 2029

9568, 11948

12007, 12075

9160, 9545

12196, 12809

2044, 2505

252, 261

333, 1771

1793, 1926

1942, 2009

64,952

154,554

26491

Discharge summary

report

Admission Date: [**2150-10-31**] Discharge Date: [**2150-11-5**] Date of Birth: [**2103-9-20**] Sex: M Service: SURGERY Allergies: cefazolin Attending:[**First Name3 (LF) 668**] Chief Complaint: End Stage Renal Disease Major Surgical or Invasive Procedure: Kidney Transplant History of Present Illness: 47-year-old man with a history of hypertension, ESRD on dialysis for more than six years, currently through a left radiocephalic fistula. He is active on blood group O transplant list. He urinates about 0.5-1L/day. He has a history of recurrent tunneled catheter infections. He usually gets exhausted after dialysis, and he does not gain any weight gain in between dialysis. He had a negative stress test about 6 months ago. Otherwise he does not complain of any other symptoms, denies any fever, chills, cough, diarrhea or recent infections. Past Medical History: Hypertension, gout, back pain Social History: Snow truck driver. Married. Lives with wife and 2 [**Name2 (NI) 25400**]. Drinks about 7 drinks a week. Denies any tobacco or illicit drug use. Family History: Brother with ESRD s/p KTX Physical Exam: Physical Exam: Vitals: T 98.9F, HR 85, BP (164/88) rr15 98% RA, pain 3 GEN: A&Ox3, NAD, conversant, pleasant CV: regular rate and rhythm, normal s1 s2 Lungs: Clear to auscultation bilaterally. ABD: Soft, non distended, appropriately tender to palpation in right lower quadrant near incision site. Staples in place no oozing or pus draining from rlq incision. Dressing CDI over removed JP incision. Abdomen otherwise non tender to palpation to rebound or guarding. Ext: Radial pulses bilaterally. Left radiocephalic AV fistula with thrill. No C/C/E. Pertinent Results: [**2150-11-3**] 01:52AM BLOOD WBC-11.6* RBC-3.12* Hgb-9.3* Hct-27.3* MCV-87 MCH-29.6 MCHC-33.9 RDW-15.6* Plt Ct-109* [**2150-11-4**] 05:45AM BLOOD WBC-5.1# RBC-3.09* Hgb-9.3* Hct-27.2* MCV-88 MCH-30.1 MCHC-34.1 RDW-15.7* Plt Ct-104* [**2150-11-5**] 07:05AM BLOOD WBC-3.0* RBC-2.95* Hgb-9.0* Hct-26.5* MCV-90 MCH-30.4 MCHC-33.8 RDW-15.4 Plt Ct-118* [**2150-11-3**] 01:52AM BLOOD PT-10.1 PTT-28.4 INR(PT)-0.9 [**2150-10-31**] 11:53PM BLOOD Glucose-94 UreaN-36* Creat-8.4*# Na-138 K-4.0 Cl-86* HCO3-40* AnGap-16 [**2150-11-4**] 05:45AM BLOOD Glucose-120* UreaN-41* Creat-6.5*# Na-135 K-4.4 Cl-94* HCO3-31 AnGap-14 [**2150-11-5**] 07:05AM BLOOD Glucose-108* UreaN-63* Creat-7.7*# Na-133 K-5.0 Cl-92* HCO3-29 AnGap-17 Urine culture Negative. CMV negative. Brief Hospital Course: HD1: Patient presented to [**Hospital1 18**] for a kidney transplant. The donor kidney was transplanted on the right side. A 19 [**Doctor Last Name **] drain was placed and incision was closed with staples. Patient received 2 units of pbrcs intraoperatively for decreased hematocrit. Blood loss during the operation was 150cc. In the PACU, the patient was hypertensive to the 190's/110s. Initially, conventional antihypertensives were tried which could not control the patients blood pressure. He was placed on a nicardipine drip. Since his blood pressure could not be controlled without nipride drip, he was transferred to the sicu HD1 for pain/blood pressure control. Also, of note, he had a femoral line placed since he subclavian/ij central access could not be attained. He received his first dose of ATG in the or. His urine output was approximately 50cc/hr. His drain output was sanguinous and putting out approx 400cc. He received another unit of red cells in the SICU. Notably, he received the standard immunosuppresion proptocol of FK506, solumedrol, renally dosed valcyte, and cellcept. HD2: Patient remained in the SICU and was given 100 lasix for low UoP. He received another unit of blood and ATG. His blood pressure was under control. His pain was well controlled on PCA. He received HD in the SICU. His diet was advanced to clears HD3: Diet advanced to regular. Was transfer to [**Wardname 13487**]. His blood pressure remained under control. His PCA was dc'd. Pain well tolerated on PO pain meds. Patient received transplant med training book. HD4: Patient received another dose of ATG [**12-31**] delayed graft function. HD5: Femoral line was DC. Blood pressure well controlled. Pain controlled. Bowel regimen to good effect and had 2 BM. Ambulatex1. Foley dc'd and able to void HD6: Pain controlled. ambulating several times. JP removed. Renal did not feel that HD was warranted as he would be receiving it the following day. The patient was tolerating a regular diet with instructions to follow up with transplant clinic, have his fk levels checked, and resume dialysis Medications on Admission: [**Last Name (un) 1724**]: Atenolol 100', Lisinopril 20'', Nifedipine 90', Calcium acetate w meals, sensipar 90', percocet prn back pain Discharge Medications: 1. prednisone 10 mg Tablet Sig: 2.5 Tablets PO ONCE (Once) for 1 doses: take [**11-6**] (last dose). Disp:*3 Tablet(s)* Refills:*0* 2. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 3. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 6. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO prn: every 6 hours as needed for pain. 7. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO 2X/WEEK (WE,SA). 8. tacrolimus 5 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 9. tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO twice a day. 10. nifedipine 90 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO DAILY (Daily). 11. PhosLo 667 mg Capsule Sig: One (1) Capsule PO three times a day: with meals. 12. Sensipar 90 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: End Stage Renal Disease s/p renal transplant delayed renal graft function htn Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for a kidney transplant. Please resume your normal dialysis schedule (Monday-Wed-Friday at [**Location (un) 270**] Dialysis)starting tomorrow [**11-6**] at 4pm. You will follow up with Dr. [**First Name (STitle) **] next week and he will inform you more about the need for doing dialysis in the future. Please take all medications that are prescribed. General Discharge Instructions: Please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**4-7**] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Followup Instructions: Saturday [**11-7**], 8:30 AM, [**Hospital Ward Name 1826**] 7, [**Hospital Ward Name 516**]; [**Location (un) **] [**Location (un) 86**]. Trough Prograf level and transplant labs Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2150-11-12**] 2:40 Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2150-11-20**] 8:30 Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2150-12-1**] 8:20

[ "585.6", "V45.11", "403.91", "274.9", "790.01" ]

icd9cm

[ [ [] ] ]

[ "00.93", "55.69" ]

icd9pcs

[ [ [] ] ]

5837, 5912

2506, 4596

293, 313

6034, 6034

1730, 2483

7577, 8214

1117, 1144

4783, 5814

5933, 6013

4622, 4760

6185, 6556

7064, 7554

1174, 1711

6588, 7049

230, 255

342, 886

6049, 6161

909, 940

956, 1101

8,556

145,762

4558+4559

Discharge summary

report+report

Admission Date: [**2113-11-5**] Discharge Date: [**2113-11-9**] Service: ACOVE HISTORY OF PRESENT ILLNESS: This is an 81-year-old male status post TVR and MVR with prolonged intubation postoperatively back in [**Month (only) **], rapid atrial fibrillation, history of loculated right-sided effusion (status post decortication), history of Methicillin resistant Staphylococcus aureus pneumonia, history of right diaphragmatic history and history of colon cancer and history of prostate cancer who re-presents from [**Hospital 1319**] Hospital with worsening shortness of breath, which has been nonresponsive to Lasix and nebulizers. As per his daughter, the patient was doing fairly well until a few days prior to admission when he developed somnolence around the time of his elective bronchoscopy. A BAL culture from [**10-31**] was positive for moderate normal flora with moderate growth Serratia marcescens of two species, both sensitive to bactrim. The patient was subsequently started on Bactrim, however, continued to develop increased somnolence and occasional episodes of nausea and vomiting. During this time, the patient also had >....<of his trachea (date of which is unclear, but as per patient, was approximately four days prior to admission). He subsequently developed worsening shortness of breath and increased 02 requirement. He was noted to have a hematocrit drop to 25 and was transfused two units of packed red blood cells in hopes of relieving the patient's dyspnea. The patient was also given Lasix between transfusions. It was unclear whether the patient was adequately diuresed or not. On the date of admission, the patient was reportedly on five liters of nasal cannula with an oxygen saturation of 90%. An arterial blood gas done at the time was 7.36/63.8/72. The patient was given additional Lasix and nebulizers without improvement of dyspnea. The patient complained of increasing orthopnea, shortness of breath, cough productive of yellow sputum and an inability to clear his secretions. The patient denies fevers, chills, no chest pain, no abdominal pain, no rashes, no pruritus. The patient does complain of "swelling of his right leg" and states that in the past, this leg has swelled larger than the left leg. He does not why there is a difference. In the Emergency Department, the patient was given 60 mg of Solu-Medrol and 1 gram of Ceftriaxone. The patient was transferred to the Medical Intensive Care Unit where he was closely monitored, restarted on digoxin and Lopressor for rapid atrial fibrillation and given frequent chest Physical Therapy, incentive spirometry and suctioning. He was tried on nasal CPAP, but did not tolerate this at night. The patient was also volume resuscitated with intravenous fluids and given no steroids as there was no evidence of chronic obstructive pulmonary disease exacerbation. His past hospitalization from [**2113-7-13**] to [**2113-9-6**], the patient was admitted for the elected TVR and MVR with a prolonged postoperative course including rapid atrial fibrillation, volume overload, right-sided loculated effusion, possible Methicillin resistant Staphylococcus aureus pneumonia and an inability to wean from the vent. The patient had trachea and percutaneous endoscopic gastrostomy placed. A VATS procedure was done for right-sided effusion and atelectasis as per operative note, which showed blood clot, which was removed. A decortication was done and re-expansion of right lower lobe was observed. No tissue was sent for pathology and the patient was sent to [**Hospital1 1319**] for a vent wean. From [**2113-9-10**] to [**2113-9-14**], the patient was re-admitted from [**Hospital1 1319**] to [**Hospital6 1760**] due to increased sputum productive, low grade fever, increasing vent support. Sputum grew out Serratia and the patient was given Levaquin and Ceftazidime. On admission, the patient was noted to have a cuff leak which was repaired and bronchoscopy revealed minimal secretions. Vancomycin, Ceftriaxone were discontinued since Serratia was sensitive to Levaquin. Serratia was thought at that time to have some element of seizure after he was diuresed, however, an echocardiogram done showed a normal ejection fraction. The patient was started on Captopril, Lasix and digoxin with improvement of bilateral effusions. It was thought he may have had Dressler's syndrome and steroid was added to his regimen at that time. The patient continued progressive vent wean and went back to [**Hospital1 1319**]. From [**10-3**] to [**10-13**] at [**Hospital1 1319**], the patient continued the vent wean and on [**10-2**], the patient felt rapid atrial fibrillation. His Captopril was decreased and beta-blocker was added with minimal response. An electrocardiogram was concerning for ST depressions in the anterior lateral leads and the patient was transferred back to [**Hospital6 256**]. The patient was given intravenous Lopressor which decreased the rate in the Emergency Department, but resulted in low blood pressure, which responded to intravenous fluid boluses. Chest x-ray at that time revealed new right upper lobe infiltrate. The patient's heart rate was controlled with beta-blockers, however, the patient continued to have intermittent hypertension, in which he was given IV fluid. The patient completed a course of vancomycin and Zosyn for pneumonia with suspected Methicillin resistant Staphylococcus aureus or other resistant organisms. Psychiatric was consulted for anxiety at that time and the patient was started on Zyprexa which decreased his vent dependence. The patient was finally discontinued from the vent and maintained on trachea mask. The [**Hospital 228**] hospital course was also notable for worsening drainage of wound from his VAT site and the patient was evaluated by Plastic Surgery who recommended conservative treatment. The patient was sent back to [**Hospital1 1319**]. PAST MEDICAL HISTORY: 1. Coronary artery disease, status post coronary artery bypass graft in [**2097**] with left main disease. 2. Atrial fibrillation on Coumadin. 3. Prostate cancer, status post prostatectomy in [**2098**], status post penile implant. 4. Colon cancer, status post colectomy in [**2107**]. 5. Pancytopenia thought to be due to MDS, however, bone marrow biopsy in [**2113-7-13**] was nondiagnostic. 6. HIT antibody positive in [**2113-8-13**]. 7. Status post ureteral stent and urostomy. 8. MVR/TVR in [**2113-7-13**] with hospital course as above. 9. Mild chronic obstructive pulmonary disease. 10. Echocardiogram in [**2113-9-12**], ejection fraction 50-55%, positive TR, moderate PA systolic hypertension, prosthetic mitral valve seen. 11. Catheterization on [**2113-7-11**]: 100% occlusion of the left main coronary artery, patent left internal mammary artery to left anterior descending, saphenous vein graft to left circumflex, patent right coronary artery stent, severe mitral regurgitation and moderate diastolic ventricular dysfunction, moderate pulmonary artery systolic hypertension (pressure 45/26). ALLERGIES: Heparin induced thrombocytopenia, antibody positive. MEDICATIONS ON TRANSFER: 1. Captopril 6.25 mg po t.i.d. 2. Zyprexa 5 mg po q.h.s., 2.5 mg po q.a.m. 3. Lopressor 25 mg po b.i.d. 4. Digoxin 0.125 mg po q.d. 5. Protonix 40 mg po q.d. 6. Prozac 40 mg po q.d. 7. Lasix 20 mg po q.d. 8. Bactrim DS 1 tablet b.i.d. to complete a course on [**11-9**]. 9. Coumadin. 10. Promote with fiber. 11. Phenergan 25 mg intravenously q.6 hour prn. 12. Ativan .5 mg po q.h.s. 13. Simethicone 80 mg po q.i.d. 14. Guaifenesin 300 mg po q.i.d. 15. Ocean nasal spray. 16. Albuterol and Atrovent nebulizers. 17. Salmeterol 1 puff b.i.d. 18. Fluticasone 220 mcg 2 puffs b.i.d. 19. Ceftriaxone 1 gram q.d. FAMILY HISTORY: Father with myocardial infarction at age 59, mother with breast cancer. SOCIAL HISTORY: Lives alone at home before surgery in [**2113-7-13**]. Since then has been at [**Hospital1 1319**]. Smoked four packs per day times 37 years, quit 35 years ago, occasional ETOH. LABORATORIES: White blood cell count 7.0, hematocrit barely stable at 30, no pandemia on discharge. Creatinine 1.1. INR 1.7 on [**11-8**], ALT 27, AST 29, alkaline phosphatase 112, amylase 54, total bilirubin 0.2. CK 28, sputum culture contaminated. Blood cultures no growth to date. Urine culture revealed enterococcus. Chest x-ray showed progressive loss of right lung volume which may represent a combination collapse and increasing pleural effusion. Lipase 25 and 60. Electrocardiogram: Atrial fibrillation, [**Street Address(2) 4793**] depressions in V4 through V6 old and an Q in V1. PHYSICAL EXAMINATION: Temperature 99.7. Heart rate 130. Blood pressure 100/72. Oxygen saturation 96% on 60% high flow, however, on discharge, at 96% on two liters and 88% on room air. In general, the patient is an elderly male, awake and alert in no acute distress, but is very hard of hearing. Head, eyes, ears, nose and throat: No gag reflex elicited. Extraocular movements intact. Pupils equal, round and reactive to light. No lymphadenopathy. Stoma from trachea is healed over. Oropharynx clear. Mucous membranes moist. Heart: Irregularly irregular, positive systolic murmur at the apex, normal S1, S2, no gallops heard. Lungs: No breath sounds at right base, clear to auscultation bilaterally otherwise. Extremities: Warm, trace edema, 2+ dorsalis pedis pulses bilaterally. HOSPITAL COURSE: The patient was transferred out of the Medical Intensive Care Unit on [**2113-11-6**] and his hypoxia resolved rather quickly with nebulizers, chest Physical Therapy and incentive spirometry and some gentle diuresis. There was a question as to whether the shortness of breath was a combination of mucous plugging plus right hemidiaphragmatic injury, as well as a question of mild congestive heart failure. The patient also was continued on a ten day course of Ceftriaxone and did well with this. It was elected not to start Solu-Medrol as the patient had no evidence of acute chronic obstructive pulmonary disease flare. For his atrial fibrillation, the patient was continued on Lopressor and digoxin, as well as Coumadin. The patient's hematocrit of 25 at the outside hospital, did not seem to be an acute decline. The patient's stool was OB positive, however, after blood transfusion, the patient responded well and the hematocrit remained stable. The patient may in the future need a colonoscopy for work-up. As far as the patient's anxiety, the wife was concerned that the patient's Zyprexa may be causing him to be somewhat tired and lethargic during the day and since the patient had never been on Zyprexa prior to the vent wean, it was thought reasonable to go ahead and wean his Zyprexa to off. The patient's Zyprexa dose was decreased to 2.5 mg b.i.d. on discharge. The patient did well throughout his hospital stay. He did well at clearing his own secretions with suctioning himself, as well as doing his incentive spirometry and he was able to be out of bed into a chair with help from the physical therapist. The patient will need further Physical Therapy, as well as to complete six more days of a Ceftriaxone course and his Coumadin will also have to be more therapeutic in light of his atrial fibrillation, as well as his MVR and TVR. Patient was discharged to [**Hospital3 **] hospital in good condition to follow-up with Dr. [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) 19395**]. MEDICATIONS ON DISCHARGE: 1. Captopril 6.25 mg t.i.d. 2. Zyprexa 2.5 mg po q.a.m. and q.h.s. to be gradually decreased to off. 3. Metoprolol 25 mg b.i.d. 4. Digoxin 0.125 mg q.d. 5. Prozac 40 mg po q.d. 6. Ativan 0.5 mg q.h.s. prn insomnia. 7. Colace 100 mg b.i.d. 8. Senna 1 tablet b.i.d. 9. Simethicone 80 mg q.i.d. 10. Salmeterol inhaler 1 puff b.i.d. 11. Fluticasone 220 mcg inhaled, 2 puffs b.i.d. 12. Promote with fiber tube feeds. Goal at 50 cc per hour with q. 4 hour flushes of 250 cc of free water. 13. Ocean nasal spray, [**12-14**] sprays in each nostril q.i.d. 14. Nystatin oral suspension 5 mg q.i.d. prn. 15. Albuterol nebulizers inhaled q. 4 hours. 16. ipratropium nebulizers inhaled q.4 hours. 17. Prevacid 30 mg q.d. 18. Guaifenesin [**4-21**] ml q.6 hour prn. 19. Ceftriaxone 1 gram intravenous q.d. times six days. 20. Coumadin 5 mg q.h.s. 21. Lasix 20 mg q.d. The patient needs INR checked on Friday, [**11-10**], and swish and swallow evaluation as the patient failed his swish and swallow here and was kept NPO. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2506**] Dictated By:[**First Name3 (LF) 19396**] MEDQUIST36 D: [**2113-11-8**] 14:12 T: [**2113-11-7**] 08:48 JOB#: [**Job Number 19397**] Admission Date: [**2113-11-5**] Discharge Date: [**2113-11-14**] Service: Acove HISTORY OF PRESENT ILLNESS: The patient has been steadily improving since admission. He is now on day #9 of 10 of the Ceftriaxone for his positive BAL for Serratia and his secretions have greatly decreased and the patient's oxygen requirement has also greatly decreased. The patient may be fibrillation the patient continues to be on Coumadin, now at 10 mg q.d. to increase his INR above 2.0. The patient's hematocrit and hemoglobin has been stable throughout the admission. For aspiration, the patient has had a swallow study on [**2113-11-10**] which he did not pass due to silent aspirations. The patient will need a follow up video swallow study on [**2113-11-17**] and he will also need Swallow study showed that the patient penetrated into the laryngeal vestibule while swallowing which ultimately results in aspiration and the patient does not cough spontaneously, although is able to clear on que. The patient's latest laboratory data were white count 6.6 on [**2113-11-13**], hematocrit 31.9, INR 2.0, sodium 136, potassium 4.1, magnesium 2.0. The patient also had an echocardiogram on [**2113-11-10**] which revealed a moderately dilated left atrium, moderately dilated right atrium and normal left ventricular function with an left ventricular ejection fraction of 50 to 55%, normal right ventricle, aortic valve leaflets, mildly thickened, no aortic regurgitation, a bioprosthetic mitral valve with no mitral regurgitation and tricuspid valve leaflets mildly thickened, valve annuloplasty ring present, moderate 2+ tricuspid regurgitation. The patient was discharged in good condition this morning on [**2113-11-14**]. Note: patient has mosaic bioprosthetic MVR which does not require longterm anticoagulation. DISCHARGE MEDICATIONS: 1. Captopril 6.25 mg t.i.d. 2. The patient is no longer on Zyprexa 3. Metoprolol 25 mg b.i.d. 4. Digoxin 0.125 mg q.d. 5. Prozac 40 mg q.d. 6. Ativan 0.5 mg q.h.s. prn 7. Colace 100 mg b.i.d. 8. Senna 1 tablet b.i.d. 9. Simethicone 80 mg q.i.d. 10. Salmeterol 1 puff b.i.d. 11. Fluticasone 220 mcg 2 puffs b.i.d. 12. Ocean nasal spray, one to two sprays, NU q.i.d. 13. Nystatin oral suspension 5 mg q.i.d. prn 14. Albuterol nebulizers q. 4 hours prn 15. Ipratropium nebulizers q. 4 hours prn 16. Prevacid 30 mg q.d. via gastrostomy tube 17. Guaifenesin 5 to 10 ml q. 6 hours prn 18. Ceftriaxone 1 gm intravenously q.d., day #9 of 10, treatment to end on [**2113-11-15**] 19. Lasix 20 mg q.d. 20. For tube feeds, Promote with fiber at 50 cc/hr and 250 cc flushes of free water q. 4 hours 21. The patient was tried on CPAP at night, however, did not tolerate it. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2506**] Dictated By:[**Last Name (NamePattern1) 4525**] MEDQUIST36 D: [**2113-11-14**] 09:19 T: [**2113-11-14**] 09:26 JOB#: [**Job Number 19398**]

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Discharge summary

report

Admission Date: [**2149-2-21**] Discharge Date: [**2149-3-29**] Date of Birth: [**2083-12-3**] Sex: M Service: MEDICINE Allergies: Nsaids Attending:[**First Name3 (LF) 3984**] Chief Complaint: hypoxia, hypotension Major Surgical or Invasive Procedure: Intubation Placement of central lines Thoracentesis Tracheotomy History of Present Illness: 65 yo male with DM, ESRD on HD 4x per week (T,TH,SAT,Sun), CHF EF 35%, tachy/brady s/p PPM placement, Afib on coumadin, CVA w/ left-sided weakness, recent hospitalization with right shoulder fx, norovirus infection, and pneumonia, who is admitted from an outside hospital with hypoxia and hypotension Pt was discharged from [**Hospital1 18**] in mid [**Month (only) 1096**] after right humerus fracture fx and went into rehabilitation facility. He was then admitted to the ICU for hypotension and was treated empirically for HCAP with cefepime and vancomycin for a total of 8 days ending on [**2148-12-15**]. He was doing well by the time of discharge and was sent to a [**Hospital1 1501**] in [**Location (un) 3844**]. As per wife he developed [**Name (NI) 20198**] 3 weeks ago and then developed a pneumonia for which he was treated with levofloxacin x 2 weeks. She states that he had a cough with increased amounts of secreation and was not improving on antibiotics. Yesterday his sats were down in the 80s% and he was transferred from his [**Hospital1 1501**] to an outside hospital. He was also found to be hypotensive w/ SBP in 80s. His recent sputum culture obtained at the [**Hospital1 1501**] grew MRSA. He was a given Levofloxain and Moxifloxacin in the OHS and then transferred here for further care. . In the ED his vitals were: 98.6, 92/59 on 2mcg of norepi, 70, 20, 96% on 5L. Pt had increase resp distress with increase in RR, increase in lethargy. He was then intubated in the ED. His CXR showed a left effusion and bilateral pulmonary air space opacities. His troponin is elevated from his baseline at 0.18 and his EKG showed new RBBB while paced. As per ED report the EKGs were sent to the Cardiology for opinion. He was also given vanco and cefepime 2gm IV x I. He had L IJ placed and placement confirmed. His labs are notable for WBC of 22.5, no bands. Electrolyte abnormalities with elevated K of 5.2, however is due to be dialyzed tomorrow. He also received 2 L of fluids. . On arrival to the MICU, pt is intubated and non-responsive. Exam significant for cold extremities. Vitals: T 101, HR in 90s, BP 90s/40s, Sat 98% on vent- AC with VT 400, RR 20, PEEP 10. Foley with dark urine. L IJ in place and pt receving levophed. Past Medical History: Diastolic heart failure (LVEF > 55%) Hypertension ESRD on HD Morbid obesity Atrial fibrillation and h/o tachy-brady syndrome s/p pacemaker placement Diabetes Mellitus DVT CVA left frontal [**2136**] - L hemiparesis Sleep apnea Restrictive lung disease (thought [**2-19**] body habitus) Gout Chronic back pain Hx of Subarachnoid hemorrhage Social History: The patient is married and has two children. He is a real estate developer and lives in [**Location 5169**] NH. Denies tobacco or IVDA. Consumes 1 alcoholic beverage every 2 weeks. Previously resided in a [**Hospital1 1501**]. Family History: Mother: died of MI at 77 Father: died age 80 [**2-19**] complication from renal disease Physical Exam: ADMISSION EXAM: Vitals: T 101, BP 90s-80s/40s, HR 90s, RR 26-30, O2Sat 98% on 80% FiO2 GEN: Intubated, sedated and uresposive, ill appearing HEENT: PERRL, no epistaxis or rhinorrhea, MM dry NECK: No JVD, right tunneled line without erythema or purulence or tenderness CHEST: Pacer in place, RRR, no M/G/R, normal S1 S2 PULM: Rhonchi throughout ABD: Soft, obese, non distended, (pt is sedated so difficult to assess abd discomfort), +BS hypoactive, no HSM, no masses EXTREM: Bilateral LE edema +2, cold extremeties + cyanotic NEURO: Non-responsive, pupils reactive and slugish. SKIN: Extremities are cool to touch, cyanosis on tips of fingers and on foot, venous dermatitis on bil LE, stage II sacral decub with no fluid fluctuation and no drainage. L heel wound. HD cath intact with no drainage. . DISCHARGE EXAM: Vitals: T 98.8, BP 80-116/40-60, HR 80s, RR 20s, O2Sat 100% on 40% FiO2 GEN: Alert and oriented, able to answer questions, NAD HEENT: PERRL, no epistaxis or rhinorrhea, MMM NECK: Supple, trach collar in place, no erythema or drainage from site, no JVD CHEST: Pacer in place, RRR, nml S1/S2, no M/G/R PULM: Rhonchi throughout, decreased breath sounds at bases ABD: Soft, NTND, NABS, no HSM, no masses EXTREM: WWP, bilateral LE edema +2 NEURO: A&Ox3, CNs grossly intact, sensation intact, strength diminished in all four extremities, unable to assess gait SKIN: Chronic dermatitis changes over both shins Pertinent Results: ADMISSION LABS: [**2149-2-21**] 07:00PM BLOOD WBC-22.5*# RBC-3.26* Hgb-9.8* Hct-31.0* MCV-95# MCH-30.0 MCHC-31.5 RDW-15.5 Plt Ct-696* [**2149-2-21**] 07:00PM BLOOD Neuts-90.6* Lymphs-5.9* Monos-3.0 Eos-0.1 Baso-0.3 [**2149-2-21**] 07:00PM BLOOD PT-28.9* PTT-45.8* INR(PT)-2.8* [**2149-2-21**] 07:00PM BLOOD Glucose-153* UreaN-23* Creat-2.9* Na-132* K-5.2* Cl-92* HCO3-25 AnGap-20 [**2149-2-21**] 07:00PM BLOOD ALT-17 AST-22 AlkPhos-124 TotBili-0.4 [**2149-2-21**] 07:00PM BLOOD Calcium-9.5 Phos-2.6* Mg-2.0 [**2149-2-21**] 07:21PM BLOOD Lactate-1.9 K-5.0 . DISCHARGE LABS: [**2149-3-29**] 03:59AM BLOOD WBC-14.9* RBC-2.60* Hgb-8.1* Hct-25.0* MCV-96 MCH-31.2 MCHC-32.4 RDW-18.7* Plt Ct-802* [**2149-3-29**] 03:59AM BLOOD Neuts-88.3* Lymphs-7.5* Monos-2.7 Eos-1.4 Baso-0.2 [**2149-3-29**] 03:59AM BLOOD PT-19.2* PTT-55.6* INR(PT)-1.8* [**2149-3-29**] 03:59AM BLOOD Glucose-118* UreaN-16 Creat-1.7* Na-134 K-3.5 Cl-95* HCO3-30 AnGap-13 [**2149-3-29**] 03:59AM BLOOD Calcium-8.2* Phos-3.1# Mg-1.9 ................................................................ MICRO: [**2-22**] Sputum Cx: Staph aureus coag positive CLINDAMYCIN----------- R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=0.5 S . [**2-23**] Respiratory viral screen: negative . [**2-24**] Sputum Cx: Staph aureus coag positive CLINDAMYCIN----------- R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S . [**3-2**] Pleural fluid: no growth . [**3-13**] Sputum Cx: Burkholderia (Pseudomonas) cepacia SENSITIVE TO MEROPENEM MIC <=1 MCG/ML. RESISTANT TO CHLORAMPHENICOL MIC >=32 MCG/ML. RESISTANT TO TIMENTIN MIC >=128 MCG/ML . [**3-20**] Sputum Cx: Burkholderia (Pseudomonas) cepacia CEFTAZIDIME----------- 16 S LEVOFLOXACIN---------- R MEROPENEM------------- 2 S TRIMETHOPRIM/SULFA---- 2 S . **All blood, urine, and stool cultures negative** ................................................................ IMAGING: [**2-21**] CXR: Bilateral pulmonary air space opacities concerning for pneumonia. Moderate left pleural effusion. . [**2-24**] CT Chest w/o con: 1. Bibasilar consolidations and multifocal ground-glass opacities and tree-in-[**Male First Name (un) 239**] opacities concerning for multifocal pneumonia. The density of the lung parenchyma at the lung bases alternatively could be explained by amiodarone toxicity. Upon resolution of the patient's presumed pneumonia, a repeat chest CT should be performed to assess for possible pulmonary effects of amiodarone. 2. Bilateral effusions. 3. Large main pulmonary artery, suggestive of pulmonary hypertension. . [**2-24**] ECHO: The left atrium is moderately dilated. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. There is moderate global left ventricular hypokinesis (LVEF = 30 %). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. The right ventricular cavity is dilated with depressed free wall contractility. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. Compared with the prior study (images reviewed) of [**2148-12-3**], the degree of pulmonary hypertension detected has decreased. . [**2-27**] CT Torso w/o con: 1. Multifocal ground-glass and tree in [**Male First Name (un) 239**] opacities opacities in both lower and right upper lobes likely represents infection. Moderate left pleural effusion. 2. Cholelithiasis without evidence of cholecystitis. No discrete abscesses were noted. . [**2-27**] RUQ U/S: Cholelithiasis with gallbladder wall thickening and small amount of pericholecystic fluid. However, these findings are equivocal for acute cholecystitis given the underlying ascites. If there is continued concern for acute cholecystitis, further evaluation with HIDA scan is recommended. . [**2-28**] Gallbladder Scan: Non-visualization of the gallbladder over 90 minutes with gallbladder visualized shortly after the administration of 2 mg of morphine. Initial non-visualization suggests gallbladder dysfunction, but visualization with morphine demonstrates cystic duct patency. No evidence of acute cholecystitic. . [**3-7**] CT Chest w/ con: 1. Stable multifocal ground-glass and tree-in-[**Male First Name (un) 239**] opacities within both lungs and bibasilar consolidations consistent with continued widespread infection. Interval decrease in size of small left pleural effusion. No lung abscess. 2. Cholelithiasis without evidence of cholecystitis. 3. Pulmonary artery hypertension. . [**3-19**] ECHO: The left ventricle is not well seen. The left ventricular cavity is dilated. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is severely depressed (LVEF=20-30%). The right ventricular cavity is unusually small. with depressed free wall contractility. The ascending aorta is mildly dilated. The aortic valve is not well seen. There is no aortic valve stenosis. The mitral valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Severely depressed LV systolic function. Unable to assess for dyssynchrony. Small, hypokinetic right ventricle. Compared with the prior study (images reviewed) of [**2149-2-24**], image quality is significantly more suboptimal. LV systolic function appears similar. The right ventricle is not well seen but is probably small and hypokinetic on the current study (was dilated and hypokinetic on prior). Comparison of valvular function could not be done. . [**3-28**] CXR: As compared to the previous radiograph, the patient has received a nasogastric tube. The tube shows a normal course, the tip of the tube is not visualized on the image. The other monitoring and support devices are unchanged. Unchanged appearance of the cardiac silhouette, the pre existing bilateral parenchymal opacities and the pre-existing left more than right pleural effusion. Unchanged aspect of the left pectoral pacemaker. . [**3-29**] Left Shoulder XR: read pending Brief Hospital Course: 65 yo man with DM, ESRD on HD, systolic CHF, tachy/brady syndrome s/p pacemaker, atrial fibrillation on coumadin, h/o CVA with residual left-sided weakness, who presented with hypoxic respiratory failure and hypotension requiring intubation and pressors. . # Hypoxic respiratory failure: He was treated in [**11/2148**] for HCAP with 8 days of cefepime and vancomycin. He then developed pneumonia in the [**Hospital1 1501**] and was treated with 14 days of levofloxacin without improvement. OSH sputum culture from [**2149-2-19**] was positive for MRSA. Repeat sputum at [**Hospital1 18**] from [**2-22**] also growing MRSA. CXR showed bilateral infiltrates with a stable left pleural effusion. He underwent a bronchoscopy with culuture growing a small amount of yeast. Galactomannan negative. Beta glucan >500 but likely related to recent zosyn. He was extubated on [**2-26**]. IP performed a thoracentesis to drain the left-sided effusion on [**3-2**], with fluid negative for growth. He temporarily had a chest tube placed. He desatted secondary to increased secretions, poor clearance, and mucus plugging, and was re-intubated on [**3-5**]. He was briefly treated with ciprofloxacin and cefepime and then completed a 14-day course of vancomycin and meropenem which were completed on [**3-16**]. The patient was unable to be weaned from the vent due to poor clearance of secretions and absent gag reflex, therefore after two weeks he and his wife decided to proceed with a tracheotomy. He is currently requiring ventilator assistance at night (current settings: 15 of pressure support, 8 of PEEP, 40% of FiO2), with trach collar during the day. Trach tube is a #8 portex perc. - Trach collar sutures will need to be removed - Patient will need repeat CT chest in 1 month to ensure resolution of pneumonia and to assess for amiodarone-induced lung changes . # Septic shock/hypotension: The patient was initally hypotensive requiring IV fluids and pressor support, thought to be due to septic shock from his underlying MRSA pneumonia. An ECHO revealed an EF 30%, similar to prior study, therefore cardiogenic shock was felt to be unlikely. All blood cultures were negative. In reviewing previous records, he was noted to be chronically hypotensive which was thought to be due to autonomic instability and improved with midodrine. He was treated with 7 days of stress dose steroids which completed on [**3-2**] and repeat cortisol was normal. He was continued on midodrine and started on fludricortisone. He continues to require small amount of norepinephrine (0.02 mcg/kg/min) intermittently. . # Leukocytosis: Patient had persistent leukocytosis in the 60s, despite treatment of the pneumonia. CT chest w/o evidence of abscess or empyema. He has poor dentition, but no obvious abscesses on exam and unlikely to account for such an elevated WBC count. No evidence of endocarditis on ECHO. C. diff negative. Repeat CT chest with stable left pleural effusion. He underwent thoracentesis which was negative for growth. CT abdomen with gallstones, but HIDA scan negative for acute cholecystitis. He was evaluated by the hematology service who felt that this was likely a leukemoid reaction, though could not rule out a myeloproliferative process, especially considering the patient's cachectic appearance and history of weight loss. BCR-ABL was negative. His WBC trended down but remained elevated around 14. - Recommend through malignancy workup when patient is more stable - Patient should follow up with hematology/oncology at [**Hospital1 18**] . # ESRD on HD: The patient underwent CVVH throughout this hospitalization as tolerated by his blood pressure. He was continued on nephrocaps and sevelamer. . # Systolic CHF: LVEF=20-30%. Troponin peaked at 0.31 but CK-MB was flat at 2-3. His EKG showed left axis deviation with new RBBB with demand pacing. Cardiology was consulted and felt that this may be due to digoxin toxicity, so the digoxin was held. Lisinopril and metoprolol are being held in the setting of hypotension. The pacer wires were replaced. . # Atrial fibrillation: Patient is currently on amiodarone and anticoagulated with heparin gtt with bridge to warfarin. INR is 1.8. - Recommend continuing the heparin gtt until INR is therapeutic ([**2-20**]) - Holding digoxin as mentioned above, in the setting of EKG changes - Holding metoprolol in the setting of hypotension - Recommend cardiology follow up . # Tachy/brady Syndrome: Has pacemaker and had wires changed during this admission. . # Humerus fx: S/p mechanical fall and underwent closed treatment of his left proximal humerus fracture on [**2148-12-9**]. He should continue with pendulum and passive range of motion, with active assisted and active range of motion, though no resisted exercises. He can wean out of his cuff and collar as he tolerates. We obtained a repeat XR of the left shoulder on [**3-29**] which orthopedics will review. . # Diabetes Mellitus: Patient has been receiving glargine 10 units QHS with an insuling sliding scale. . # Nutrition: Tubefeeds through Dobhoff; patient will need speech and swallow evaluation to assess for safety and improved swallowing function to determine if safe for oral feeding. If he is not deemed safe for oral feeding he may require PEG tube placement. . # Access: HD tunneled line, PICC # PPx: - DVT: Heparin gtt, warfarin - GI: Lansoprazole - Bowel: Docusate sodium, senna, miralax # Code: Full Code # Communication: [**Name (NI) 714**] (wife) ([**Telephone/Fax (1) 20199**] Medications on Admission: 1. Albuterol 2 puffs Q6H 2. Allopurinol 100 mg QOD 3. Amiodarone 400 mg daily 4. Warfarin 5. Digoxin 125 mcg ([**1-19**] tab QMWFSat) 6. ASA 325 mg daily 7. Flovent 2 puffs Q12H 8. Insulin NPH 34 units QAM and 45 units QPM 9. Insulin HISS 10. Lisinopril 2.5 mg QMWFSat 11. Multivitamin 12. Metoprolol succinate 50 mg daily 13. Miralax daily 14. Percocet 1 tap Q3Pm/Q11pm 15. Pantoprazole 40 mg daily 16. Renagel 1600 mg TID 17.Senna 2 tabs QHS 18. Simvastatin 40 mg QHS 19. Tylenol 1500 mg Q3PM/Q11pm 20. Vitamin D 1000 units daily 21. Zinc sulfate 220 mg daily Discharge Medications: 1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Month/Day (2) **]: Two (2) puffs Inhalation every six (6) hours. 2. allopurinol 100 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO every other day . 3. amiodarone 400 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO once a day. 4. warfarin 1 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO Once Daily at 4 PM. 5. aspirin 325 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily). 6. Flovent HFA 110 mcg/Actuation Aerosol [**Month/Day (2) **]: Two (2) puffs Inhalation every twelve (12) hours. 7. insulin glargine 100 unit/mL Solution [**Month/Day (2) **]: Twenty (20) units Subcutaneous at bedtime. 8. insulin lispro 100 unit/mL Solution [**Month/Day (2) **]: sliding scale Subcutaneous four times a day. 9. Miralax 17 gram Powder in Packet [**Month/Day (2) **]: One (1) packet PO once a day. 10. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 11. sevelamer carbonate 800 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times a day). 12. senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). 13. simvastatin 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO at bedtime. 14. Tylenol 8 Hour 650 mg Tablet Extended Release [**Last Name (STitle) **]: One (1) Tablet Extended Release PO three times a day as needed for fever or pain. 15. Vitamin D 1,000 unit Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day. 16. zinc sulfate 220 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day. 17. norepinephrine bitartrate 1 mg/mL Solution [**Last Name (STitle) **]: 0.01-0.4 mcg/kg/min Intravenous TITRATE TO (titrate to desired clinical effect (please specify)) as needed for hypotension: map 55 (baseline BP high 80s-low 100s). 18. B complex-vitamin C-folic acid 1 mg Capsule [**Last Name (STitle) **]: One (1) Cap PO DAILY (Daily). 19. midodrine 5 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO TID (3 times a day). 20. fludrocortisone 0.1 mg Tablet [**Last Name (STitle) **]: 0.1 mg PO DAILY (Daily). 21. heparin (porcine) in D5W 25,000 unit/500 mL Parenteral Solution [**Last Name (STitle) **]: 1600 (1600) units Intravenous per hour: Titrate to goal PTT 60-100. 22. HYDROmorphone (Dilaudid) 0.25 mg IV Q4H:PRN Pain Hold for sedation, RR<12 23. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Last Name (STitle) **]: Three (3) Adhesive Patch, Medicated Topical DAILY (Daily): Apply 2 to left arm, 1 to right arm, 12 hours on/ 12 hours off. . 24. chlorhexidine gluconate 0.12 % Mouthwash [**Last Name (STitle) **]: Fifteen (15) ML Mucous membrane [**Hospital1 **] (2 times a day). 25. sodium citrate Solution [**Hospital1 **]: 1.2 MLs PO ASDIR (AS DIRECTED) as needed for catheter not in use: for HD catheter. 26. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and PRN. 27. 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. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**] Discharge Diagnosis: Primary diagnosis: - Pneumonia - Sepsis - Heart failure . Secondary diagnosis: - End stage renal disease - Atrial fibrillation Discharge Condition: Mental Status: Clear and coherant. Level of Consciousness: Alert and interactive; able to mouth words. Activity Status: Out of Bed with assistance to chair. Discharge Instructions: Mr. [**Known lastname 20200**], You were admitted with low blood pressure and low oxygenation in the setting of pneumonia. We treated the pneumonia with antibiotics. You required ventilator support for your breathing and now have a tracheostomy. You are also on medications to help with your blood pressure. You are being discharged to a rehab facility where you can continue to get stronger and work with the physical therapists. . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. . We have made the following changes to your medications: - CHANGED insulin from NPH 34 units QAM and 45 units QPM to glargine 20 units QPM - CHANGED pantoprazole to lansoprazole - CHANGED sevelamer from 1600mg TID to 800mg TID - STOPPED digoxin, lisinopril, and metoprolol - STOPPED percocet and STARTED dilaudid - STARTED nephrocaps, midodrine, fludrocortisone, norepinephrine, lidocaine patch, heparin gtt, chlorhexadine gluconate oral rinse Followup Instructions: Department: CARDIAC SERVICES When: MONDAY [**2149-4-7**] at 1 PM With: [**Year (4 digits) **] [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . Department: CARDIAC SERVICES When: MONDAY [**2149-4-7**] at 2:00 PM With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . Department: CARDIAC SERVICES When: MONDAY [**2149-4-7**] at 2:30 PM With: DEVICE CLINIC [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**] Completed by:[**2149-3-29**]

[ "518.81", "812.20", "428.20", "E888.9", "785.51", "707.25", "995.92", "428.0", "785.52", "707.03", "482.42", "V45.11", "425.4", "403.91", "250.00", "584.9", "707.07", "V45.01", "V58.61", "585.6", "427.31", "038.9" ]

icd9cm

[ [ [] ] ]

[ "45.13", "39.95", "38.95", "33.23", "96.72", "34.91", "96.04", "31.1", "00.51", "38.93" ]

icd9pcs

[ [ [] ] ]

21023, 21123

11699, 17205

288, 353

21294, 21294

4794, 4794

22468, 23439

3252, 3342

17817, 21000

21144, 21144

17231, 17794

21477, 22028

5367, 11676

3357, 4155

4171, 4775

22057, 22445

228, 250

381, 2629

21223, 21273

4810, 5351

21163, 21202

21309, 21453

2651, 2991

3007, 3236

32,286

141,332

51181

Discharge summary

report

Admission Date: [**2180-3-19**] Discharge Date: [**2180-3-25**] Date of Birth: [**2105-9-27**] Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Ace Inhibitors / Angiotensin Receptor Antagonist / Keflex Attending:[**First Name3 (LF) 99**] Chief Complaint: Pancreatitis Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname **] is a 74yo M with history of myelofibrosis on hydroxyurea, history of chronic c diff, and recent admission for pneumonia discharged on [**3-14**] who presents with nausea, vomiting and diarrhea. Today he reported feeling "like he was going to die" so he came into the ER. . In the ED, initial vs were: T 97 P 80 BP 139/79 R 24 O2 sat 100%. CXR was significant for new R pleural effusion and consolidation. He had a CT of his abdomen/pelvis which showed new acute, possibly necrotizing pancreatitis. Patient was given 4L NS, vancomycin, flagyl, levaquin, zofran and morphine. Surgery was consulted regarding questionable necrotizing pancreatitis and felt he did not acutely require intervention as he has had his gallbladder removed. Vitals on transfer were 70, 113/46, 19, 100% 2L. . In the ICU, patient is oriented to hospital and [**Location (un) 86**] but not [**Hospital1 **]. He knows the month but not date or year. Per HCP and patient, he has felt poorly since previous discharge and never felt better despite PNA treatment. He has had decreased PO intake for the past week with decreased, dark urine output. He developed nausea and vomiting on Friday with new abdominal pain yesterday. Patient has had chronic diarrhea. . Review of systems: Per HPI, otherwise difficult to obtain given confusion Past Medical History: - Idiopathic myelofibrosis - Anemia associated with CKD & Fe deficiency - PVD with recurrent LE venous stasis ulcers - PAF s/p [**Hospital1 4448**] - CHF (EF 45% in [**4-9**]) - HTN - Hyperlipidemia - Hypothyroidism - BPH - Depression - H/o chronic C. diff - Diverticulitis - recurrent delirium Social History: - Tobacco: Previously smoked, quit in [**2151**] - EtOH: h/o heavy alcohol use, quit in [**2151**]. Currently lives in the [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **]. Retired trial lawyer. Married but currently seperated. Has 9 children. Family History: MI - father who died at 56y CAD, Parkinson's disease, renal failure - brother AS - mother EtOH abuse - mother, brother Bipolar d/o - daughter . Physical Exam: ADMISSION PHYSICAL: Vitals: T: 94.7 BP: 111/39 P: 71 R: 13 O2: 100% 2L NC General: Alert, oriented to person and year, no acute distress HEENT: NC/AT, PERRL, sclera anicteric, MM dry, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally with decreased breath sounds on right, no wheezes, rales, rhonchi appreciated anteriorly CV: Regular rate and rhythm, normal S1 + S2, [**2-6**] holosystolic murmur over LLSB Abdomen: soft, bilateral upper quadrant tenderness, worse at RUQ, non-distended, bowel sounds present, mild guarding, no rebound tenderness, no organomegaly appreciated GU: foley Ext: slightly cool feet, 1+ DP pulses bilaterally, no clubbing, cyanosis or edema . DISCHARGE PHYSICAL: Pertinent Results: ADMISSION LABS: . DISCHARGE LABS: . MICRO: . STUDIES: CXR [**2180-3-19**]: IMPRESSION: 1. Increased right middle and lower lobe opacities, reflecting combined pneumonia and pleural effusion. 2. Worsening congestive heart failure. . CTAP [**2180-3-19**]: IMPRESSION: 1. Recurrent acute pancreatitis, with enlargement and hypoenhancement of pancreatic head and peripancreatic standing, suspicious for necrosis. No organized fluid collections. 2. Small amount of ascites. 3. Large right and small left pleural effusions, with right lower lobe collapse/consolidation. 4. Moderate cardiomegaly and pericardial effusion. 5. Hepatosplenomegaly. 6. Severe atherosclerosis. . KUB [**2180-3-19**]: Single abdominal radiograph demonstrates air within dilated small bowel segments in the mid abdomen. If there is concern for obstruction, then CT would be helpful for further assessment. . MICRO: UCx [**2180-3-19**]: no growth [**Month/Day/Year **] Cx [**3-18**], [**3-19**], [**3-20**]: pending Brief Hospital Course: HOSPITAL COURSE: Mr. [**Known lastname **] is a 74yo M with history of myelofibrosis and recent PNA here with acute pancreatitis. Pt was treated aggressively with IVF's and started on broad-spectrum abx Vanc/Meropenem/Flagyl while in the MICU. His course was complicated by hypercarbic respiratory distress, requiring intubation. He continued to require IVF's, and required pressor support. A family meeting was held on # Acute pancreatitis: As evidenced by abdominal pain, elevated lipase. CT scan was concerning for necrotizing component in the pancreatitic head. The underlying cause of his pancreatitis is unclear as he is s/p cholecystectomy and denies alcohol ingestion. He recently had a lipid profile which showed triglycerides of 84 which makes hypertriglyceridemia unlikely. Medication effect is also a possibility and this could be due to the levaquin he was discharged on or hydroxyurea as this is listed as a possible side effect. Pt was treated with aggressive IVF's, and started on broad spectrum abx with Vanc/Meropenem/Flagyl. Surgery was consulted, and recommended no acute surgical intervention. Patient was followed and treated for 6 days with gradual deterioration and multisystem organ failure. A family meeting was held and after careful consideration he was made CMO. He passed on [**2180-3-25**] with his family at his side. Medications on Admission: 1. Lotemax 0.5 % Drops, Suspension Sig: One (1) left eye Ophthalmic twice a day. 2. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 3. hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. trazodone 50 mg Tablet Sig: 0.25 Tablet PO HS (at bedtime) as needed for insomnia. 7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 8. oxycodone 15 mg Tablet Sig: One (1) Tablet PO once a day: in the morning. 9. oxycodone 10 mg Tablet Sig: One (1) Tablet PO three times a day. 10. tobramycin-dexamethasone 0.3-0.1 % Ointment Sig: One (1) Appl Ophthalmic HS (at bedtime). 11. hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO QMOWEFR (Monday -Wednesday-Friday). 12. Decubi Vite 400-50-500 mcg-mg-mg Capsule Sig: One (1) Capsule PO once a day. 13. multivitamin Tablet Sig: One (1) Tablet PO once a day. 14. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. [**Year (4 digits) **] 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime. 18. Acidophilus Capsule Sig: One (1) Capsule PO twice a day. 19. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 3 days. Disp:*3 Tablet(s)* Refills:*0* 20. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 3 days. Disp:*11 Tablet(s)* Refills:*0* 21. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for pain: to right side of chest. Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2* 22. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours). Discharge Medications: deceased Discharge Disposition: Expired Discharge Diagnosis: deceased Discharge Condition: deceased Discharge Instructions: deceased Followup Instructions: deceased

[ "272.4", "276.2", "995.94", "585.9", "518.81", "707.03", "416.8", "403.90", "428.23", "286.9", "707.19", "707.20", "276.1", "V45.01", "459.81", "560.1", "238.76", "285.21", "584.5", "577.0" ]

icd9cm

[ [ [] ] ]

[ "34.91", "96.72", "57.94", "99.15" ]

icd9pcs

[ [ [] ] ]

7648, 7657

4289, 4289

364, 370

7709, 7719

3277, 3277

7776, 7787

2355, 2501

7615, 7625

7678, 7688

5669, 7592

4306, 5643

7743, 7753

3313, 4266

2516, 3258

1680, 1737

311, 326

398, 1661

3294, 3296

1759, 2056

2072, 2339

14,397

147,602

3328

Discharge summary

report

Admission Date: [**2157-11-24**] Discharge Date: [**2157-11-28**] Date of Birth: [**2102-4-3**] Sex: F Service: CSU HISTORY OF PRESENT ILLNESS: This is a 55 year old female who reports regional exertional chest pain relieved by nitroglycerin with one episode of chest pain at rest. She was seen prior to her surgical admission by the Cardiac Surgery Team on [**2157-10-31**]. Stress test showed a reversible apical anterior and septal wall defects. Cardiac catheterization was performed preoperatively on [**2157-10-31**], which showed a left main 70 percent lesion, 80 percent left anterior descending lesion, right coronary artery 40 percent lesion and ejection fraction of 70 percent. The patient reports angina which radiates to her arm. PAST MEDICAL HISTORY: Noninsulin dependent diabetes mellitus, Type 2. Hypertension. Hypercholesterolemia. Breast cancer, [**2157-5-17**], status post four rounds of chemotherapy and radiation, due to start on [**2157-11-15**], two weeks after we saw her. PAST SURGICAL HISTORY: Lumpectomy with lymph node dissection. ALLERGIES: No known drug allergies. The patient states she was allergic to latex which produced hives. SOCIAL HISTORY: The patient works full time as a physician's assistant at our institution. She had no tobacco history and no significant alcohol history. She lives with her elderly mother. [**Name (NI) **] mother also had myocardial infarction at 58 and her father died of myocardial infarction at 63. PHYSICAL EXAMINATION: On examination she was 5 foot 6 inches, 181 pounds. Sinus rhythm 59. Blood pressure 166/64, sating 98 percent on room air. Respiratory rate 12. She was lying flat on the bed on the first examination post catheterization in no apparent distress. She was alert and oriented and appropriate. Her lungs were clear anteriorly. Her heart was regular rate and rhythm, S1 and S2, tone was normal. No rub or gallop. Her abdomen was soft, obese, nontender, nondistended with positive bowel sounds. Extremities were warm and well perfused with trace peripheral edema and a varicosity noted in her right calf. She had 2 plus bilateral radial pulses, 2 plus bilateral dorsalis pedis pulses and 1 plus posterior tibial on the right and 2 plus posterior tibial pulse on the left. MEDICATIONS PRIOR TO ADMISSION: Medications prior to admission when she was seen and updated on [**2157-11-16**], were as follows: Glyburide 5 mg p.o. daily, Lopressor 50 mg p.o. twice a day, Lisinopril 10 mg p.o. daily, Lipitor 40 mg p.o. daily, aspirin 325 mg p.o. daily and sublingual Nitroglycerin daily. LABORATORY DATA: White count 5.7, hematocrit 32.5, platelet count 130,000, ALT 60, AST 17, alkaline phosphatase 67, total bilirubin 0.5, repeat white count 3.3 on [**2157-11-16**], repeat hematocrit 34.9. PT 12.5, PTT 27.1, platelet count 183,000, INR 1.0, all on repeat laboratory data at preadmission testing. Urinalysis was negative. Sodium was 143, potassium 3.7, chloride 106, bicarbonate 26, BUN 12, creatinine 0.5 with a blood sugar of 108 and anion gap of 15. Repeat liver function tests showed ALT 53, AST 30, alkaline phosphatase 93, total bilirubin 0.5, total protein 6.5, albumin 4.1, globulin 2.4. HPA1c 7.0 percent. Preoperative chest x-ray showed no acute cardiopulmonary process. Preoperative electrocardiogram showed sinus rhythm at 77 with T wave inversion in leads V2 to V5. Please refer to the office electrocardiogram report dated [**2157-11-24**]. HOSPITAL COURSE: The patient was a same day admit, [**2157-11-24**] and underwent coronary artery bypass grafting times three by Dr. [**Last Name (STitle) **] with left internal mammary artery to the left anterior descending coronary artery, vein graft to diagonal, vein graft to the obtuse marginal. Surgery was undertaken after the patient was cleared by her oncologist, due to her recent chemotherapy. The patient was a little bit anemic postoperatively and did receive some packed red blood cells. Transesophageal echocardiography in the Operating Room showed normal left ventricle with trace mitral regurgitation. On postoperative day Number 1, the patient had been extubated over night and had been weaned from her Neo-Synephrine drip which she left the Operating Room on at 0.5 mcg/kg/minute. On postoperative day Number 1, her white count was 8.6, hematocrit 28, platelet count 186,000, potassium 3.7, BUN 5, creatinine 0.4. She was on an insulin drip at 1 unit per hour and a nitroglycerin drip at 0.3 mcg/kg/minute. She started Lasix diuresis as well as Beta blockade with Lopressor and was doing very well and was transferred out to the floor. Foley catheter was discontinued as were her chest tubes later that day. On postoperative day Number 2, the patient had been unable to be transferred for lack of bed on the evening before, so the patient was transferred out to the floor on postoperative day Number 2. Her laboratory data were stable. She was at 14.4 kg, was sating 93 percent on 3 liters of nasal cannula with 100 sinus tachycardia with blood pressure of 157/76. She continued with intravenous Lasix twice a day as well as Lopressor and aspirin. She remained in sinus rhythm. Chest tubes were removed. The patient began ambulating almost right away with the physical therapist on the floor. Aggressive diuresis continued and she was ambulating. Her beta blocker was increased to 37.5 b.i.d., Lopressor, pacing wires were removed and she also started Motrin. She was sating 93 percent on 2 liters with a good blood pressure of 111/61. She remained slightly tachycardiac but was not symptomatic. She had Motrin added to her Percocet with good effect for incisional pain. Her incisions were clean, dry and intact. Her sternum was stable. She did remarkably well with physical therapy. She continued to receive regular insulin, sliding scale. On the day of discharge her lung sounds were diminished at the base but she was producing a strong, dry cough and was using her incentive spirometer. She had trace nonpitting edema in both of her lower extremities. Her incision was clean, dry and intact. She did one flight of stairs independently, thus achieving a Level 5 and she was very anxious to be discharged to home, and she was discharged to home on [**11-28**] with laboratory data as follows. White count 6.3, hematocrit 27.4, platelet count 112,000, potassium 3.9, BUN 11, creatinine 0.6 with blood sugar of 125, INR 1.1. Her Lasix was decreased to once daily dose of 20 for one week. The patient was instructed to restart herself on her half dose of Glyburide. He examination was unremarkable, and the patient was discharged to home with the following diagnoses. DISCHARGE DIAGNOSIS: Coronary artery disease. Status post coronary artery bypass grafting times three. Noninsulin dependent diabetes mellitus. Hypertension. Hypercholesterolemia. Status post breast cancer with lumpectomy and chemotherapy. DISCHARGE INSTRUCTIONS: The patient was instructed to follow up with Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 9022**] in one to two weeks postoperatively, primary care physician [**Telephone/Fax (1) 12744**], and to follow up with Dr. [**Last Name (STitle) **], her surgeon postoperatively at one month for postoperative surgical visit. DISCHARGE MEDICATIONS: 1. Lasix 20 mg p.o. once a day for seven days. 2. Potassium chloride 20 mEq p.o. once a day for seven days. 3. Colace 100 mg p.o. twice a day. 4. Percocet 5/325 one to two tablets p.o. prn q. 4 hours for pain. 5. Aspirin, enteric coated 81 mg p.o. once a day. 6. Ibuprofen 800 mg p.o. q. 8 hours prn pain. 7. Metoprolol 50 mg p.o. twice a day. 8. Glyburide 5 mg p.o. once a day. 9. Lipitor 40 mg p.o. once a day. DISCHARGE DISPOSITION: The patient was discharged to home with [**Hospital6 407**] services in stable condition on [**2157-11-28**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**], [**MD Number(1) 1715**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2157-12-19**] 11:16:26 T: [**2157-12-19**] 12:04:15 Job#: [**Job Number 15461**]

[ "401.9", "285.1", "250.00", "414.01", "272.0", "174.8" ]

icd9cm

[ [ [] ] ]

[ "99.04", "36.12", "39.61", "99.05", "36.15" ]

icd9pcs

[ [ [] ] ]

7819, 8199

7377, 7795

6733, 6957

3511, 6711

6982, 7354

1052, 1198

2336, 3493

1528, 2303

166, 769

792, 1028

1215, 1505

47,683

126,886

50221

Discharge summary

report

Admission Date: [**2159-2-14**] Discharge Date: [**2159-2-19**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2840**] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: CVL placement and removal. History of Present Illness: This is an 84 yo M with a past medical history significant for multiple myeloma (gets care at DF), on dexamethasone, who presents to the ED today with complaints of weakness and fatigue for several days. He does not endorse any localizing symptoms, but notes that he is "not feeling well" and feels weak. He describes that he had a near syncopal event yesterday. He describes that he was about to leave his home and suddenly fell. He did not have his walker with him. He endorses a prodrome of lightheadedness and felt "woozy" but denies loss of consciousness. He did scrape his right knee and side of the face a little bit. He saw his gerontologist the same day, but felt better by that time. He describes possible fever/chills at home, but did not measure his temperature. He denies any n/v/d, sick contacts, myalgias, chest pain, palpitations or headache. He is complaining about severe sweating that occurs at night without any reason for which he had a work up at the VA that was unrevealing. Upon arrival to the ED, initial vital signs were 98.2 80 80/43 20 98% on room air. Tmx was 99.7. Exam was nonlocalizing with a benign abdominal exam. His lactate was 1.3, but labs were otherwise significant for a leukocytosis to 26,000 with a left shift, acute renal failure with a creatine of 2.3. He had a normal cxr, neg UA. Blood/urine cx were drawn and he was given 3L of NS with little improvement in his blood pressure. ECG was without acute change, and a troponin was elevated at 0.44, prompting a cardiology consult who advised that this was likely in the setting of ARF and hypotension and was not ACS. He was given an aspirin. At this time, the concern for relative adrenal insufficiency was raised and he was given a dose of stress dose hydrocortisone, with subsequent improvement in his BP to 88/39. He was mentating clearly throughout. He is being admitted to the MICU for hypotension. At time of transfer to the MICU, his vitals were 73 88/39 20 96%ra, but he subsequently dropped his pressures to the 60??????s. A CVL was placed, he was started on levophed and given a dose of vanco, CTX and flagyl. He now has a CVL and 2 18g PIV's for access, and has been started on his 4th L NS. Upon arrival to the ICU, the patient is alert and talkative. He feels ??????better??????. He notes that he always has some amount of shortness of breath, and although he appears somewhat breathless, he will not endorse that this is any worse from his baseline. He denies pleuritic chest pain, palpitiations. Past Medical History: Multiple Myeloma - treated at DF currently, on dexamethasone DVT x 2, on coumadin Valvular heart disease Hyperlipidemia BPH Constipation Hypertension Plantar fasciitis Severe leg pain appendectomy and tonsillectomy as a child a kidney stone removed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 986**] in [**2146**] cholecystectomy by Dr. [**Last Name (STitle) **] in [**2153-9-17**] Social History: He does not smoke nor drink. He is widowed, wife died approx 6 months ago, has a son and a daughter. [**Name (NI) **] used to run a sportswear factory. Family History: His father died at 90 of cancer in the brain and his mother at 52 of breast cancer. . Physical Exam: Gen: mild distress, mild dyspnea, states he feels comfortable CVS: +S1/S2, no M/R/G, RRR LUNGS: +crackles, no rhonchi ABD: +BS, NT/ND EXT: no c/c/e Pertinent Results: [**2159-2-14**] 07:18PM WBC-25.9*# RBC-3.97*# HGB-13.1* HCT-37.7* MCV-95# MCH-32.9* MCHC-34.7 RDW-13.5 [**2159-2-14**] 07:18PM NEUTS-91* BANDS-1 LYMPHS-6* MONOS-2 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 OTHER-0 [**2159-2-14**] 07:18PM PT-19.1* PTT-25.1 INR(PT)-1.8* [**2159-2-14**] 07:18PM GLUCOSE-90 UREA N-54* CREAT-2.3* SODIUM-134 POTASSIUM-5.3* CHLORIDE-98 TOTAL CO2-26 ANION GAP-15 [**2159-2-14**] 07:18PM ALT(SGPT)-30 AST(SGOT)-35 CK(CPK)-96 ALK PHOS-46 TOT BILI-0.6 [**2159-2-14**] 07:18PM cTropnT-0.44* [**2159-2-14**] 08:44PM LACTATE-1.3 [**2159-2-14**] 09:33PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-15 BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-NEG [**2159-2-14**] 09:33PM URINE RBC-0-2 WBC-[**3-22**] BACTERIA-MOD YEAST-NONE EPI-0-2 . CXR ([**2-16**]): Persistent CHF, slightly worse when compared to [**2159-2-15**]. . CT C/A/P: 1. Small bilateral pleural effusions, slightly larger on the right, with adjacent compressive atelectasis. 2. No source for sepsis identified on CT of the chest, abdomen, and pelvis. 3. Multiple renal cysts, measuring up to 11 cm on the right and 4 cm on the left, containing simple fluid. A smaller 14-mm exophytic cyst along the upper pole of the right kidney, is slightly hyperdense, possibly representing proteinaceous material or blood products, although a solid lesion cannot be excluded without administration of IV contrast. 4. Status post cholecystectomy. 5. Scattered colonic diverticula without evidence of diverticulitis. 6. Mild prostatic enlargement. 7. Bilateral fat-containing inguinal hernias. 8. Multilevel compression fractures in the thoracolumbar spine of indeterminate chronicity, status post kyphoplasty at two levels. No associated soft tissue component is noted along the spine. 9. Possible non-displaced acute/subacute lateral right 9th rib fracture. . CARDIAC ECHO: The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The number of aortic valve leaflets cannot be determined. No masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. Mild to moderate ([**1-19**]+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: No valvular vegetations seen, but technical study quality precludes definite asssessment of valvular morphology. Mild aortic regurgitation. Mild to moderate mitral regurgitation. Preserved biventricular systolic function. Mild pulmonary hypertension. Brief Hospital Course: 84 yo M with history of MM, DVT, admitted with hypotension and ARF. . MICU COURSE: He was admitted to the MICU for hypotension. At time of transfer to the MICU, his vitals were 73 88/39 20 96%ra, but he subsequently dropped his pressures to the 60??????s. A CVL was placed, he was started on levophed and given a dose of vanco, CTX and flagyl. Upon arrival to the ICU, the patient was alert and talkative. He received stress dose steroids out of concern for AI in the setting of chronic dx use. He was started on Vanc/Zosyn/Azithro for ? infiltrate in retrocardiac space. He received volume resuscitation with 8 liters and subsequently developed bilateral pleural effusions. He was briefly on bipap overnight for 5 minutes because patient appeared uncomfortable, but no clinical change. A CT c/a/p showed bilateral renal cyst, for which he has urology f/u. On transfer to floor, he felt better. He notes that he always has some amount of shortness of breath, and although he appears somewhat breathless, he will not endorse that this is any worse from his baseline. He denies pleuritic chest pain, palpitiations. . HYPOTENSION: Patient had mild fever and leukocytosis but no localizing symptoms. Hypotension was originally fluid refractory but responded to steroids. CT C/A/P showed no evidence of infection. UA negative. Cardiac Echo did not point to a cardiac [**Last Name (un) 68421**]. Cultures negative. Flu negative. Most likely cause is mild viral vs. bacterial infection worse in setting of adrenal insufficiency. In ICU, he was started on broad spectrum abx with vanco, zosyn, azithro for planned 10 day course with goal stop date [**2-23**]. His antibiotics were narrowed to Ceftriaxone/Azithro to [**Last Name (un) 76271**] possible CAP. His stress dose steroids to prednisone 30mg daily and discharged on a [**Last Name (LF) 15123**], [**First Name3 (LF) **] his primary oncologist. . # PULMONARY EDEMA: Patient flashed in setting of aggressive volume repletion. Cardiac enzymes negative. No clear evidence of heart failure. He responded well yo gentle diuresis. . # HEMATURIA: Patient with hematuria along with bilateral renal cysts on CT scan. Urology consulted and have recommended cytology, which was sent. Will f/u as outpatient. . #. ARF - likely prerenal azotemia.- Now resolved . #. Multiple Myeloma - multiple myeloma for which he takes dexamethasone weekly on a regular basis. Per primary oncologist, MM is in remission . #. History of DVT- continue coumadin . #. Depression - continue citalopram. SW consulted. . Code status: Full code . Communication: Daughter - [**Known lastname 104753**] [**Telephone/Fax (1) 104754**] (house) [**Telephone/Fax (1) 104755**] (cell). Medications on Admission: ACETIC ACID - 2 % Solution - half cc in ears twice a day AMOXICILLIN - 500 mg Capsule - 4 Capsule(s) by mouth once a day as needed for for dental procedure CITALOPRAM - 20 mg Tablet - 1 Tablet(s) by mouth at bedtime DEXAMETHASONE - 4 mg Tablet - 10 Tablet(s) by mouth once a day every monday FINASTERIDE - (Prescribed by Other Provider) - 5 mg Tablet - 1 Tablet(s) by mouth once a day GABAPENTIN - 100 mg Capsule - 1 Capsule(s) by mouth at bedtime and then increase it up to 300 mg tid LISINOPRIL - 20 mg Tablet - 1 Tablet(s) by mouth once a day OXYCODONE-ACETAMINOPHEN - (Prescribed by Other Provider) - 5 mg-325 mg Tablet - 1 Tablet(s) by mouth once a day as needed for as needed for pain in legs RANITIDINE HCL - 150 mg Capsule - 1 Capsule(s) by mouth twice a day TAMSULOSIN [FLOMAX] - (Prescribed by Other Provider) - 0.4 mg Capsule, Sust. Release 24 hr - 1 Capsule(s) by mouth once a day WARFARIN [COUMADIN] - (Prescribed by Other Provider) - Dosage uncertain - 5mg most recently per patient Medications - OTC ACETAMINOPHEN - (Prescribed by Other Provider) - Dosage uncertain ASPIRIN - (Prescribed by Other Provider) - Dosage uncertain CALCIUM-CHOLECALCIFEROL (D3) [CALCIUM+D] - (OTC) - Dosage uncertain CHLORHEXIDINE GLUCONATE - 2 % Liquid - mouth wash twice a day DOCUSATE SODIUM - 100 mg Capsule - 2 Capsule(s) by mouth twice a day FOLIC ACID - 0.4 mg Tablet - 1 Tablet(s) by mouth once a day GUAR GUM [BENEFIBER (GUAR GUM)] - (Prescribed by Other Provider) - Dosage uncertain MULTIVITAMINS WITH MINERALS [MULTI-VITAMIN W/MINERALS] - (Prescribed by Other Provider; OTC) - Dosage uncertain SENNA - 8.6 mg Tablet - 2 Tablet(s) by mouth once a day Discharge Medications: 1. Prednisone 5 mg Tablet Sig: as directed Tablet PO once a day for 9 days: 4 tabs for 3 days; then 2 tabs for 3 days; then 1 tab for 3 days. Disp:*21 Tablet(s)* Refills:*0* 2. Acetic Acid 2 % Solution Sig: One (1) half cc Otic twice a day: in ears. 3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Dexamethasone 4 mg Tablet Sig: Ten (10) Tablet PO once a week: on mondays. Do not resume for 3 weeks. 5. Finasteride 5 mg Tablet Sig: One (1) Tablet PO once a day. 6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO three times a day. 7. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO once a day as needed for pain. 8. Ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO once a day. 9. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. 10. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 11. Calcitrate-Vitamin D 315-200 mg-unit Tablet Sig: One (1) Tablet PO twice a day. 12. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 13. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 15. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 4 days. Disp:*4 Tablet(s)* Refills:*0* 16. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day for 4 days. Disp:*8 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 701**] VNA Discharge Diagnosis: Primary: HYPOTENSION ADRENAL INSUFFICIENCY PULMONARY EDEMA HEMATURIA ARF Secondary: Multiple Myeloma History of DVT Depression Benign prostatic hypertrophy Nutrition Discharge Condition: Stable Discharge Instructions: You were admitted for low blood pressure. We looked for signs of infection but did not observe any. You were treated in the intensive care unit with medications to elevate your blood pressure. These symptoms were likely due to a viral infection in the setting of steroid use. Do not take your blood pressure medications until your next appointment with your PCP this week. You were started on prednisone, which you should [**Location (un) 15123**] slowly. Please take decreasing doses over 9 days as directed. Following this, you should not take your dexamethasone for 2 weeks. If you have fevers, chills, feel week or lightheaded, or have any other concerning symptoms. Please seek medical attention. Followup Instructions: You should follow up with your PCP, [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2159-2-22**] 9:30 You are scheduled to see urology for follow up with Urology. You have an appointment scheduled on with Dr. [**Last Name (STitle) 770**] on [**3-26**] a 3:30PM, [**Hospital Ward Name 23**] [**Location (un) 470**]. You should keep your previously scheduled oncology appointment. Completed by:[**2159-3-5**]

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

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Discharge summary

report

Admission Date: [**2124-11-23**] Discharge Date: [**2124-12-6**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 896**] Chief Complaint: Left leg swelling, weight gain of 6 pounds Major Surgical or Invasive Procedure: Thoracentesis (right) with pigtail placement ([**2124-11-30**]) Thoracentesis (left) with pigtail placement ([**2124-12-2**]) History of Present Illness: Hospitalist Admission Note: PCP: [**Name10 (NameIs) **], [**Name11 (NameIs) **] [**Age over 90 **] year-old woman who presented to her PCP on the day of admission with increasing lower extremity edema over the [**3-16**] weeks prior to admission. She notes no associated orthopnea, paroxysmal nocturnal dyspnea, dyspnea with exertion, cough or anginal pain. She reports that the last times she had leg swelling, it was associated with the need to see her doctor and sometimes led to hospitalization. She notes that her weight had been stable for the past few months, until noted by Dr. [**Last Name (STitle) **] today in the office with a 7-lb weight gain (from 129 to 136.5 lb). She denies change in abdominal girth, and notes no nausea, vomiting or diarrhea. She reports her appetite is improved after her her PCP changed her medications (she believes that it is the mirtazapine, but is not sure of the name). She denies dizziness, recent falls, syncope or changes in gait. She notes walking with a rolling walker at baseline in her independent living facility, and reports planning to move to the [**Hospital3 **] area in the next week. In her PCP's office, she was noted to have dullness on the right side of her chest, BP 122/74, HR 106, and she was oxygenating 91% on RA. The patient's PCP referred the patient to the ED given her suspected recurrent effusion, for evaluation for CHF and rate control of atrial fibrillation. In the ED, the patient was found to have a significant right pleural effusion, and was given 40mg IV lasix and levofloxacin 750mg x 1 IV. 10-system ROS is otherwise non-contributory. Including, patient denies changes in abdominal girth, no rashes, no changes in sleep patterns, no recent pain at any site. Past Medical History: Diastolic CHF Atrial fibrillation with h/o RVR, on Coumadin Hypothyroidism s/p thyroidectomy HTN Dyslipidemia CKD stage 3 Chronic venous stasis Depression Social History: Patient reports planning to move to [**Hospital3 **] in the week after admission, now living in independent living. Son lives in [**Name (NI) 5622**], niece is in the area ([**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 410**]). Never smoked, no alcohol or drugs. Is a retired administrator for an Xray office in [**Location (un) **]. Walks with a walker at baseline. Family History: daughter- breast ca, died in her 40s sister- breast ca mother-esophageal ca sister- lung ca, smoker brother- MI in 40s brother- [**Name (NI) 97631**] as child, died of perf appendicitis Physical Exam: VS on arrival to floor: Temp 95.2F BP 90/60 HR 80 (afib on EKG) HR 22 95% on 2Liters NC Patient denies pain of any type at this time, includig her leg. Gen: No dyspnea, patient conversant, thin elderly female HEENT: Moist mucous membranes, no scleral icterus CV: Irregularly irregular, S1S2, no murmurs Lungs: Decreased BS right side, up to [**3-16**] on right associated with dullness to percussion. Fine rales left base, up 1/3 way, without associated wheezes or rhonchi. Abd: Soft, non-tender. Ext: Left leg with 3+ pitting edema to thigh, bruising and mild ecchymosis on anterior aspect, without fluctuance or evidence of dimpling or cellulitis. Neuro: Alert and oriented x 3, conversant, fluent speech, global memory to events of the day intact (patient aware of medications administered in the ED, that she saw her internist earlier, why she is being admitted). Sat up in bed independently. Pertinent Results: ADMISSION LABS: [**2124-11-23**] WBC-8.4 RBC-3.93* Hgb-11.4* Hct-33.9* MCV-86 MCH-29.0 MCHC-33.6 RDW-15.4 Plt Ct-325 PT-30.0* PTT-33.3 INR(PT)-2.9* Glucose-94 UreaN-59* Creat-1.7* Na-141 K-4.1 Cl-99 HCO3-31 AnGap-15 cTropnT-<0.01 proBNP-3158* CXR [**2124-11-23**]: Bilateral pleural effusions, right much greater than left. The large right effusion has enlarged in the interval since prior exam. ECG [**2124-11-23**]: Atrial fibrillation with controlled ventricular response. Possible old anteroseptal myocardial infarction. Compared to the previous tracing there has been slowing of the ventricular response rate. Left lower extremity ultrasound [**2124-11-23**]: No DVT Brief Hospital Course: 1. CHF, acute on chronic diastolic with hypoxemia and respiratory failure 2. Pleural effusions 3. Acute renal failure with CKD, stage 3 4. Hypothyroidism 5. Atrial fibrillation 6. Acute blood loss anemia 7. Constipation Found to have significant bilateral pleural effusions. She was diuresed with IV furosemide, but this was somewhat limited by blood pressure and kidney function. On [**11-27**], she developed hypercarbic/hypoxemic respiratory failure, requiring transfer to the ICU. She was diuresed further there, with improvement. She did not require intubation. She was transferred back to the general medical [**Hospital1 **] on [**11-29**]. She underwent bedside right-sided thoracentesis with pigtail placement on [**11-30**], followed by left-sided thoracentesis with pigtail placement on [**12-2**]. Drains was left in place until [**2124-12-5**]. Analysis of pleural effusion revealed transudate. The left-sided procedures once complicated by minor bleeding which resolved with pressure dressings and administration of ddAVP. Her acute renal failure was likely related to diuresis. This improved over the stay. Medications on Admission: (patient notes that she receives her medications from [**Doctor Last Name **] Pharmacy at [**Street Address(2) 3375**] already alotted into daily dosing, and is not familiar with her doses or medications. She does report that Dr [**Last Name (STitle) **] has an updated list of her medications.) Medications per Dr[**Name (NI) 2056**] note from [**2124-11-23**]: FUROSEMIDE - 40 mg Tablet - 1 [**2-13**] Tablet(s) by mouth once a day LEVOTHYROXINE [SYNTHROID] - 137 mcg Tablet - 1 Tablet(s) by mouth daily METOPROLOL TARTRATE - 25 mg Tablet - 1 [**2-13**] Tablet(s) by mouth twice a day MIRTAZAPINE - 15 mg Tablet - 1 Tablet(s) by mouth at bedtime OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth once a day POLYETHYLENE GLYCOL 3350 - 17 gram/dose Powder - 1 tablespoon by mouth in 8 oz water qd SIMVASTATIN - 10 mg Tablet - 1 Tablet(s) by mouth once a day WARFARIN - 1 mg Tablet - 1.5 Tablet(s) by mouth alternating with 2 mg in the morning Medications - OTC ASPIRIN - 81 mg Tablet, Delayed Release (E.C.) - one Tablet(s) by mouth daily CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 500 + D] - 500 mg calcium (1,250 mg)-200 unit Tablet - 1 Tablet(s) by mouth once a day CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D-3] - 400 unit Capsule - 1 Capsule(s) by mouth daily DOCUSATE SODIUM - 100 mg Capsule - 1 Capsule(s) by mouth twice a day MULTIVITAMIN - Tablet - 1 Tablet(s) by mouth once a day Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO Q6H (every 6 hours). 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. 10. calcium carbonate-vitamin D3 500 mg(1,250mg) -400 unit Tablet Sig: One (1) Tablet PO once a day. 11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 12. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. warfarin 1 mg Tablet Sig: 1.5 Tablets PO Once Daily at 4 PM. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: 1. CHF, acute on chronic diastolic with hypoxemia and respiratory failure 2. Pleural effusions 3. Acute renal failure 4. CKD, stage 3 5. Hypothyroidism 6. Atrial fibrillation 7. Constipation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Ms. [**Known lastname 665**], you were admitted because of weight gain, leg swelling, and pleural effusions (fluid around your lungs) related to congestive heart failure. You were treated with diuretic medicines to try to remove fluid. At one point, your oxygen levels were quite low, requiring that you be transferred to the ICU for closer monitoring. Your oxygen levels improved, and you were transferred out of the ICU. You underwent a thoracentesis (drainage of fluid fluid the right lung) on the [**11-30**], and the drain was left in place. This was then done on the left on [**12-2**]. After removal of these drains the fluid did not immediately return. In the future, you may require repeat procedures if the fluid increases. Followup Instructions: Department: CARDIAC SERVICES When: WEDNESDAY [**2125-1-10**] at 1 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

[ "34.04" ]

icd9pcs

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Discharge summary

report

Admission Date: [**2188-10-1**] Discharge Date: [**2188-10-22**] Date of Birth: [**2133-11-10**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2160**] Chief Complaint: Fever, chills Major Surgical or Invasive Procedure: Placement of new right tunneled catheter Transfusion of 2 units of packed red blood cells in total History of Present Illness: 54 cantonese only speaking male with CAD, HTN, DM, ESRD on HD was found to be febrile after he had his hemodialysis on DOA. He complained of chills and fevers since Friday. No n/v/diarrhea. He did have some back pain for 1-2 days. Does not have any chest pain, SOB, palpitations, dizziness. His fevers were most likely from infected tunnelled RIJ. 2 sets of blood cultures were sent and he was given Vanc 1 gm, Gent 60 mg. Past Medical History: HTN DM ESRD due to IgA nephropathy/DM diabetic retinopathy- Blindness R subclavian Thrombus history of coumadin (seems to have stopped around [**12-9**]) Anemia of chronic disease Hyperlipidemia CAD - Cardiac catheterization from [**2188-2-4**] showed three-vessel disease with a 30% left main, a diffusely diseased LAD with 80% mid stenosis, 90% diagonal, 60% second diagonal, and 90% OM1. No suitable for PCI Social History: Cantonese speaking with some English, immigrated to the US 10 yrs ago, currently lives with wife and 3 children, has been blind for approx 3 years, has not worked recently; No history of tobacco use, alcohol, or illicit drug use. Wife injects insulin. Family History: No DM, CAD, Stroke, HTN, or Renal Disease Physical Exam: 98.6, 167/97, 79, 22, 94%/RA, FSG 198, Wt 128 lbs Gen: Comfortable, intermittent hiccups HEENT: NAD, Neck: no JVD, tunnel catheter line nontender/ no erythema at insertion site Lungs: Lungs clear Heart: RRR no m/r/g Abd: +bs, soft, NTND, no palpable masses, no reboud, no guarding Ext: wwp, no edema Neuro: AOx3 . Pertinent Results: IMAGING: . CXRAY [**2188-10-1**] Cardiomegaly. No evidence of CHF or pneumonia. Hemodialysis catheter unchanged in position . MR L SPINE W/O CONTRAST [**2188-10-3**] 11:21 AM At L2/3, there is a mild disc bulge, which is not causing canal or foraminal stenoses. At L4/5, there is a mild disc bulge eccentric to the left, which is not causing canal stenosis, but is mildly narrowing the left subarticular zone. There is no foraminal stenoses. No paraspinal soft tissue abnormalities are noted. IMPRESSION: Somewhat limited exam due to lack of gadolinium, but no evidence of spondylodiscitis or epidural or paraspinal abscess formation. Minimal degenerative changes without canal or foraminal stenoses. . CXR [**2188-10-14**] IMPRESSION: Improvement of pulmonary congestive pattern since previous examination four days earlier. Also, heart size has decreased slightly. No evidence of new discrete infectious pulmonary infiltrates. . CT CHEST W CONTRAST [**2188-10-15**] 1. Findings in the right middle lobe and right lower lobe are consistent with multifocal pneumonia. 2. Mild CHF. 3. Small right pleural effusion and tiny on the left. 4. Small right internal jugular venous thrombus. 5. No evidence of pulmonary infarction. . CT HEAD [**2188-10-15**] IMPRESSION: No intracranial hemorrhages or areas of abnormal enhancement. . TTE ECHO [**2188-10-15**] - compared with the findings of the prior study (images reviewed) of [**2188-2-19**], a possible pulmonic valve vegetation is now seen. - moderate symmetric LVH - overall left ventricular systolic function is normal (LVEF 60-70%) - right ventricular pressure overload - a small pericardial effusion with no echocardiographic signs of tamponade . KUB [**2188-10-17**] done in context of abdominal pain, N/V IMPRESSION: No evidence of ileus or obstruction. . Repeat CT head [**2188-10-17**] IMPRESSION: No acute intracranial hemorrhage or mass effect. . TEE [**2188-10-20**] IMPRESSION: Trace aortic regurgitation with normal valve morphology. Normal pulmonic valve morphology with no evidence of vegetation or abscess. Mild mitral and tricuspid regurgitation. . LABS CHEM/CBC [**2188-10-1**] 06:50PM BLOOD WBC-19.0*# RBC-4.04* Hgb-12.6* Hct-36.0* MCV-89 MCH-31.2 MCHC-35.1* RDW-16.4* Plt Ct-255 [**2188-10-2**] 05:45AM BLOOD WBC-15.7* RBC-3.77* Hgb-11.4* Hct-34.8* MCV-92 MCH-30.4 MCHC-32.9 RDW-16.4* Plt Ct-294 [**2188-10-10**] 12:00PM BLOOD WBC-6.8 RBC-2.90* Hgb-9.2* Hct-26.8* MCV-92 MCH-31.6 MCHC-34.2 RDW-17.6* Plt Ct-244 [**2188-10-11**] 09:25AM BLOOD WBC-5.6 RBC-3.01* Hgb-9.4* Hct-27.6* MCV-92 MCH-31.1 MCHC-33.9 RDW-17.6* Plt Ct-215 [**2188-10-1**] 06:50PM BLOOD Glucose-279* UreaN-11 Creat-3.6*# Na-135 K-6.8* Cl-95* HCO3-30 AnGap-17 [**2188-10-2**] 05:45AM BLOOD Glucose-221* UreaN-18 Creat-4.8*# Na-139 K-3.8 Cl-96 HCO3-33* AnGap-14 [**2188-10-10**] 12:00PM BLOOD Glucose-159* UreaN-31* Creat-4.4*# Na-138 K-3.8 Cl-100 HCO3-28 AnGap-14 [**2188-10-11**] 09:25AM BLOOD Glucose-190* UreaN-14 Creat-3.2*# Na-137 K-3.4 Cl-95* HCO3-33* AnGap-12 . CARDIAC ENZYMES [**2188-10-8**] 03:24PM BLOOD CK-MB-NotDone cTropnT-0.29* [**2188-10-8**] 11:00PM BLOOD CK-MB-NotDone cTropnT-0.29* [**2188-10-9**] 09:56AM BLOOD CK-MB-NotDone cTropnT-0.36* . OTHER LABS [**2188-10-1**] 06:58PM BLOOD Lactate-1.0 K-5.0 [**2188-10-2**] 02:38AM BLOOD Lactate-0.9 K-3.7 [**2188-10-8**] 03:24PM BLOOD LD(LDH)-274* CK(CPK)-56 [**2188-10-9**] 09:56AM BLOOD CK(CPK)-73 [**2188-10-3**] 05:43AM BLOOD Lipase-21 [**2188-10-4**] 05:50AM BLOOD Lipase-23 [**2188-10-8**] 07:48AM BLOOD Lipase-31 Brief Hospital Course: Assessment: 54 year old Cantonese-speaking male with DM and ESRD on HD, and CAD s/p CABG, difficult to control HTN, who had a 3 week hospital course for MSSA septicemia from an infected hemodialysis catheter, aspiration pneumonia, unstable angina/demand ischemia with new ST depressions on EKG, and co-management of other chronic medical issues. MSSA septicemia from infected HD catheter - 54 year old Cantonese-only speaking male with CAD, HTN, DM and ESRD on HD presented with fever and chills [**2188-10-1**]. He was found to have a MSSA RIJ HD catheter infection by cultures on [**10-1**] and [**10-2**]. He was given Vanc/Gent in the ED. The catheter was removed and he had a temporary line placed. He was treated for the infection with vancomycin, dosed with HD, per the renal attending. The patient had a tunnelled HD catheter placed on [**2188-10-9**] after dialysis. The patient was continued on vancomycin on the floor, day# 1= [**2188-10-1**] to finish a 3-week course of antibiotics the day of discharge. Daily vancomycin levels were checked and he was dosed at HD ([**Month/Day/Year 766**], Wednesday, Friday) to keep the vancomycin greater than 15. The patient was kept on vancomycin for MSSA because the patient did not have good IV access until an emergent midline was placed on [**2188-10-17**] at which time the patient needed vancomycin coverage for aspiration/nosocomial pneumonia. So, throughout the hospital course, the patient was kept on vancomycin for MSSA instead of switching to nafcillin. All surveillance blood cultures showed no growth. The new tunnelled catheter had bleeding around the site during the 24 hours that the patient was receiving heparin gtt for possible NSTEMI with new ST depressions. Since then, the catheter has had some oozing from the site when accessed by hemodialysis during his sessions but has been controlled with pressure at the site. A CT scan of the chest revealed a RIJ thrombus around the site of the new tunnelled catheter. Per the renal team, there was no indication to change the catheter and patient will need to have a follow-up CT scan of his chest in [**3-8**] months to assess this clot. Initially, he also complained of back pain in the setting of the bacteremia and had an MRI and RUQ ultrasound to eval for other possible source of septicemia, which were negative. The patient also had a TTE that showed a possible pulmonary valve vegetation on [**2188-10-14**] but a TEE done 6 days later on [**2188-10-20**] showed no endocarditis. The patient was discharged after finishing a 3 week course of vancomycin per ID team recommendations, at hemodialysis for septicemia from line infection by [**2188-10-22**], his day of discharge. Aspiration pneumonia - During the patient's course in the hospital, he had episodes of vomiting with likely aspiration. He had both CXR and CT chest on [**2188-10-15**] which showed areas in the right middle lobe and right lower lobe consistent with multifocal pneumonia. The patient was started on IV zosyn and placed on aspiration precautions. By the day of discharge, the patient completed a 7 day course of zosyn and was saturating well on room air, without cough or fever for more than 72 hours. New ST depressions in lateral leads on EKG [**2188-10-14**] - On the AM of [**2188-10-14**], patient was found to have unretractable vomiting, and EKG taken showed new 2-3mm ST depressions in leads V4-6. His cardiac enzymes were slightly elevated at 0.2-0.4, but his baseline troponins were also in the 0.2 range. The patient had no complaints of chest pain, although he was a difficult historian. Patient was started on a heparin gtt for concern of NSTEMI, cardiology was consulted but no interventions were recommended as the patient was with no areas amenable for PCI by his last cardiac cath, and was not a good surgical candidate. By his last cardiac cath, the patient had moderate to severe disease in almost all his coronary arteries. The patient was maintained on aspirin, plavix, and as the patient had concern of septic emboli from presumed pulmonary valve endocarditis by TTE at the time, concern for cerebral hemorrhage given acute change in mental status, the patient's heparin gtt was discontinued after 24 hours on [**2188-10-15**]. The patient's daily 12-lead EKGs continued to have ST depressions, and some new ST elevations in V3 throughout his hospital stay and no events on telemetry. The patient was discharged on aspirin, plavix, beta blocker, [**Last Name (un) **], and statin. He was also started on long acting nitrates with good response. Cardiology consult team followed him as well and recommended the above. HTN/Acute pulmonary edema in the setting of hypertensive urgency requiring transfer to the MICU on [**2188-10-10**]. Prior to HD, the patient received, two (Hydralazine 50 mg and amlodipine 10 mg) out of his five HTN medications. Initial BP 154/104, but HD RN reported labored breathing and O2 sat 84-87%. Soon after initiation of therapy his BP increased to 216/100. He was seen by the renal fellow and medical team and adamantly refused oxygen. His other oral BP medications were given with minimal effect. He underwent 2.5 liter ultrafiltration but remained hypertensive and hypoxic. He was given 10 mg IV Hydralazine X 2 and 10 mg IV Labetalol X 1 with minimal effect. O2 sat remained 85-90% RA. Several discussions via Cantonese interpreter and his wife were done by the medical team and the patient adamantly refused oxygen or ABG. BP remained 215/106 and 1 inch nitropaste placed on patient. The patient was transferred to the MICU for further management of acute pulmonary edema. 2.5 L ultrafiltrate removed during HD on date of admission, with addn 2 L removed in CCU. He was transferred back to the floor on [**2188-10-11**] with no oxygen requirements after removal of 4.5 liters of fluid by HD. Throughout the rest of his hospital course, the patient's blood pressure regimen was optimized on discontinuing hydralazine and starting minoxidil and imdur. He was discharged on minoxidil and imdur in addition to his home regimen of maximum doses of metoprolol, amlodipine, and losartan. By discharge, his blood pressures were ranging 120-140s SBP on this regimen, with good O2 sat on RA. Blood pressure control was also maintained by his M,W,F regimen of HD with fluid removal. Acute on chronic anemia - The patient had anemia with Hcts below his baseline of 33-34 likely due to chronic kidney disease with acute illness. Given his acute coronary syndrome with the new ST depressions, the patient received 2 units of PRBC transfusions during his hospital stay with his Hct goal to be maintained above 30. He also receives EPO at hemodialysis. DM/CKD stage 5 - The patient was followed by both the renal and [**Last Name (un) **] diabetes teams during his hospital stay. His fluid status and ESRD were maintained by hemodialysis three times a week on M,W,F, and his diabetes was maintained on NPH 70/30 8units QAM, 6units QPM with a regular insulin sliding scale. He was discharged with follow up with his dialysis at [**Hospital1 336**] and new appointments were made for him with Cantonese and Mandarin-speaking providers at [**Last Name (un) **] for follow up on diabetes control and nutrition (both for diabetes and diastolic CHF). Small pericardial effusion found on ECHO - The patient remaied without signs of HD compromise and no signs of cardiac tamponade by ECHO. No JVD or hypotension. He will need follow up on this with his PCP as an outpatient. Code status - Initially in the ICU, discussions with an interpreter found the patient to be DNI but not DNR. Given his many chronic medical problems and the patient's ongoing wish to go home and leave the hospital, the palliative care team was consulted to have a formal code status discussion and also goals of care discussion with the patient and wife. The result of this discussion with a Cantonese interpreter was the that patient and wife decided to continue to pursue resuscitation in the event of a cardio-pulmonary arrest, and be changed to Full Code status. This was documented in the chart. The patient was discharged on [**2188-10-22**] home with close follow up. Medications on Admission: - Metoprolol Tartrate 150 TID - Atorvastatin 40 mg - Pantoprazole 40 mg - Amlodipine 10 mg QD - Calcium Carbonate 500 mg TID - Lisinopril 40 mg QD - Sevelamer 800 mg TID - Aspirin 325 mg QD - Clonidine 0.3 mg/24 hr QSUN - Losartan 100 mg QD - Clopidogrel 75 mg QD - Hydralazine 50 mg QID - Insulin NPH 7 units QAM, 7 units QHS - Folic Acid 1 mg QD Discharge Medications: 1. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Calcium Carbonate 500 mg Tablet Sig: One (1) Tablet PO three times a day. 6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO three times a day. 8. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 9. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSUN (every Sunday). 10. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO once a day. 12. Erythromycin 5 mg/g Ointment Sig: 0.5 gm in OS Ophthalmic QID (4 times a day). 13. Minoxidil 2.5 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 14. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 15. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 16. Insulin Regular Human 100 unit/mL Solution Sig: One (1) unit subcutaneous per insulin sliding scale Injection QACHS. 17. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension Sig: One (1) 8 units Subcutaneous QAM, once a morning before breakfast. Disp:*qs * Refills:*2* 18. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension Sig: Six (6) units subcutanous Subcutaneous QPM every night before dinner. Disp:*qs * Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Final diagnosis Septicemia secondary to infection in hemodialysis catheter . Secondary diagnosis Aspiration pneumonia Unstable angina/ Non ST elevation Myocardial infarction Pulmonary edema Acute Diastolic congestive heart failure Hypertensiion, malignant Chronic kidney disease stage 5; on hemodialysis ([**Date Range 766**], Wednesday, Friday) Coronary artery disease, native Hyperlipidemia Anemia of chronic disease Discharge Condition: Good, good O2 sat on room air, no cough, new HD tunneled catheter in place. Discharge Instructions: You were admitted for fever and chills at hemodialysis and was found to have a bacterial infection in your bloodstream from an infection in your dialysis catheter. To treat this, we removed your infected catheter and are treating you with antibiotics at hemodialysis treatment. While you were here, you were transferred to the intensive care unit because you had a very high blood pressure and had fluid in your lungs leading to shortness of breath. After you had sessions of hemodialysis to remove extra fluid, you improved and were transferred back to the medical floor. We also placed a new hemodialysis catheter. We made sure that you did not have other sources of the infection in your spine and abdomen by a MRI of you spine and ultrasound of your abdomen. However, you were found to have an infection in your lung, so we started a second antibiotic to treat this. We were also worried about a possible infection on your heart valves and were treating you with antibiotics for this, but the accurate ultrasound of your heart showed there was no bacteria on your heart valves. . During your hospital stay, you were also found to have tracings on your heart which showed that your heart was not getting enough blood. The heart doctors were following [**Name5 (PTitle) **], but because of your other medical problems and the severity of your heart disease, you are not a good candidate for surgery of placement of a stent in your heart. For this, we have been treating your heart disease with medicine and monitoring your heart tracing. You also received a total of two units of blood transfusion during your hospital stay for your low blood counts. You were also found to have a small clot at the end of your current hemodialysis catheter which you will need to follow up with a repeat CT scan of your chest in [**3-8**] months. There is no indication to remove this catheter according to the kidney doctors. [**First Name (Titles) 357**] [**Last Name (Titles) **] this with your primary care doctor. . On discharge from the hospital, you will be finished with a 3 week course of antibiotics for your catheter line infection, and finished with a 1 week course of antibiotics for your pneumonia. You will need to continue your hemodialysis on [**Last Name (Titles) 766**], Wednesday, Friday at [**Hospital1 336**]. We also made the following changes to your medications: 1. We started a blood pressure medication called minoxidil, which you should take 2.5mg two times a day 2. We started a blood pressure medication called imdur 30mg daily for your blood pressure 3. We stopped your hydralazine medication for your blood pressure. Do not take this medication anymore. 4. We started you on a medication called nephrocaps (B Complex-Vitamin C-Folic Acid) for your renal disease. Please take one daily. 5. We adjusted your standing insulin dose to be 8 units of the NPH insulin before breakfast and 6 units of the NPH at night. . Also, it is very important that you eat a low salt diet, less than 2 grams per day, and restrict your fluid to 1,500ml per day. You should weigh yourself daily and call your physician if your weight changes by more than 3 lbs. . Please return to the hospital if you experience any fever, chills, tenderness or pain at your hemodialysis catheter site, uncontrolled nausea or vomiting, chest pain, shortness of breath, or swelling in your legs. Followup Instructions: You have an appointment with your primary care doctor tomorrow on [**10-23**] at 1:30pm. Provider: [**Name10 (NameIs) 32199**],[**Name11 (NameIs) 3078**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 8236**]. You will need a follow up CT scan of your chest in [**3-8**] months to follow up on the small blood clot around the tip of your hemodialysis catheter. . You have an appointment with a dietician, [**First Name8 (NamePattern2) 8463**] [**Last Name (NamePattern1) 13260**] to work on your nutrition. She is a Cantonese speaker. The appointment is on [**10-30**], at 3pm. Please go to [**Hospital **] clinic on [**Last Name (un) 19749**] on the [**Location (un) **]. If you have any questions, call [**Doctor First Name **], who is a Cantonese speaker, her telephone number is [**Telephone/Fax (1) 58905**]. . You have an appointment at the [**Hospital **] Clinic at [**Last Name (un) **] Diabetes center on [**12-11**], Thursday afternoon at 4:30pm to follow up on your diabetes control. The physician is [**Name Initial (PRE) **] mandarin speaker. Please go to [**Hospital **] clinic on [**Last Name (un) 3911**] on the [**Location (un) **]. If you have any questions, call [**Doctor First Name **], who is a Cantonese speaker, her telephone number is [**Telephone/Fax (1) 58905**]. . Continue hemodialysis [**Telephone/Fax (1) 766**], Wednesday, Friday at [**Hospital 58906**]. [**Hospital1 336**] HD center: F ([**Telephone/Fax (1) 58907**]. T ([**Telephone/Fax (1) 58908**] . Your other appointments at [**Hospital1 18**] are as follows: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12902**], MD Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2188-10-30**] 9:20 Provider: [**Name10 (NameIs) **] PROCEDURE Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2188-10-30**] 10:00 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 5003**] Date/Time:[**2188-12-30**] 9:40

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icd9cm

[ [ [] ] ]

[ "39.95", "99.04", "38.95", "97.49" ]

icd9pcs

[ [ [] ] ]

15960, 15966

5545, 13740

331, 432

16429, 16507

1999, 5522

19931, 21926

1606, 1649

14138, 15937

15987, 16408

13766, 14115

16531, 19908

1664, 1980

278, 293

460, 884

906, 1320

1336, 1590

15,367

169,503

21124+57233

Discharge summary

report+addendum

Admission Date: [**2121-7-27**] Discharge Date: [**2121-7-29**] Date of Birth: [**2063-6-10**] Sex: F Service: MED Patient is a 58-year-old female with a history of end-stage renal disease and rapidly compressive scleroderma who presents via Med Flight after being found acutely short of breath, tachypneic with labored breathing. EMS unable to obtain SAO2. Patient noted to be cyanotic appearing with minimal breath sounds. Blood pressure at that time 194/128. Patient was transferred to [**Hospital3 4298**] ED, emergently intubated. ABG peri-intubation 7.13 with a PCO2 of 74, PO2 167. Was given Nitro paste, Versed. Chest x-ray showed bilateral fluffy infiltrates. Was started on Nitro drip and given Bumex then transferred to [**Hospital3 **] for further care. PAST MEDICAL HISTORY: Scleroderma, Raynaud's, end-stage renal disease, arthritis status post atrial myxoma removal, questionable asthma, questionable hip fracture. ALLERGIES: 1. Zestril 2. Verapamil 3. Latex SOCIAL HISTORY: Lives in [**Hospital3 **]. MEDICATIONS ON TRANSFER: 1. Nitro drip 2. Diovan 325 3. Duragesic 150 mcg 4. Prilosec 28 b.i.d. 5. Prednisone 5 a day 6. Norvasc 2.5 7. Hydrochlorothiazide 25 8. Neurontin 100 b.i.d. 9. Ativan 1 mg t.i.d. p.r.n. 10. Aspirin 11. Nephro caps 12. Vitamin C 13. Tums 14. Oxycodone p.r.n. 15. Wellbutrin 100 b.i.d. 16. Quinine PHYSICAL EXAMINATION AT TIME OF ADMISSION: Temperature 94, blood pressure 157/90, was on AC 400 x 14 with an FIO2 of 50 percent. In general, is sedated, intubated. Skin appears tight, grayish color; no rash. HEENT: Pupils are 2 mm, 1 mm bilaterally. Neck is difficult to assess jugulovenous pressure. Chest with decreased breath sounds anteriorly and laterally at the bases with wheezing. Cardiovascular is tachy; frequent ectopy; no murmurs; hyperdynamic. Abdomen is soft, nondistended, positive bowel sounds. Extremities: Sclerodactyly with ulcerations on the fingers and toes. No lower extremity edema. LABORATORY DATA: Chest x-ray showed bilateral diffuse infiltrates, neurovascular redistribution. EKG: Sinus at 140, normal axis, positive left ventricular hypertrophy, lateral T wave inversion. Chem-7 remarkable for a potassium of 5.9, BUN 31, and creatinine 3.9, white count 11.9, hematocrit 39, platelets 192, LDH 267. HOSPITAL COURSE BY PROBLEM: Respiratory failure: Patient was intubated emergently at the outside hospital but after discussion with the family which revealed the patient was Do Not Resuscitate/Do Not Intubate and that she would not have wanted to be intubated. Her sedation was lightened and, by communicating through writing, patient stated that she wished to be extubated and that she would not ever want to be reintubated. Thus, on the evening of patient's admission on [**2121-7-27**] she was extubated without event. In terms of etiology of patient's respiratory failure, she underwent a CTA which revealed no evidence of pulmonary embolism, but there was evidence of large bilateral effusions as well as extensive subcutaneous edema and ascites. It was felt that fluid overload and congestive heart failure may have been the cause of patient's decompensation. A transthoracic echocardiogram was performed which revealed severe global hypo/akinesis with an estimated ejection fraction of approximately 20 to 25 percent. Patient underwent hemodialysis to assist in fluid removal and was started on afterload reduction with Hydralazine and nitro paste. Patient has a questionable allergy to her ACE inhibitor and also was having difficulty taking pills and thus intravenous and transdermal medications were used. Additionally, patient has an extremely low albumin due to malnutrition and felt that this was contributing to her anasarca and pleural effusions. In terms of other possible etiologies, an induced sputum for pneumocystis carinii pneumonia was sent and is pending at the time of this dictation, and patient was treated with Levaquin for a question of possible pneumonia. Clostridium difficile colitis: Patient had extensive diarrhea during her hospital stay. Was sent for Clostridium difficile and came back positive. Patient was started on a course of Flagyl. End-stage renal disease: Patient was continued on hemodialysis as per Renal and started on calcium carbonate as a phos blanket. Dysphagia: Patient had extensive difficulties with swallowing food, liquid, and even pills. A Speech and Swallow evaluation was ordered, but this is pending at the time of this dictation. Patient's medications were given intravenously as possible. Pain control: Patient apparently is on 150 mcg Fentanyl patch as an outpatient although arrived in the hospital with only a 50 mcg patch. Due to the concern over the confusion of the dose and the concern of possibly suppressing the patient's respiratory drive, the Fentanyl patch was dosed at 75 mcg an hour, and breakthrough pain was managed through intravenous Morphine given the patient's inability to take POs. Code status: Patient is confirmed a Do Not Resuscitate/Do Not Intubate. The remainder of this discharge summary, including patient's discharge medications and discharge diagnoses will be dictated as part of an addendum to this summary. [**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D. Dictated By:[**Last Name (NamePattern1) 12327**] MEDQUIST36 D: [**2121-7-28**] 18:28:31 T: [**2121-7-28**] 19:12:45 Job#: [**Job Number 56040**] Name: [**Known lastname 10545**], [**Known firstname 739**] Unit No: [**Numeric Identifier 10546**] Admission Date: [**2121-7-27**] Discharge Date: [**2121-7-29**] Date of Birth: [**2063-6-10**] Sex: F Service: MED ADDENDUM: Transferred to [**Hospital 2653**] Hospital Patient was previously prescribed Levofloxacin for sputum that showed gram negative rods. Cultures came back as E. Coli today on the day of discharge. Sensitivities showed fluoroquinolone resistance to Cipro and Levofloxacin. She was changed to P.O. Bacitracin. The antibiotic sensitivities were as follows: Sensitive to ampicillin, ampicillin/Sulbactam, cefazedone, cefepime, ceftazidime, ceftriaxone, Gentamicin, Meropenem, piperacillin, pip/Tazol, tobramycin, Bactrim. Intermediate resistance was noted to cefuroxime. Resistance was noted to Cipro and Levo. The patient during this admission was also found to be C. diff positive and was put on Flagyl. She will need C diff precautions at [**Hospital 2653**] Hospital. The nurse noted during feeds that the patient had intermittent difficulty with coughing while swallowing. A bedside swallowing evaluation was done which could not rule out aspiration. The patient will need a video swallow evaluation at her new hospital but this evaluation did not warrant delaying transfer. Patient's albumin during this noted to be 2.7. She appears cachectic and may benefit from calorie count and supplement PPN/TPN to optimize nutritional status. Patient is Do Not Resuscitate/Do Not Intubate. [**Name6 (MD) 3354**] [**Last Name (NamePattern4) 5357**], M.D. [**MD Number(1) 7079**] Dictated By:[**Last Name (NamePattern1) 10547**] MEDQUIST36 D: [**2121-7-29**] 15:06:18 T: [**2121-7-31**] 13:21:23 Job#: [**Job Number 10548**]

[ "789.5", "443.0", "518.81", "428.0", "263.8", "710.1", "482.82", "008.45", "403.91" ]

icd9cm

[ [ [] ] ]

[ "96.71", "97.39", "88.72", "38.93", "39.95" ]

icd9pcs

[ [ [] ] ]

2384, 7343

1077, 2355

818, 1007

1024, 1052

57,330

128,869

42152

Discharge summary

report

Admission Date: [**2132-11-13**] Discharge Date: [**2132-11-18**] Date of Birth: [**2054-12-31**] Sex: M Service: MEDICINE Allergies: Beta-Blockers (Beta-Adrenergic Blocking Agts) Attending:[**Name (NI) 9308**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: Pericardiocentesis Pericardial Window Thoracostomy History of Present Illness: Mr. [**Known lastname 5057**] is 77M with h/o HTN, HLD, COPD, and newly diagnosed NSCLC c/b pericardial effusion wtih tamponade s/p pericardiocentesis in [**8-/2132**] and s/p one round of taxol/carboplatin chemotherapy, recent new heart failure diagnosed in [**9-/2132**] (EF 40-45%), who is presenting with worsening SOB and DOE for the last few days. As per the patient's wife, the patient has been having worsening dyspnea on exertion for the last few days, that acutely worsened earlier today when he was walking up the stairs. In addition, also reports having worsening orthopnea over the last few days as well (he usually uses one pillow at night, but reports that for the last few days he has been using two pillows). Pt also reports decreased PO intake for the last few days. Denies any chest pain, no anginal like symptoms, denies any increasing swelling in legs. Denies any wheezing, reports that this shortness of breath does not feel like his COPD. Denies increasing use of his nebs. He uses 2L NC at home at his baseline. .. Of note, the patient was admitted to CCU at the end of [**Month (only) 216**] for pericardial effusion with e/o tamponade physiology s/p pericardiocentesis taking out ~1L of bloody fluid, malignant cells found on cytology. The patient was also found to have new heart failure in [**9-/2132**], with EF 40-45% (previous ECHOs with EF >55%). Was thought that his heart dysfunction could be secondary to mid LAD ischemia, with suggestion of cardiac cath. .. Denies any chest pain, shortness of breath, recent fevers/chills, coughing. Does report having L shoulder and arm pain yesterday, that self resolved in 20 minutes; reports having this pain in the past, but usually responds to Tylenol. Does not report any associated diaphoresis, chest pain. Denies any n/v, abdominal pain, no changes in his BMs, no numbness or tingling, no headache, no changes in vision, no night sweats. .. On initial evaluation in the ED, the patient was in respiratory distress, breathing at a rate of 30 and was triggered for hypoxia. Was started on NRB at 10-15L, satting mid 90s. .. EKG in ED showing RBBB, no STE, mild depression V4-6, HR 106, NSR. There was question of irregular rhythm while patient en route to ED, but has been in NSR since he has been here. D-dimer elevated to 19,998 and BNP 8510. Trop 0.55, creat 1.9. Heparin drip was started out of concern for PE; no CTA done because of ARF. A bedside ECHO showed no recurrence of pericardial effusion. Pt was admitted to CCU for possible cath out of concern for latent LAD thrombosis. .. On transfer to CCU, patient satting 100% on 3L NC, with HR in low 100s, breathing at 20-22. Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: - CABG: - PERCUTANEOUS CORONARY INTERVENTIONS: - PACING/ICD: 3. OTHER PAST MEDICAL HISTORY: HTN HLD NSCLC Gout Social History: Lives with his wife, 1.5 ppd for 60 years, still currently smoking a few cigarettes a day; has two children, involved in his care, one lives in MA, another in CT. 1 glass of wine/night. No illicit drugs. Family History: Family: MI when 50 y/o, pancreatic cancer in father, paternal grandfather with MI, maternal grandfather with MI Physical Exam: ADMISSION PHYSICAL EXAM: VS: 98.6 105/62 103 22 98 on 3L General: pleasant elderly gentleman, NAD, sitting up comfortably in bed, breathing comfortably with NC HEENT: scleral anicteric, moist mucous membranes Neck: supple, no JVP appreciated CV: RRR, normal S1, S2, no murmurs/rubs/gallops appreciated lungs: bronchial breath sounds throughout, inspiratory crackles at the bases b/l abdomen: soft, nontender, nondistended, +BS extremities: no LE edema, cool toes b/l with some purple tinging of his toes and soles of his feet PULSES: Right: Carotid 2+ DP 1+ PT dopp Left: Carotid 2+ DP 1+ PT dopp Neuro: CN 2-12 grossly intact (except hard of hearing), normal strength and sensation throughout . DISCHARGE PHYSICAL EXAM: VS: 97.8 139/88 95 26 96% on 2L General: pleasant elderly gentleman, NAD, sitting up comfortably in chair, breathing comfortably with NC HEENT: scleral anicteric, moist mucous membranes Neck: supple, no JVP appreciated CV: RRR, normal S1, S2, no murmurs/rubs/gallops appreciated lungs: slight inspiratory crackles as bases, bronchial breath sounds throughout abdomen: soft, nontender, nondistended, +BS extremities: no LE edema, cool toes b/l PULSES: Right: Carotid 2+ DP 1+ PT dopp Left: Carotid 2+ DP 1+ PT dopp Neuro: CN 2-12 grossly intact (except hard of hearing), normal strength and sensation throughout Pertinent Results: ADMISSION LABS: . [**2132-11-13**] 07:05PM BLOOD WBC-10.6# RBC-2.85* Hgb-8.9* Hct-27.5* MCV-97 MCH-31.4 MCHC-32.5 RDW-17.8* Plt Ct-105* [**2132-11-13**] 07:05PM BLOOD Neuts-84.0* Lymphs-11.5* Monos-3.4 Eos-0.8 Baso-0.3 [**2132-11-13**] 07:05PM BLOOD PT-18.6* PTT-27.0 INR(PT)-1.7* [**2132-11-13**] 07:05PM BLOOD Plt Ct-105* [**2132-11-13**] 07:05PM BLOOD Glucose-176* UreaN-50* Creat-1.9* Na-137 K-4.8 Cl-97 HCO3-25 AnGap-20 [**2132-11-13**] 07:05PM BLOOD ALT-49* AST-47* AlkPhos-138* TotBili-0.4 [**2132-11-13**] 07:05PM BLOOD Calcium-9.2 Phos-3.4 Mg-1.6 [**2132-11-13**] 07:05PM BLOOD D-Dimer-[**Numeric Identifier 45280**]* [**2132-11-13**] 07:05PM BLOOD CK-MB-5 proBNP-8510* [**2132-11-13**] 07:05PM BLOOD cTropnT-0.55* [**2132-11-13**] 07:20PM BLOOD Lactate-3.4* . PERTINENT LABS: . [**2132-11-13**] 07:05PM BLOOD CK-MB-5 proBNP-8510* [**2132-11-13**] 07:05PM BLOOD cTropnT-0.55* [**2132-11-14**] 03:31AM BLOOD CK-MB-4 cTropnT-0.44* [**2132-11-13**] 07:05PM BLOOD D-Dimer-[**Numeric Identifier 45280**]* [**2132-11-13**] 07:20PM BLOOD Lactate-3.4* [**2132-11-14**] 09:34AM BLOOD Lactate-2.4* [**2132-11-14**] 07:20AM OTHER BODY FLUID WBC-[**Numeric Identifier 961**]* Hct,Fl-42.0* Polys-73* Bands-1* Lymphs-11* Monos-2* Eos-1* Other-12* [**2132-11-14**] 07:20AM OTHER BODY FLUID TotProt-6.2 Glucose-1 LD(LDH)-1214 Amylase-257 Albumin-3.6 . DISCHARGE LABS: [**2132-11-17**] 01:58AM BLOOD WBC-11.5* RBC-3.54* Hgb-10.8* Hct-32.0* MCV-90 MCH-30.3 MCHC-33.6 RDW-18.8* Plt Ct-69* [**2132-11-18**] 03:36AM BLOOD WBC-12.5* RBC-3.55* Hgb-10.8* Hct-32.3* MCV-91 MCH-30.3 MCHC-33.2 RDW-18.7* Plt Ct-72* [**2132-11-18**] 03:36AM BLOOD PT-17.4* PTT-26.4 INR(PT)-1.5* [**2132-11-17**] 01:58AM BLOOD Glucose-79 UreaN-34* Creat-1.2 Na-138 K-4.2 Cl-101 HCO3-32 AnGap-9 [**2132-11-18**] 03:36AM BLOOD Glucose-125* UreaN-30* Creat-1.1 Na-135 K-4.8 Cl-98 HCO3-29 AnGap-13 [**2132-11-18**] 03:36AM BLOOD ALT-24 AST-52* AlkPhos-109 TotBili-1.2 [**2132-11-17**] 01:58AM BLOOD Calcium-8.5 Phos-2.4*# Mg-1.9 [**2132-11-18**] 03:36AM BLOOD Albumin-2.9* Calcium-8.6 Phos-2.8 Mg-2.0 . . MICRO/PATH: . Blood Culture x 2 [**11-13**]: . [**2132-11-13**]: Blood Culture, Routine (Preliminary): STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. Anaerobic Bottle Gram Stain (Final [**2132-11-15**]): Reported to and read back by DR. [**Last Name (STitle) **]. KOTOVA ON [**2132-11-15**] AT 0245. GRAM POSITIVE COCCI IN CLUSTERS. Aerobic Bottle Gram Stain (Final [**2132-11-15**]): GRAM POSITIVE COCCI IN CLUSTERS. . Pericardial Cultures 11/4: [**2132-11-14**] 7:20 am FLUID,OTHER PERECARDIAL. GRAM STAIN (Final [**2132-11-14**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Preliminary): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED. ACID FAST SMEAR (Final [**2132-11-15**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. . [**2132-11-14**] 7:20 am FLUID RECEIVED IN BLOOD CULTURE BOTTLES PERECARDIAL. Fluid Culture in Bottles (Preliminary): STAPHYLOCOCCUS, COAGULASE NEGATIVE. STRAIN 1. FINAL SENSITIVITIES. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. STAPHYLOCOCCUS, COAGULASE NEGATIVE. STRAIN 2. FINAL SENSITIVITIES. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE | STAPHYLOCOCCUS, COAGULASE NEGATIVE | | CLINDAMYCIN-----------<=0.25 S <=0.25 S ERYTHROMYCIN---------- =>8 R <=0.25 S GENTAMICIN------------ <=0.5 S <=0.5 S LEVOFLOXACIN---------- 0.5 S <=0.12 S OXACILLIN-------------<=0.25 S <=0.25 S TETRACYCLINE---------- <=1 S <=1 S VANCOMYCIN------------ 1 S Anaerobic Bottle Gram Stain (Final [**2132-11-16**]): Reported to and read back by [**Doctor First Name **] CROSS @ 1:02A [**2132-11-16**]. GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. Urine Culture [**11-15**]: <10,000 organisms/ml. . IMAGING/STUDIES: . . Brief Hospital Course: Mr. [**Known lastname 5057**] is 77M with h/o HTN, HLD, COPD, and newly diagnosed NSCLC c/b pericardial effusion wtih tamponade s/p pericardiocentesis in [**8-/2132**] and s/p one round of taxol/carboplatin chemotherapy, who presented with worsening SOB and DOE from recurrent pericardial effusion . #Pericardial effusion: On [**11-14**] the patient had an echo that revealed signs of tamponade. He was brought to the cardiac catheterization lab for pericardial drainage. 750cc's of fluid was drained and the tamponade releived, he was then brought to the operating room with Dr [**First Name (STitle) **] for pericardial window, please see operative report for details. In summary he had a small left anterior chest incision with pericardial window created and drainage tube placed. He tolerated the operation well and was transferred from the operating room to the CVICU in stable condition. He was extubated on the day of surgery and remained hemodynamically stable throughout his stay in the CVICU. He was slated to be transferred to the cardiac surgery floor after his pericardial drain was removed however these tubes continued to drain significant amounts of serosanguinous fluid and on POD3 he was transferred to the cardiology ICU instead of remaining in the CVICU. In the CCU his pericardial drain stopped draining and was removed. His chest tube continued to have a small amount of drainage. Thoracic surgery was consulted for possible placement of a pleurex catheter. However they recommended removing the drain because the output was low and not placing another drain. The chest tube was removed and per the patients request he was discharged with hospice. . #Non-small cell lung cancer: He had stage stage IV lung cancer with recurrent malignant pericardial effusion. Prior to admission he underwent on cycle of cisplatin and taxol. However afterwards the patient declined further chemotherapy. After his drains were removed he was discharged with hospice. Medications on Admission: 1. allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. beclomethasone dipropionate 80 mcg/Actuation Aerosol Sig: One (1) Spray Inhalation twice a day. 4. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) Capsule Inhalation once a day. Disp:*30 capsules* Refills:*2* 7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: [**1-13**] puff Inhalation every four (4) hours as needed for shortness of breath or wheezing. 8. lisinopril 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 9. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 10. Home Oxygen 1-4 liters per minute continuous oxygen via nasal cannula [**Male First Name (un) **]: 99 months Diagnosis: COPD 11. Lasix 20 mg Tablet Sig: Two (2) Tablet PO once a day. Disp:*60 Tablet(s)* Refills:*0* Discharge Medications: 1. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig: 2-20 mg PO q1hr as needed for pain / dyspnea. Disp:*30 mL* Refills:*2* 2. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for anxiety. Disp:*30 Tablet(s)* Refills:*2* 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp:*60 Capsule(s)* Refills:*2* 4. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. Disp:*60 Tablet(s)* Refills:*2* 5. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 8. allopurinol 300 mg Tablet Sig: 0.5 Tablet PO once a day. 9. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day as needed for Gout. 10. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) Inhalation four times a day as needed for shortness of breath or wheezing. 11. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) Inhalation once a day. Discharge Disposition: Home With Service Facility: Hospice of the Good [**Doctor Last Name 9995**] Discharge Diagnosis: Primary Diagnoses: Pericardial effusion with cardiac tamponade Pulmonary effusion . Secondary Diagnoses: Non-small cell lung cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 5057**], It was a pleasure taking care of you while you were hospitalized at [**Hospital1 18**]. You were admitted to the hospital because of worsening shortness of breath at home. An echocardiogram showed that you had fluid surrounding your heart and a drain was placed by the cardiologists to drain the extra fluid. We think that your lung cancer is the reason the fluid accumulated around your heart and because we thought that it would likely recur, the heart surgeons did a procedure called a pericardial window to stop fluid from accumulating. During that procudure they also placed a tube in your chest. This stopped draining fluid and we removed the tube. If you begin to feel shortness of breath, this may be because of fluid reaccumulation. There was also a small amount of bacteria in the fluid from around your heart. The infectious disease specialist thought that this is most likley contamination and did not need to be treated. If you start to develop fevers shortness of breath or any other concerning symptoms you can come back to the hospital for evaluation and treatment if you want to. . Medication changes: Please stop atorvastatin Please stop aspirin . Please take morphine as directed by hospice Please take lorazepam (ativan) as directed by hospice . Please start docusate 100 mg twice a day as needed for constipation Please start senna 8.6 mg twice a day as needed for constipation Please continue taking all other medications as you have been Followup Instructions: Please follow up with your home hospice team. They will help you set up an appointment with your doctor if you wish to see them.

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Discharge summary

report

Admission Date: [**2186-6-27**] Discharge Date: [**2186-8-4**] Date of Birth: [**2145-8-8**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1711**] Chief Complaint: RUQ pain, breathlessness, nausea and vomiting Major Surgical or Invasive Procedure: - CTA w/ contrast [**2186-6-28**] - Right IJ central venous line placement [**2186-6-30**] by ICU team - Left PICC line placement [**2186-7-8**] by ICU team - Right heart catheterization [**2186-7-14**] by Dr. [**Last Name (STitle) **] - Transjugular liver biopsy [**2186-7-25**] by Dr. [**Last Name (STitle) 45331**] - Right heart catheterization [**2186-7-27**] by Dr. [**First Name (STitle) 1255**] History of Present Illness: Ms. [**Known lastname 70197**] symptoms began 2 weeks ago when she experienced sudden, severe pain in the right upper quadrant of her abdomen; the pain did not radiate to any other part of her body, was not precipitated by the intake of food, and became worse on deep inspiration. She immediately called her rheumatologist, who, after discussion over the phone, advised her to increase the dose of her prednisolone (her lupus was controlled with methotrexate, low-dose prednisolone, and Planquenil). After following these instructions, she felt healthy for 2-3 days, after which the pain returned with a new onset of breathlessness. The pain was similar in nature to the first episode, and she felt like she could not take deep breaths because of it. The breathlessness was not associated with any chest pain or cough; it did not increased upon lying down, but, rather, was directly associated with the inability to fully inspire due to the abdominal pain. This episode was also associated with profuse sweating, but she reported no fever. . Upon further follow-up with her rheumatologist, her prednisolone dosage was increased and she did not have a full-blown attack of her previously-stated symptoms. . During the night of [**2186-6-24**], her symptoms re-appeared, prompting a visit to [**Hospital 189**] hospital emergency room. She was put on a face mask and oxygen, and a chest x-ray and CT-angio of the chest were performed, both of which were negative. She was told that she was suffering from a lupus flare-up and could leave, but within 10 minutes developed nausea and vomitting; the vomitus was yellow in color and contained food. After resting in the ED for two hours, she went home. During a visit to the bathroom, she lost consciousness while urinating; her husband told her she was shaking and her eyes were rolled upwards. She was not biting her tongue or frothing at the mouth. She refused going to a hospital. Ms. [**Known lastname **] was then healthy until [**2186-6-27**], when she visited her rheumatologist. Upon examination, she was found to have bilateral lower limb edema and so was taken to [**Hospital1 18**] for further evaluation and management. . Of note, she claims to have had hematuria with no dysuria, in addition to arthalgia in the large and small joints of her upper limbs. She did not have any history of chest pain, palpitations or productive cough. Furthermore, she had no changes in weight, no loss of appetite, or diarrhea. . Her workup in the ED, where she had vital signs of Temp: 96.8 HR: 85 BP: 115/70 Resp: 18 O(2)Sat: 99, and on the medical floor included a RUQ u/s that showed gallstones but no cholecystitis, as well as a HIDA scan that was similarly negative for cholecystitis. CT of her abdomen/pelvis showed possible hepatitis, ascites, colitis, and pelvic fluid. She had LENI's that were negative for DVT, and CTA that showed no pulmonary embolism. Surgery was consulted in the ED for potential cholecystitis. GI was consulted for her abdominal pain, which was attributed to intermittent vasospasm from scleroderma. Rheumatology was consulted, and recommended continuing with increased dose steroids and hydroxychloroquine. . On [**2186-6-29**], the floor staff was unable to measure an oxygen saturation, and a blood gas (likely venous) was obtained, showing mixed respiratory and metabolic acidosis, with an elevated lactate. CXR was unchanged from prior. She was transferred to the ICU on a non-rebreather mask, and shortly thereafter, she was able to maintain stable oxygen saturations with moderate-flow nasal cannula (3-4 L/min). Her vital signs upon arrival at the ICU were On the floor her vitals were: HR: 106, O2Sat: 95%, RR: 30, BP: 110/93. Lab results were WBC: 15.1, RBC: 4.12, Hgb: 14.0, Hct: 42.8, MCV: 104, Plt: 358. Repeat labs demonstrated new leukocytosis, a widening anion gap, and modest elevations in her transaminases. Repeat blood gases (primarily venous) revealed varying levels of metabolic acidosis. A sodium bicarbonate infusion was started, and a CVL was placed. . Review of Symptoms: (+) Per HPI (-) Denies headache, sinus tenderness, rhinorrhea or congestion. Denies any history of wheezing. Denies history of frequency, urgency or flank pain. Denies history of photosensitivity or rash. Denies alopecia, photosensitivity, mucosal ulcerations, and Raynaud's symptoms. Furthermore, no history of seizures or blood clots in lungs or legs, miscarriages. Rest of ROS per HPI. Past Medical History: - SLE: Diagnosed 6 years ago, originally presented with inflammatory polyarthritis and Raynaud's phenomenon; positive for [**Doctor First Name **], rheumatoid factor, [**Doctor Last Name 1968**], RNP, SSA, SSB, had high ESR and mild leukopenia. She was initially on prednisone and Plaquenil, then Plaquenil and Imuran. She moved to [**Country 149**] for 8 months, ran out of medications and her symptoms worsened. She was then started on methotrexate. Last [**Doctor First Name **] >1:1280 speckled. CRP [**5-3**] was 23. dsDNA on [**1-3**] 1:20. - Mixed connective tissue disease: diagnosed 3 years ago; overlap of symptoms with SLE, with some sclerodactyly. - Polyclonal hypergammaglobulinemia - History of nasal septal operation Social History: She is originally from [**Country 149**]. In [**Country 149**] she was a cook. She emigrated to the US 10 years ago. She lives with her husband and two children. She is not currently working. Cigarettes: [ X] never [ ] ex-smoker [] current Pack-yrs: quit: ______ ETOH: [x] No [ ] Yes drinks/day: _____ Drugs: none Marital Status: [ X] Married [] Single Received influenza vaccination in the past 12 months [ X]Y [ ]N Received pneumococcal vaccinationin the past 12 months [ ]Y [X ]N Family History: Father died of complications from DM at age 68. Her mother is in good health. Mother has breast cancer but now is in remission. No family history of GI disorders. She has two children who were visiting her mother at the beginning of her hospitalization. Physical Exam: Admission to [**Hospital Unit Name 153**] exam: VS T 97.8 P 65 BP 126/69 RR 24 O2Sat 100% on RA GENERAL: Slightly tired but well appearing young female who appears her stated age. Nourishment:good. Grooming: good Mentation: alert, she Eyes:NC/AT, PERRL, EOMI without nystagmus, no scleral icterus noted Ears/Nose/Mouth/Throat: [**Hospital Unit Name 5674**], no lesions noted in OP Neck: supple Respiratory: , LLL crackles Cardiovascular: RRR, nl. S1S2, 3/6 SEM at LUSB. Gastrointestinal: nabs, soft, Lower mid quadrant tenderness and pronounced RUQ tenderness. Pelvic exam: limited by lack of speculum but there appears to be blood in the vaginal vault. No CMT. Skin: no rashes or lesions noted. Extremities: [**1-26**]+ pitting edema b/l DP and PT pulses b/l could not be appreciated. I was able to doppler DPPs b/l. Lymphatics/Heme/Immun: No cervical lymphadenopathy noted. Neurologic: -mental status: Alert, oriented x 3. Able to relate history without difficulty. -cranial nerves: II-XII intact -motor: normal bulk, strength and tone throughout. No abnormal movements noted. -DTRs: 2+ biceps, triceps, brachioradialis, patellar and 1+ ankle jerks bilaterally. Plantar response was flexor bilaterally. No foley catheter/tracheostomy/PEG/ventilator support/chest tube/colostomy Psychiatric: Tired but WNL. ACCESS: [X]PIV []CVL site ______ FOLEY: []present [X]none TRACH: []present [X]none PEG:[]present [X]none [ ]site C/D/I COLOSTOMY: :[]present [X]none [ ]site C/D/I Discharge Exam from [**Hospital Unit Name 153**]: VS T 97.6 P 95 BP 115/78 RR 21 O2Sat 100% on 5 L nasal cannula GENERAL: Patient was sitting up in bed speaking comfortably, complained of tiredness which has been gradually improving MENTATION: Alert, sometimes tired EYES: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus noted ENT: [**Hospital Unit Name 5674**], no lesions noted in OP NECK: supple, elevated JVP RESPIRATORY: Bilateral air entry with scattered wheezes and subtle bibasilar crackles; otherwise no added sounds such as ronchi or coarse crackles. Chest expansion is adequate CARDIOVASCULAR: RRR, nl. S1S2, 3/6 SEM at LUSB, also heart at LLSB. GASTROINTESTINAL: soft and lax, non-tender with no obvious distension SKIN: no rashes or lesions noted. EXTREMITIES: 2+ pitting edema b/l, peripheral pulses felt in all extremities. There was no evidence of clubbing or peripheral cyanosis LYMPHATICS: No cervical lymphadenopathy noted NEUROLOGIC: - Mental status: Alert, oriented x 3 - Cranial nerves: II-XII intact - Motor: normal bulk, strength and tone throughout. No abnormal movements noted. - DTRs: Not assessed ACCESS: PICC Line FOLEY: [X]Present []none TRACH: []Present [X]none PEG:[]present [X]none [ ]site C/D/I COLOSTOMY: :[]present [X]none [ ]site C/D/I Admission to [**Hospital Ward Name 121**] 3 ([**Hospital1 1516**] Service) Exam: VS: 97.9 107/77 91 20 93% on 3L GENERAL: pleasant middle aged woman, sitting up in bed with NC, breathing heavily, very tired looking, in and out of sleep during interview [**Hospital1 4459**]: NCAT. Sclera anicteric NECK: Supple CARDIAC: split S2, regular rate LUNGS: dry crackles [**12-25**] to 3/4 up back ABDOMEN: tenderness to palpation of lower abdomen, R>L, soft, nondistended, +BS EXTREMITIES: +purpulish discoloration of fingertips b/l cold toes b/l, poor perfusion, slight discoloration of toes could not appreciated LE pulses [**1-25**] edema, 2+ pitting edema up leg to upper thigh. Discharge from [**Hospital Ward Name 121**] 3 ([**Hospital1 1516**] service) exam: VS: T 97.5 BP 96/66 [89-123/61-99] HR 78 [76-83-] RR 18 SaO2 95% on 3L [94-96% on 3L; 94% on 2L] I/O: [**Telephone/Fax (1) 70198**] Wt: 81.5 (from 81.7) GENERAL: NAD, lying in bed in private room, mother present [**Name (NI) 4459**]: [**Name (NI) 5674**], minimal scleral icterus NECK: Supple, JVP elevated to 5 cm CARDIAC: RRR, Nl S1/S2, soft rumbling systolic murmur loudest at LLSB LUNGS: CTAB, good air movement, no crackles ABDOMEN: soft, nondistended, nontender, +BS. Bruising on lower abdomen persists. No bruising in RUQ. EXTREMITIES: 2+ pitting edema up to knees bilaterally. Bruising on arms. PICC dressing changed, no drainage or erythema. Pertinent Results: Admission labs and studies: . [**2186-6-27**] 01:42PM BLOOD Glucose-100 UreaN-14 Creat-0.6 Na-134 K-3.9 Cl-102 HCO3-22 AnGap-14 [**2186-6-27**] 01:42PM BLOOD WBC-11.2*# RBC-4.10* Hgb-13.6 Hct-40.1 MCV-98 MCH-33.1* MCHC-33.9 RDW-18.4* Plt Ct-313 [**2186-6-27**] 01:42PM BLOOD ALT-61* AST-48* LD(LDH)-312* AlkPhos-65 TotBili-0.4 [**2186-6-27**] 01:42PM BLOOD Lipase-18 [**2186-6-27**] 01:42PM BLOOD Plt Smr-NORMAL Plt Ct-313 [**2186-6-27**] 04:18PM URINE Blood-LG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-MOD [**2186-6-27**] 04:18PM URINE RBC-11* WBC-8* Bacteri-FEW Yeast-NONE Epi-4 [**2186-6-28**] 01:30AM BLOOD HCG-<5 [**2186-6-28**] 07:30PM BLOOD dsDNA-NEGATIVE [**2186-6-28**] 07:30PM BLOOD C3-110 C4-30 [**2186-6-28**] 08:48AM BLOOD Calcium-8.2* Phos-3.4 Mg-2.0 [**2186-6-29**] 07:20AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE IgM HAV-NEGATIVE [**2186-6-29**] 07:20AM BLOOD HCV Ab-NEGATIVE . . Relevant labs: . Cultures: [**6-28**]: Blood culture negative x3 [**6-29**]: Blood culture negative [**6-30**] & [**7-2**]: Urine culture negative [**6-30**]: MRSA screen negative [**7-7**]: Urine culture negative [**7-8**]: Catheter tip culture negative [**7-26**]: Catheter tip culture pending . Pathology: [**7-25**] Transjugular liver biopsy: 1. Prominent centrilobular hepatocyte necrosis and parenchymal collapse involving 25-30% of the parenchyma with minimal associated inflammation (confirmed with reticulin stain). 2. Mild to moderate canalicular cholestasis without neutrophils or ductular proliferation. 3. No pathologic abnormalities or significant inflammation seen in portal areas. 4. Trichrome stain demonstrates focal perivenular fibrosis surrounding residual central veins; no increase in portal fibrosis is recognized. 5. Iron stain shows no stainable iron. . . Discharge labs: [**7-23**]: Complement C3 50, C4 20 [**7-24**]: Ceruloplasmin negative [**7-26**]: D-Dimer 1887, Haptoglobin 12 [**7-27**]: WBC [**9-30**], Hgb 9.4, Hct 29.1, Plt 80 [**7-27**]: Na 126, K 3.8, Cl 91, HCO3 27, BUN 29, Cr 0.8, Glucose 79, Calc 6.7, Mag 2.9, Phos 2.6 [**7-27**]: PT 19.3, PTT 35.4, INR 1.8 [**7-27**]: ALT 113, AST 161, LDH 773, ALK 149, TBili 4.3 [**7-27**]: Fibrinogen 72, ESR 1 . . Relevant imaging: . Outside imaging: From [**Hospital 70199**] medical center on [**2186-6-25**] CT chest with contrast: [**2186-6-25**] No evidence of PE. Central airways are patent. Small geographic regions of gorund glass opacities are seen within both lower lungs which could represent air trapping. . CT Abdomen and Pelvis [**2186-6-28**]: thickened R colonic wall w/ moderate-to-large amt of free fluid, but normal appendix and no free air; most c/w colitis. . RUQ US [**2186-6-28**]: IMPRESSION: 1. Gallstones with sub-cm gallbladder polyp. Mild gallbladder wall thickening and trace pericholecystic fluid, but no specific signs for acute cholecystitis. 2. Small amount of ascites, with largest pocket in the right lower quadrant. 3. Normal kidneys without evidence of hydronephrosis or renal calculi. . [**6-28**] + [**7-7**] - LENIs negative . [**6-30**] - Echo: IMPRESSION: Severe right ventricular cavity enlargement with free wall hypokinesis. Moderate to severe pulmonary artery systolic hypertension. Moderate to severe tricuspid regurgitation. Patent foramen ovale with small right-to-left shunt. Significant pulmonary regurgitation. These findings are suggestive of a primary pulmonary process (e.g., pulmonary embolism, primary pulmonary hypertension, etc.). . [**7-14**] Right heart cath: Resting hemodynamics revealed elevated left- and right-sided pressures. The RA pressure was 26 mmHg, PA pressure was 39 mmHg, and wedge pressure was 21 mmHg. There was no step-up in oxygen saturation to indicate a left-to-right shunt. The patient's cardiac output was on the low side of normal. FINAL DIAGNOSIS: 1. Elevated left and right pressures. 2. Low cardiac output. 3. No step-up in oxygen saturation to indicate a left-to-right shunt. . [**7-18**] Liver/GB U/S: 1. There has been interval filling of the gallbladder with sludge in comparison to prior study from [**2186-7-1**]. However, there is no evidence of intra- or extra-hepatic biliary duct dilatation with the common bile duct measuring 3 mm. Gallbladder is not distended and there is no gallbladder wall edema. 2. Trace perihepatic ascites. 3. Biphasic morphology of the Doppler and main portal vein is representative of congestive hepatopathy. . [**7-22**] Spleen U/S: No splenomegaly identified. . [**7-24**] Liver/GB U/S: 1) Sludge-filled gallbladder without evidence of intra or extrahepatic biliary ductal dilatation. There is no gallbladder distention or gallbladder wall edema. 2) Significant interval increase in ascites of unclear etiology. [**2186-7-27**] Right Heart Cath: 1. Resting hemodynamics on oxygen at 2 L/min NC revealed elevated Right sided filling pressures with a baseline RA mean of 27 mmHg (with V wave up to 42 mm Hg) . Left sided filling pressures were normal with a PCWP of 12 mmHg. There was pulmonary arterial hypertension with a mean PA pressure of 38 mmHg. The pulmonary vascular resistance was 578 dynes-sec/cm5. The cardiac index was low at 1.8 l/min/m2. The RA waveform appeared ventricularized withV waves to 44 mm Hg. 2. Treatment wiht 100% FiO2 demonstrated lowering of the pulmonary vascular resistance (to 411 dynes-sec/cm5) due to decrease of PA-[**Month/Day/Year **] difference with stable calculated cardiac output. 3. Treatment with inhaled NO at 40 ppm in addition to 100% FiO2 did not change the pulmonary pressures significantly with a mean PA pressure of 35 mmHg. The pulmonary artery resistance increased due to a relative decrease in [**Name (NI) **] to 8 mmHg with a mild decrease in cardiac output to 3.3 L/min. 4. Treatment with Milrinone increased cardiac output to 4.25 L/min and pulmonary artery mean pressure to 40 mm Hg with no significant change in pulmonary vascular resistance. [**2186-7-28**] TTE (milrinone gtt): Dilated and hypokinetic right ventricle with pressure/volume overload. Small left ventricle with vigorous systolic function. Moderate to severe tricuspid regurgitation. Significant pulmonary hypertension, not further quantified on this study. Brief Hospital Course: Ms. [**Known lastname **] is a 40 y/o F with h/o of lupus, mixed connective tissue disorder with scleroderma features who was initially admitted [**2186-6-27**] for RUQ pain, worsening LE edema, and vaginal bleeding, course c/b ICU stay for hypoxemia with subsequent pulmonary HTN and R heart failure on ECHO and subsequent congestive hepatopathy and acute renal failure. . Summary of Hospital Course: . # Pulmonary Hypertension and Right Heart Failure: As the patient presented wtih shortness of breath and hypoxia, she was admitted to the [**Hospital Unit Name 153**] on a non-rebreather. Initial differential for hypoxia included PE, despite recent negative CTA, as patient was hypoxic and tachycardic, with signs of R heart strain on ECG (prominent p waves in II, TWI III). Extensive work-up for PE (V/Q mismatch scan, LENIs, repeat CT angio of the chest) was done; however, these tests were unequivocally negative. DVT prophylaxis was initiated. Radiologic investigation showed evidence of significant right heart strain on CT scan, predisposing her to right->left shunt. Further investigation with echocardiogram showed a patent foramen ovale with right to left shunt, now thought to be secondary to pulmonary hypertension (which, in turn, was due to her underlying mixed connective tissue disease with features of scleroderma). The reason for her acute decompensation is not completely clear; however, she had been in [**Country 149**] for an extended period of time (>8 months) during the past 1.5 years, during which she had ran out of her medications (methotrexate + prednisolone + planquenil) and not replaced them. It is thought that this allowed for a more chronic decompensation with extensive pulmonary vasculature damage, eventually causing right heart pressures so high that right-->left shunt ensued. . The patient had a large oxygen requirement since her arrival, starting with 2 L nasal cannula which was then increased to 5 L O2 on nasal cannula. She was treated with aggressive diuresis, initially with lasix but then changed to turosemide due to thrombocytopenia (thought to be secondary to use of lasix) and inadequate diuretic response. In addition to diuretic therapy, sildenafil was started to promote vasodilatation of pulmonary vasculature. She was briefly transferred to the floor, and a right heart catheterization was performed on [**7-14**]. However she continued to show e/o volume overload and had a high oxygen requirement despite aggressive diuresis. She was admitted to the CCU to begin treatment with milrinone. Unfortunately she had no improvement in cardiac output to milrinone or nifedipine, and both were discontinued. She was restarted on sildenafil. The Rheumatology service was consulted for management of her MCTD. She was initially on her chronic daily daily oral prednisone doses of 5 mg but then started on high dose IV solumedrol in hopes of decreasing inflammation and improving her pulmonary hypertension. . On [**7-30**] her Hct acutely decreased from 28 to 23 within 24 hours, which raised concern for acute bleed given her coagulopathy and thrombocytopenia. Her BP decreased to 70s/40s and her O2 requirement increased, requiring emergent intubation and pressor support. CT chest/abdomen/pelvis showed no acute bleed. She was transfused RBCs and FFP. NG tube drained coffee-ground colored fluid, c/f acute gastritis or ulcer. She was evaluated by GI service and started on IV PPI. Her Hct then stabilized. She had endoscopy which showed no active bleed. She was evaluated by the Hematology service for further workup of her coagulopathy. Her labs were not c/w DIC or heparin-induced thrombocytopenia, and her coagulopathy was thought most likely due to her hepatic congestopathy and cirrhosis. . She was evaluated by the pulmonary service regarding possibility of starting Flolan therapy. However this was not able to be pursued since the patient's insurance would not cover this therapy. She was started on cytoxan but her cardiac output continued to decline. On [**8-3**], a family meeting was held and the family chose to change her code status to DNR as chest compression would not likely be effective for her in the event of cardiac arrest. On the morning of [**8-4**] she passed away with her family at bedside. Family declined autopsy. Medications on Admission: Reviewed with patient on admission AMLODIPINE - 5 mg daily Setraline 50 mg po qd FOLIC ACID - 2 mg daily HYDROXYCHLOROQUINE [PLAQUENIL] - 200 mg [**Hospital1 **] LEVOTHYROXINE - 25 mcg daily METHOTREXATE SODIUM - 25 mg q week OMEPRAZOLE - 40 mg daily PREDNISONE - 20 mg daily Calcium and vitamin D Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Primary diagnoses: Right heard failure Pulmonary hypertension Mixed connective tissue disorder Discharge Condition: Deceased Discharge Instructions: N/A Followup Instructions: N/A

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icd9cm

[ [ [] ] ]

[ "50.11", "96.72", "39.95", "45.13", "96.04", "37.21", "33.24", "38.97", "89.64", "37.23", "88.56" ]

icd9pcs

[ [ [] ] ]

21986, 21995

17291, 17665

348, 752

22133, 22144

11034, 12854

22196, 22203

6556, 6812

21958, 21963

22016, 22112

21636, 21935

14888, 17268

22168, 22173

12870, 13269

7816, 9280

6827, 7720

17693, 21610

263, 310

13287, 14871

780, 5242

9333, 11015

9295, 9317

5264, 5997

6013, 6540

897

141,600

21463

Discharge summary

report

Admission Date: [**2199-12-3**] Discharge Date: [**2199-12-12**] Date of Birth: [**2160-1-28**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2181**] Chief Complaint: Transfer from OSH for hypotension Major Surgical or Invasive Procedure: S/p R ureteral stent placement History of Present Illness: 39 yo F w/ h/o nephrolithiasis presented to OSH [**12-2**] with R flank pain associated with n/v/f/c and was found to have stone in R ureter. She underwent ureteral stent placement and postoperately she was developed fever to 102 with rigors. She rapidly developed hypotension unreponsive to fluids and eventually requiring pressors. She also had evidence of DIC, ARF and respiratory distress requiring NRB mask to keep O2 sats in mid-90s. She was given cipro, gent, and zosyn, and was transferred to [**Hospital1 18**] for further w/u. Past Medical History: 1. Kidney stone ~4 years ago 2. Depression with psychotic features Social History: Remote h/o tobacco, quit age 20. No h/o EtOH or IVDU. Lives with parents in [**Location (un) **], MA. Family History: Mom with h/o colon ca and cyst in brain, still A+W. Physical Exam: T 99.4, BP 115/50, P 82, RR 34, O2 sat 95% 2L I/Os: 2475 / 5390 Gen: Young female, flat affect, breathing moderately labored with full sentences HEENT: PERRL, anicteric sclera, dry MM clear OP Neck: Supple, no LAD/ masses, no JVP noted CV: RRR, nl S1, S2 I/VI SEM Pulm: decreased BS at bases o/w clear Abd: soft, NT/ND + BS Extr: No c/c/e, 2+ pedal pulses Pertinent Results: [**12-9**] CXR - 1. Removal of endotracheal and nasogatric tubes since the prior examinations. 2. Progressive consolidation of the left upper lobe or a portion of it, with air bronchograms, consistent with pneumonic consolidation. 3. Persistent left lower lobe atelectasis or consolidation with a small adjacent pleural effusion. 4. Continued patchy infiltrates in the right lung. 5. Considerable improvement in the degree of bilateral predominantly alveolar diffuse opacities. [**2199-12-3**] 03:43AM freeCa-1.01* [**2199-12-3**] 03:43AM GLUCOSE-201* LACTATE-3.4* NA+-137 K+-3.4* [**2199-12-3**] 03:43AM TYPE-ART PO2-69* PCO2-30* PH-7.33* TOTAL CO2-17* BASE XS--8 [**2199-12-3**] 04:12AM FIBRINOGE-351 [**2199-12-3**] 04:12AM PT-17.8* PTT-42.2* INR(PT)-2.0 [**2199-12-3**] 04:12AM PLT COUNT-124* [**2199-12-3**] 04:12AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2199-12-3**] 04:12AM NEUTS-91* BANDS-1 LYMPHS-3* MONOS-5 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2199-12-3**] 04:12AM WBC-27.3* RBC-3.12* HGB-9.7* HCT-29.5* MCV-95 MCH-31.2 MCHC-33.0 RDW-14.1 [**2199-12-3**] 04:12AM CORTISOL-140.9* [**2199-12-3**] 04:12AM TSH-1.1 [**2199-12-3**] 04:12AM ALBUMIN-2.9* CALCIUM-6.7* PHOSPHATE-2.3* MAGNESIUM-1.7 [**2199-12-3**] 04:12AM LIPASE-9 [**2199-12-3**] 04:12AM ALT(SGPT)-33 AST(SGOT)-31 LD(LDH)-206 ALK PHOS-57 TOT BILI-0.4 [**2199-12-3**] 04:12AM GLUCOSE-197* UREA N-20 CREAT-1.1 SODIUM-141 POTASSIUM-3.6 CHLORIDE-115* TOTAL CO2-15* ANION GAP-15 [**2199-12-3**] 04:40AM FDP-80-160* [**2199-12-3**] 05:26AM TYPE-ART TEMP-37.0 RATES-/32 O2-100 PO2-79* PCO2-23* PH-7.36 TOTAL CO2-14* BASE XS--10 AADO2-629 REQ O2-100 INTUBATED-NOT INTUBA [**2199-12-3**] 05:30AM URINE VoidSpec-REQUISITIO [**2199-12-3**] 07:18AM CORTISOL-121.2* [**2199-12-3**] 07:18AM CORTISOL-122.6* [**2199-12-3**] 07:49AM O2 SAT-98 [**2199-12-3**] 07:49AM LACTATE-3.2* [**2199-12-3**] 07:49AM TYPE-ART PO2-128* PCO2-28* PH-7.36 TOTAL CO2-16* BASE XS--7 [**2199-12-3**] 02:56PM WBC-26.7* RBC-3.15* HGB-9.9* HCT-29.3* MCV-93 MCH-31.4 MCHC-33.8 RDW-14.7 [**2199-12-3**] 02:56PM PLT COUNT-96* [**2199-12-3**] 03:12PM freeCa-1.12 [**2199-12-3**] 03:12PM O2 SAT-97 [**2199-12-3**] 03:12PM GLUCOSE-97 LACTATE-2.2* [**2199-12-3**] 03:12PM TYPE-ART PO2-108* PCO2-31* PH-7.36 TOTAL CO2-18* BASE XS--6 [**2199-12-3**] 05:04PM URINE RBC-420* WBC-26* BACTERIA-NONE YEAST-NONE EPI-0 [**2199-12-3**] 05:04PM URINE BLOOD-LGE NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM [**2199-12-3**] 05:04PM URINE COLOR-LtAmb APPEAR-Hazy SP [**Last Name (un) 155**]-1.020 [**2199-12-3**] 05:46PM O2 SAT-77 [**2199-12-3**] 05:46PM TYPE-MIX PO2-38* PCO2-32* PH-7.36 TOTAL CO2-19* BASE XS--6 CT abd pelvis: 1. Bilateral pleural effusions with some associated bibasilar atelectasis. 2. Ascites within the peritoneal cavity, in the pelvis and adjacent to the liver and gallbladder. 3. A right-sided ureteric stent is present, extending from the right renal pelvis to the bladder. No hydronephrosis identified bilaterally. A hypodense lesion is seen in the right kidney, likely representing a renal cyst. 4. There are no discrete focal fluid collections with areas of rim enhancement to suggest abscesses or othersignificant signs of infection. CXR: Improving multifocal pulmonary opacities, most likely due to provided history of pneumonia and ARDS Brief Hospital Course: [**Hospital Unit Name 153**] course: She was admitted to [**Hospital Unit Name 153**] for treatment of sepsis, presumed urinary source. She was initially treated with Zosyn and Cipro, agressive IV hydration and pressor support. She was intubated secondary to hypoxic respiratory failure on [**12-4**], felt to be likely ARDS. Urology was consulted and requested STU which revealed a well positioned ureteral stent without hydro or extravasation of contrast. She responded to treatment initially with WBC decreasing from 35.2 at maximum to 14.2 on [**12-6**]. A urine culture from OSH grew E-coli and abx changed to ceftriaxone on [**12-5**]. She then spiked a fever to 101.8-102.2 on [**12-6**] and [**12-7**] and WBC began to rise again. All [**Hospital1 18**] cultures, including C-diff remained negative. Antibiotics changed to Vanco, Gent, Ceftriaxone to treat possible VAP. On [**12-8**], successfully extubated with decreasing O2 requirement. Currently afebrile, HD stable of pressors, oxygenating well on 2L N/C and awaiting transfer to floor. 1. Respiratory failure - patient extubated on [**12-8**] and doing well with decreasing O2 requirement. Remains mildy tachypneic but comfortable. Pleural fluid without growth to date. O2 was weaned over next few days. Ultimately changed to levoquin PO as wt ct came down. PCP to follow up bld cx. 2. Leukocytosis - WBC rising from 14 on [**12-6**] to 29.9 today with 10% bands yesterday. Source not entirely clear as blood, sputum, urine cultures NGTD. Pneumonia possible. No diarrhea to suggest C-Diff. Abx cont and then changed once WBC ct improved. CXR and UA did not show an explanation for the course. 3. Urosepsis - Ecoli grew in urine culture from OSH. HD stable and now afebrile. Recommended cont abx. 4. Nephrolithiasis: pt now with ureteral stent and ? passage of stone. Urology following. Recent Abd CT demonstrates ureteral stent is in good location with no hydronephrosis, delay in excretion or extravasation of fluid. No need for intervention currently. Urology f/u as outpt 5. Renal function - back to baseline. 6. Psychiatry Pt will be started back on fluoxetine and clozaril now that she is successfully extubated cont clozaril at 25mg/day and titrate up to 125 mg per psych with f/u . 7. Anemia - HCT stable. Will need a repeat diff as outpt. 8. F/E/N - taking good clears now. Encourage PO diet. Has had some vomiting after drinking so monitor for signs of swallow dysfuncion s/p intubation. Repleted K+ 9. Dispo - home afebrile improved 10. Full Code Medications on Admission: Prozac 40 mg po qd Clozaril 175 mg po qd Discharge Medications: 1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed for 2 weeks. Disp:*qs 1* Refills:*0* 2. Fluoxetine HCl 20 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*2* 3. Lidocaine HCl 2 % Solution Sig: Five (5) ML Mucous membrane TID (3 times a day) as needed: for motuh discomfort. Disp:*30 ML(s)* Refills:*0* 4. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Disp:*7 Tablet(s)* Refills:*0* 5. Clozapine 25 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime): increase by 25 mg(one tablet) each day until at 175 mg dose (7 tablets). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: 1. Uretral stone 2. Sepsis 3. Respiratory distress/pneumonia 4. Depression with psychotic features 5. Anemia Discharge Condition: Good Discharge Instructions: If you have fever/chills, shortness of breath, difficulty urinating, chest pain, please call your PCP or come to the ED. Followup Instructions: Please call your PCP Dr [**Last Name (STitle) 13311**] for a f/u appt in 1 week. Will need repeat CBC with diff (atypical cells seen on last diff), follow up on blood cx results done at [**Hospital1 **]. Wed. [**12-18**] 11:45 am Psychiatry: Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 56657**] (please call for an appt in [**2-8**] weeks, message left that you would need an appt) Dr. [**Last Name (STitle) **]. Wood ([**Telephone/Fax (1) 56658**]) pls call for appt in [**2-8**] weeks, message left by pscyh attending

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icd9cm

[ [ [] ] ]

[ "38.93", "96.72", "34.91", "96.6", "96.04", "38.91" ]

icd9pcs

[ [ [] ] ]

8436, 8442

5105, 7665

350, 382

8595, 8601

1620, 5082

8770, 9300

1175, 1228

7756, 8413

8463, 8574

7691, 7733

8625, 8747

1243, 1601

277, 312

410, 950

972, 1040

1056, 1159

6,661

184,708

19301

Discharge summary

report

Admission Date: [**2191-2-19**] Discharge Date: [**2191-2-23**] Date of Birth: [**2127-7-3**] Sex: M Service: HISTORY OF PRESENT ILLNESS: Patient is a 63-year-old male with a history of hyperlipidemia, who developed sudden onset of sharp substernal chest pain [**8-30**] at 8 p.m. Pain radiated to the jaw, but not to the back or extremities. Patient attempted to relieve the pain with over-the-counter NSAIDs with no relief. Patient does report diaphoresis, no nausea, or vomiting. No PND. No orthopnea, no dyspnea on exertion. Patient was transported to an outside hospital, and an EKG showed 1-[**Street Address(2) 1766**] elevations in II, III, aVF in leads V4 through V6 with an initial CK of 145. The patient was transferred to [**Hospital1 **] Catheterization Laboratory, where it was revealed that he had a lesion 100% occluded most likely old in the RCA, and a new 100% LCX lesion plus 80% LAD lesion. The RCA and left circumflex received Cypher stents, cardiac index of 4.03 with a wedge pressure of 28. Patient had an episode of hypotension in the Catheterization Laboratory requiring dopamine and Neo-Synephrine. There is concern about allergic reaction to the dye, and the patient was given Solu-Medrol and Pepcid in the laboratory. The patient was transferred to the CCU off pressors and stable. HOME MEDICATIONS: Lipitor 10. REVIEW OF SYSTEMS: Negative. Cardiac review of systems is positive for chest pain, diaphoresis. Denies dyspnea on exertion, PND, orthopnea, shortness of breath, edema, palpitations, syncope, presyncope. PREVIOUS MEDICAL HISTORY: Hypercholesterolemia. SOCIAL HISTORY: Patient is a school custodian. He is still working. He is married. He has no children. He has a tobacco history, although no longer smokes. FAMILY HISTORY: Patient has a noncontributory family history. PHYSICAL EXAMINATION ON ADMISSION: Heart rate 89, blood pressure 150/87. In general, patient is comfortable in no acute distress. Mucous membranes are moist. ENT is within normal limits. No JVD. No thyroid nodules are palpated. Respiratory: Clear to auscultation bilaterally. Cardiovascular examination: Rate is regular, normal S1, S2, no S3, S4, no murmurs. Abdominal examination: Soft, nontender, nondistended, positive bowel sounds. Extremities: No edema, 2+ posterior tibial pulses and no edema on extremities. Patient has a right groin hematoma. Skin: Patient has a rash over the chest. EKG on admission: Sinus, 84, normal axis, normal intervals, left atrial abnormality, 1-[**Street Address(2) 15827**] elevations in II, III, aVF, V4 through V6. Post catheterization, patient has sinus rhythm, normal axis, normal intervals, Q waves in aVF and III. Cardiac catheterization showed LAD with 80% mid lesion of the diag bifurcation. RCA with 100% proximal occlusion. Left circumflex with 100% mid occlusion. Cypher stent 3 x 3 in the RCA, Cypher 2.5 x 18 in the left circumflex, and additional 3 x 8. Hemodynamics: Cardiac output 7.82. Cardiac index 4.03. Right atrial 12. RV 37/9. PA pressure 40/24. Wedge pressure 28. LABORATORIES ON ADMISSION: White count 12, 82% segs, 11% lymphocytes, 4 monocytes, and 1 eosinophil. Hematocrit 33.2, platelets 212. Electrolytes: 145, 3.4, 110, 28, 22, 135, magnesium 1.8. ASSESSMENT AND PLAN: This is a 63-year-old male with a history of hyperlipidemia transferred to [**Hospital3 **] for emergent catheterization that revealed 100% stenosis and occlusion of the RCA and left circumflex lesions successfully stented. The patient experienced hypotensive reaction to dye during catheterization procedure. Was quickly resuscitated with fluids and pressors. HOSPITAL COURSE: 1. Cardiovascular: A. Coronary artery disease: Patient was maintained on Integrilin for 18 hours, placed on aspirin for life, and Plavix for nine months. Patient had a beta blocker which was titrated up as well as an addition of an ACE inhibitor. CKs were cycled and peaked at 4,869. CK MB peaked at 468 on [**2191-2-20**]. Patient had an 80% stenosis of the LAD which was left untreated during this admission. The patient received cardiac rehab with a nutrition consult with Physical Therapy. A hemoglobin A1C was checked and found to be 5.7. Patient initially had elevated blood glucoses that returned to [**Location 213**] levels prior to his discharge. B. Pump: Patient had an echocardiogram in [**2191-2-21**], which demonstrated a left ventricular ejection fraction of 45%, left ventricular systolic function was mildly depressed with inferior hypokinesis to akinesis. Patient was maintained on a beta blocker, which was titrated up as well as an ACE inhibitor. C. Rhythm: Patient experienced some nonsustained V-tach on telemetry, which resolved post MI. Forty-eight hours the patient was transferred to the floor and maintained on telemetry until discharge. Patient was scheduled for an outpatient exercise stress test [**2191-3-23**] for further evaluation of his LAD lesion as well as followup with Dr. [**Last Name (STitle) **] for further plans to treat this LAD lesion. 2. Renal: Patient's creatinine was stable throughout this admission. 3. FEN and GI: Patient had a normal hemoglobin A1C, mildly elevated blood glucoses that returned to [**Location 213**] prior to his discharge. 4. Heme: Patient had a large hematoma, but maintained stable hematocrit throughout the admission. 5. Allergy: Patient has a new documented allergy to contract dye. On discharge, patient underwent Physical Therapy and nutrition counseling for cardiac diet. Patient was given a letter to excuse him from work by attending. FINAL DIAGNOSIS: 1. Acute myocardial infarction status post catheterization and stent placement x2. 2. Hypotensive reaction to contact dye. 3. Congestive heart failure with an ejection fraction of 45. 4. Coronary artery disease. FOLLOWUP: 1. Dr. [**Last Name (STitle) 13248**], [**2191-3-3**] at 11 a.m. for referral for a stress test. 2. Exercise stress [**2191-3-23**] [**Hospital Ward Name 23**] [**Location (un) **]. 3. Cardiology followup with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Telephone/Fax (1) 4022**]. DISCHARGE CONDITION: Patient was walking well, working with Physical Therapy, taking p.o., and educated on a cardiac diet, on a statin with stable hemodynamics. POST DISCHARGE MEDICATIONS: 1. Aspirin 325. 2. Plavix 75. 3. Tylenol and docusate prn. 4. Senna prn. 5. Protonix. 6. Atorvastatin 20 q.d. 7. Lisinopril 2.5 q.d. 8. Toprol XL 100 q.d. DISCHARGE STATUS: The patient was discharged home. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7169**] Dictated By:[**Last Name (NamePattern1) 5713**] MEDQUIST36 D: [**2191-2-24**] 14:26 T: [**2191-2-25**] 04:13 JOB#: [**Job Number 52568**]

[ "998.12", "428.0", "458.29", "410.21", "E879.2", "414.01", "427.1", "E947.8", "272.4" ]

icd9cm

[ [ [] ] ]

[ "99.20", "88.56", "36.05", "37.23", "36.07" ]

icd9pcs

[ [ [] ] ]

6212, 6358

1806, 1874

6381, 6881

3700, 5642

5659, 6190

1357, 1370

1390, 1627

155, 1338

3130, 3683

1644, 1789

17,469

104,351

10266

Discharge summary

report

Admission Date: [**2119-2-7**] Discharge Date: [**2119-2-18**] Date of Birth: [**2042-10-8**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2597**] Chief Complaint: Pulsation in Abdomen for some time, without any associated symptoms. Loosing weight over last year. Major Surgical or Invasive Procedure: Resection repair of abdominal week aneurysm with 24 x 12 bifurcated aortobi-iliac graft. History of Present Illness: 76 y.o old male with hx of being aware of a pulsation in his abdomen for some time, with out any associated symptoms. He has been loosing weight. Pt reiceved a CT scan. Showed an aortic anuerysm. Referd to Dr.[**Last Name (STitle) **] Dr. [**Last Name (STitle) **] for repair. Past Medical History: IMI CABG ( NEDH): LIMA to LAD, SVG to dLAD, SVG to D1, SVG to OM1,SVG to OM2 ETT with myoview Exercised 7 minutes 15 seconds [**Doctor First Name **]. 96% PHR. Stopped d/t chest pain and EKG changes. 2mm inferior and anterolateral ST depression. Pain continued 6 minutes into recovery. + LV cavity dilatation with stress, moderate territory of inferior and lateral ischemia. Small amount of anterior ischemia. EF 66%. left sided facial twitch CAD Appy TIA CVA Melenoma GIB Social History: denies smoking denies alcohol Family History: non contributary Physical Exam: A/O x 3, NAD NCAT, PERRL, EOMI / neg lesions oral pharnyx, auditory canals, nare SUPPLE, FAROM / neg lyphandopathy, supra clavicular nodes CTA B/L with slight crackles at the bases Irregular, irregular Soft, NTTP, ND, pos bowel signs, neg CVA LE DP/PT 2 plus Pertinent Results: [**2119-2-16**] BLOOD WBC-6.5 RBC-3.50* Hgb-11.3* Hct-33.8* MCV-97 MCH-32.1* MCHC-33.3 RDW-14.0 Plt Ct-149* [**2119-2-17**] Glucose-98 UreaN-41* Creat-1.8* Na-146* K-4.1 Cl-111* HCO3-30* AnGap-9 [**2119-2-17**] Calcium-7.6* Phos-2.7 Mg-2.0 [**2119-2-16**] Swallowing Study SUMMARY / IMPRESSION: Pt is demonstrating overt s&s aspiration at bedside with thin liquids, consistently, however he appears to be tolerating nectar thick liquids and softer solids. Unclear etiology of dysphagia though pt is presenting with some generalized oral and pharyngeal weakness. As such, would suggest initiate modified po diet texture at this time with repeat bedside swallow evaluation in [**1-20**] days. [**2119-2-14**] Cardiology Report ECG Atrial flutter with ventricular premature beat. Incomplete right bundle-branch block. Since the previous tracing of [**2119-2-14**] atrial wave morphology is slightly more suggestive of flutter, but probably no significant change. Intervals Axes Rate PR QRS QT/QTc P QRS T 75 0 114 400/428.57 0 48 17 [**2119-2-7**] CHEST (PORTABLE AP) SUPINE PORTABLE CHEST X-RAY: Swan-Ganz catheter is present with its tip in the right ventricular outflow tract. There is an NG tube in good position and endotracheal tube also in good position. Prominence of the aortic knob is noted. There is no pneumothorax. Sternotomy wires and mediastinal clips are noted again. Lung volumes are lower than on the prior film, but there are no focal areas of opacity with the exception of some subsegmental atelectasis in the left lower lobe. There is some blunting of the left CP angle, may relate to atelectasis or small effusion. IMPRESSION: Satisfactory lines and tubes without pneumothorax. Possible small left pleural effusion. Brief Hospital Course: Pt admitted to the vascular service [**2119-2-7**] Pt underwent a resection repair of abdominal week aneurysm with 24 x 12 bifurcated aortobi-iliac graft. on [**2119-2-7**]. Pt tolerated the procedure well with no complications. Pt transferred to the [**Date Range 13042**] in stable condition, In the [**Name (NI) 13042**] pt did recieve fluids. He was weaned off the vent on [**2119-2-8**]. On [**2119-2-8**] pt [**Date Range **] to the VICU in stable condition. [**2117-2-9**] pt had difficulty maintaining o2 sats, a CXR, was obtained - showed mild CHF. Pt was was given lasix with good response. Pt also experienced ICU pshychosis - give haldol. During this state of confusion the pt again became hypoxic. Pt transferd to the SICU. [**2119-2-10**] - [**2119-2-16**] In the SICU multiple of entites occured. 1) PT experienced A - Fib, started on heperin. given beta blocker for rate control. Pt R/O for MI. 2) Pt also experienced increase of temperature to 101, pt was pan cx. his sputum grew gram neg rods, CXR showed RUL pneumonia - tx with AB, CPT, NEBS. 3) CHF, pt treated with restriction of fluids, lasix, weight monitered. This resolved. 4) Pt experienced ARF secondary to hypovolemai from lasix. Pt cret.pre op was 1.2 got to 2.3, on DC improved to 1.8. [**2119-2-15**] Pt started to improve, PT/Casemanagement/ got involved. Also pt had a hard time swallowing a swallowing study was obtained. Pt swallowing gradually improved uon discharge. Coumadin was started for a-fib. [**2119-2-16**] Pt [**Name (NI) 22925**] to floor. Foley was [**Name (NI) 1788**], pt was able to ambulate without difficulty. [**2119-2-17**] PT discharged in stable condition. Medications on Admission: ASA 81 mg PO QD Baclofen 20 mg po tid Lipitor 20 mg po qd Clonazepam .5 mg po tid Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 3. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 5. Warfarin Sodium 1 mg Tablet Sig: One (1) Tablet PO ONCE (once) for 1 doses. 6. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Discharge Disposition: Extended Care Facility: [**Location (un) 34165**] of [**Location (un) 2498**] Discharge Diagnosis: Hospital Stay Abdominal aortic aneurysm. Pneumonia PAF (INR goal 2 - 2.5) P/O ICU pshycosis ARF baseline creat - 1.2, high 2.3, On discharge 1.8 Pre admission IMI CABG ( NEDH): LIMA to LAD, SVG to dLAD, SVG to D1, SVG to OM1,SVG to OM2 ETT with myoview Exercised 7 minutes 15 seconds [**Doctor First Name **]. 96% PHR. Stopped d/t chest pain and EKG changes. 2mm inferior and anterolateral ST depression. Pain continued 6 minutes into recovery. + LV cavity dilatation with stress, moderate territory of inferior and lateral ischemia. Small amount of anterior ischemia. EF 66%. left sided facial twitch CAD Appy TIA CVA Melenoma GIB Discharge Condition: Stable Discharge Instructions: Pt. must have his Coumadin adjusted by checking levels of his PTT. Take 1 mg today and tomorrow. Pt has difficulty swallowing, please watch for aspiration. Try to keep HOB elevated. Watch for signs of systemic infection - fever, chills and night sweats. If this happens take approriate measures Check wound for infection - erythema, swelling, discharge Call Dr [**Last Name (STitle) **] [**Name (STitle) 2678**] if this happens. Physycal Therapy Adjust dosing of coumadin for INR 2 - 2.5 for a fib. Followup Instructions: Follow up with Dr. [**Last Name (STitle) **] in two weeks. Please call for appt. at [**Telephone/Fax (1) 34166**]. Follow up with your cadiologist for post op atrial fibrillation. Please call Dr [**Last Name (STitle) **] and make appt. Call [**Telephone/Fax (1) 34167**]. Completed by:[**2119-2-18**]

[ "276.5", "V58.61", "427.31", "584.9", "441.4", "427.32", "287.5", "428.0", "V45.81", "412", "507.0" ]

icd9cm

[ [ [] ] ]

[ "38.44", "38.93", "39.25" ]

icd9pcs

[ [ [] ] ]

5919, 5999

3471, 5142

413, 504

6681, 6689

1684, 3448

7242, 7546

1372, 1390

5275, 5896

6020, 6660

5168, 5252

6713, 7219

1405, 1665

274, 375

532, 810

832, 1309

1325, 1356

2,018

116,924

15802

Discharge summary

report

Admission Date: [**2112-6-1**] Discharge Date: [**2112-6-8**] Date of Birth: [**2039-7-15**] Sex: F Service: HISTORY OF PRESENT ILLNESS: This is a 72-year-old female with a history of type 2 diabetes mellitus and hypertension who presented with confusion, lightheadedness, and malaise. The patient reported some visual hallucinations for approximately 10 months which were not mentioned during her earlier hospitalization in [**2111-12-12**]. She reports feeling thirsty but not urinating frequently. She admits to a 50-pound weight loss, increased fatigue, weak legs with minimal ambulation during the past two months. By report, the patient was a somewhat poor historian on initial evaluation. Initially, the patient was thought to have significant mental status changes, lethargy, and borderline unresponsiveness. In the Emergency Department, she was noted to be in acute renal failure with a creatinine increased to 5.8 from a baseline of 0.7. Her arterial blood gas was notable for a bicarbonate of 8. The patient was initially transferred to the Intensive Care Unit for immediate care and management. In the Intensive Care Unit, the patient was treated with Kayexalate with resolution of her hyperkalemia. The Renal team was consulted for acute renal failure and acidosis. Initially, there was some question if the patient had a renal tubular acidosis, specifically type 1, given her metabolic derangements. However, the patient responded immediately to intravenous fluids with her creatinine decreasing from 5.8 to 2 quickly, making prerenal acute renal failure the most likely diagnosis. Further history revealed the patient had some question of increased ostomy output, although there was no reported decrease in oral intake. Gastroenterology was consulted, .................... nongap acidosis possibly related to increased ostomy output. In addition, the patient had been on an ACE inhibitor prior to admission. PAST MEDICAL HISTORY: 1. Type 2 diabetes mellitus times 12 years. 2. Hypertension. 3. Lower gastrointestinal bleed secondary to diverticulosis; failed embolization requiring subtotal colectomy with ileostomy in [**2111-12-12**]. 4. Uterine fibroids. 5. Colonic polyps. MEDICATIONS ON ADMISSION: 1. Glipizide 10 mg once per day. 2. Glucophage 500 mg twice per day. 3. Lisinopril 5 mg once per day. PHYSICAL EXAMINATION ON PRESENTATION: Vital signs on initial presentation revealed a temperature of 98.1, her blood pressure was 125/52, her heart rate was 78, her respiratory rate was 11, and 97% on room air. An elderly female, lethargic. Head, eyes, ears, nose, and throat examination revealed atraumatic. The pupils were equal, round, and reactive to light. The mucous membranes were moist. The neck was supple. No lymphadenopathy. No thyromegaly. No jugular venous distention. Cardiovascular examination revealed a regular rate and rhythm. Normal first heart sounds and second heart sounds. A [**2-16**] diastolic murmur. Her lungs were clear to auscultation bilaterally. No crackles, wheezes, or rhonchi. Her abdomen was soft, nontender, and nondistended. Active bowel sounds. The ostomy was clean and intact. There was no costovertebral angle tenderness bilaterally. Her extremities were without edema. Her skin showed several seborrheic keratoses over the back, face, and chest. Her neurological examination was alert and oriented times three without asterixis. PERTINENT LABORATORY VALUES ON PRESENTATION: Notable for a creatinine of 5.8, her potassium was 7.5, and her lactate was 0.8. Urinalysis showed a specific gravity of 1.000, leukocyte esterase was negative, nitrites were negative, protein was negative, and glucose was negative. The patient's serum osmolalities were 322. Her urine creatinine was 0, sodium was less 10, urine osmolalities were 3. Her fractional excretion of sodium was initially greater than 1. RADIOLOGY/IMAGING FINDINGS: The patient had an electrocardiogram with a normal sinus rhythm in the 60s, normal axis, first-degree AV block, flat T waves in aVL, biphasic in V5 and V6. No ST segment changes. Read as unchanged from prior. Her renal ultrasound showed no hydronephrosis, stones, or masses. BRIEF SUMMARY OF HOSPITAL COURSE: This is a 72-year-old female with a past medical history of hypertension and type 2 diabetes times 12 years who presented with confusion and was noted to have acute renal failure. 1. ACUTE RENAL FAILURE ISSUES: The patient was initially evaluated in the Intensive Care Unit. There was some concern the patient had type 1 renal tubular acidosis; however, the patient responded quickly to intravenous hydration, and it was felt that this picture was most likely consistent with prerenal acute renal failure. The patient's creatinine returned to the 1.3 to 1.4 range from a peak of 5.8 quite quickly over several days with intravenous fluids. The patient was deemed stable enough to be transferred to the general medical floor on [**2112-6-3**]. At the time of transfer, her creatinine had improved to 2. The patient had several kidney studies including the renal ultrasound which was negative for obstruction. She had a serum protein electrophoresis and urine protein electrophoresis sent which were normal; to rule out multiple myeloma. In addition, she had urine eosinophils sent to evaluate for allergic interstitial nephritis which were negative. The patient had a urinalysis sent and a urine culture which was no growth to date. It was felt that the prerenal state was likely induced secondary to increased ostomy output. The ostomy output was followed closely and was noted to be in the normal range; approximately 1 liter to 1.5 liters per day. It was felt that the patient was likely just not keeping up with the by mouth fluid requirements given her ostomy output. The patient was encouraged to continue to take adequate by mouth hydration. The Gastroenterology Service had been consulted to further evaluate the ostomy. This will be discussed further down. 2. EXCESSIVE OSTOMY OUTPUT ISSUES: There was a concern raised that the patient was actually having excessive ostomy output which was causing her prerenal state. However, further observation revealed that the patient was simply not keeping up with her output. Gastroenterology did evaluate the patient with an ileoscopy and did not note any abnormalities. In addition, the patient had an endoscopy performed which noted several duodenal ulcerations. The patient was begun on a higher dose of Protonix 40 twice per day for eight weeks. She will continue this medication for eight weeks and then decrease to 40 mg by mouth every day. 3. TYPE 2 DIABETES MELLITUS ISSUES: The patient's by mouth hypoglycemics were discontinued on admission given her acute renal failure. As her renal failure improved, the patient was restarted on glipizide at initially 5 mg and then titrated up to 10 mg by mouth once per day. At the time of discharge, the patient was not taking her metformin. Her primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 10208**], was contact[**Name (NI) **] and was aware that the patient will need to have her fingerstick glucoses followed and will likely need to restart her Glucophage as an outpatient. 4. HYPERTENSION ISSUES: The patient had been on an ACE inhibitor which may have contributed to the prerenal picture. The ACE inhibitor was held during this admission. She was started on a beta blocker; 50 mg by mouth twice per day was the dose she was discharged on. This was also communicated to her primary care physician (Dr. [**Last Name (STitle) 10208**]. 5. ANEMIA ISSUES: The patient had iron studies sent which were borderline for anemia of chronic disease. The patient was continued on by mouth liquid iron. She did have one guaiac-positive stool during this hospital stay. It was felt that this was likely secondary to her duodenal ulcerations. The Gastroenterology Service stated that the patient should not need a small-bowel follow-through to further evaluate her anemia. 6. MENTAL STATUS CHANGES: The patient's mental status significantly improved with improvement of her renal failure. On discharge, the patient was alert and oriented. She felt nearly back to herself; not quite 100% but was ambulating without difficulty and eating a good by mouth diet. CONDITION AT DISCHARGE: Stable, eating a full diet, and ambulating without difficulty. DISCHARGE STATUS: To home with [**Hospital6 407**] services. [**Hospital6 407**] for home safety evaluation, blood pressure checks, fingerstick checks, and blood draw to check her creatinine. DISCHARGE DIAGNOSES: 1. Acute renal failure; prerenal. 2. Status post ileostomy. 3. Type 2 diabetes mellitus. 4. Hypertension. 5. Duodenal ulcerations. MEDICATIONS ON DISCHARGE: 1. Tylenol 325 mg one to two tablets by mouth q.4-6h. 2. Iron sulfate 300-mg liquid 5 mL by mouth twice per day. 3. Pantoprazole 40 mg one tablet by mouth twice per day times eight weeks then decrease to 40 mg by mouth once per day ongoing. 4. Glipizide 10 mg by mouth once per day. 5. Metoprolol 50 mg by mouth twice per day. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was to follow up with her primary care physician (Dr. [**Last Name (STitle) 10208**]. 2. She was aware that she needs to call Dr. [**Last Name (STitle) 10208**] for an appointment in the next week. 3. In addition, she will have followup by the [**Hospital6 1587**] for home blood pressure checks, as well as fingerstick checks to follow her glucose level, and a laboratory draw two days after discharge to follow up on her creatinine. 4. The [**Hospital6 407**] were advised that they should call these results to Dr. [**Last Name (STitle) 10208**] (her primary care physician) [**University/College 45471**] Health Center. Dr. [**Last Name (STitle) 10208**] can be contact[**Name (NI) **] at [**Telephone/Fax (1) 35879**]. [**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. [**MD Number(1) 3475**] Dictated By:[**Name8 (MD) 3482**] MEDQUIST36 D: [**2112-6-8**] 15:23 T: [**2112-6-8**] 18:01 JOB#: [**Job Number 45472**]

[ "532.90", "276.5", "585", "285.9", "V10.3", "250.00", "584.9", "V44.2" ]

icd9cm

[ [ [] ] ]

[ "45.13", "45.16" ]

icd9pcs

[ [ [] ] ]

8695, 8832

8858, 9191

2256, 4234

9224, 10219

4263, 8400

8415, 8674

154, 1955

1977, 2230

74,556

166,219

37800

Discharge summary

report

Admission Date: [**2124-8-30**] Discharge Date: [**2124-9-13**] Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3227**] Chief Complaint: Confusion Major Surgical or Invasive Procedure: [**2124-9-1**]: Right Temporal Craniotomy for Tumor Excision History of Present Illness: Pt is an 86 yo male w/ PMHx sig for DM and afib on Coumadin who presented to [**Hospital1 **] [**Location (un) 620**] for several weeks of increased fatigue and lethargy. Also, today the patient was driving and missed a familiar road as well as had difficulty getting to his own home. He had and MRI at [**Hospital1 **] [**Location (un) 620**] that shows a large R temporal heterogeneous enhancing mass with vasogenic edema. He was loaded with Dilantin and then transferred to [**Hospital1 18**] for further evaluation. Past Medical History: DM, afib on Coumadin, TIAs Social History: Lives with wife Family History: non-contributory Physical Exam: On admission: Vitals: T 98.2; BP 130/76; P 116; RR 16; O2 sat 99% General: lying in bed NAD Neck: supple Extremities: no c/c/e. Neurological Exam: Mental status: A & O x3, difficulty with MOYB. Fluent speech with no paraphasic or phonemic errors. Adequate comprehension. Follows simple and multi-step commands. Registers [**12-28**], recalls 0/3 at 30 seconds, [**12-28**] with prompting. Repetition intact. Difficulty naming low frequency objects. No left/right mismatch. No apraxia/neglect. Cranial Nerves: I: Not tested II: PERRL, 4-->2mm with light. optic discs sharp. Left visual field cut. III, IV, VI: EOMI. no nystagmus. V, VII: facial sensation intact, facial strength VIII: hearing intact b/l to finger rubbing. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: SCM [**3-28**] XII: Tongue midline without fasciculations. Motor: Normal bulk. Normal tone. No pronator drift. Does not comply with formal testing due to inattention. Sensation: intact to light touch Reflexes: 1+ throughout with absent left patella. Toes downgoing bilaterally Pertinent Results: [**2124-9-12**] 05:50AM BLOOD WBC-10.4 RBC-4.15* Hgb-11.6* Hct-32.9* MCV-79* MCH-28.0 MCHC-35.3* RDW-14.9 Plt Ct-271 [**2124-9-9**] 09:53PM BLOOD Neuts-73* Bands-5 Lymphs-8* Monos-9 Eos-4 Baso-0 Atyps-1* Metas-0 Myelos-0 [**2124-9-12**] 05:50AM BLOOD Plt Ct-271 [**2124-9-12**] 05:50AM BLOOD Glucose-204* UreaN-26* Creat-1.0 Na-140 K-4.2 Cl-106 HCO3-25 AnGap-13 [**2124-9-12**] 05:50AM BLOOD Calcium-8.7 Phos-3.1 Mg-1.9 Brief Hospital Course: Mr [**Known lastname **] was admitted to [**Hospital1 18**] neurosurgery for evaluation and treatment of right temporal lesion. He went to the OR on [**9-3**] for right temporal craniotomy for attempt at debulking the mass. Frozen section revelaed GBM. He was extubated postoperatively. Post-op Head CT showed the expected post-surgical changes. He was observed in the ICU for 24 hours. He was later transfered to the step down unit. He became febrile to 101.2 on [**9-6**]. A fever workup was initiated. WBC was 10.3. CXR-showed no atelectasis. LENS were negative for DVT. All other fever work ups were unremarkable. He was started on subcutaneous heparin. Swallow eval was requested but unable to be done due to lethargy and cooperation. Tube feeds were tailered per nutrition recommendations. Speech & Swallow evaluation was able to be performed and he was cleared for small amounts of pureed solids/nectar thick liquids with supervision. All meds were given via Dobhoff. Final pathology was resulted as GBM. His exam improved on a daily basis. As his exam improved he was able to tolerate pureed solids and nectar thick liquids with supervision. His Dobhoff and tube feeds were dc'd. On discharge he was awake, alert X2 with slight left lower extremity weakness. He would answer simple question and follow simple commands. His incision was clean and dry Medications on Admission: Metformin, Lopressor, Glyburide, Coumadin Discharge Medications: 1. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 3. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 5. Levetiracetam 1,000 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Tablet(s) 6. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 7. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed for gi distress. 8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/temp>100/HA. 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation . 10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Discharge Disposition: Extended Care Facility: NE [**Hospital1 **]- [**Location (un) 86**] Discharge Diagnosis: Right Temporal Tumor Pathology:Gloablastoma Multiforme Discharge Condition: Neurologically stable Discharge Instructions: General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and/or staples have been removed. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. Please have results faxed to [**Telephone/Fax (1) 87**]. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions Follow up in the brain tumor clinic on [**10-2**] at 2:00 [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] [**Location (un) **] Completed by:[**2124-9-13**]

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icd9cm

[ [ [] ] ]

[ "01.59", "96.6" ]

icd9pcs

[ [ [] ] ]

5030, 5100

2568, 3933

276, 339

5199, 5223

2124, 2545

6797, 7000

993, 1011

4025, 5007

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958, 976

10,425

168,354

48325

Discharge summary

report

Admission Date: [**2201-2-2**] Discharge Date: [**2201-2-6**] Date of Birth: [**2138-9-5**] Sex: M Service: MEDICINE Allergies: Captopril / Prednisone / infed Attending:[**First Name3 (LF) 3624**] Chief Complaint: Low hematocrit Major Surgical or Invasive Procedure: Right native kidney embolization History of Present Illness: 62M h/o LURT and pancreas-after-kidney transplant c/b rejection with subsequent transplant pancreatic artery-small bowel fistula and massive GI bleed requiring explantation of the pancreas and R iliac covered stent p/w decreased hct in the setting of recent admission for urosepsis/R-sided pyelonephritis requiring R nephrostomy placement. Briefly, he was hospitalized recently from [**1-12**] to [**1-30**] for urosepsis/R-sided pyelonephritis c/b hypotension/tachycardia, requiring brief MICU stay. At the time of discharge, hct was 25.8, and CTX x14d until [**2201-2-5**] was planned. Following discharge, he reports recovering well, endorsing only minimal lightheadedness and dyspnea on exertion, both of which he attributed to the normal course of recovery. His wife estimates 60-80 cc serosanguinous nephrostomy output dauly. He denies f/c/s, chest pain, abdominal pain or distention, BRPRP, melena, hematochezia, hematuria, or back pain. On routine outpatient monitoring, he was found to have hct of 25 this morning and sent to the [**Hospital1 18**] ED. In the ED, he was afebrile with stable VS, including HR 77 and BP 144/60, and downtrending hct of 21 and 17. Guiac negative. EKG was notable for persistent ST depression accompanied by elevated Tn to 2.69, attributed by cardiology service to demand ischemia requiring no intervention. Following IVF resuscitation and administration of 2u pRBC, he was transferred to the floor, where he remained HD stable and received a third unit pRBC. Per renal transplant, IR-guided R renal artery embolization v. R nephrectomy is planned for tomorrow for presumptive bleeding from the R native kidney. REVIEW OF SYSTEMS: Negative, except as noted above. Past Medical History: Diabetes s/p failed pancreas transplant Renal failure s/p LURT GI bleed from pancreas transplant related fistula Celiac sprue Depression Diabetic retinopathy OA Osteoporosis Diabetic neuropathy CAD hx TIA [**2190**] hx Afib PSH: Tonsillectomy Removal bladder tumor [**2183**] Lap chole [**2184**] B/L cataracts [**2192**] LURT [**2192**] PAK [**2192**] Ex lap/pancreatic graft explantation/SBR/bl chest tubes [**8-/2199**] abdominal closure [**8-/2199**] Social History: Lives with his wife. [**Name (NI) **] ETOH, tobacco, or illicit drug use. Family History: Noncontributory. Physical Exam: On Admission: VS - Afebrile 80 157/53 24 96% RA GENERAL - Well-appearing in NAD. HEENT - PERRLA, EOMI, sclerae anicteric, MMM NECK - Supple, no thyromegaly, no LAD HEART - RRR, S1, S2, III/VI SM throughout precordium (longstanding per patient) LUNGS - CTAB ABDOMEN - +BS, NT/ND, no guarding/rebound, LLQ ecchymoses ([**1-8**] insulin/heparin use per patient) EXTREMITIES - WWP, no c/c/e BACK - No CVAT NEURO - awake, A&Ox3, CNs II-XII grossly intact TLD - R nephrostomy with ~50 cc sanguinous drainage, RUE PICC line. Pertinent Results: Admission Labs: Hct 17.3 BUN/Cr 23/1.7 (c/w baseline) TnT/CK-MB 2.69/3 Lactate 1.4 UA negative Microbiology: BCx x1 pending Admission EKG: NSR @77bpm. Stable ST depressions in V4 - V6. Imaging: CT abdomen/pelvis w/o contrast: 1. Interval placement of a right-sided nephrostomy tube without sequela of complication of placement. 2. No findings to explain the patient's 8-point hematocrit drop. 3. Interval development of very small bilateral pleural effusions. 4. Multiple chronic changes unchanged including vascular calcifications, pancreatic atrophy, atrophy of the left kidney, degenerative changes of the bony structures. Brief Hospital Course: Brief Course: # Low hematocrit: Likely [**1-8**] bleed from R native kidney nephrostomy. No other obvious source of bleeding in the absence of RP bleed on noncontrast abdominal CT. Negative hemolysis labs. Hct bumped appropriately from 17 on admission to 29 following 3u pRBC, remaining stable x3 (26.8-28.9), and he underwent uncomplicated R native kidney embolization prior to transfer to the floor. He remained HD stable throughout. # Elevated TnT: TnT of 2.69 and CK-MB of 3 in the setting of persistent ST depressions attributed by cardiology to demand ischemia, with no procedural intervention required. Home ASA 325 mg and simvastatin 20 mg continued, given concern for NSTEMI in the setting of known CAD, with plans to resume home clopidogrel following R kidney embolization. Repeat TnT (2.58) and CK-MB (2) downtrended appropriately without further EKG changes. #Diabetes mellitus: FSBG of 41 with mild blurry vision at 3am on [**2-3**] likely [**1-8**] receipt of home glargine despite poor PO intake, with increase in FSBG to 60s-70s following 2 amps dextrose and subsequently 80s on continuous D51/2NS. Home glargine held with continuation of SS for glycemic coverage. #Recent h/o R-sided pyelonephritis: No e/o persistent infection in the absence of fever, HD instability, or bacteremia. Planned course of ceftriaxone continued. Medications on Admission: Clopidogrel 75 mg daily (held at last admission) Doxercalciferol 0.5 mcg daily Lantus 9 in AM 18 in PM Regular insulin sliding scale Levothyroxine 137 mcg daily Pantoprazole 40 mg daily Prednisone 5 mg daily Sertraline 200 mg daily Simvastatin 20 mg daily Bactrim SS daily Tacrolimus 3 mg [**Hospital1 **] Diovan 320 mg daily (held at last admission) Aspirin 325 mg daily Ferrous sulfate 325 mg daily MVI Discharge Medications: 1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. doxercalciferol 0.5 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. valsartan 320 mg Tablet Sig: One (1) Tablet PO once a day. 7. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 8. tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H (every 12 hours). 9. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 13. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 14. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO twice a day for 2 weeks. Disp:*28 Tablet(s)* Refills:*0* 15. insulin glargine 100 unit/mL Cartridge Sig: Twenty (20) units Subcutaneous at bedtime. 16. Apidra 100 unit/mL Solution Sig: One (1) injection Subcutaneous per sliding scale. Discharge Disposition: Home With Service Facility: [**Location (un) 1110**] VNA Discharge Diagnosis: Acute anemia due to kidney bleed H/o renal transplant Coronary artery disease Insulin dependent diabetes mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 7324**], You were admitted to [**Hospital1 18**] because you were anemic. We think this likely happened because of a bleed in your right kidney. You had a procedure called an embolization of the artery to the kidney and the bleeding stopped. You had low blood sugars at times during your hospitalization, and your insulin glargine dose was decreased to 20 units at bedtime, no glargine in the morning. Please follow up with your primary care physician for continued titration of your insulin regimen. Please note the following changes to your medications: -STOP IV ceftriaxone, start ciprofloxacin 250mg twice daily by mouth - take for 2 weeks or until Dr. [**Last Name (STitle) **] tells you to stop -DECREASE insulin glargine (Lantus) to 20 units once daily at bedtime only, no glargine in the morning -RESTART plavix and follow up with your primary care physician or cardiologist regarding whether to stop this medication -RESTART diovan for blood pressure We made no other changes to your medications while you were in the hospital. Please continue taking the rest of your medications as prescribed by your outpatient providers. Please see below for your currently scheduled appointments at [**Hospital1 18**]. You will have your nephrostomy tube removed by Dr. [**Last Name (STitle) **] at your next appointment. It has been a pleasure taking care of you and we wish you a speedy recovery. Followup Instructions: Department: TRANSPLANT CENTER When: TUESDAY [**2201-2-10**] at 9:40 AM With: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: TRANSPLANT CENTER When: TUESDAY [**2201-2-17**] at 9:00 AM With: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: TRANSPLANT CENTER When: FRIDAY [**2201-7-31**] at 10:30 AM With: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**] MD [**MD Number(1) 3629**]

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icd9cm

[ [ [] ] ]

[ "39.79", "88.45" ]

icd9pcs

[ [ [] ] ]

6976, 7035

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249, 265

365, 2018

3247, 3863

2707, 3212

7208, 7320

2094, 2552

2568, 2644

68,391

104,896

20516

Discharge summary

report

Admission Date: [**2144-3-13**] Discharge Date: [**2144-4-3**] Date of Birth: [**2076-8-1**] Sex: M Service: MEDICINE Allergies: Heparin Agents Attending:[**First Name3 (LF) 2297**] Chief Complaint: hypoxia, shortness of breath, chest pain Major Surgical or Invasive Procedure: none History of Present Illness: 67 M with poorly controlled IDDM, afib on coumadin, s/p partial right foot amputation p/w erythema, swelling, & wounds on RLE. Pt states that symptoms began 4 day ago with purulent drainage from foot lesions. Endorses fevers at home yesterday. Pt recently treated for cellulitis in RLE 1 months ago with good resolution. No antecedent trauma but pt scratching legs vigorously. . Also endorses decreased appetite with 20 lb weight loss in the past month. . Vital signs in the ED: 98.0, 149/70, 80, 18, 98% 2L . In the [**Name (NI) **], pt given IV vancomycin in ED. . REVIEW OF SYSTEMS: (+): As above (-): Chest pain, SOB, abdominal pain, nausea, vomiting, diarrea, headache. Past Medical History: -CHF EF 45% ([**12/2143**]) - on home oxygen 1-2L -CAD s/p 4 MI's ([**2125**], [**2134**], [**2142**]), s/p 3 vessel CABG and recent BMS of D1 ([**3-27**]) -Chronic Atrial Flutter -Diabetes mellitus type II c/b Neuropathy, Retinopathy, diabetic foot ulcer s/p amputations -PVD -Hypertension -Hyperlipidemia -GERD -Depression -h/o alcoholism- stopped drinking 25 years ago -Ischemic colitis -Left Subclavian Stenosis (45 mmHg pressure drop across the stenotic lesion, Cath [**5-/2142**]) . Past Surgical History: L 2nd toe amp R TMA R partial colectomy for ischemic colitis 3 vessel CABG R fem-DP l fem-[**Doctor Last Name **] with stent bilaterally s/p aortoiliac stenting Social History: Patient lives in [**Location **] with 3 of his brothers. [**Name (NI) **] retired in his late 50s but he previously owned a radiator repiar business. No ETOH X 25 years, but hx of heavy drinking X 15 years ("all day long"), Hx of tobacco use (4ppd X 15 years), no IVDU. Family History: -no CAD, lung disease, or DM in the family -HTN in father -Breast cancer in mother Physical Exam: ON ADMISSION: Tcurrent: 37 ??????C (98.6 ??????F) HR: 94 (94 - 94) bpm BP: 121/32(53) {121/32(53) - 121/32(53)} mmHg RR: 21 (21 - 22) insp/min SpO2: 98% Heart rhythm: AF (Atrial Fibrillation) GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. muddy sclera. EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of in line with jaw line CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: Crackles at bilateral bases, good air movement throughout ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. missing front foot on R, missing toes and ulcerations on remaining on left, RLE dressing c/d/i PULSES: Right: DP 1+ PT 1+ Left: DP 1+ PT 1+ . AT DISCHARGE: Pertinent Results: - ECG: LBBB at rate 90-112. Greater than 5mm ST elevations than previous, although hard to delineate ST baseline. . - ECHO: [**12-27**]: The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with severe hypokinesis of the inferior, inferolateral and basal inferoseptal segments. The remaining segments contract normally (LVEF = 40%). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild regional left ventricular systolic dysfunction, c/w CAD. Mild mitral regurgitation. Moderate pulmonary hypertension. Compared with the report of the prior study (images unavailable for review) of [**2143-1-15**], the findings appear similar. . - CARDIAC CATH: RHC [**1-26**]: COMMENTS: 1. Resting hemodynamics revealed normal right ventricular filling pressures with RVEDP 7 mmHg and mildly elevated left sided filling pressures with PCWP 19 mmHg. There was pulmonary arterial hypertension with a mean PA pressures of 33 mmHg (PA prrresure 55/19 mmHg). The pulmonary vascular resistance was 157 dynes-sec/cm5. The cardiac index was normal at 3.26 L/min/m2. 2. Treatment with 100% FiO2 demonstrated lowering of the pulmonary artery resistance (97 dynes-sec/cm5) due to a rise in calculated cardiac index (5.27 L/min/m2) with a stable PCW of 19 mmHg. The mean PA pressure was measured at 33 mmHg. 3. Treatment with inhaled NO at 40 ppm in addition to 100% FiO2 did not change the pulmonary pressures significantly with a mean PA pressure of 30mmHg. There was just a mild change in the mean PCWP measured at 17 mmHg. The pulmonary artery resistance was (107 dynes-sec/cm5) due to a rise in the calculated cardiac index (4.43 l/min/m2). FINAL DIAGNOSIS: 1. Pulmonary arterial hypertension at baseline with no improvement in mean PA pressures with 100% o2 and iNO at 40ppm. 2. Mildly elevated left ventricular filling pressures. . LHC [**5-26**]: COMMENTS: 1. Coronary angiography in this left-dominant system revealed diffuse coronary artery disease. The LMCA was a small caliber vessel without disease. The LAD had 60-70% calcified stenoses of the proximal section, as well as the diagonal branch, and was occluded after the mid-section. The LCX had sequential stenoses of the proximal and distal LCX, with occluded OM1 and OM2 branches, and total occlusion after the distal LCX. The RCA was a non-dominant vessel with sequential 80% stenoses. 2. Selective graft venography revealed a widely patent SVG-PDA and LPL graft. The SVG-OM1 graft had a 30-40% stenosis in the mid-SVG, and was patent to the OM1 branch. 3. Selective graft arteriography revealed a widely patent LIMA-LAD graft. 4. Resting hemodynamics revealed elevated right- and left-sided filling pressures, with mean RA pressure of 15 mmHg, and mean PCW pressure of 30 mmHg. The wedge tracing was notable for a prominant v-wave with pressure of 51 mmHg, consistent with possible mitral regurgitation. There was mild pulmonary hypertension with mean PA pressure of 38 mmHg, and mild systemic hypertension, with SBP of 140mmHg. The cardiac output was normal at 5.1 L/min. There was no aortic stenosis detected by pullback technique. 5. Nonselective left subclavian injection revealed a 70% stenosis of the proximal left subclavian artery, with a 45 mmHg pressure drop across the stenotic lesion. FINAL DIAGNOSIS: 1. Diffuse coronary artery disease. 2. Elevated left- and right-sided filling pressures. 3. Mild pulmonary and systemic hypertension. 4. Subclavian stenosis. Brief Hospital Course: Patient expired as explained in OMR Death Note summarized here: At approximately 12:30AM, telemetry in the ICU demonstrated ventricular tachycardia. Dr. [**Last Name (STitle) 39070**] [**Name (STitle) 39071**] was present at bedside and the patient was found to be pulseless. Code status was noted to be DNR and he became asystolic shortly thereafter. Dr. [**Last Name (STitle) 39071**] called the time of death to be 12:36AM on [**2144-4-3**] after listening for breath sounds bilaterally and not appreciating any. He also listened for heart sounds and did not appreciate any. He felt for peripheral pulses for 1 minute at both radial arteries, and did not appreciate any. He had absent corneal reflexes bilaterally. Dr. [**Last Name (STitle) 39071**] has made several phone calls to patients brothers in attempt to inform them of grave situation. Organ bank was also notified by Dr. [**Last Name (STitle) 39071**] and they have declined. Below is a brief summary of his hospital course: Mr. [**Known lastname 17029**] is a 67 year old man with a past medical history significant for CABG, CAD, sCHF, DM, PVD, originally admitted for RLE cellulitis who was transferred to the CCU after developing acute pulmonary edema. His course was complicated by pulseless VT arrest on [**3-21**] and respiratory failure and is now in the MICU for further management . # Hypoxemic Respiratory Failure: Initially upon admission, Mr. [**Known lastname 17029**] had an SpO2 of 100% on 2L. Given appearance of hypovolemia on exam, and concern for infection his home torsemide was held and he was given 1L NS. On the first night of admission, he became hypoxemic to SpO2 in the 70s. CXR at the time demonstrated pulmonary edema. SBP was 150. Hypoxemia initially improved with BiPap and diuresis. He was transferred to the CCU for further management given concern for ACS. On [**3-15**] he was able to be weaned from bipap with lasix gtt and nitro gtt after 2L of diuresis, however on [**3-15**] he removed his NRB mask and desaturated to the 60s, was obtunded and bradycardic in aflutter with variable block and he was intubated. ABG initially demonstrated a moderate P/F ratio of ~250 suggestive of [**Doctor Last Name **] which has roughly remained constant. CT chest demonstrated bilateral ground glass opacities worsened in non-dependent areas since [**1-26**] of unknown etiology. Overall, non-resolving infiltrates were seen as likely secondary to flash pulmonary edema with component of alveolar hemorrhage given profound coagulopathy on admission. Given spike to 102 on [**2143-3-20**] and CXR with worsening bilateral infiltrates, VAP was seen as likely and broad spectrum Abx (Vanc, Zosyn, and Levofloxacin) were started. Furthermore, Swan on [**2143-3-21**] demonstrated wedge of 15-18 indicating a smaller component of L heart dysfunction than previously thought. Furthermore PVR in 800s indicated that pulmonary hypertension occurred out of proportion to left heart dysfunction. After 1 week of intubation, his mental status had improved to the point where he could be safely extubated on [**2144-3-24**]. P/F ratio prior to extubation demonstrated a ratio of 250 which was similar to his baseline. For one day following extubation, he was able to maintain an SpO2 of 97-99% on the high flow mask, but progressively became more tachypneic and demonstrated paradoxical respirations. Bipap was initiated on [**2144-3-25**]. . He was transferred to the MICU for further care [**3-26**]. Upon arrival his mental status was poor and appeared having significant difficulty on bipap. It was decided to re-intubate the patient. He was continued on vancomycin and meropenem. A bronchocsopy was performed which showed hemosiderin laden macrophages. His hypoxia was felt to be a combination of cardiogenic pulmonary edema given elevated V waves on swan plus intrinsic pulmonary process of undiagnosed etiology. A lung biopsy was considered. . # PULSELESS VT ARREST: While Mr. [**Known lastname 17029**] was being weaned from sedation on [**2144-3-21**], he experienced an episode of pulseless VT. There was no evidence of cardiac ischemia, electrolytes were within normal limits, and QTc was 420. He had ROSC after 1 shock and an amiodarone load. The etiology of this event was unclear, but was thought to occur secondary to catecholamine surge in the setting of sedation wean and profound agitation. In the MICU, the patient had increased ectopy and NSVT. Due to the increasing frequency, he was restarted on amiodarone with improved ectopy. . # [**Last Name (un) **] ?????? With diuresis, Mr. [**Known lastname 54896**] renal function progressively deteriorated to a peak BUN/Cr of 178/4.5 from a baseline of 34/1.7. After a peak Cr of 4.5, Mr. [**Known lastname 54896**] cr began to improve to a Cr of 2.8 upon transfer to the MICU. HE continued to maintain good UOP and followed closely by nephrology. He did not need renal replacement therapy while in the MICU. . # Hypernatremia: Mr. [**Known lastname 17029**] became quite hypernatremic when his tube feeds were held following extubation. Initial attempts to replete with 1/2 NS were unsuccessful, and his Na was 157 on [**2144-3-26**] consistent with a 6.5 L free water deficit. D5W and free water flushes were started with good effect. . #AMS ?????? A large component of Mr. [**Known lastname 54896**] prolonged intubation was altered mental status. Following initial sedation with fentanyl and midazolam he became quite sedated and would not follow commands. Sedation was changed to propofol after inadequate sedation with precedex. Given supratherapeutic INR, CT head was obtained which demonstrated atrophy but no acute changes. Neuro consult was obtained, and their assessment was that his delerium was secondary to toxic metabolic causes (sedation, uremia, hypernatremia, and ICU delerium). EEG shows metabolic encephalopathy, no epileptiform activity. As his renal function and hypernatremia improved, the patient's mental status slowly improved while on the vent. . # Nutrition: Upon transfer to the MICU, mental status precluded PO intake, and Bipap precluded nasogastric tube feeds. Tube feeds were initiated in the MICU. . # DM ?????? Blood sugars were difficult to control in the CCU, and an insulin drip was started. [**Last Name (un) **] was consulted and saw the patient often for close monitoring of his blood sugars. . # Fevers/Infection: Fever to 102 on [**2144-3-22**] with leukocytosis peak to 24 on [**2144-3-26**]. There existed concern for VAP with prolonged intubation (no definite infiltrates for VAP), as well as UTI given prolonged foley catheterization (prior UA with WBCs but urine cx with only yeast). Less likely was meningitis given AMS, because time course/physical exam was inconsistent (he became altered before fevers started and no nuchal rigidity). Initially vanc/zosyn/levofloxacin were started for VAP on [**2144-3-18**]. Levofloxacin was stopped on [**2144-3-21**] following VT arrest and concern for QT prolongation. He was broadened to vancomycin and [**Last Name (un) 2830**] upon transfer to the MICU and his wbc improved. . # CAD ?????? Mr. [**Known lastname 17029**] experienced chest pain in setting of respiratory decompensation on admission without EKG changes from baseline, cardiac enzymes peaked on [**3-15**] with MB of 21 and trop of 1.21. Troponin was baseline and worsened with worsening CKD. Overall his MB bump was seen as demand related to his hypoxemia and there was little concern for ACS. He remained CP free since initial decompensation. # LIVER: LFTs were elevated on admission to ALT/AST in the 300s. Etiology is likely secondary to congestive hepatopathy as RUQ US ruled out abscess or reversal of flow, but was suggestive of CHF and congestive hepatopathy. HCV ab was negative. HBV serologies negative. Given downtrending LFTs with diuresis, further workup was deferred. Furthermore, INR improved dramatically with Vit K administration c/w malnutrition. . #Anemia. Hematocrit slowly worsened from baseline of 29 on admission to a nadir of 22.1. He was transfused on [**2143-3-21**] due to low SvO2 of 35%. Cause of anemia has been thought to be secondary to CKD and/or anemia of chronic disease. Hemolysis was ruled out with negative smear for schistocytes, elevated haptoglobin, and normal fibrinogen. In light of brown guiac positive stools, protonix [**Hospital1 **] was initiated. In the MICU, he had a low Hct of 20.6 and received two units of pbrcs with good effect. Medications on Admission: - Aspirin 81 mg QD - Trazodone 100 mg QHS PRN - Atorvastatin 80 mg QHS - Sertraline 100 mg QD - Clonazepam 0.5 mg TID PRN anxiety - [**Hospital1 23928**] 10 mg QD - Torsemide 20 mg QD - Warfarin 1 mg QD - Spironolactone 12.5 mg QD - Isosorbide mononitrate 60 mg ER QD - Fluticasone-salmeterol 250-50 mcg/dose Disk [**Hospital1 **] - Metoprolol succinate 12.5 mg ER QD - Albuterol sulfate 90 mcg MDI [**2-17**] INH Q6H PRN SOB, wheeze - Humulin-N 100 unit/mL Suspension 20 units QAM, 24 units QPM - Humalog 100 unit/mL Solution 10 units QAM, 12 units QPM Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired

[ "492.8", "285.21", "V49.86", "585.4", "486", "428.23", "V58.67", "427.1", "276.0", "112.2", "707.15", "V46.2", "501", "443.9", "276.2", "V49.73", "518.81", "250.60", "428.0", "410.71", "V45.81", "427.5", "287.5", "348.31", "V58.61", "427.31", "682.7", "414.00", "403.90", "V49.87", "311", "515", "584.9", "286.9", "573.0", "427.32" ]

icd9cm

[ [ [] ] ]

[ "99.60", "89.64", "96.72", "38.97", "33.24", "96.04", "96.6" ]

icd9pcs

[ [ [] ] ]

16024, 16033

6887, 7865

314, 320

16084, 16093

2910, 5061

16149, 16159

2026, 2110

15992, 16001

16054, 16063

15414, 15969

7882, 15388

6704, 6864

16117, 16126

1561, 1723

2125, 2125

2891, 2891

934, 1025

234, 276

348, 915

2139, 2875

1047, 1538

1739, 2010

28,690

136,982

47768

Discharge summary

report

Admission Date: [**2120-11-25**] Discharge Date: [**2120-12-19**] Date of Birth: [**2068-12-17**] Sex: F Service: MEDICINE Allergies: Iodine Containing Agents Classifier / Codeine Attending:[**First Name3 (LF) 2745**] Chief Complaint: lethargy and hypertension Major Surgical or Invasive Procedure: TEE [**2120-11-29**] History of Present Illness: The patient is a 51 year old woman with history of asthma, hypertension, chronic knee/back pain on chronic narcotics who was admitted to an OSH 6 days ago with lethargy. She was found by her son as minimally arousable on [**2120-11-19**]. The son called EMS the following day after being asked to do so by her husband who lives in [**Name (NI) 3844**]. The patient was admitted to the OSH for evaluation of the lethargy that was presumably due to the narcotics. Urine tox + for benzos and barbituates. Her mental status improved with administration of Narcan both by EMS and by the ED physicians. Subsequent to that she was notably hypertensive that was attributed to clonidine withdrawal. A head CT was done to further evaluated her mental status which showed old infarct as well as subacute infarcts. The patient had been hypokalemic at the OSH with low of 2.6. A psychiatry consult evaluated her and placed her on a Section 12 given the concern for an intentional overdose. It was the opinion of the consulting psychiatrist that she would likely benefit from an inpatient psychiatry stay once medically stabilized. She was transferred to [**Hospital1 18**] for further management. Prior to transfer her blood pressure was 140/82 after receiving oral and topical medications. . The patient states that she took too many of her pills because she "just felt like it." She denies wanting to hurt herself or kill herself. She denies worsening feelings of depression. . ROS: no headache. no chest pain. no shortness of breath. cough produtive of green or white sputum. no blood in sputum. no nausea or vomiting. no pain with urinating. Past Medical History: asthma hypertension chronic knee/back pain COPD depression migraine s/p open cholecystectomy Social History: Lives in MA with her son; husband lives in [**Name (NI) 3844**]. per report cannot leave MA due to multiple arrest warrants. per report has history of kleptomania. one son killed ~2 year ago by a train. She had a recent medical hospitalization [**8-3**] because she had an overdose on diet pills. This was two prior to hospitalization when she took an overdose of over-the-counter diet pills. Long history of self-injury (cutting, cigarrette burns which per recent neurology note she connects this behavior with a history of trauma where she was raped twice as an adult woman (approx 10yrs ago). [**Name (NI) 1094**] mother died this past [**Name (NI) **] [**2119**]. Family History: brother with schizophrenia Physical Exam: Vitals: 99.4 74 174/82 29 97% Gen: fatigued. obese woman in NAD HEENT: NGT in place. pupils 4->2mm bilat. EOMI. no jaundice. no pallor. MMM. crowded oropharynx Neck: supple. no pain with flexion. carotid ausculation obscured by breath sounds Chest: clear anteriorly and laterally w/o I:E prolongaton. CV: RRR no m/r/g Abd: obese. well healed RUQ surgical scar. soft. NT. active bowel sounds. Ext: trace LE edema Skin: no rash Neuro: -MS: awake. answers questions appropriately. oriented to self, [**Hospital3 **], New Years -CN: II-XII. visual fields -Motor: moving all 4. hand grip strong bilat. plantar felx -DTR: trace at patellars. toes downgoing -[**Last Name (un) **]: light touch intact to face/hands/feet Pertinent Results: CBC WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2120-12-3**] 05:38AM 8.4 4.38 13.5 38.2 87 30.9 35.4* 15.8* 331 [**2120-11-25**] 08:32PM 11.0 4.15* 12.8 36.9 89 30.9 34.8 16.8* 319 . RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 [**2120-12-3**] 05:38AM 144* 18 0.6 139 4.0 100 27 [**2120-11-25**] 08:32PM 129* 14 0.5 138 3.8 102 25 . ENZYMES & BILIRUBIN ALT AST LD(LDH) AlkPhos TotBili [**2120-11-25**] 08:32PM 14 12 197 80 0.6 . DIABETES MONITORING %HbA1c [**2120-12-5**] 06:55AM 6.1*1 . LIPID/CHOLESTEROL Cholest Triglyc HDL CHOL/HD LDLcalc [**2120-11-26**] 04:42AM 175 187* 29 6.0 109 . MRA Brain & Neck w/o contrast [**2120-11-26**] 1. Slow diffusion involving the [**Doctor Last Name 352**] matter of the right insula and the adjacent right temporal lobe. This finding likely represents acute or subacute infarcts. However, if there is concern for an infectious process, this may represent cerebritis. 2. Old infarcts of the right parietal and occipital lobes which are new compared to [**2120-2-12**]. 3. Abrupt cutoff of the M1 segment of the right middle cerebral artery. The acuity of this finding is uncertain. 4. Diffusely decreased T1 signal of the bone marrow which may represent marrow reconversion but an infiltrative process cannot be excluded. . Carotid doppler series [**2120-11-27**] - Normal study . Echocardiogram [**2120-11-29**] Complex and calcified atheroma in the aortic arch. No thrombus identified in the left atrium or ventricle. No evidence of PFO or ASD. Brief Hospital Course: ASSESSEMENT/PLAN: 51 year old woman with chronic pain, COPD, depression, cluster B disorders p/w lethargy in setting of methadone overdose, complicated by hypertension, found to have subacute CVA. . # CVA: Pt noted to have subacute stroke on imaging involving the right insula and adjacent R temporal lobe with clinical evidence of L facial droop, L pronator driift and distal UE weakness. She was followed closely by the neurology service, concern for an embolic stroke. TTE & carotid ultrasound were unremarkable. TEE showed complex atheroma in aortic arch and pt was continued on aspirin 325mg daily, which she had not been in the past - neurology held off on coumadin due to high risk for bleeding. She has also been started on Lipitor. CTA was not performed due to her dye allergy with anaphylaxis. PT& OT eval for rehabilitation. Speech improved and per swallow examination increased pt to ground solid food & thin liquids. She should be re-evaluated and her diet advanced. Pt is scheduled to follow up with Dr.[**First Name8 (NamePattern2) 2530**] [**Name (STitle) **] in neurology for followup. . # Hypertension: Pt with labile HTN during hospitalization, was only on single [**Doctor Last Name 360**] Nifedipine at home. She was started on Labetolol, captopril & clonidine to control SBP <140, clonidine was stopped. BP currently well controlled on 3 agents, labetalol, nifedipine and lisinopril with SBP ranging 120-140's. . # SI/depression: On admission, pt was actively suicidal in the ICU and psychiatry was consulted. s/p overdose with narcotics, benzos. Althought Section 12 on admission, requiring 1:1 sitter, prior to discharge reevaluation revealed no SI. She was restarted on celexa 20mg qhs. Psych felt that she did not warrant inpatient therapy and recommended outpatient psych followup with Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1681**]. . # Diabetes: Newly diagnosed during admission based on FSG during hospitalization. FSG were well controlled on glyburide 2.5mg po daily. . # Chronic pain: Although pt was chronically on methadone and benzo's for multiple pains including back and knees, she has not been on any narcotic regimen during admission. She was provided tylenol, ultram for occasional pains, fiorcet for headache control. . # UTI: per urine culture. Completed 7 day course of ciprofloxacin. . # R submandibular lymph node: Present; Per pt, recurrent & painful but currently without any pain; has been evaluated in the past. Would recommend outpatient f/u, no acute issue. . # Asthma: Continued pt on Advair. Albuterol & atrovent PRN . Pt has reached maximal hospital benefit and is being discharged home with 24hr supervision as well as multiple home services including PT, social work and nursing. She is to follow up with PCP as well as Dr.[**First Name8 (NamePattern2) 2530**] [**Name (STitle) **] in Neurology. Medications on Admission: Home Medications (per OMR): ADVAIR DISKUS 500-50MCG 1 puff:[**Hospital1 **] ALBUTEROL neb QID:PRN ATROVENT 18 mcg 2 puffs TID CLONAZEPAM 2-4MG qhs Citalopram 20 mg qhs Clonidine 0.3 mg/24 hour--apply 2 patches every week DYAZIDE 37.5-25MG daily FLONASE 50 mcg daily Methadone 40 mg TID NIFEDIPINE 90 mg daily NITROGLYCERIN 0.4MG prn OXYCONTIN 40 mg q8hrs PERCOCET 5 mg-325 mg 2 tablet TID PREMPHASE 0.625 mg-5 mg--2 tablet daily SEROQUEL 100 mg qhs VENTOLIN 90MCG--4 puffs q 4hrs . Medications on Transfer: amlodopine 10 mg daily labetalol 400 mg TID labetalol 10 mg IV q1prn heparin sc clonidine 0.3 mg [**Hospital1 **] clonidine 0.3mg/24hr patch qSat haldol 5 mg IV q1prn albuterol neb q4prn ativan 1 mg PO q4 ativan 2mg iv q2prn pantoprazole 40 mg q24 nystatin topical [**Hospital1 **] (under breasts) seroquel 100 mg daily advair 500/50 [**Hospital1 **] tube feed: Osmolite goal 70cc/hr Discharge Medications: 1. Nifedipine 60 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO DAILY (Daily). Disp:*60 Tablet Sustained Release(s)* Refills:*2* 2. Labetalol 200 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:*270 Tablet(s)* Refills:*2* 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Butalbital-Aspirin-Caffeine 50-325-40 mg Capsule Sig: [**11-27**] Caps PO Q6H (every 6 hours) as needed for headache. Disp:*30 Cap(s)* Refills:*0* 6. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). Disp:*30 Tablet(s)* Refills:*2* 7. Atorvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 8. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 9. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for knee pain. Disp:*30 Tablet(s)* Refills:*0* 10. Fioricet 50-325-40 mg Tablet Sig: 1-2 Tablets PO twice a day as needed for headache. Disp:*30 Tablet(s)* Refills:*0* 11. Ventolin HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: Four (4) puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 12. Atrovent HFA 17 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation four times a day as needed for shortness of breath or wheezing. 13. Flonase 50 mcg/Actuation Spray, Suspension Sig: One (1) spray in each nostril Nasal once a day. 14. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 15. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). 16. Outpatient Occupational Therapy Please provide cognitive retraining 17. Outpatient Physical Therapy Physical therapy evaluation and treatment 18. Outpatient Speech/Swallowing Therapy Please evaluate pt for advancement of diet from thin liquids and ground solids. 19. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Narcotic overdose Partial right MCA stroke Diabetes II Hypertension Asthma Discharge Condition: Stable Discharge Instructions: You were admitted after an overdose of your pain medications. You were found to have a stroke and high blood pressure. . NEW MEDICATIONS - Aspirin for prevention of stroke - Atorvastatin to lower cholesterol - Lisinopril & Labetalol for BP control - Glyburide for diabetes - Prilosec for acid reflux . You have also been diagnosed with diabetes, hence you were started on glyburide, you will need to check your blood glucose before meals & at bedtime. Please record these values and show them to your PCP . Please STOP TAKING clonazepam, clonidine patches, dyazide, methadone, seroquel & premphase. . Please come to the ED or call your PCP if you develop chestpain, shortness of breath or any other worrisome symptoms. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10134**], MD Phone:[**Telephone/Fax (1) 7976**] Date/Time:[**2120-12-31**] 12:00 . NEUROLOGY - Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2121-1-20**] 2:00 . NEUROPSYCHIATRY - Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 1682**] Date/Time:[**2121-1-8**] 2:00

[ "493.20", "276.8", "401.9", "440.0", "719.46", "724.5", "434.11", "311", "309.81", "292.81", "785.6", "965.02", "250.00", "E950.0", "599.0", "787.20", "338.29" ]

icd9cm

[ [ [] ] ]

[ "88.72", "96.6" ]

icd9pcs

[ [ [] ] ]

11278, 11327

5233, 8112

335, 358

11446, 11455

3616, 5210

12222, 12730

2839, 2867

9053, 11255

11348, 11425

8138, 8620

11479, 12199

2882, 3597

270, 297

386, 2020

8645, 9030

2042, 2137

2153, 2823

71,070

123,260

41374

Discharge summary

report

Admission Date: [**2164-5-17**] Discharge Date: [**2164-5-23**] Date of Birth: [**2088-3-15**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: back/shoulder pain Major Surgical or Invasive Procedure: cardiac cath History of Present Illness: Mr. [**Known lastname **] is a 76M with CAD (s/p Cath [**2157**], medically managed), with PPM, PVD s/p RLE angioplasty, CEA ('[**52**]), DM, and multiple strokes who was transferred on [**5-17**] from OSH with NSTEMI and Cardiogenic Shock requiring IABP. The patient was initially transferred to the Cardiac Surgery service, but is thought to have Coronary anatomy amenable to PCI rather than CABG. Patient is being transferred to the CCU Service for further management. . Briefly, the patient reports that over the past two weeks he has noted numbness in both of his upper extremities with exertion. The patient reported that he started to have intermittent back and shoulder pain (bilateral) over the past two days (at rest and with exertion) and that led him to seek care from his cardiologist who referred him to OSH ED for further evaluation. . At [**Hospital **] Hospital, the patient was found to he in heart failure and ruled in for NSTEMI with Trop T of 1.02; CK 639, CKMB 43.1. The patient had cardiac catheterization that showed normal LMCA, 90% prox LAD stenosis, D1 with mild Dz, Chronically occluded Ramus, 100% RCA CTO, with L to R collateralization. Patient's CI was 1.6 and IABP was placed in setting of cardiogenic shock. Patient was given Lasix IV x 1 for diuresis. . The patient was transferred to [**Hospital1 18**] on [**5-17**] by [**Location (un) 7622**] and was admitted to the surgical service for CABG. After review of his anatomy, the patient was thought to be a candidate for PCI and is being tranferred to the CCU service after his catheterization. . On review of systems, he denies any 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. . Cardiac review of systems is notable for current absence of chest pain. Patient reported dyspnea on exertion prior to admission to OSH. No current orthopnea, ankle edema, palpitations, syncope or presyncope. Patient has a history of syncope requiring PPM. . Past Medical History: 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension 2. CARDIAC HISTORY: - PERCUTANEOUS CORONARY INTERVENTIONS: **** Cath [**2157**] with R Dominant system, small occluded ramus with otherwise mild-moderate disease (per [**11/2163**] office note). Per patient, this has been medically managed. - PACING/ICD: PPM placed in [**2158**] after syncopal episode (unclear what patient's rhythm was) 3. OTHER PAST MEDICAL HISTORY: Peripheral Artery Disease --> s/p L CEA 13 years ago --> s/p 3 RLE angioplasties in [**2163**] for RLE ulcer CVA h/o Appendectomy Herniorrhaphy Cataracts Social History: Occupation: retired machinist Tobacco:denies ETOH:denies Family History: - No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: On Admission: t: 97.8, HR: 71, BP: 141/70, RR: 16 95% GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 12cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. +S3 LUNGS: Clear anterolaterally, unable to auscultate bases ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. R femoral IABP in place SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ DP/PT dopplerable Left: Carotid 2+ DP/PT dopplerable . On Discharge: Tmax: 37 ??????C (98.6 ??????F) Tcurrent: 37 ??????C (98.6 ??????F) HR: 85 (68 - 102) bpm BP: 110/57(69) {93/43(57) - 114/90(95)} mmHg RR: 23 (17 - 28) insp/min SpO2: 91% Heart rhythm: SR (Sinus Rhythm) Wgt (current): 63 kg (admission): 64.8 kg Height: 67 Inch GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclerae anicteric. PERRL, EOMI. Conjunctivae were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP at clavicle CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. LUNGS: CTAB, decreased breath sounds at bilateral bases, no rales, wheezes or rhonchi appreciated ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominal bruits. EXTREMITIES: No C/C/E SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ DP/PT dopplerable Left: Carotid 2+ DP/PT dopplerable NEURO: Stable deficits from previous strokes Pertinent Results: Labs on admission: [**2164-5-17**] 05:50PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.024 [**2164-5-17**] 05:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2164-5-17**] 05:30PM GLUCOSE-178* UREA N-44* CREAT-1.6* SODIUM-137 POTASSIUM-4.7 CHLORIDE-100 TOTAL CO2-27 ANION GAP-15 [**2164-5-17**] 05:30PM estGFR-Using this [**2164-5-17**] 05:30PM ALT(SGPT)-20 AST(SGOT)-77* ALK PHOS-41 TOT BILI-1.1 [**2164-5-17**] 05:30PM ALBUMIN-3.6 CALCIUM-9.0 PHOSPHATE-4.4 MAGNESIUM-1.9 [**2164-5-17**] 05:30PM %HbA1c-7.2* eAG-160* [**2164-5-17**] 05:30PM WBC-10.8 RBC-4.04* HGB-13.7* HCT-39.7* MCV-98 MCH-33.9* MCHC-34.5 RDW-14.1 [**2164-5-17**] 05:30PM PT-14.0* PTT-42.8* INR(PT)-1.2* [**2164-5-17**] 05:30PM PLT COUNT-210 On Discharge: [**2164-5-23**] 03:46AM BLOOD WBC-14.9* RBC-3.56* Hgb-12.2* Hct-35.0* MCV-98 MCH-34.3* MCHC-34.9 RDW-14.0 Plt Ct-218 [**2164-5-21**] 02:36AM BLOOD PT-13.6* PTT-32.7 INR(PT)-1.2* [**2164-5-23**] 03:46AM BLOOD Glucose-202* UreaN-48* Creat-1.2 Na-137 K-4.2 Cl-98 HCO3-30 AnGap-13 [**2164-5-19**] 05:00PM BLOOD CK-MB-7 cTropnT-2.46* [**2164-5-23**] 03:46AM BLOOD Calcium-8.5 Phos-2.6* Mg-2.2 Imaging: ECHO [**2164-5-17**] The left atrium is mildly dilated. Overall left ventricular systolic function is severely depressed (LVEF= 20-25 %). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened (?#). The study is inadequate to exclude significant aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. IMPRESSION: Severely depressed global left ventricular systolic function with relative preservation of the basal inferolateral and anteroseptal segments. Inadequate image quality to exclude significant aortic stenosis. Certainly by transaortic valvular gradient and peak velocity severe aortic stenosis does not appear to be present, however given the severely impaired left ventricular systolic function it cannot be ruled out. Mild mitral regurgitation. Normal pulmonary artery systolic pressure. Dr. [**Last Name (STitle) **] notified of the results by e-mail on [**2164-5-17**] at 10:10 p.m. [**2164-5-18**] CAROTID SERIES IMPRESSION: Findings as stated above which indicate: 1) 60-69% right ICA stenosis. 2) A 40-59% left ICA stenosis, graded closer to 40%. 3) High-grade stenosis involving both external carotid arteries which may account for any bruit heard on physical exam. [**2164-5-19**]: CXR As compared to [**2164-5-17**], there is significant worsening of pulmonary edema, currently alveolar and involving the entire lungs. Bilateral pleural effusions are most likely present. Cardiomediastinal silhouette is unchanged. There is no evidence of pneumothorax. Brief Hospital Course: Mr. [**Known lastname **] is a 76M with CAD (s/p Cath [**2157**], medically managed), with PPM, PVD s/p RLE angioplasty, CEA ('[**52**]), DM, and multiple strokes who was transferred on [**5-17**] from OSH with NSTEMI and Cardiogenic Shock requiring IABP. . # Cardiogenic Shock: Patient s/p NSTEMI with OSH Cath revealing RCA CTO and proximal 90% LAD. Echo [**5-17**] shows LVEF of 20-25%. Patient with R Femoral IABP in place with MAP 70. On trial of 1:4, the patient's SBP dropped to 80s transiently, suggesting that patient is still IABP dependent. Patient's anatomy is likely amenable to PCI and is not thought to be a CABG candidate at this point. He underwent a PCI and was started on Plavix 75mg daily, ASA325mg, simvastatin 40mg daily and Metoprolol 50mg [**Hospital1 **]. Heparin was continued as was his heparin and aortic pump. IABP site was continued overnight and pulled the next morning without acute complications. Pt did well after pulling the IABP. His pressures were stable and there were no complications related to pulling of the pump or the groin site. . # s/p NSTEMI: Patient with OSH Trop T of 1.02; CK 639, CKMB 43.1. No Cardiac Enzymes to trend at [**Hospital1 18**]. Echo [**5-17**] reveals severely depressed global left ventricular systolic function with relative preservation of the basal inferolateral and anteroseptal segments, with LVEF 20-25%. OSH Cath shows Normal LMCA, 90% prox LAD stenosis, D1 with mild Dz, Chronically occluded Ramus, 100% RCA CTO, with L to R collateralization. His troponins were trended and peaked at 3.67. He had a [**Month/Day (4) **] placed to his LAD and flow distally improved. He was transferred to the CCU for cardiogenic shock, but this resolved and the the balloon pump was removed with no complications. His medications were changed and he was ultimately discharged on atorvastatin 80mg PO Daily, Metoprolol 200mg PO Daily, lisinopril 2.5mg Daily, torsemide 10mg PO daily. He was continued on plavix 75mg PO daily and will need it for 1 year s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) 5175**]. He was also started on Aspirin 325mg PO daily. He will follow up with his cardiologist for further management in the outpatient setting. . # Acute Renal Failure: Unclear baseline, however Cr. at OSH was 1.3. Cr 1.6 on tranfer, and 1.9 today. Likely has some component of renal insufficiency given HTN, DM, however rise in Cr is likely from cardiogenic shock and poor renal blood flow. Despite risk of Contrast Nephropathy, the patient will still likely have cardiac catheterization given his critical LAD stenosis and poor hemodynamic status. His Cr. was trended and on the day of discharge trended down to 1.2. . # HTN: Initially patient had MAP in the 70s - with an IABP in place. Patient was started on NTG gtt to assist with anginal control and BP management. As he stabilized the Nitro gtt was stopped and IABP was removed. His pressures were subsequently controlled with PO meds and his regiment was titrated throughout the course of his hospital stay. On the day of discharge he was initially slightly orthostatic and it was felt to be due to overdiuresis. He was seen by PT in the afternoon and he was no longer orthostatic and was walking around well. As a result he was sent home on torsemide 10mg PO Daily (instead of 20mg as he was on here in the hospital). He was ultimately discharged on the regiment detailed above. # DM II: A1c 7.2. On oral hypoglycemics at home. started SSI while he was in the hospital. At the time of discharge, he was restarted on glyburide 2.5mg PO Daily. . # h/o Multiple Strokes: The patient has had 3 strokes in [**2143**], however it is unclear if these were embolic or related to small vessel disease. The patient is currently on ASA, Plavix, and Dipyrimidole per patient (confirmed with family). Unclear indication for triple therapy. Patient had [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5175**], he will be on dual antiplatelet for at least 1 year - will need to review PCP records for indication for Dipyrimidole. His dipyridimole was discontinued but his asa/plavix was continued at the time of discharge. Medications on Admission: Plavix 75mg daily Metformin 500mg [**Hospital1 **] --- Stopped 2 months ago Glipizide Dipyridamole 25mg daily Metoprolol Tartrate 50mg [**Hospital1 **] Simvastatin 40mg daily Calcarb 600 w Vit D Lisinopril 5mg daily Discharge Medications: 1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for CAD. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for CAD: prox LAD [**Hospital1 **]: please DO NOT stop this medication, please take this medication every day. Disp:*30 Tablet(s)* Refills:*11* 3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. metoprolol succinate 200 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2* 5. glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day. 6. torsemide 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 7. lisinopril 2.5 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: Primary Diagnosis: Non ST elevation Myocardial Infarction . Secondary diagnosis: Diabetes, Dyslipidemia, Hypertension Peripheral Artery Disease --> s/p L CEA 13 years ago --> s/p 3 RLE angioplasties in [**2163**] for RLE ulcer CVA h/o Appendectomy Herniorrhaphy Cataracts 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 are being discharged from [**Hospital1 1170**]. It was a pleasure taking care of you. You were transferred to [**Hospital1 **] because you were found to have a heart attack at another hospital. You also required a balloon pump in order to help pump your blood forward. This was quickly removed as your Blood pressure improved. They initially thought you would need open heart surgery, but later you required a stent to be placed in one of your arteries. After the stent was placed Your symptoms improved dramatically and you began to feel much better. We also gave you a water pill to help remove some fluid in order to improve your breathing. We will send you home on some new medications and will also have you see Rehab at home in order to improve your strength. . The following medications were STARTED: Plavix 75mg by mouth Daily (Take for 12 MONTHS) Aspirin EC 325mg by mouth Daily Torsemide 10 mg by mouth DAILY . The following medications were CHANGED: Metoprolol Tartrate 50mg [**Hospital1 **] --> Metoprolol Succinate XL 200 mg by mouth DAILY Lisinopril 5mg daily --> Lisinopril 2.5 mg by mouth DAILY Simvastatin 40mg daily --> Atorvastatin 80mg by mouth Daily . The followin medication was STOPPED: Dipyridamole 25mg daily . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. . Please take your other medications as prescribed Followup Instructions: Please follow up with your cardiologist, Dr. [**First Name (STitle) 1075**]. They will call you with the appointment. If you do not receive a call from them within 3 days please call [**Telephone/Fax (1) 6256**]. Also, please call you PCP and set up a follow up appointment.

[ "410.71", "428.0", "584.9", "403.90", "414.2", "414.01", "428.21", "443.9", "V12.54", "585.9", "272.4", "V45.01", "250.40", "785.51" ]

icd9cm

[ [ [] ] ]

[ "97.44", "88.56", "00.40", "36.07", "00.66", "00.45" ]

icd9pcs

[ [ [] ] ]

13444, 13493

7976, 12187

331, 345

13809, 13809

4979, 4984

15404, 15683

3130, 3247

12454, 13421

13514, 13514

12213, 12431

13992, 15381

3262, 3262

2532, 2853

5808, 7953

273, 293

373, 2428

13595, 13788

13533, 13574

4999, 5794

13824, 13968

2884, 3040

2450, 2512

3056, 3114

7,096

162,682

24679

Discharge summary

report

Admission Date: [**2116-12-10**] Discharge Date: [**2116-12-20**] Service: MEDICINE Allergies: Codeine Attending:[**First Name3 (LF) 348**] Chief Complaint: Syncope and lsot of consciousness Major Surgical or Invasive Procedure: Dual Chamber Pace Maker Placement Intubation History of Present Illness: 84 y/o M (hard of hearing) with h/o HTN, ?CAD p/w syncope. He is a school monitor who was at the school. He says that he was watching kids play and he passed out. The next thing he remembers was that he was in the SICU at [**Hospital1 18**]. Per EMS, a child intiated rescue breathing at the school. Patient had a laceration to the back of the head and was unresponsive. He was then intubated by EMS for airway protection and flown to [**Hospital1 18**]. Eventually extubated in the SICU and doing well. . ROS: Pt has h/o of DOE; he says that he can climb one flight of stairs. He had an episode of dizziness last year when he stood up from sitting position. He also has some swelling of feet for the past 2 years which has been waxing and [**Doctor Last Name 688**]. No h/o of chest pain, palpitations, n/v/diaphoresis. No h/o of any transient loss of vision/blurriness. His bowel and bladder habits are normal. Past Medical History: PMHx: HTN CAD: EF 40-45% w/ hypokinesis of post/lat walls w/ moderate decrease in overall systolic fn of left ventricle Squamous cell carcinoma s/p PPN, intravesicular mitomycin '[**05**] Diverticulosis causing rectal bleeding Sigmoid polyps Hemorhoids Shingles Melanoma . PSHx: Hernia repair x2 Ear surgeries for Melanoma resection Anal fissure Social History: Lives at home in [**Location (un) **]; has a 15 pack smoking history; occasional drinking. He used to work in Navy as a transporter. Family History: Mother Died of Kidney disease [**Name (NI) 62283**] a violent death Physical Exam: Vitals: 98.6, 124/71, 89, 16, 95%/RA Gen: confortable, alert awake, oriented x3 HEENT: PERRLA, EOMI, Anicteric, Carotid Bruit on left Heart: S1/S2, Trigeminy, no m/r/g Lungs: CTAB Abd: soft, obese, NT Ext: 2+ bilateral edema Skin: Occipital lac Neuro: hard of hearing, no focal deficits Pertinent Results: ECHO Study Date of [**2116-12-15**] The left atrium is dilated. The left ventricular cavity size is normal. LV systolic function appears depressed with inferolateral hypokinesis and mild hypokinesis elsewhere (estimated ejection fraction ?40%). The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is an anterior space which most likely represents a fat pad, though a loculated anterior pericardial effusion cannot be excluded. * EEG Study Date of [**2116-12-12**] Mildly abnormal EEG with some focal slowing noted over the right temporal region intermittently, and further anatomic correlation is recommended. * CT CHEST/ABDOMEN/PELVIS W/CONTRAST [**2116-12-10**] 1. Numerous ovoid high-attenuation foci in the stomach which could represent swallowed pills. 2. Orogastric tube tip in the distal esophagus. 3. Bilateral renal cysts. * CT CERVIAL SPINE No evidence of fracture or subluxation. * CT HEAD Left scalp hematoma. No evidence of an acute intracranial hemorrhage. * CAROTID SERIES COMPLETE [**2116-12-14**] Moderate plaque with a left 40-59% and a right less than 40% carotid stenosis. Brief Hospital Course: # Syncope: Unclear if pt tripped or had syncopal episode. He was not orthostatic on examination. Initially he had bigemies and trigeminies. However eventually he developed Afib a few days after admission. ECHO showed LV sys function depressed with inferolateral hypokinesis with EF of around 40%. EF unchanged from prior ECHO done few year back at OSH. Carotid USG shows moderated stenosis in both Carotids. The EMS EKG tracings showed evidence of pauses. This could have potentially caused him to have a syncope. Read below for further management of dysrhythmia. . # Afib: Per his PCP, [**Name10 (NameIs) **] had rhythm disturbances in the past but never had Afib. During this admission, he developed Afib. He was started on Metoprolol which was increased to 75 TID. This did not rate control him. He was then given IV bolus of 25 mg Dilt for rate control and then started on Dilt drip. He was later put on 90 mg Dilt PO QID and transitioned to long acting Dilt 360 mg QD. EP evaluated him and decided to place Dual Chamber Pacer which was placed on [**2116-12-18**]. He was also started on Coumadin during this admission. He will follow up with the Device clinic at [**Hospital1 18**]. . # UTI: Initially after admission, he developed UIT. He also had a foley placed on admission which was D/C'ed. He was started on Ciprofloxacin and completed a 7 day course of it. He was not sent home on Ciprofloxacin. . # Rising Creatinine: on admission, his creatinine was 1.3 which increased to 1.5 as he was on lasix intially. Lasix was then discontinued. His creatinine remained stable at 1.5 during the course of this admission. . #DOE: had DOE at baseline. ECHo was done which showed EF of 40% with inferolateral hypokinesis. He could also have an element of COPD. We recommended outpatient PFT's. . # HTN: He was continued on Atenolol, Lisinopril. . # Laceration: He had laceration/abrasions on his scalp from his initial syncopal fall. He received wound care for that. Discharge Medications: 1. Keflex 500 mg Capsule Sig: One (1) Capsule PO twice a day for 4 doses. Disp:*4 Capsule(s)* Refills:*0* 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 5. Diltiazem HCl 360 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). Disp:*30 Capsule, Sustained Release(s)* Refills:*2* 6. Erythromycin 5 mg/g Ointment Sig: One (1) application Ophthalmic QID (4 times a day) for 1 weeks. Disp:*28 application* Refills:*0* 7. Outpatient Lab Work Please get your INR, Creatinine checked and report it to your primary care physician. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Syncope Atrial Fibrillation Discharge Condition: All vitals are stable. Discharge Instructions: Please take all your medications and follow up with all your appointments. Please report to the ED or to your physician if you have any chest pain/discomfort, palpitations, dizziness or any concerns at all. . Please get your INR checked on Monday [**12-21**] in your Primary care Physician's clinic. Please discuss this with your primary care physician and adjust the dose of Coumadin. Please also get your Creatinine checked at the same time. . Please take oral antibiotics for 2 days after discharge. . Please follow up with the Device clinic at [**Hospital1 18**] for your Pacemaker check. Followup Instructions: You have a follow up appointment in the Device Clinic at [**Hospital1 18**]. Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2116-12-28**] 3:00 . Please Call to schedule with your Primary Care Physician. [**Name Initial (NameIs) 2169**]: [**Name10 (NameIs) **],[**Name11 (NameIs) 1955**] [**Name Initial (NameIs) **] [**Telephone/Fax (1) 62284**] appointment . Other appointments that you can make: Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 9472**] Call to schedule appointment Completed by:[**2116-12-23**]

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icd9cm

[ [ [] ] ]

[ "37.83", "96.71", "37.72", "86.59" ]

icd9pcs

[ [ [] ] ]

6371, 6428

3555, 5523

250, 297

6500, 6525

2169, 3532

7166, 7787

1776, 1846

5546, 6348

6449, 6479

6549, 7143

1861, 2150

177, 212

325, 1240

1262, 1610

1626, 1760

45,684

121,917

35752

Discharge summary

report

Admission Date: [**2170-2-27**] Discharge Date: [**2170-3-13**] Date of Birth: [**2100-6-21**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4748**] Chief Complaint: Right foot ulcer Major Surgical or Invasive Procedure: Angiogram with angioplasty and stent placement in right Common femoral artery. Right Carotid endarterectomy [**2170-3-1**] ?Right Leg Common Femoral to PT bypass Angiogram with angioplasty and stent placement in right Common femoral artery. Right Carotid endarterectomy [**2170-3-1**] ?Right Leg Common Femoral to PT bypass History of Present Illness: HPI: 69 diabetic female, with PMH of lung ca presents w/ lesion right second toe referred from OSH for further evaluation of ulcer and PVD. Pt first notice the appearance of second right toe and right heel ulcer in [**12-22**] after c/o pain in her foot. PT initially presented to outside podiatrist referred her to [**Hospital1 18**] for angiographic evaluation of bilateral LE. PT [**Name (NI) **] that the toe ulcer can be quite painful 8/10 intensity with dressing changes and with walking. She is of limited mobility due to the discomfort and walk only from bedroom to kitchen in a small mobile home. She denies fever, chills, N/V/D/C, chest pain, or SOB and is otherwise in USOH. Pt is followed by her PCP for her DM with Blood sugars ranging routinely in the 200s , but occasionally as high as 400. Per patient's own report she is often non compliant with medications and follow up. ROS is significant for weight loss of 15 lbs over the past 6 months due to decreased appetite. Past Medical History: PMH: DMII,Lung ca Angina NOS, MS [**First Name (Titles) **] [**Last Name (Titles) **] w. resolution, ETOH and Medication abuse, pericarditis. PSH: S/p lobectomy 07, Thyroidectomy, hysterectomy. Social History: History of ETOH and narcotic addiction. At present pt does not drink nor use narcotics. Former smoker [**12-15**] PPD x 40 years pt quit last year after lung ca diagnosis. Family History: Mother: Stomach Ca Father: CAD, hypercholesterolemia Physical Exam: PE: Gen: NAD, A&O x 3, thin appearing female not obviously malnourished. CVS: RRR no m/r/g. Carotid bruit on the right side. Pulm: CTAB bilaterally with decreased lung sound on the right lower lung base. Abd: S/ NT/ ND no masses Sacrum: 1 cm shallow stage II decubital ulcer on sacrum. Ext : WWP decreased hair and moderate atrophy bilateral calf muscles. Right second digit with shallow based wet ulcer, and 3 cm ulcer at right heel; neither probes to bone, nor is there surrounding erythema or induration. Bilateral feet slightly cool to touch. third digit on the left foot has callous <0.5 cm. Pulses: Fem DP PT R 1+ - D L 2+ D D Pertinent Results: Carotid U/S: [**2-27**] CXR: No evidence of acute pulmonary infiltrates, cardiomegaly or pulmonary congestion. Preoperative chest examination. Findings compatible with right lower lobectomy. Clinical correlation recommended. [**2-27**] EKG: Sinus tachycardia with sinus arrhythmia Possible left atrial abnormality Left ventricular hypertrophy Lateral ST-T changes are probably due to ventricular hypertrophy No previous tracing available for comparison Brief Hospital Course: [**2170-2-27**]: Pt admitted to the vascular service. Preoperative lab work, ekg , CXR obtained. Pt pretreated with bicarba nd ,ucomyst prior to angiography on [**2-28**]. [**2170-2-28**]: Pt underwent angiography demonstrating significant occlusion of her right superficial femoral artery. There was a more proximal occlusion of her right Common femoral artery thus an angioplasty and stent were placed. Pt did well post angio without hematoma formation. PT scheduled for right leg femoral to PT bypass. [**2170-3-1**] PT underwent preoperative carotid ultrasound for carotid bruit heard on the right side. U?S demonstrated a 80-99% stenosis. The Patient was then canceled for her bypass and scheduled for a Right Carotid endarterectomy instead. [**2170-3-2**]:POD#1 no overnight events,transfused 2 units PRBC"s for HCt.of 20.6 post transfusion Hct. transfusion 28.7. patient delined, diet advanced, ambulation instuted and transfered to regular nursing floor from VICU. Neuro intact wound with hematoma but stable. episode of tachycardia with low systollic B/p fluid resustated. cortisol level 21.9 cardiac enzymes cycled negative for MI. [**Date range (1) 81310**] POD#4 Antibiotics started for temp 102. blood and urine c/s obtained finalized no growth. stool for C. diff negative.wound care for stage 2 ulcer. continues with episodes of low SBP and sinus tachy cardia which respond to fluid boluses. cardiac enzymes negative.started on diclox for MSSA wound infection [**2170-3-6**] POD#%/DOS rt. CFA-PT bpg. [**2170-3-7**] POD#[**6-13**] requiring low dose IV neo to maintain B/P >90 WBC continues to be elevated 17.9 c/s are no growth and wounds are clean.[**Last Name (un) 104**] stim done.44.1-49.2-21.9 midrone started 2.5 tid and increased for orthostatic b/p changes.and increased to 5mg tid. Sopcial service consult for family social issues. [**2170-3-8**] POD#[**7-15**] WBC 21.1 CXR obtained. aline and foley d/c'd. midrone increased to7.5mgm tid for orthostasis. Sacral decube care.failed to void foley repalced. [**2170-3-9**] POD#[**8-16**] WBC19.1, CXR without focal consolidation. PT to work with patient. [**2170-3-10**] POD#[**9-16**] Pt continued to be hypotensive with sbps in the 70s, but asymptomatic clinically. Midodrine increased to 10 mg and florinef started at 0.05 mg. [**2170-3-11**] POD [**10-18**]: no issues, her BP responded to florinef. [**2170-3-12**] POD [**11-18**]: Pt was ready for D/C, however it was noted that her WBC jumped from 17 to 20, though she was afebrile and o/w stable. A UA, and CXR were unremarkable. She has had chronic leukocytosis since admission in the high teens to low 20s, but work-up has been negative, including labs, cx, c.diff, etc. [**2170-3-13**] POD 13/7: CBC was repeated and down to 19.3. She continued to be stable and felt ready for D/C to rehab. Important to note that a wbc in the high teens for her seems to be baseline since her admission in the face of a negative work-up. Medications on Admission: metformin 500mgm [**Hospital1 **] glipazide 10mg [**Hospital1 **] levothyroxine 100mcg daily potassium 30meq tid folic acid 1mgm daily thiamin 100mg daily lipitor 80mg daily celexa 20mg daily prilosec 20mg daily fosamax 70mg weekly Discharge Medications: 1. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:*50 Tablet(s)* Refills:*0* 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 13. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Docusate Sodium 100 mg 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. 17. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Location (un) 169**] Discharge Diagnosis: Right carotid stenosis 80-99% Right subclavian stenosis Right leg ischemia sacral decubitus stage2 Discharge Condition: VSS, tolrating a regular diet, pain well controlled with PO pain medications Discharge Instructions: What to expect when you go home: 1. Surgical Incision: ?????? It is normal to have some swelling and feel a firm ridge along the incision ?????? Your incision may be slightly red and raised, it may feel irritated from the staples 2. You may have a sore throat and/or mild hoarseness ??????1 Try warm tea, throat lozenges or cool/cold beverages 3. You may have a mild headache, especially on the side of your surgery ??????2 Try ibuprofen, acetaminophen, or your discharge pain medication ??????3 If headache worsens, is associated with visual changes or lasts longer than 2 hours- call vascular surgeon??????s office 4. It is normal to feel tired, this will last for 4-6 weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? You may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 5. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? No excessive head turning, lifting, pushing or pulling (greater than 5 lbs) until your post op visit ?????? You may shower (no direct spray on incision, let the soapy water run over incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ??????1 Changes in vision (loss of vision, blurring, double vision, half vision) ??????2 Slurring of speech or difficulty finding correct words to use ??????3 Severe headache or worsening headache not controlled by pain medication ??????4 A sudden change in the ability to move or use your arm or leg or the ability to feel your arm or leg ??????5 Trouble swallowing, breathing, or talking ??????6 Temperature greater than 101.5F for 24 hours ??????7 Bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions Followup Instructions: Please follow up with Dr [**Last Name (STitle) 1391**] 2 weeks please call ([**Telephone/Fax (1) 29063**] to schedule. Completed by:[**2170-3-13**]

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icd9cm

[ [ [] ] ]

[ "39.29", "88.48", "00.41", "39.90", "88.42", "00.44", "39.50", "00.46", "00.40", "38.12" ]

icd9pcs

[ [ [] ] ]

7997, 8047

3344, 6319

331, 658

8190, 8269

2863, 3321

11058, 11208

2105, 2159

6601, 7974

8068, 8169

6345, 6578

8293, 10456

10482, 11035

2174, 2844

275, 293

686, 1679

1701, 1898

1914, 2089

11,683

137,920

12953

Discharge summary

report

Admission Date: [**2142-10-29**] Discharge Date: [**2142-11-1**] Date of Birth: [**2066-1-13**] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old male with a history of end stage cardiomyopathy and an ejection fraction of 15% and a recent admission at [**Hospital6 11241**] on [**9-29**] to [**10-19**] with multiple episodes of respiratory and cardia decompensation, requiring intubation and pressors. The patient was discharged to [**Hospital3 2558**] nursing facility for further care and, over the past week, has had increasing shortness of breath. He denies any chest pain, nausea, vomiting, diaphoresis or syncope. No light headedness. Question of mild fever although not documented temperature. No cough. On the day of presentation, the patient had acute shortness of breath and severe paroxysmal nocturnal dyspnea and three pillow orthopnea. The patient and wife went to Dr. [**Last Name (STitle) **] at [**Hospital3 2558**], also associated with [**Hospital3 4262**] Group and had long discussion about the patient's goals. The patient was previously made DNR/DNI. The patient hoped to go to [**Location 11206**] VA for further care of this acute crisis and possible further discussion about hospice management and palliative management of current complaints. However, on transport with EMS, the patient became hypotensive with systolic in the 80's; diastolic pressure was not palpable by EMS; therefore, the patient was taken to [**Hospital1 69**]. In the Emergency Department, the patient was given one dose of 40 intravenous Lasix with good urinary output. He was put on Dopamine mom[**Name (NI) 11711**]. [**Name2 (NI) **] pressure increased to the 130's. Heart rate began to have ectopy. Dopamine was discontinued within minute and [**Name2 (NI) **] pressure was sustained in the 130's. The patient mentated well throughout the entire episode and had no complaints. Of note, the patient also reports that he has chronic diarrhea over the last few weeks. He received multiple antibiotics at his last admission at [**Hospital1 69**]. He also was checked for Clostridium difficile at that point. He was treated with Flagyl but was reportedly Clostridium difficile negative. PAST MEDICAL HISTORY: Coronary artery disease; status post coronary artery bypass graft. All information at outside hospital. Congestive heart failure with an ejection fraction of 15%, documented in [**9-17**]. No other information available. Status post abdominal aortic aneurysm repair, unknown when. Paroxysmal atrial fibrillation, not on Coumadin, not known why. Chronic renal insufficiency, supposed baseline of 1.9. Hypercholesterolemia. Anion gap metabolic acidosis, ongoing since [**Month (only) **]. The patient has received much magnesium and bicarbonate at [**Hospital3 2558**] with unknown cause. The patient has a history of chronic abdominal pain. Recently, he had an exploratory laparotomy at [**Hospital1 69**] to rule out mesenteric ischemia. No abdominal processes were found to be the cause of his abdominal pain. However, cardia hypoperfusion is presumed. MEDICATIONS: Digoxin 0.125 mg 1. day. Captopril 12.5 three times a day. Zantac 150 mg twice a day. Loperamide 2 mg prn. Roxanol 20 mg over 5 cc to be given prn. Tylenol prn. Dulcolax prn. Multi-vitamins q. day. Pureed regular nectar thick diet. ALLERGIES: Reports allergy to Quinidine and Proscar, unknown response. SOCIAL HISTORY: He denies any history of tobacco, illicit drugs or alcohol. PHYSICAL EXAMINATION: Vital signs on admission revealed: Temperature 100.9, [**Hospital1 **] pressure 120/90; heart rate 103; respiratory rate 28; 100% saturation on non rebreather. In general, he was alert, oriented to place. He was a very thin, cachectic looking African-American male on a non rebreather with shallow respiratory rate but overall pretty calm. HEAD, EYES, EARS, NOSE & THROAT: Anicteric with moist mucous membranes. Oropharynx is clear. JVP was at the mandible at 45 degrees with diffuse point of maimal impulse, laterally displaced. CARDIOVASCULAR: Regular rate, occasionally tachy rhythm. Could not appreciate any murmurs, rubs or gallops. RESPIRATORY: Shallow tachypneic breathing. No intercostal retractions. Crackl LUNGS: Clear to auscultation Crackles half way up, left greater than the ABDOMEN: Scaphoid, soft, nontender, nondistended, normoactive bowel sounds. No organomegaly appreciated. Extremities were cool, dry, withh lower extremities, due to presumed vasoconstriction. NEUROLOGICAL: Cranial nerves 2 through 12 were grossly intact. There were no gross deficits throughout. Skin was dry without any rashes. Stage II sacral decubitus noted across the sacrum, approximately 4 by 8 cm with Duoderm patch in place. Access: The patient has triple lumen catheter inserted in his groin by the Emergency Department. LABORATORY FINDINGS: Potassium of 6.3; bicarbonate of 18; creatinine of 1.9. Troponin of .35. CK 134. MB of 9. White count of 7.2. No shift. Hematocrit of 34. INR of 1.6. Lactate of 4.3. [**Hospital1 **] cultures were drawn. ELECTROCARDIOGRAM; Rate of 102; normal axis; regular low limb lead voltage; left bundle branch block. No ST or T wave changes whatsoever. Chest x-ray with a left effusion, very small. Multiple chamber enlargement. Cephalization of the vessels and increased vascularization. Our impression initially was that this 76-year-old man with respiratory compromise, likely due to congestive heart failure exacerbation, ejection fraction of 15%. Although it was not presumed that there was an infectious cause, we figured that we could not see an infiltrate on chest x-ray given the congestive heart failure pattern. The patient was given Levofloxacin times one dose in the Emergency Department. The patient received Lasix diuresis until he put out 1.5 liters over the first couple of days of admission. Oxygen was titrated down to two liters nasal cannula. Ace inhibitor was continued for after load reduction. Digoxin level was checked and found to be within normal limits. Digoxin was continued. The patient was weighed daily and had a [**2138**] liter fluid restriction and a 2 gram sodium diet. Within two days of admission, the patient was breathing well on two liters of nasal cannula, almost near his baseline per his reports and per wife's reports. Coronary artery disease, status post coronary artery bypass graft. The patient was started on aspirin. Lipids were checked and found to be within normal limts so no statin was started. The patient was ruled out myocardial infarction. Enzymes were cycled. He was monitored on telemetry and was noted to have ectopy and random premature ventricular contractions but no concerning rhythm. He had a history of atrial fibrillation, now in sinus during this admission. He was continued on Digoxin. He was given no rate control despite his tachycardia, because it was thought that this was cardiac output, given his low ejection fraction. It was unclear why the patient was not on Coumadin; however, once reaching discussion about Palliative Care, it was determined not to start this. Metabolic acidosis without a gap. The patient had a history of this at [**Hospital1 69**] and at [**Hospital3 2558**] per his primary care physician, [**Name10 (NameIs) 1023**] saw him in house at [**Hospital1 69**]. It was likely due to his chronic diarrhea. When the patient was hydrated well and diuresed, bicarbonate level corrected. Chronic renal insufficiency: It was presumed that he was at his baseline, even though no past records were available to us. He was given careful diuresis. on day of discharge, creatinine was 1.7. Furea and FENa were both checked throughout admission and were very low, consistent with being a prerenal problem, consistent with poor cardiac output. Hyperkalemia on admission, presumed to be due to metabolic acidosis. It was thought that it would be very unlikely that it would be due to ace inhibitors. The patient was given [**Doctor First Name 233**]-Exalate. Electrocardiograms were monitored. Electrocardiograms throughout admission revealed no changes from the time of admission. Potassium came down the day after admission and potassium levels were monitored throughout the stay and remained normal. The patient had a history of abdominal pain, thought to be abdominal angina due to poor ejection fraction. The patient had no abdominal pain throughout the entire admission and required no analgesic medications. Diarrhea: The patient had stool studies sent to evaluate diarrhea. Clostridium difficile came back negative times one. At the time of discharge, stool ova and parasites, Cryptosporidium, Giardia, Cyclospora, culture, microsporidian, E.coli, urisinia and vibrio were all pending. It was presumed that once this was found to be negative, the patient could be restarted on Loperamide for discomfort. During his stay, a rectal tube was placed and the patient reported that this was more comfortable than having multiple bowel movements throughout the entire day. Fluids, electrolytes and nutrition: The patient had low magnesium and high potassium and then low potassium throughout the admission. These were monitored carefully given his renal insufficiency. He was maintained on a pureed diet with nectar thick liquids and Boost supplements prn. He received Zantac twice a day and multi-vitamins with mineral throughout his stay. Propylaxis was maintained with Pneumoboots and bowel regimen and pain regimen and aspiration precautions. Discussions were held regularly with the patient and his wif, who is his health care proxy. It was presumed that the patient, once out of congestive heart failure, could be discharged back to [**Hospital3 2558**] nursing facility; however, after multiple family discussions, it was determined that the best thing for him, given his chronic debilitating cardiac function, would be to be in a hospice care facility to maximal symptom management. On the day of discharge, discussion was held between the primary team, the patient and the patient's wife, his health care proxy. The patient reported that he only wanted his symptoms managed. He understood that there was no cure for his illness. There was nothing more that could be medically done to maximize his treatment. He reported that he wanted to have high quality of life with his family. He did not want to be a burden to his wife and he did not want to be hospitalized again. The patient was discharged to skilled nursing facilty with hospice care services. DISCHARGE CONDITION: Breathing well with normal oxygen on two liters nasal cannula, eating and drinking, voiding with a Foley, having diarrhea via rectal tube. Unable to walk or get out of bed on his own. He was discharged to a skilled nursing facilty. RECOMMENDED FOLLOW-UP: Only with his primary physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], as well as a doctor [**First Name8 (NamePattern2) **] [**Last Name (Titles) 669**] VA for symptom management. DISCHARGE DIAGNOSES: Congestive heart failure, due to systolic dysfunction. Hypotension. Paroxysmal atrial fibrillation. Chronic renal insufficiency. Non anion gap acidosis. Hyperkalemia. Hypokalemia. Hypermagnesemia. Coronary artery disease, status post coronary artery bypass graft. CODE: DNR/DNI, documented previously during admission. DISCHARGE MEDICATIONS: Digoxin .125 mg q. day. Zantac 150 mg twice a day. Tylenol 325 mg prn. Bisacodyl prn constipation. Senna prn constipation. Multi-vitamin with mineral q. day. Levofloxacin 250 mg. p.o. q. 24 hours times seven days for pneumonia. Lisinopril 2.5 mg p.o. q. day. Morphine sulfate 20 mg per ml solution, take 1 ml p.o. every four to six hours sublingually as needed for shortness of breath or wheezing. Scopolamine patch 1.5 mg q. 72 hours to be used to dry the secretions in his throat secondary to heart failure. Oxygen, two liters nasal cannula. Ativan, .5 mg take one tablet p.o. every six to eight hours as needed for shortness of breath, wheezing or anxiety. Duoderm patch, to be applied to sacral wound for skin protection daily. [**Name6 (MD) 2467**] [**Last Name (NamePattern4) 10404**], M.D. [**MD Number(1) 10405**] Dictated By:[**Last Name (NamePattern1) 39756**] MEDQUIST36 D: [**2142-10-31**] 04:05 T: [**2142-10-31**] 16:07 JOB#: [**Job Number 39757**]

[ "427.31", "428.0", "790.7", "276.4", "428.23", "414.8", "707.0", "584.9", "518.82" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10634, 11097

11118, 11440

11463, 12464

3549, 10612

157, 2242

2265, 3449

3466, 3527

25,413

195,989

44606+58737

Discharge summary

report+addendum

Admission Date: [**2137-10-14**] Discharge Date: [**2137-11-12**] Date of Birth: [**2080-10-24**] Sex: M Service: NEUROSURGERY HISTORY OF PRESENT ILLNESS: The patient was admitted after three days complaining of headache increasing in intensity and frequency. He initially presented to the Emergency Room awake, alert, and oriented times three. He had some slight slurring of his speech which resolved spontaneously. He was spontaneously. Otherwise he was neurologically intact with full range of motion, full strength, and full sensation. No pronator drift was noted. Vitals signs were stable. Visual fields were intact. Labs were within normal limits except for a PT of 2.7, but he is on Coumadin. CAT scan revealed a subarachnoid hemorrhage with blood in Otherwise PE was unremarkable. PAST MEDICAL HISTORY: Hypertension. Gallbladder disease. Mitral valve prolapse. Atrial fibrillation. Congenital abnormality of his right thumb. PAST SURGICAL HISTORY: Mitral valve repair in [**2137-5-4**] along with an AFB repair. He also has had pilonidal cyst excision and digit removal. MEDICATIONS ON ADMISSION: Lopressor, Coumadin. HOSPITAL COURSE: On [**10-15**], he underwent a cerebral angiogram which revealed a dissecting fusiform aneurysm of the superior cerebellar artery and underwent GDC aneurysm coiling to achieve parent vessel occlusion (PVO) in the Angiography Suite. He was transferred to the Intensive Care Unit. Triple therapy was started with Cardiology input. He was in rapid atrial fibrillation in the 140s which was difficult to control with Labetalol and Amiodarone. He self-extubated on the 15th and was subsequently reintubated on [**10-20**] for increased work of breathing. He remained in rapid atrial fibrillation, and he was treated with Diltiazem with some affect. On the 17th, a PA line was inserted due to hemodynamic instability. Cardiac index was found to be 17. On the next morning on 18th, a balloon pump was placed for hemodynamic support. Low-dose Heparin was also started for anticoagulation. He spiked a temperature to 103-104??????. He did have some gram-negative rods in his sputum which was treated with a [**6-12**] day course of antibiotics. He also had a catheter tip culture which was positive, but blood cultures were negative, so that was not treated. On the 19th, he had some increasing LFTs. He had a right upper quadrant ultrasound which was negative. His LFTs came down on its own without treatment. On the 20th, hemodynamics slowly improved since the balloon pump was put in, and that was subsequently removed with a last index of 30. On the 23rd, he had some bibasilar vasospasms and was started on Heparin. On the 27th, he was extubated and has done well since. On [**11-5**], he discontinued his vent drain himself, and he was later transferred to the floor. On the 4th, he had a swallow study done, and he passed. Physical Therapy and Occupational Therapy evaluated him, and he will require acute rehabilitation. DISCHARGE MEDICATIONS: Heparin IV 1550 U/hr, Protonix 40 mg p.o. q.d., Reglan 10 mg p.o. q.i.d., Diltiazem 60 mg p.o. q.i.d., Tylenol 1000 p.o. q.6 hours p.r.n., sliding scale Insulin, Docusate 100 mg p.o. b.i.d. FOLLOW-UP: The patient will need to follow-up with [**Doctor Last Name 1132**] in two weeks after discharge. CONDITION ON DISCHARGE: The patient was stable at the time of discharge. [**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2137-11-6**] 12:05 T: [**2137-11-6**] 14:03 JOB#: [**Job Number 95493**] 1 1 1 DR Name: [**Last Name (LF) 15136**],[**Known firstname **] Unit No: [**Numeric Identifier 15134**] Admission Date: [**2137-10-14**] Discharge Date: [**2137-11-12**] Date of Birth: [**2080-10-24**] Sex: M Service: ADDENDUM: The patient's discharge was delayed secondary to lack of a rehabilitation bed. The patient was discharged to [**Hospital6 8525**] on [**2137-11-12**] in stable condition. He will follow up with Dr. [**Last Name (STitle) 365**] in one to two weeks. [**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 5862**] Dictated By:[**Last Name (NamePattern1) 366**] MEDQUIST36 D: [**2138-1-9**] 09:51 T: [**2138-1-9**] 10:03 JOB#: [**Job Number 15137**]

[ "785.51", "401.9", "997.3", "428.0", "427.31", "486", "518.5", "430", "997.1" ]

icd9cm

[ [ [] ] ]

[ "39.72", "37.61", "96.72", "96.6", "88.41", "38.91", "37.64", "02.2", "96.04" ]

icd9pcs

[ [ [] ] ]

3050, 3352

1145, 1167

1185, 3026

994, 1118

176, 821

844, 970

3377, 4449

14,914

190,329

43772

Discharge summary

report

Admission Date: [**2163-5-22**] Discharge Date: [**2163-6-1**] Date of Birth: [**2078-6-20**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1406**] Chief Complaint: chest pain, dizziness Major Surgical or Invasive Procedure: [**2163-5-27**] Aortic valve replacement with 23mm Trifecta tissue valve History of Present Illness: 84M male known to cardiac surgery service with significant aortic stenosis who presented to the ED on [**5-22**] with complaints of chest pain, dizziness and diaphoresis. He reports that he was getting dressed in his rehab facility when he developed chest pressure, dyspnea, lightheadedness, nausea and vomiting. He was given O2 and 325mg of aspirin at the facility and his symptoms resolved prior to arrival at the emergency department. He reports exertional angina for the past few years which resolved at rest, but had not had presyncope or syncope until recently. He was admitted to [**Hospital1 18**] [**157-5-28**] for syncope. He admitted at that time with worsening substernal chest pressure, radiation to L arm, lightheadededness and a syncopal event which lasted 5 minutes. He was found to have NSTEMI from demand secondary to critical AS. He was evaulated at that time for open high risk AVR vs Corevalve and it was recently decided by the family and the patient to decline enrollment in the study and proceed with open AVR. Cardiac surgery was reconsulted for evaluation. Past Medical History: 1. CARDIAC RISK FACTORS: +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: - Atrial fibrillation - Aortic stenosis, [**Location (un) 109**] 0.8 cm2 [**2163-4-22**] - CAD s/p silent MI (though pt denies this) 3. OTHER PAST MEDICAL HISTORY: ESRD secondary to hypertensive nephropathy s/p ECD transplant on [**2161-1-30**] and s/p nephrostomy tube placements, most recently on [**2161-5-8**]; had been on PD prior to transplant - Gout - BPH s/p TURP - PVD s/p L renal stents - Hiatal hernia - s/p right TKR - Hemorroidectomy - s/p L carpal tunnel release x 2 - [**2161-3-5**] UTI, MDR E. coli - [**2161-3-5**] bacteremia, MDR E. coli Social History: He lives with his wife and two sons. Wife currently has hematologic malignancy; home life is stressful. He retired last year from being an administrate assistant to the mayor; used to be a fire fighter for many years. Denies tobacco, alcohol, or drug use. Family History: HTN in multiple family members. Elevated creatinine in several children. Older brother had pericarditis and MI. Sister has [**Name (NI) 4522**] disease. Physical Exam: Pulse:61 Resp:18 O2 sat:99% RA B/P Right: 119/62 Height:5'9" Weight:71.8 General: AAO x 3 in NAD Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [] Irregular [x] Murmur [] grade IV/VI SEM Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema: Trace Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right:1+ Left:1+ DP Right:1+ Left:1+ PT [**Name (NI) 167**]:1+ Left:1+ Radial Right:1+ Left:1+ Carotid Bruit: transmitted murmur b/l vs bruit Pertinent Results: [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 94050**] (Complete) Done [**2163-5-27**] at 10:12:33 AM PRELIMINARY Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 18**] - Department of Cardiac S [**Last Name (NamePattern1) 439**], 2A [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2078-6-20**] Age (years): 84 M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Intraoperative TEE for AVR ICD-9 Codes: 424.1, 424.0 Test Information Date/Time: [**2163-5-27**] at 10:12 Interpret MD: [**First Name8 (NamePattern2) **] [**Name8 (MD) 17792**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 17792**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2012AW-:1 Machine: p2 Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *5.8 cm <= 4.0 cm Left Atrium - Four Chamber Length: *7.2 cm <= 5.2 cm Left Ventricle - Septal Wall Thickness: *1.6 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: *1.4 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.6 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 3.9 cm Left Ventricle - Fractional Shortening: *0.15 >= 0.29 Left Ventricle - Ejection Fraction: 45% to 50% >= 55% Aorta - Annulus: 2.5 cm <= 3.0 cm Aorta - Sinus Level: 3.5 cm <= 3.6 cm Aorta - Sinotubular Ridge: 2.7 cm <= 3.0 cm Aorta - Ascending: *3.6 cm <= 3.4 cm Aorta - Descending Thoracic: *2.8 cm <= 2.5 cm Findings LEFT ATRIUM: Marked LA enlargement. Mild spontaneous echo contrast in the body of the LA. Moderate to severe spontaneous echo contrast in the LAA. Depressed LAA emptying velocity (<0.2m/s) RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. No ASD by 2D or color Doppler. LEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size. Mildly depressed LVEF. RIGHT VENTRICLE: Borderline normal RV systolic function. AORTA: Mildly dilated ascending aorta. Mildly dilated descending aorta. Simple atheroma in descending aorta. No thoracic aortic dissection. AORTIC VALVE: Three aortic valve leaflets. Severely thickened/deformed aortic valve leaflets. Bioprosthetic aortic valve prosthesis (AVR). Paravalvular leak. Critical AS (area <0.8cm2). Mild to moderate ([**11-29**]+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular calcification. Mild to moderate ([**11-29**]+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Physiologic (normal) PR. GENERAL COMMENTS: Written informed consent was obtained from the patient. A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. patient. Conclusions PRE-CPB: The left atrium is markedly dilated. Mild spontaneous echo contrast is seen in the body of the left atrium. Moderate spontaneous echo contrast is present in the left atrial appendage. The left atrial appendage emptying velocity is depressed (<0.2m/s). No atrial septal defect is seen by 2D or color Doppler. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed (LVEF= 40-50 %). The RV is normal sized with borderline normal free wall function. The ascending aorta is mildly dilated. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. No thoracic aortic dissection is seen. The aortic valve leaflets (3) are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). Mild to moderate ([**11-29**]+) central aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is moderate calcification of the posterior annulus. Mild to moderate ([**11-29**]+) mitral regurgitation is seen. POST-CPB: After initial separation from bypass, a bioprosthetic valve is seen in the aortic position with a paravalvular leak likely localizing to the area of the left coronary cusp. The jet is eccentrically directed across the face of the aortic valve. CPB is reinitiated for repair of paravalvular leak. After second separation from bypass, the bioprosthetic valve is again seen in the aortic position. The valve is well seated with normally mobile leaflets. There is trace central AI. There remains a tiny jet of paravalvular leak in the same location, significantly improved from pior. The peak gradient across the aortic valve is 8mmHg, the mean gradient is 4mmHg with CO of 4.2L/min. The left ventricular systolic function remains mildly depressed, estimated EF=45%. The right ventricular systolic function appears normal. The mitral regurgitation remains mild to moderate. Other valvular function remains unchanged. There is no aortic dissection. Dr [**Last Name (STitle) **] was notified of findings at time of study. Brief Hospital Course: Mr. [**Known lastname 3794**] was admitted to the [**Hospital1 18**] on [**2163-5-22**] for further management of his severe aortic stenosis. He was medically optimized in preparation for surgery. The cardiac surgical service was consulted for replacement of his aortic valve. He was worked-up in the usual preoperative manner. A dental consultation was obtained for oral clearance for surgery. He was found to require teeth extraction prior to surgery which was performed by the oral surgical service on [**2163-5-26**]. On [**2163-5-27**], he was cleared for surgery and taken to the operating room where he underwent replacement of his aortic valve using a tissue prosthesis. Please see operative note for details. Postoperatively he was taken to the intensive care unit for monitoring. On the same day he was extubated and weaned from inotropic support. His chest tubes were removed. The renal service followed him to guide his care given his past renal transplant. he was doses with lasix 40mg po prn for lower extremity edema- his creat at discharge was 1.7 and he was given 40mg po lasix on [**2163-6-1**]. On post-operative day two Mr. [**Known lastname 3794**] transferred to the cardiac step down floor. His epicardial wires were removed without incident. He was seen in consultation by the physical therapy service. By post-operative day #5 he was ready for discharge. He was discharged to [**First Name8 (NamePattern2) 3075**] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) **] for Living with appropriate follow-up instructions. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. Tamsulosin 0.4 mg PO HS 2. Tacrolimus 1 mg PO Q12H 3. Sulfameth/Trimethoprim DS 1 TAB PO DAILY 4. Aspirin 325 mg PO DAILY 5. Allopurinol 100 mg PO DAILY 6. Mycophenolate Mofetil 250 mg PO BID 7. Famotidine 20 mg PO DAILY 8. Acetaminophen 325 mg PO Q6H:PRN pain 9. Rosuvastatin Calcium 20 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q4H:PRN pain 2. Aspirin EC 81 mg PO DAILY 3. Mycophenolate Mofetil Suspension 250 mg PO BID 4. Tacrolimus 1 mg PO Q12H 5. Tamsulosin 0.4 mg PO HS 6. Bisacodyl 10 mg PR DAILY:PRN constipation 7. Artificial Tears 1-2 DROP BOTH EYES PRN irritation 8. Allopurinol 100 mg PO DAILY 9. Rosuvastatin Calcium 20 mg PO DAILY 10. Docusate Sodium 100 mg PO BID 11. Metoprolol Tartrate 50 mg PO BID Hold for HR < 55 or SBP < 90 and call medical provider. 12. sodium citrate-citric acid *NF* 500-334 mg/5 mL Oral tid 15mEq tid * Patient Taking Own Meds * 13. Famotidine 20 mg PO DAILY 14. Sulfameth/Trimethoprim DS 1 TAB PO DAILY 15. Senna 2 TAB PO BID:PRN constipation 16. Furosemide 40 mg PO DAILY:PRN edema Discharge Disposition: Extended Care Facility: [**First Name8 (NamePattern2) 3075**] [**Last Name (NamePattern1) **] Discharge Diagnosis: -Dyslipidemia -Hypertension - Atrial fibrillation - Aortic stenosis, [**Location (un) 109**] 0.8 cm2 [**2163-4-22**] - CAD s/p silent MI (though pt denies this) -ESRD secondary to hypertensive nephropathy s/p ECD transplant on - Gout - Hiatal hernia - [**2161-3-5**] UTI, MDR E. coli - [**2161-3-5**] bacteremia, MDR E. coli Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with tylenol Incisions: Sternal - healing well, no erythema or drainage Edema: 1+ lower extremity edema Discharge Instructions: 1) Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage. 2) Please NO lotions, cream, powder, or ointments to incisions. 3) Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart provided. 4) No driving for approximately one month and while taking narcotics. Driving will be discussed at follow up appointment with surgeon when you will likely be cleared to drive. 5) No lifting more than 10 pounds for 10 weeks 6) Please call with any questions or concerns [**Telephone/Fax (1) 170**] *Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**Last Name (STitle) **] on [**2163-6-23**] at 1:15PM [**Telephone/Fax (1) 170**] in the [**Hospital **] medical office building [**Doctor First Name **] [**Hospital Unit Name **] Cardiologist/PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**2163-6-15**] at 12PM [**Telephone/Fax (1) 7728**] Previously scheduled appts: Provider: [**First Name8 (NamePattern2) 161**] [**Name11 (NameIs) 162**] [**Name8 (MD) 163**], MD Phone:[**Telephone/Fax (1) 921**] Date/Time:[**2163-10-12**] 2:30 Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2163-8-2**] 1:40 **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:[**2163-6-7**]

[ "410.72", "416.8", "428.0", "443.9", "522.4", "287.5", "274.9", "413.9", "427.31", "V43.65", "427.89", "401.9", "272.4", "428.32", "424.1", "V42.0" ]

icd9cm

[ [ [] ] ]

[ "23.09", "39.61", "35.21" ]

icd9pcs

[ [ [] ] ]

11532, 11628

8764, 10327

332, 407

11998, 12187

3312, 8741

13161, 14052

2470, 2624

10784, 11509

11649, 11977

10353, 10761

12211, 13138

2639, 3293

1619, 1753

270, 294

435, 1523

1784, 2179

1545, 1599

2195, 2454

52,754

184,571

36321

Discharge summary

report

Admission Date: [**2174-5-26**] Discharge Date: [**2174-6-4**] Date of Birth: [**2111-6-22**] Sex: M Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 1505**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: [**2174-5-26**] cardiac catherization [**2174-5-31**] Three Vessel Coronary Artery Bypass Grafting utilizing the left internal mammary artery to the diagonal artery, with vein grafts to first and second obtuse marginal. History of Present Illness: 62 year old male who has been experiencing intermittent episodes of chest "heaviness" over his upper and left sternal region over the last few months. Describes as if a flat hand is pushing lightly on his chest. No exertional component to this chest discomfort and no sharp pains. He also denies associated SOB, syncope, dizziness, nausea or vomiting. Occasional brief palpitations lasting "a few seconds". Past Medical History: Dyslipidemia Hypertension NSTEMI in setting of GI bleed in [**2163**] per records PERCUTANEOUS CORONARY INTERVENTIONS: Prior LCX stent placed at [**Hospital1 336**] in [**2167**] after several months of DOE and cardiac catheterization showed 90% occlusion LCX. Gout UGI bleed after NSAIDs and ASA in late [**2163**] ( no colonoscopy per patient) Hemorrhoids Social History: Lives with girlfriend [**Name (NI) 1403**] full time as a food buyer or an emergency assistance program run by the state Tobacco history: smoked 20 pack year history, quit 18 months ago. ETOH: about [**2-8**] drinks per week Illicit drugs: denies Family History: Father with CABG at age 65-years old. Uncle died of MI at 59 years old Physical Exam: VS: temp 97.1F, BP 146/91, HR 54, RR 16, 97% RA GENERAL: Obese male in NAD. A& O x3. Mood, affect appropriate. HEENT: NC/AT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 9 cm, no LAD. CARDIAC: RRR, normal S1/S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: CTA bilaterally. ABDOMEN: Soft. NT/ND. No HSM or tenderness. Due to habitus abdominal aorta exam limited, unable to palpate for aorta. EXTREMITIES: 1+ edema of LE bilaterally. No femoral bruits, right groin site is dressed, no bleeding, no edema, very small bruise 2cm/forming. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+, Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+, Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: [**2174-6-3**] 05:40AM BLOOD WBC-10.2 RBC-3.60* Hgb-10.6* Hct-31.2* MCV-87 MCH-29.5 MCHC-34.1 RDW-14.5 Plt Ct-196 [**2174-5-31**] 02:55PM BLOOD PT-14.8* PTT-37.3* INR(PT)-1.3* [**2174-6-3**] 05:40AM BLOOD Glucose-104 UreaN-21* Creat-1.1 Na-139 K-4.2 Cl-102 HCO3-24 AnGap-17 Brief Hospital Course: Mr. [**Known lastname **] presented for cardiac catherization and was found to have severe coronary artery disease. He was admitted for a plavix washout and pre-operative workup. He was transported the operating room for coronary artery bypass graft surgery. Please see the operative report for further details. He received vancomycin for perioperative antibiotics. He was transfered to the intensive care unit on propofol. In the first twenty four hours he was weaned from sedation, awoke neurologically intact and was extubated without complications. Post operative day one he was started on betablockers and diuretics and he was transfered to the post operative floor. Physical therapy worked with him on strength and mobility. His chest tubes and epicardial wires were removed. A small apical pneumothorax was seen on his chest radiograph after his chest tube removal, which remained stable on subsequent films. He was diuresed toward his pre-operative weight. By post-operative day four he was discharged to home. Medications on Admission: ASA 81mg daily Simvastatin 40mg PO daily Metoprolol Succinate 50mg daily Plavix 75 mg daily Discharge Medications: 1. 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* 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. 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* 4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. 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* 6. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*2* 7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days. Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 2203**] VNA Discharge Diagnosis: Coronary Artery Disease s/p CABG Hypertension Dyslipidemia History of Myocaridal Infarction [**2163**] History of GI Bleed [**2163**] Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Dr. [**Last Name (STitle) **] (cardiac surgery)in 4 weeks please call to schedule ([**Telephone/Fax (1) 11763**]. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (cardiology) in [**1-7**] weeks please call to schedule. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5936**] ([**Telephone/Fax (1) 6699**]) in [**1-7**] weeks please call to schedule. Completed by:[**2174-6-4**]

[ "411.1", "412", "401.9", "274.9", "414.01", "512.1", "782.3", "V45.82", "272.4" ]

icd9cm

[ [ [] ] ]

[ "36.15", "37.22", "36.12", "88.56", "39.61" ]

icd9pcs

[ [ [] ] ]

5027, 5086

2842, 3872

308, 530

5264, 5271

2544, 2819

5782, 6202

1630, 1702

4015, 5004

5107, 5243

3898, 3992

5295, 5759

1717, 2525

258, 270

558, 967

989, 1349

1365, 1614

15,644

185,896

43800

Discharge summary

report

Admission Date: [**2111-3-14**] Discharge Date: [**2111-3-18**] Date of Birth: [**2056-9-29**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 4393**] Chief Complaint: Hydrothorax Major Surgical or Invasive Procedure: Diagnostic and therapeutic thoracentesis Diagnostic Esophagogastroduodenoscopy History of Present Illness: Ms. [**Known lastname 1692**] is a 54 F with a history of decompensated hepatitis C cirrhosis, recently admitted [**2111-2-11**] for dyspnea and found to have left-sided hydrothorax, who presents now with a 4-day history of poor appetite, nausea, vomiting and malaise. She states that she began feeling nauseous and vomiting (occasionally bile, occasionally mucous/sputum) shortly after her last admission, though symptoms had initially improved some and have recurred over the past few days. She has cough with sputum, occasional blood streaks but no gross blood. She had one episode of watery diarrhea yesterday evening, no recurrence. Has noticed decreased UOP last 2 days. Also reports increased abdominal fullness (epigastric) and chest pressure. On her last admission, she underwent thoracentesis with 1.1 L of fluid removed which was terminated early due to coughing, then had a repeat procedure the following day with 800 cc removed. She had no significant ascites on RUQ ultrasound during that admission. This fluid was expected to reaccumulate and she was planned for follow up in liver clinic to address the need for further titration of medications or additional thoracentesis; however, she did not attend her appointment. She states that she takes her medications as prescribed but is unable to provide details. Upon arrival to the ED vitals were: T 98.6, HR 88, BP 117/69, RR 20, 98% 15L NRB. She did not receive any fluids or medications. She was admitted to the MICU for thoracentesis. Vitals prior to transfer to the MICU were: afebrile, HR 92, BP 123/74, 96% on 6L. On arrival to the floor, patient is very anxious, reporting that she does not want thoracentesis because it hurt her too much the last time. Most of review of systems is positive which seems to reflect patient's anxiety over questions about these symptoms to some degree. REVIEW OF SYSTEMS: (+)ve: (-)ve: fever, chills, night sweats, loss of appetite, fatigue, chest pain, palpitations, rhinorrhea, nasal congestion, cough, sputum production, hemoptysis, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, diarrhea, constipation, hematochezia, melena, dysuria, urinary frequency, urinary urgency, focal numbness, focal weakness, myalgias, arthralgias Past Medical History: - HCV cirrhosis - hypothyroidism - depression/ anxiety - MSSA spinal osteomyelitis/ discitis/ epidural abscess/paravertebral abscess and cord compression s/p C2-C3 laminectomy in [**2107**] with resultant disability and "paralysis" - prior IV cocaine use of short duration - negative PPD several years ago Social History: On disability since her epidural abscess s/p laminectomy in [**2107**]. Prior to that was a nurses aid, teacher, crossing guard. Ambulates minimally with a rolling walker, but mostly confined to wheelchair. Lives at home with her children, 19 and 21 years old. Quit smoking in [**2110**]. Formerly smoked [**1-4**] ppd x 5 years; quit [**2110-6-3**]. Denies current ETOH or IVDA. Used to use cocaine. Family History: Mother with HTN and DM. Father unknown. Sister passed away from pancreatic cancer. Grandmother with lung cancer. Physical Exam: ADMISSION: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Labs on admission: [**2111-3-14**] 01:55PM WBC-7.0 RBC-4.09* HGB-12.9 HCT-38.0 MCV-93 MCH-31.4 MCHC-33.9 RDW-16.6* [**2111-3-14**] 01:55PM NEUTS-57.8 LYMPHS-30.0 MONOS-7.4 EOS-4.0 BASOS-0.9 [**2111-3-14**] 01:55PM PLT COUNT-62* [**2111-3-14**] 01:55PM PT-17.1* PTT-32.6 INR(PT)-1.5* [**2111-3-14**] 01:55PM GLUCOSE-109* UREA N-24* CREAT-1.2* SODIUM-135 POTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-21* ANION GAP-12 [**2111-3-14**] 01:55PM ALT(SGPT)-146* AST(SGOT)-205* ALK PHOS-184* TOT BILI-3.3* [**2111-3-14**] 01:55PM ALBUMIN-3.2* CALCIUM-9.1 PHOSPHATE-3.7 MAGNESIUM-2.0 [**2111-3-14**] 01:55PM AMMONIA-66* [**2111-3-14**] 02:06PM LACTATE-2.3* [**2111-3-14**] 04:55PM LACTATE-1.6 [**2111-3-14**] 05:20PM URINE COLOR-DkAmb APPEAR-Hazy SP [**Last Name (un) 155**]-1.034 [**2111-3-14**] 05:20PM URINE BLOOD-NEG NITRITE-POS PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-8* PH-6.0 LEUK-NEG [**2111-3-14**] 05:20PM URINE RBC-0 WBC-1 BACTERIA-MOD YEAST-NONE EPI-6 [**2111-3-14**] 05:20PM URINE HYALINE-33* ECG [**2111-3-14**]: Sinus rhythm. Early R wave progression. Since the previous tracing of [**2111-2-11**] probably no significant change. CXR [**2111-3-14**]: FINDINGS: Single AP portable upright chest radiograph was obtained. There is a new large left pleural effusion, with associated collapse of the entire left lower lobe. The aerated portion of the left upper lobe is unremarkable. The right lung is well expanded and clear, without focal consolidation, pleural effusion, or pneumothorax. There is mild shift of the trachea and mediastinum to the right. No acute osseous abnormality is detected. IMPRESSION: Large left pleural effusion with associated collapse of the left lower lobe. KUB [**2111-3-15**]: Current study demonstrates diffuse spread of the bowel gas within the abdomen, with no evidence of obstruction. Decubitus view demonstrates no evidence of free air or pathologic air-fluid levels. US: CLINICAL HISTORY: 54-year-old female with hepatitis C. Assess for portal vein thrombosis. TECHNIQUE: Grayscale and limited Doppler ultrasound of the abdomen was performed, with Doppler interrogation of the portal venous system. COMPARISON STUDY: Abdominal ultrasound from [**2111-1-7**]. FINDINGS: Hepatic echotexture is diffusely heterogeneous with a nodular contour, findings compatible with cirrhosis. No focal liver lesions are identified. There is no intra- or extra-hepatic biliary duct dilation. The common bile duct measures 5 mm in thickness. The gallbladder is not visualized and may be completely contracted. The main, right, and left portal venous branches are widely patent with normal direction of flow. A small left pleural effusion is noted. There is no abdominal ascites. The spleen is enlarged, measuring 13.4 cm. Included portions of the pancreatic body and head are unremarkable. The tail of the pancreas is excluded. Included portions of the abdominal aorta and IVC are unremarkable. IMPRESSION: 1. Patency of the portal venous system. 2. Hepatic cirrhosis without focal lesion identified. 3. Small left pleural effusion. 4. Nonvisualization of the gallbladder, which may be due to contraction. CXR on [**2111-3-17**] COMPARISON: Radiographs dating back to [**2111-3-14**] and most recently [**2111-3-15**]. FINDINGS: The left pleural effusion has significantly reduced in size and has not re-accumulated, a small left pleural effusion remains. The right lung is normal in appearance. The cardiac size is at the upper limits of normal. Heterogenous focal opacity in the left upper lobe was not present on the radiograph of [**2111-3-15**] and may represent evolving consolidation, meriting further surveillance radiographs. IMPRESSION: 1. Interval resolution of large left pleural effusion, only residual small effusion remains. 2. Heterogenous opacity in the left upper lobe may represent evolving consolidation and merits radiographic surveillance. Discharge labs: [**2111-3-18**] 04:40AM BLOOD WBC-3.0* RBC-3.29* Hgb-10.3* Hct-30.7* MCV-93 MCH-31.3 MCHC-33.6 RDW-16.4* Plt Ct-47* [**2111-3-18**] 04:40AM BLOOD Glucose-74 UreaN-24* Creat-1.3* Na-140 K-4.3 Cl-108 HCO3-26 AnGap-10 [**2111-3-18**] 04:40AM BLOOD ALT-88* AST-132* AlkPhos-118* TotBili-2.1* [**2111-3-18**] 04:40AM BLOOD Albumin-3.4* Mg-2.4 . [**2111-3-14**] 5:20 pm URINE Site: CLEAN CATCH **FINAL REPORT [**2111-3-18**]** URINE CULTURE (Final [**2111-3-18**]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. OF TWO COLONIAL MORPHOLOGIES. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Brief Hospital Course: Ms. [**Known lastname 1692**] is a 54 F with a history of decompensated hepatitis C cirrhosis, recently admitted [**2111-2-11**] for dyspnea and found to have left-sided hydrothorax, who re-presented with a hydrothorax in addition to a UTI and found to have epigastric pain without evidence of portal vein clot which was thought to be secondary to Gastritis after an EGD. . ACTIVE ISSUES: # HEPATIC HYDROTHORAX: This is the patient's second presentation for this issue in approximately one month. The hydrothorax is most likely secondary to liver cirrhosis, which explains the reaccumulation of fluid over a short interval. She had increases to her diurectic regimen at her last admission, but although she states that she has been compliant with her medication, she is unable to name the medicines, describe the dose changes or explain how she has been taking the medications at this time. She reports that the bottle of the "small pill" (? furosemide) has recently run out. She was supposed to have a follow up appointment in liver clinic on [**2111-2-26**] to assess for fluid reaccumulation but did not attend this appointment. Therefore, non-compliance may also play a role in this presentation. She underwent bedside thoracentesis which showed 1L of clear fluid. Repeat CXR showed a decrease in her effusion. . # Decompensated HCV CIRRHOSIS with Mild Enecephalopathy: Patient noted to have transaminases elevated but slightly lower than recent baseline, TB elevated to 3.3 (highest recent value), and INR of 1.5 (similar to prior), consistent with MELD of 17. She is not currently on the liver transplant list. She was oriented but reported frequently feeling confused at home and requiring help from her sisters to run her household and manage her illness consistent with mild/low grade encephaopathy. Ammonia level was 66 on arrival to ED. She reports taking her lactulose but does not have multiple BM daily, rather reports constipation generally. She is not currently on the transplant list though reports that Dr. [**Last Name (STitle) **] has raised this possibility in the past. Due to her low grade enecephalopathy, she was started on a more aggressive bowel regiment with miralax in addition to lactulose. , # LOW URINE OUTPUT: The patient reported dysuria and low UOP x 2 days on arrival. She was noted to have dark, concentrated urine on arrival with bacteria and + nitrites, though only 1 WBC and negative LE. Cutlure grew out E. coli. On arrival to the MICU, UOP was < 50 cc/hr. She was given a dose of 40 mg IV furosemide and UOP increased to > 100 cc/hr. . #UTI: Upon admission you had a urine culture sent which grew out E. Coli you were started on Bactrim to complete a 7 day course. . # ACUTE RENAL FAILURE: Creatinine was elevated to 1.2 on admission from baseline 0.8-1.0. Over the course of this admission, creatinine remained stably elevated above her baseline. She was instructed to hold her diurectic until five days after discharge. . # NAUSEA, VOMITING: Patient complained of nausea/vomiting on and off since her last discharge. However, on arrival to the MICU she stated that she was not nauseous but rather hungry. Clear liquid diet was suggested but patient strongly preferred regular diet and felt she would tolerate. Had episode of vomiting in the morning after admission following breakfast of undigested food. Of note, she was not taking her prescribed PPI because she believed she may have had a reaction (rash) to "a medicine prescribed after EGD" in the past. However, she is unable to provide clear history regarding which medication this was, and she received omeprazole during her last admision with no apparent reaction. Omeprazole was therefore restarted. Of note, she continued to be nauseous throughout her hospital stay without resolution of her symptoms. It was thought, therefore, that her nausea was multifactorial given her UTI, gastritis, . # Epigastric Pain: Unclear etiology, she had a slow drift down in her Hgb but no evidence of acute blood loss. She also has not had a bowel movement since friday, making a brisk UGIB unlikely. She underwent an EGD which showed minimal erythema in the antrum, but was otherwise unremarkable. An US of the portal venous system did not demonstrate a clot. Therefore, her epigastric pain was attributed to a mild form of gastritis and her PPI was increased and she was started on sucralfate. . INACTIVE ISSUES . # HYPOTHYROISISM: TSH noted to be increased in the past to < 10, never treated. Recommend follow up with PCP to trend TSH as outpatient. Hypothyroidism may contribute to her chronic constipation. Discharge: Home Transiation of care: Patient will need careful follow up regarding her medication prescriptions Medications on Admission: - furosemide 40 mg PO BID - lactulose 10 gram/15 mL 30 ML PO TID - spironolactone 100 mg 1.5 Tablets PO DAILY - tramadol 50 mg PO twice a day as needed for pain (patient not taking) - omeprazole 20 mg PO BID (prescribed; patient not taking) - multivitamin 1 tab PO DAILY Discharge Medications: 1. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 3 days. Disp:*7 Tablet(s)* Refills:*0* 2. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever pain: do not exceed 2grams (2000mg) in 24 hrs. 3. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed for constipation. 6. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen (17) grams PO DAILY (Daily): dissolved in fluid daily, hold for loose stools. Disp:*1 bottle* Refills:*2* 7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 8. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*120 Tablet(s)* Refills:*2* 9. furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day: Do not restart until [**2111-3-23**]. 10. spironolactone 50 mg Tablet Sig: Three (3) Tablet PO once a day: do not restart until [**2111-3-23**]. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: -Decompensated Hepatitis C Cirrhosis complicated by hepatic hydrothorax and acute kidney injury -Gastritis -Acute bacterial cystitis Secondary Diagnoses: -Hypothyroidism -Depression/Anxiety Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for difficulty breathing and abdominal pain. Your difficulty with breathing improved after getting fluid drained off your lungs. We think your abdominal pain was due to inflammation of the lining of your stomach, which we are treating with acid blocking medications. You also had a urinary tract infection, which we are treating with antibiotics. Your medications have been changed. You have been started on sucralfate (Carafate) and your dose of omeprazole (PRILOSEC) has been increased in order to help your stomach heal. You have also been started on a medication called TRIMETHOPRIM-SULFAMETHAXASOLE (BACTRIM) for your urinary tract infection. You will need to take another three days of this medication. Finally, we have started you on a more intenvsive bowel regimen with polyethylene glycol (MIRALAX) and senna to help you keep your bowels moving, which is important to avoid confusion from your liver disease. Your other medications have not been changed but you will hold your diuretics (water pills) for an additional five days and restart them on Monday, [**3-23**]. It will be important for you to take these medications as previously to prevent reaccumulation of the fluids around your lung. Followup Instructions: Name: [**Last Name (LF) 94105**], [**Name8 (MD) **], NP. Location: [**Location (un) **] COMMUNITY HEALTH CENTER Address: [**State **], [**Location (un) **],[**Numeric Identifier 5138**] Phone: [**0-0-**] When: TUESDAY, [**3-24**], 2:45PM Department: LIVER CENTER When: FRIDAY [**2111-3-20**] at 10:40 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 2422**] Building: LM [**Hospital Unit Name **] [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: TRANSPLANT When: THURSDAY [**2111-5-7**] at 2:20 PM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 4407**] Completed by:[**2111-6-4**]

[ "789.59", "595.0", "070.54", "041.4", "300.4", "511.89", "584.9", "571.5", "535.50" ]

icd9cm

[ [ [] ] ]

[ "45.13", "34.91" ]

icd9pcs

[ [ [] ] ]

15510, 15516

9263, 9638

284, 365

15770, 15770

4024, 4029

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39937

Discharge summary

report

Admission Date: [**2145-10-31**] Discharge Date: [**2145-11-4**] Date of Birth: [**2103-12-23**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 896**] Chief Complaint: Syncope, dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: HPI: Mr. [**Known lastname 87813**] is a 41 yo otherwise healthy male who presents with syncope. His history is significant for a recent motorcycle accident 2 wks prior to admission, for which he underwent knee surgery at [**Hospital1 2177**] for a fractured left kneecap. He was placed in a soft brace, was minimally ambulatory, and did not receive outpatient anticoagulation therapy. 3 days prior to admission, he developed shortness of breath on exertion, for which he used his albuterol inhaler with limited benefit. He denies any associated chest pain, fevers or chills. On the morning of admission ([**10-31**]), he experienced a syncopal episode and fell while walking down the stairs. Per his family, he was found at the bottom of the stairs, had a frothy substance in his mouth, urinated involuntarity, but did not have any tongue biting or tonic-clonic movements. He was then brought to the ED at [**Hospital **] hospital. . In the [**Hospital **] hospital ED, he was not in acute distress and had no signs of head trauma. Vital signs: T 98.1, HR 110, BP 116/78, RR 11, O2 94% on RA, 100% on 3-4L. CT of the head and neck showed no abnormalities. A CTA showed R ventricular enlargement with a saddle pulmonary embolus obstructing the R & L main pulmonary arteries. A bedside ultrasound showed RV dilatation without collapse of LV. Labs were significant for PT 14.5, INR 1.6, WBC 20 (78% neuts, 13% lymps), Hct 36.2, Plt 469. He received a 5000 unit heparin bolus with 1000 units / hour thereafter, and was transferred to the [**Hospital1 18**] for additional care. . In the [**Hospital1 18**] ED, he appeared stable and did not have chest pain or shortness of breath. Vital signs: T 98.1 HR:110 BP:116/78 Resp:18 O(2)Sat:100. He received 1L NS, was continued on heparin, and admitted for further monitoring and treatment. Past Medical History: - Asthma - Right 5th digit injury - MVA, L knee surgery Social History: - Works as a manager for a seafood company - Unmarried, lives with girlfriend, has no kids - Occasional EtOH, denies tobacco or other recreational drugs Family History: - Mother with hypertension - Father with hyperlipidemia - Sister with allergies - Denies FH of bleeding disorders Physical Exam: Physical Exam: Vitals: T: 97 BP: 109/76 P: 107 R: 22 O2: 98% on 4L General: Pale appearing. alert, oriented, no acute distress. HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: Erythematous maculopapular rash in genital folds bilaterally. Ext: Soft brace on L knee. Lower extremities warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNs II-XII intact, motor function grossly normal Pertinent Results: Labs upon admission: [**2145-10-31**] 11:45AM BLOOD WBC-17.0* RBC-3.84* Hgb-11.0* Hct-33.5* MCV-87 MCH-28.6 MCHC-32.8 RDW-13.1 Plt Ct-525* [**2145-10-31**] 08:09PM BLOOD WBC-13.6* RBC-3.96* Hgb-11.5* Hct-33.4* MCV-85 MCH-29.0 MCHC-34.3 RDW-13.2 Plt Ct-508* [**2145-10-31**] 11:45AM BLOOD Neuts-86.3* Lymphs-9.2* Monos-3.4 Eos-0.7 Baso-0.5 [**2145-10-31**] 11:45AM BLOOD PT-15.2* PTT-49.0* INR(PT)-1.3* [**2145-10-31**] 11:45AM BLOOD Glucose-119* UreaN-17 Creat-0.8 Na-139 K-4.1 Cl-103 HCO3-25 AnGap-15 [**2145-10-31**] 08:09PM BLOOD ALT-59* AST-27 LD(LDH)-345* CK(CPK)-88 AlkPhos-159* Amylase-58 TotBili-0.3 DirBili-0.1 IndBili-0.2 [**2145-10-31**] 11:45AM BLOOD CK-MB-4 proBNP-1668* [**2145-10-31**] 11:45AM BLOOD cTropnT-0.45* [**2145-10-31**] 08:09PM BLOOD TotProt-6.4 Albumin-3.5 Globuln-2.9 Calcium-9.2 Phos-4.3 Mg-2.4 UricAcd-4.9 [**2145-10-31**] 07:14PM BLOOD Type-ART pO2-66* pCO2-34* pH-7.47* calTCO2-25 Base XS-1 [**2145-10-31**] 11:52AM BLOOD Glucose-113* Lactate-2.0 K-4.2 . Labs at the time of discharge: [**2145-11-4**] 07:20AM BLOOD WBC-7.1 RBC-4.01* Hgb-11.4* Hct-34.4* MCV-86 MCH-28.4 MCHC-33.1 RDW-13.6 Plt Ct-551* [**2145-11-4**] 07:20AM BLOOD Plt Ct-551* [**2145-11-4**] 07:20AM BLOOD PT-18.3* PTT-32.0 INR(PT)-1.7* [**2145-11-4**] 07:20AM BLOOD Glucose-99 UreaN-13 Creat-0.9 Na-140 K-4.7 Cl-103 HCO3-29 AnGap-13 [**2145-11-4**] 07:20AM BLOOD Calcium-9.3 Phos-3.9 Mg-2.4 . Head & neck CT ([**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]): Negative noncontrast head CT scan. No acute cervical fracture or malalignment. . Chest CT ([**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]): There are large filling defects in R and L main pulmonary arteries as well as the subsegmental pulmonary arteries supplying the upper lobes, lower lobes, and right middle lobe. A saddle embolism is noted. There is right ventricular enlargement consistent with R heart strain. No airspace consolidation or pleural effusion. Multiple subcentimeter hilar and mediastinal lymph nodes are present, clinical correlation recommended. . EKG: Sinus tachycardia. Nonspecific ST changes. . Echocardiogram: Right ventricular cavity enlargement with free wall hypokinesis. Pulmonary artery systolic hypertension. Mild-moderate tricuspid regurgitation. Dilated ascending aorta. No definite intracardiac shunt identified. . L Knee x-ray: There is an overlying brace which limits fine bony detail. There are anterior surgical skin staples. There is irregularity of the inferior pole of the patella compatible with recent surgery. There is soft tissue swelling anteriorly. No additional fractures are seen. Brief Hospital Course: 41 yo otherwise healthy male with recent history of MVA and knee surgery who presents with SOB and syncope due to saddle pulmonary embolism. . # Pulmonary embolism: Mr. [**Known lastname 87813**] was found to have a saddle PE by chest CT from an OSH. His PE was likely secondary to immobilization in the setting of a recent MVA and surgery for L patellar fracture. In the hospital, he had an episode of hypoxia (PaO2 66) and tachycardia, prompting admission to the ICU. He was treated with bolus and continuous IV heparin therapy. Fibrinolysis was not performed given his hemodynamic stability. An echocardiogram on [**11-1**] showed R ventricular cavity enlargement with free wall hypokinesis, mild-moderate tricuspid regurgitation. After remaining hemodynamically stable in the ICU, he was transferred to the medicine service, where he remained stable until the time of discharge. Heparin was discontinued and Lovenox bridge to Coumadin was started. At the time of discharge (hospital day 4), he was comfortable, had an ambulatory O2 saturation of 99%, and had an INR of 1.7. He will require 3 months of anticoagulation for a provoked PE. An echocardiogram is recommended in 3 months to evaluate for resolution of R heart dilation. He will follow up with his PCP for discontinuation of Lovenox and continued Coumadin dosing. . # s/p L knee surgery: He underwent orthopedic surgery for L patellar fracture at PBMC 2 wks PTA. In the [**Hospital1 18**], his pain was well controlled with oxycodone and acetaminophen. On exam, there were scattered open wounds on lateral aspect of the L knee, intact staples, and moderate areas of bruising. No active infections were noted. Dressings were changed daily. He worked with physical therapy and demonstrated ability to ambulate safely with crutches. Ortho recommended removing his staples in [**4-30**] days, and he will follow-up with Ortho at [**Hospital1 18**] on [**11-9**]. At the time of discharge, his pain was well controlled and he was able to ambulate with crutches. . # Tinea Cruris: identified clinically on presentation treated with Miconazole topical cream with good effect. He should continue miconazole 2% topical cream twice a day for 2 weeks. Medications on Admission: - Albuterol 0.083% nebulizer Q4-6hrs as needed. - Percocet 325mg 1-2 tablets Q4-6hrs PRN knee pain. - Colace 100mg [**Hospital1 **] as needed for constipation Discharge Medications: 1. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for belching. Disp:*60 Tablet, Chewable(s)* Refills:*0* 2. miconazole nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) for 10 days. Disp:*2 tubes* Refills:*0* 3. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain for 10 days. Disp:*60 Tablet(s)* Refills:*0* 4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed for dyspnea or wheezing. 5. warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. Disp:*90 Tablet(s)* Refills:*0* 6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*20 Tablet(s)* Refills:*0* 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:*20 Capsule(s)* Refills:*0* 8. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours) for 7 days: please consult your PCP on when you may stop this medication. Disp:*14 * Refills:*0* 9. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours for 7 days. Disp:*28 Tablet(s)* Refills:*0* 10. Outpatient Lab Work Your primary care physician will follow up with your INR, to be checked on Monday, [**11-8**]. Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Primary: - Pulmonary Embolism . Secondary: - S/P L knee surgery - Constipation - Fungal infection of the groin Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted because of shortness of breath and fainting. You were found to have a blood clot in your lungs. This was likely caused by a dislodged clot which formed in your right leg during prolonged immobillity after your knee surgery. You were treated with heparin to prevent further clotting and allow your lung clot to disipate. You will need to continue anti-coagulation therapy for 3-6 months. . You are discharged with the following medication: . # Sub Cutaneous Enoxaparine (Lovenox) 80mg injection. Please continue to take one injection every 12 hours untill your INR is greater than 2 for 2 consecutive days (please verify with your primary care physician). . # Warfarin 2.5 mg tablet. Please continue to take 2 tablets every 24 hours. You will need to have a blood test no later than Monday morning to determine your INR and recieve guidance on further warfarin dosing. Your INR should be kept between 2 and 3. Please be aware that while your anti-coagulation therapy reduces the risk of blood clot formation it also increases your risk of bleeding. You should avoid activities that may expose you to injury (e.g. contact sports, weight bearing on L leg) while you are receiving this treatment. Please continue to use your brace for support, and limit extensive motion in the L knee. . # Oxycodone 5mg tablet. Please take one tablet every 6 hours as needed for pain. . # Tylenol 500mg. Please take 1 tablet as needed for pain upto 6 times daily. . # Senna 8.6mg tablet. Please take one tablet twice daily as needed for constipation. . # Docusate Sodium 100mg tablet. Please take 1 tablet twice daily as needed for constipation. . # Simethicone 80mg tablet. Please take one tablet every 6h as needed for belching. Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) 1730**] L. Location: [**Hospital3 **] - [**Location (un) **] Address: [**Street Address(2) 87814**], [**Location (un) **],[**Numeric Identifier 76341**] Phone: [**Telephone/Fax (1) 30738**] When: Tuesday, [**11-9**], 9AM Department: [**Hospital 1774**] [**Hospital 197**] Clinic Location: [**Street Address(2) 87815**], [**Location (un) 8985**] MA Phone: [**Telephone/Fax (1) 83400**] Instructions: Please verify your appointment over the phone. Please stop by the clinic during office hours, by Monday ([**11-8**]) at the latest to have your INR checked. Department: ORTHOPEDICS When: THURSDAY [**2145-11-11**] at 8:40 AM With: ORTHO 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: THURSDAY [**2145-11-11**] at 9:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1984**], MD [**Telephone/Fax (1) 1228**] Building: [**Hospital6 29**] [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2145-11-7**]

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33635+57863+57864

Discharge summary

report+addendum+addendum

Admission Date: [**2137-8-29**] Discharge Date: [**2137-9-4**] Date of Birth: [**2063-12-24**] Sex: F Service: CARDIOTHORACIC Allergies: Morphine / Baclofen / adhesive bandage / penicillin G / Aldomet Attending:[**First Name3 (LF) 1406**] Chief Complaint: non healing sternal wound Major Surgical or Invasive Procedure: [**2137-9-2**] - Debridement of sternal wound with negative pressure therapy, VAC placement. History of Present Illness: [**2137-7-18**]: Coronary artery bypass grafting x2, with reversed saphenous vein graft to the ramus intermedius artery and a free left internal mammary artery graft to the obtuse marginal artery Y'd to the vein graft. Discharged home on POD4, seen in wound clinic several times for followup of nonhaling inferior sternal wound which has been treated with the VAC dressing. Inferior wound smaller but the middle portion of the sternal incision is now dehisced with a subcutaneous track superiorly noted. Will admit and have plastic surgery see the patient to assist with debridement and sternal wound closure. Past Medical History: s/p cabg x2 with reversed saphenous vein graft to the ramus intermedius artery and a free left internal mammary artery graft to the obtuse marginal artery Y'd to the vein graft [**2137-7-18**] PMH: coronary artery disease, dyspnea on exertion, bilateral knee replacement [**2132**], sleep apnea, hiatal hernia, GERD, diabetes mellitus, hypertension, Hyperlipidemia, Restless leg syndrome, s/p stent to LAD in [**2126**], Stent to RCA and OM in [**2128**], appendectomy, hysterectomy, CTR left wrist, laser surgery OU, cataract Social History: Occupation:retired Cigarettes: denies Other Tobacco use:denies ETOH: denies Illicit drug use:denies Lives with: alone in a senior complex, Ambulates with a four wheel walker. Contact:[**Name (NI) **] and [**Name (NI) **] (son and daughter-in-law) Family History: Premature coronary artery disease- Brother with CABG at age 65 Race:Caucasian Physical Exam: Weight preoperative: 217 current:223 HR 40, B/P 142/43 RR 18 97% sat Physical Exam Gen-not feeling well-diaphoretic, fatigued Cardiac: RRR [x] Irregular [] Murmur-none Chest: Lungs clear bilateral [x] Abdomen: Soft [x] Nontender [x] Nondistended [x] Extremities: Warm [x] Well perfused [] Edema: Right +1 Left +1 Sternal incision: erythema no[] yes[]minimal drainage no[+] yes[] well approximated yes [] no [+] wound open after removal of VAC, inferior portion has some granulation tissue at mid portion with tracking to bone, some granulation tissue present, mildy odiferous, excoriated tissue surrounding sternal click no[x] yes[] Pertinent Results: Admission labs: [**2137-8-29**] 05:15PM PT-12.9 PTT-21.7* INR(PT)-1.1 [**2137-8-29**] 05:15PM PLT COUNT-223 [**2137-8-29**] 05:15PM WBC-7.3 RBC-4.34 HGB-12.6 HCT-36.9 MCV-85 MCH-29.0 MCHC-34.1 RDW-15.9* [**2137-8-29**] 05:15PM %HbA1c-7.2* eAG-160* [**2137-8-29**] 05:15PM ALBUMIN-4.4 MAGNESIUM-2.1 [**2137-8-29**] 05:15PM ALT(SGPT)-17 AST(SGOT)-23 LD(LDH)-218 ALK PHOS-96 TOT BILI-0.6 [**2137-8-29**] 05:15PM GLUCOSE-202* UREA N-63* CREAT-1.6* SODIUM-136 POTASSIUM-3.8 CHLORIDE-96 TOTAL CO2-26 ANION GAP-18 Discharge Labs: [**2137-9-4**] 05:50AM BLOOD WBC-5.2 RBC-3.30* Hgb-9.5* Hct-28.2* MCV-85 MCH-28.7 MCHC-33.6 RDW-15.0 Plt Ct-244 [**2137-9-4**] 05:50AM BLOOD Plt Ct-244 [**2137-9-4**] 05:50AM BLOOD Glucose-140* UreaN-31* Creat-1.0 Na-135 K-4.2 Cl-98 HCO3-29 AnGap-12 [**2137-9-3**] 05:06AM BLOOD Mg-2.0 Radiology Report CHEST PORT. LINE PLACEMENT Study Date [**2137-9-2**] 12:03 PM REASON FOR THIS EXAMINATION: 48cm left picc. tip? Final Report: The lungs show evidence of bibasilar scarring versus atelectasis, left greater than right. A pacemaker with three intact leads is unchanged. No definite signs of pneumonia. The cardiomediastinal silhouette is stable. Sternal wires are intact and unchanged. There is a new left-sided PICC with tip at the atrialcaval junction. Brief Hospital Course: Ms [**Known lastname 77879**] is well known to cardiac suregry service, she was seen in followup clinic for nonhealing sternal wound that was initially treated with VAC therapy. On day of admission she was again seen and felt to require further debridement of wound. She was admitted, plastic suregery and infection diseases were consulted and she was brought to the operating room for wound debridement. See operative report for details, in summary she tolerated the operation well and was transferred from the operating room to the PACU then to the cardiac surgery stepdown floor. On the night following surgery her blood sugars were elevated into the 400 range and she was transferred to the Cardiac surgery ICU for insulin infusion. [**Last Name (un) **] was consulted to assist with glucose management. She returned to the operating room for cleanout and evaluation for closure on HD4, it was decided to delay closure nad the VAC was put back in place. She will go to rehabilitation for 2 weeks and return for sternal closure device removal and flap closure with plastic surgery in 3 weeks. She will remain on antibiotics until that time. Medications on Admission: ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider) - 80 mg Tablet - 1 Tablet(s) by mouth at bedtime CPAP WITH 2 LITERS OF OXYGEN AT NIGHT - (Prescribed by Other Provider) - Dosage uncertain FUROSEMIDE - (Prescribed by Other Provider) - 80 mg Tablet - 1 Tablet(s) by mouth twice a day HYDROMORPHONE - (Prescribed by Other Provider) - 2 mg Tablet - [**12-16**] Tablet(s) by mouth every four (4) hours as needed for pain INSULIN LISPRO [HUMALOG] - (Prescribed by Other Provider) - 100 unit/mL Solution - per sliding scale LISINOPRIL - (Prescribed by Other Provider) - 5 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily) METOLAZONE - (Prescribed by Other Provider) - 2.5 mg Tablet - 1 Tablet(s) by mouth once a day METOPROLOL TARTRATE - (Prescribed by Other Provider) - 25 mg Tablet - 3 Tablet(s) by mouth three times a day PANTOPRAZOLE - (Prescribed by Other Provider) - 40 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth every morning\ POTASSIUM CHLORIDE - (Prescribed by Other Provider) - 10 mEq Tablet Extended Release - 2 Tablet(s) by mouth every twelve (12) hours PRAMIPEXOLE [MIRAPEX] - (Prescribed by Other Provider) - 0.5 mg Tablet - 1 Tablet(s) by mouth at bedtime Medications - OTC ACETAMINOPHEN - (Prescribed by Other Provider) - 325 mg Tablet - 2 Tablet(s) by mouth every four (4) hours as needed for pain, fever ASCORBIC ACID - (Prescribed by Other Provider) - 500 mg Tablet - 2 Tablet(s) by mouth DAILY (Daily) ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth DAILY (Daily) CHOLECALCIFEROL (VITAMIN D3) - (Prescribed by Other Provider) - 400 unit Tablet - 1 Tablet(s) by mouth DAILY (Daily) FISH OIL-DHA-EPA [FISH OIL] - (Prescribed by Other Provider) - 1,200 mg-144 mg Capsule - 1 Capsule(s) by mouth three times daily MULTIVITAMIN - (Prescribed by Other Provider) - Tablet - 1 Tablet(s) by mouth DAILY (Daily) NPH INSULIN HUMAN RECOMB [HUMULIN N] - (Prescribed by Other Provider) - 100 unit/mL Suspension - 72 units twice a day Discharge Medications: 1. cefepime 2 gram Recon Soln Sig: Two (2) Recon Soln Injection Q12H (every 12 hours) for 2 weeks. 2. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush. 5. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. ascorbic acid 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. omega-3 fatty acids Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. prednisolone acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic DAILY (Daily). 12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation for 1 months. 13. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 14. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 15. pramipexole 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 16. Insulin Sliding Scale Please see attached sheet Discharge Disposition: Extended Care Facility: [**Hospital 2971**] Rehabilitation and Nursing Center - [**Hospital1 1474**] Discharge Diagnosis: Sternal wound infection Asociated Diagnosis: s/p cabg x2 [**2137-7-18**] CAD DOE B TKA [**2132**] sleep apnea hiatal hernia GERD DM HTN Hyperlipidemia Restless leg syndrome s/p stent to LAD in [**2126**], Stent to RCA and OM in [**2128**] appendectomy hysterectomy CTR left wrist laser surgery OU cataract Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesics Incisions: Sternal - VAC in place Leg Right/Left - healing well, no erythema or drainage. Edema Discharge Instructions: -Your sternal wound vac dressing will need to be changed every 3 days while you are at home. This will be done by visiting nurse service. 1) Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage. 2) Please NO lotions, cream, powder, or ointments to incisions. 3) Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart provided. 4) No driving for approximately one month and while taking narcotics. Driving will be discussed at follow up appointment with surgeon when you will likely be cleared to drive. 5) No lifting more than 10 pounds for 10 weeks 6) Please call with any questions or concerns [**Telephone/Fax (1) 170**] *Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: Provider: [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2137-9-10**] 3:15 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8583**], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2137-9-19**] 1:45 Plastic surgery is planning to remove hardware in [**1-17**] weeks. This will be scheduled for you. Completed by:[**2137-9-4**] Name: [**Known lastname 12586**],[**Known firstname 634**] J Unit No: [**Numeric Identifier 12587**] Admission Date: [**2137-8-29**] Discharge Date: [**2137-9-4**] Date of Birth: [**2063-12-24**] Sex: F Service: CARDIOTHORACIC Allergies: Morphine / Baclofen / adhesive bandage / penicillin G / Aldomet Attending:[**First Name3 (LF) 135**] Addendum: Ms [**Known lastname **] will be discahrged to Braemore Nursing and Rehabilitation Center in [**Hospital1 328**] Discharge Disposition: Extended Care Facility: [**Hospital 371**] Rehabilitation and Nursing Center - [**Hospital1 328**] [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 137**] MD [**MD Number(2) 138**] Completed by:[**2137-9-4**] Name: [**Known lastname 12586**],[**Known firstname 634**] J Unit No: [**Numeric Identifier 12587**] Admission Date: [**2137-8-29**] Discharge Date: [**2137-9-4**] Date of Birth: [**2063-12-24**] Sex: F Service: CARDIOTHORACIC Allergies: Morphine / Baclofen / adhesive bandage / penicillin G / Aldomet Attending:[**First Name3 (LF) 135**] Addendum: Updated Discharge Medication Schedule 1. cefepime 2 gram Recon Soln Sig: Two (2) Recon Soln Injection Q12H (every 12 hours) for 2 weeks. 2. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush. 5. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. ascorbic acid 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. omega-3 fatty acids Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. prednisolone acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic DAILY (Daily). 12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation for 1 months. 13. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 14. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 15. pramipexole 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 16. Insulin Sliding Scale Please see attached sheet 17. docusate sodium 100 mg Capsule Sig: One (1) Capsule 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 for constipation. 19. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 20. insulin glargine 100 unit/mL Solution Sig: Sixty Five (65) units Subcutaneous Q breakfast and dinner. 21. Humalog 100 unit/mL Solution Sig: sliding scale Subcutaneous QAC&HS: see insulin sheet. Discharge Disposition: Extended Care Facility: [**Hospital 371**] Rehabilitation and Nursing Center - [**Hospital1 328**] [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 137**] MD [**MD Number(2) 138**] Completed by:[**2137-9-4**]

[ "V45.82", "414.00", "E878.2", "250.00", "998.59", "553.3", "041.7", "V85.39", "V43.65", "401.9", "V45.81", "333.94", "327.23", "530.81", "584.9", "278.00", "V45.01", "998.30", "272.4" ]

icd9cm

[ [ [] ] ]

[ "38.97", "77.61", "86.22" ]

icd9pcs

[ [ [] ] ]

13989, 14246

4038, 5183

356, 451

9105, 9307

2718, 2718

10421, 11366

1922, 2003

7261, 8626

8773, 9084

5209, 7238

9331, 10398

3255, 3621

2018, 2699

291, 318

3650, 4015

479, 1090

2734, 3239

1112, 1641

1657, 1906

25,326

191,645

4877

Discharge summary

report

Admission Date: [**2117-8-24**] Discharge Date: [**2117-9-11**] Date of Birth: [**2058-5-23**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2297**] Chief Complaint: SIRS Major Surgical or Invasive Procedure: removed tunneled HD catheter placed temporary femoral HD catheter ? placed new tunneled HD catheter hemodialysis CVVH lumbar puncture History of Present Illness: 59 y/o M with PMHx of ESRD, CAD s/p MI, CMP, Seizure disorder and CVA who fell in his apt on Sunday, two days prior to presentation, and was reportedly found down by his landlord 48 hours later. Patient reports he had not eaten for 36 hours for unclear reasons, and went to the bathroom and felt weak as he got up to flush the toilet. Pt reports collapsing to the floor due to weakness, hit his head, and was unable to get up because he felt profoundly weak. Denies LOC, aura, alteration of mental status, vision changes, palpitations, chest pain, shortness of breath but reported several days of productive cough with minimal white/yellow sputum. He reports the day prior to his fall, he had eaten only breakfast and had 3-4 episodes of non-bloody nausea and vomiting that night, which he attributes to the food he ate that morning. Per report, pt pulled himself to his bedroom and laid there for two days until found. However, pt is now denying moving himself to his bedroom. . In the ED, initial vitals were T99.2 , BP 113/62, R 20, unable to get an O2 saturation anywhere. Pt was placed on 4L NC and had an ABG with PaO2 123. Pt was found to be hypoglycemic on arrival, and received 2 amps of glucose. Pt was complaining of total body pain, but denied chest pain or abdominal pain. He was placed in a c-collar due to total body pain. EKG showed NSR with first degree block, LBBB with [**Street Address(2) **] depressions. Patient was admitted to the floor in anticipation of dialysis and for further workup and management. . Today, pt was notably tachycardic and hypotensive. He was given boluses IVF and BP improved. Blood Cultures returned positive for GPCs and CT revealed multiple lung abscesses. Pt was transferred to the ICU given concern for sepsis with leukocytosis, hypotension, +bld cultures and abscesses. On transfer to the [**Name (NI) **] pt still endorses general malaise and full body pain. . Review of systems: (-) Denies any cough, shortness of breath, chest pain, palpitations. . Social History: The patient has a Ph.D. in history and had a successful academic career until [**2103**], when he went on disability for unclear reasons. The patient currently is homeless. Although patient reports he is an organist and choir director at a local church, the church does not corroborate this. He denies tobacco and illicit drugs. ETOH twice weekly per his report Family History: F - DM. M - Deceased age 41 of renal failure. One son - healthy. Physical Exam: General: Alert, oriented, sleepy appearing after receiving IV pain medication. HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema MSK: Pt noted to have diffuse 4-/5 with flexion/extension of hip, dorsi/plantarflexion, flexion/extension in UE, Grip strength. No specific focal deficits noted. Sensation is intact and equal in b/l UE and LE. Toe Down Babinski's noted. Pt's weakness is attributed to pain per pt. Pertinent Results: On admission: [**2117-8-24**] 04:11PM TYPE-ART PO2-123* PCO2-29* PH-7.31* TOTAL CO2-15* BASE XS--10 [**2117-8-24**] 01:22PM PH-7.18* [**2117-8-24**] 01:22PM LACTATE-1.6 NA+-134* K+-6.4* CL--98* TCO2-13* [**2117-8-24**] 01:22PM HGB-13.6* calcHCT-41 [**2117-8-24**] 01:15PM GLUCOSE-233* UREA N-134* CREAT-18.9*# SODIUM-135 POTASSIUM-7.0* CHLORIDE-94* TOTAL CO2-12* ANION GAP-36* [**2117-8-24**] 01:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2117-8-24**] 01:15PM WBC-18.4*# RBC-4.72 HGB-12.1* HCT-39.9* MCV-84 MCH-25.7* MCHC-30.4* RDW-15.7* [**2117-8-24**] 01:15PM PLT COUNT-182 [**2117-8-24**] 01:15PM PT-13.9* PTT-29.5 INR(PT)-1.2* ----- on discharge: [**2117-9-11**] 03:22AM BLOOD WBC-8.0 RBC-2.46* Hgb-6.6* Hct-21.3* MCV-86 MCH-26.8* MCHC-31.1 RDW-16.4* Plt Ct-586* [**2117-9-11**] 03:22AM BLOOD Glucose-98 UreaN-35* Creat-6.6*# Na-141 K-4.3 Cl-98 HCO3-30 AnGap-17 ------ Imaging: . CT Chest [**9-9**]: 1. Increasing moderate to large dependent bilateral pleural effusions, which are incompletely evaluated without intravenous contrast. 2. Multiple cavitating lung lesions of various sizes most likely septic emboli, predominantly in the left upper lobe and right lower lobe. 3. Multiple dilated vascular structures in the anterior chest wall and axilla could potentially reflect collaterals in setting of central venous obstruction, but the latter cannot be assessed for in absence of intravenous contrast. 4. Left thyroid lobe goiter, unchanged. 5. Multiple renal cysts and calcified gallbladder stones, incompletely evaluated. . CT Head [**2117-9-8**]: 1. No acute hemorrhage or vascular territorial infarction detected.If there is continued clinical concern of acute infarct, an MRI with DWI is recommended. 2. Interval increase in the opacification of bilateral maxillary sinuses and frontal opacification.Multiple paranasal sinus opacification could be related to the patient's intubated status. . EMG [**2117-9-8**]: Abnormal but nondiagnostic study. The denervation seen in bilateral vastus lateralis and left tibialis anterior could be consistent with a neurogenic process or with a myopathy with denervating features. The inability of the patient to provide a sustained muscle contraction prevents accurate diagnosis or exclusion of a myopathic process. All nerve conduction studies should be interpreted with extreme caution due to the patient's edema . ECHO [**2117-9-6**]: The left atrium is mildly dilated. The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thicknesses and cavity size are normal. There is mild-moderate regional systolic dysfunction with hypokinesis of the inferior, inferolateral, and septal walls. The remaining segments contract well (LVEF = 40 %). 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 appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2117-8-26**], the findings are similar (global LVEF was underestimated on review of the prior study). . MR [**Name13 (STitle) 1093**] [**2117-8-30**]: 1. Diffusely low bone marrow signal on T1-weighted images, which could be related to anemia or chronic systemic illness, such as end-stage renal disease in this case. However, an infiltrative disorder cannot be excluded. 2. Multifocal signal abnormalities in the discs and adjacent endplates in the cervical, thoracic, and lumbar spine correspond to areas of extensive spondylosis and are likely caused by the spondylosis. However, discitis/osteomyelitis may have similar appearance, though the extensive multifocality would be unusual. If there is a high clinical suspicion for infection at a particular level, then follow-up imaging of that level may be obtained in a week. There is no epidural collection to suggest an epidural abscess. 3. Mild spinal canal stenosis at C6-7. Spondylosis without spinal canal stenosis in the thoracic and lumbar spine. 4. Enlarged and heterogeneous thyroid gland. Further evaluation by ultrasound is recommended when the patient is stable, if not performed previously. 5. Partially visualized pleural effusions. The right pleural effusion appears loculated. Brief Hospital Course: Assessment and Plan: This is a 59 y.o. Male with HD dependent ESRD, CAD s/p MI, non-ischemic CMY EF 35-40%) p/w 3 day h.o. malaise, found down and initially hyperkalemic with back pain. Pt transferred from the floor for MSSA sepsis. . #. Sepsis: Given the hypotension, hypoglycemia, leukocytosis with blood cultures growing MSSA. Pt also found to have multiple pulmonary abscesses and grew MSSA out of multiple BAL specimens. Pt also grew MSSA from tunneled HD catheter tip which was pulled on [**8-26**]. Suspect source to be tunnelled catheter line, perhaps seeding of heart valves (though TTE did not show vegetations). Pt was initially treated with vancomycin and then transitioned to nafcillin when sensitivities returned. Pt also completed a course of broad spectrum antibiotics to cover for aspiration pneumonia. No abscesses noted in spleen or liver. No brain abscesses seen on head CT. Pt had LP while on abx which was negative and also had MRI of entire spine (no contrast) to look for epidural abscess, and no lesions compressing cord were identified. Temporary HD catheter was placed on [**8-26**]. Pt continued to spike occasional fevers from [**8-26**] through [**9-5**], despite negative blood cultures. This was felt to perhaps be [**1-25**] lung abscesses, however, the possibility of seeding of the temp catheter placed [**8-26**] was also considered. Temp catheter was pulled on [**9-5**] and new temporary line was placed. Culture of this catheter tip has also been negative to date. CT chest on [**9-9**] showed improvement in pulmonary abscesses. Repeat TTE and CT head were unchanged and showed no new vegetations/emboli. He remained persistently febrile, likely [**1-25**] fact that pulmonary abscesses not yet sterile. ID recommend switch to cefazolin with HD. LAST DAY OF ABX SHOULD BE [**2117-10-6**]. Please see directions re: weekly lab tests and abx monitoring in page 1. . # Respiratory failure: intubated for airway protection after seizure, but had copious purulent secretions and altered mental status so vent was weaned slowly and eventually discontinued on [**2117-9-3**]. He was saturating at 97-100% on 2L NC on discharge. . #. Back Pain: Pt on admission was noted to have full body pain and specifically back pain. In the [**Name (NI) **] pt was placed on a C-spine given his pain and underwent a C/T/L Spine CT with contrast which showed no gross abscess but did show the aforementioned lung abscesses. Pt remained in C collar because unable to clear c-spine for 9 days. Upon extubation pt was able to follow commands and denied pain over his spine. Cspine cleared and collar removed. Pt recieved fentanyl boluses initially for pain control, switched to drip when intubated and then transitioned to a fentanyl patch on extubation. . #Anemia ?????? Pt with chronic anemia in setting of CRF on HD. Pt was occasionally transfused (transfusion goal >21). Pt was started on epo 5000 3x weekly. Hct on discharge 21. He should have 1 unit PRBC with next HD session. . #Hypotension: Likely secondary to persistent infection and lung abscesses. Initially requiring pressors, but able to wean pressors along with weaning sedation. Generally seemed to be fluid responsive. He tolerated pressures to 80's and 90's systolic with no change in lactate or mental status. He likely has a low baseline in light of his other comorbidities. . ##. ESRD: Pt currently HD dependent, was on CVVH, now on HD ?????? 2 liters negative yesterday. Pt was initially continued on both phoslo and sevelamer. Pt continued HD initially and then transitioned to CVVH [**1-25**] hypotension. Pt was able to restart HD on [**9-5**]. Sevelamer was discontinued as pt became hypophosphatemic while on HD. . #? Ileus: Feculent material from NGT on [**9-1**]. KUB and CT abd/pelvis were reassuring as did not indicate ileus or SBO. Surgery evaluated pt as well. This resolved without intervention and pt was able to tolerate tube feeds by [**9-2**]. . ##. Non-Ichemic CMY: Pt's prior Echo in [**2114**] shows EF of 35-40% as well as left ventricular severe hypokinesis/near akinesis of the basal to mid septal, anterior and inferior segments, repeat TTE was similar. Pt was continued on home digoxin. . ##. Seizure d.o.: Pt did have one grand mal seizure in setting of HD and not on oxcarbezepine ([**1-25**] no ngt at that time). NGT was placed and pt resumed home regimen of Levetiracetam, Oxcarbazepine. Per neuro pt should cont on *Keppra 500mg [**Hospital1 **] with an extra dose on HD days and *Oxcarbamazepine 300mg TID, extra dose on HD days. Also pt started on Neurontin 300mg [**Hospital1 **]. . # elevated INR: INR of 1.4- has been stable, likely [**1-25**] NPO and abx. . # PPI: Pt started on PPI [**Hospital1 **] while intubated. Have reduced this to pantoprazole 40mg daily. Would suggest stopping this medication if patient has no symptoms of reflux. . # ? renal mass: per CT read: "Right renal high denity region (2, 30) in a setting of end-stage renal disease, likely represents a hyperdense cyst, although underlying tumor cannot be ruled out" Pt should have re-imaging as outpt and urology follow up. Patient was a FULL code on this admission Medications on Admission: 1. Allopurinol 100 mg Tablet PO DAILY 2. Calcium Acetate 667 mg Capsule Sig: Four (4) Capsule PO TID W/MEALS 3. Digoxin 125 mcg Tablet PO 4X/WEEK ([**Doctor First Name **],TU,TH,SA). 4. Folic Acid 1 mg Tablet PO DAILY 5. Sevelamer HCl 1600 mg PO TID W/MEALS 7. Aspirin 81 mg Tablet Chewable PO DAILY 8. Oxcarbazepine 300 mg Tablet PO BID: take third dose post dialysis on HD days. 9. Levetiracetam 500 mg Tablet PO BID: take third dose after dialysis on dialysis days. 10. Vancomycin 1,000 mg Recon Soln Intravenous 3x per week after dialysis Discharge Medications: 1. Morphine 15 mg Tablet Sig: One (1) Tablet PO every 6-8 hours as needed for pain: please try to limit narcotics. please give before PT prn. 2. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO TID ON HD DAYS (): TID on M, W, F (please give 3rd dose post HD). 3. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID ON NONHD DAYS (): [**Hospital1 **] on Tu, Th, Sat, Sun. 4. Cefazolin 10 gram Recon Soln Sig: Three (3) grams Injection QFRIDAY (): Please give 3g on friday after dialysis. LAST DAY OF ABX SHOULD BE [**2117-10-6**]. 5. Cefazolin 10 gram Recon Soln Sig: Two (2) grams Injection QMONDAY AND WEDNESDAY (): please give 2 grams after dialysis on monday and wednesday. LAST DAY OF ABX SHOULD BE [**2117-10-6**]. 6. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen. 7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY SUN, TUE, [**Doctor First Name **], SAT (). 8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO EVERY OTHER DAY (Every Other Day). 10. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 11. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed) as needed for dryness. 12. Oxcarbazepine 150 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day): please give TID on non-HD days (Tu, Th, Sat, Sun). 13. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 14. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 15. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 16. Outpatient Lab Work Please check CBC c diff, LFTs, BUN, Cr every Monday ([**9-13**], [**9-20**], [**9-26**], [**10-4**], [**10-11**]) and fax results to Dr [**First Name (STitle) **] at [**Telephone/Fax (1) 7043**]. 17. Oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO four times a day: QID on HD days (M-W-F) give last dose post HD. 18. Sevelamer HCl 800 mg Tablet Sig: Two (2) Tablet PO three times a day: TID with meals. 19. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: primary diagnosis: methacillin sensitive staph aureus bacteremia, methacillin sensitive staph aureus lung abscesses secondary diagnoses: ends dialysis dependent, seizure disorder, anemia Discharge Condition: occasional low grade fevers, alert, oriented to place and person, irritable and occasionally withdrawing from light touch, severe weakness of extremities, no gag reflex Discharge Instructions: FOR PATIENT: You were admitted with a bacteria called methacillin sensitive staph aureus in your blood. The source was felt to be your hemodialysis line and that line was removed. You recieved another temporary line instead. You were also found to have pockets of bacteria (abscesses) in your lungs, which are also likely the same bacteria. When you had the infection you had some trouble breathing and a breathing tube was placed for you which we were later able to remove. You were treated with antibiotics and you slowly improved. You were initially continued on your regular hemodialysis but for a little while your blood pressures were too low and you were switched to a different kind of dialysis called CVVH which causes less of an effect on blood pressure. Eventually, we were able to switch you back from CVVH to regular dialysis. FOR REHAB: -Please dialyze pt [**Name (NI) 12075**]. Dr [**First Name (STitle) 805**] will follow pt while at [**Hospital 100**] Rehab. -Please monitor vitals per routine. -Please check CBC c diff, LFTs, BUN, Cr every Monday ([**9-13**], [**9-20**], [**9-26**], [**10-4**], [**10-11**]) and fax results to Dr [**First Name (STitle) **] at [**Telephone/Fax (1) 7043**]. -All questions regarding outpatient antibiotics should be directed to the infectious disease R.Ns. at ([**Telephone/Fax (1) 14199**] r to on [**Name8 (MD) 138**] MD in when clinic is closed -Pt will need extensive physical therapy Followup Instructions: -Pt must be seen in [**Hospital **] clinic within 2 weeks. please call [**Telephone/Fax (1) 457**]. Please tell receptioninst that he will need urgent care ID slot c any avail fellow or attg per their request while he was an inpatient. - Furthermore, pt should see [**First Name8 (NamePattern2) 4648**] [**Last Name (NamePattern1) **] MD, also of infectious diseases, on [**4-8**] at 10am (appointment already made). -Pt should also be scheduled for a repeat chest CT noncontrast early in [**Month (only) **] prior to the appointment on 16th. Please call [**Hospital1 18**] radiology at [**Telephone/Fax (1) 2756**] to set up that appointment. -Please also make an appointment with first available neurologist for his seizure disorder and muscular weakness. The number for neurology clinic is ([**Telephone/Fax (1) 2528**]. -Pt will also need urology evaluation for renal mass seen on abdominal CT. Urology phone number is ([**Telephone/Fax (1) 772**]. -Lastly, when pt is discharged please make pt appointment with his regular PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD at [**Telephone/Fax (1) 250**]. Completed by:[**2117-9-11**]

[ "412", "721.0", "686.9", "359.81", "349.82", "428.0", "345.10", "428.22", "513.0", "995.92", "999.31", "585.6", "285.21", "338.29", "275.5", "276.2", "425.4", "403.91", "507.0", "V12.54", "414.01", "038.11", "415.12", "518.81", "584.9", "511.9", "V45.11" ]

icd9cm

[ [ [] ] ]

[ "39.95", "33.24", "96.72", "38.93", "33.23", "96.6", "38.91", "03.31", "86.05", "38.95", "96.04" ]

icd9pcs

[ [ [] ] ]

16220, 16286

8212, 13376

320, 455

16517, 16688

3755, 3755

18177, 19374

2885, 2951

13970, 16197

16307, 16307

13402, 13947

16712, 18154

2966, 3736

16444, 16496

4464, 8189

2415, 2488

276, 282

483, 2396

16326, 16423

3769, 4450

2504, 2869

9,829

117,067

8207

Discharge summary

report

Admission Date: [**2131-4-17**] Discharge Date: [**2131-4-23**] Date of Birth: [**2057-10-17**] Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3645**] Chief Complaint: neurogenic claudication Major Surgical or Invasive Procedure: L4/5 laminectomy History of Present Illness: As you know, he comes to us with a chief complaint of right-sided leg pain. This has been ongoing since [**2130-11-2**]. He states he was in [**Location 29174**]celebrating his grandson's birthday and was walking and began having a sensation of weakness in his right leg. He had trouble walking three blocks due to a combination of both pain and weakness. It became progressively worse. Upon returning back to [**State 350**], he went back to a local emergency room and was given oxycodone. He had been visiting the [**Location (un) 1121**] Spine Center and they have recommended that he do an epidural steroid injection. He underwent an injection for treatment of his right foot pain in [**11/2130**] and that was very helpful. He also began a course of physical therapy. He was doing quite well. However, on [**2131-1-23**], he was exercising on the treadmill per the recommendation of physical therapy and began having pain in the sole of his foot. He was diagnosed initially with cellulitis and then with gout. He saw both a podiatrist as well as Dr. [**Last Name (STitle) **]. He was treated with indomethacin, but is now weaning off of that per the recommendation of his nephrologist. His right leg pain persists. He has significant difficulty walking. Prior to this, he did have a chronic low back pain, was able to manage this and was walking about 40 minutes a day. More recently, he has not been able to do this. He is sent here for an evaluation for a lumbar stenosis. Past Medical History: Heart disease, triple bypass in [**2124**], lung resection for TB 40 years ago, and kidney problems, anemia, prostate removal for cancer. Surgical History: Include prostate removal in [**2127**], bypass grafting [**2124**], cataract surgery bilaterally in [**2123**]. Medications: Atenolol, Hectorol, [**Doctor First Name **], furosemide, Apidra, Crestor, Kayexalate, Diovan, alpha lipoic acid, vitamin C, baby aspirin, ferrous sulfate, folic acid, Centrum Silver, and Metamucil. Allergies: No known allergies. Social History: He is retired and he was working as a city engineer for [**Hospital1 **] up until last year. He does not smoke. He drinks alcohol. He is married. Family history includes pancreatitis and strokes. Review of Systems: He reports he is in good health other than diabetes. Denies recent unexplained weight loss. He is deaf in his right ear. He is currently having gout in his right foot. A 13-point review of systems is otherwise negative. On physical exam, Mr. [**Known lastname 29175**] is a pleasant 73-year-old male accompanied by his wife. [**Name (NI) **] is alert and oriented x3. Affect within normal limits. He appears well groomed and well nourished. He has significant difficulty walking. He is able to stand up on his toes and his heels but with much difficulty. Bilateral lower extremity strength demonstrates slight weakness in his left [**Last Name (un) 938**] at 4/5, but otherwise it is [**5-19**]. Sensation grossly intact. Straight leg raise negative. No pain with internal and external rotation of his hips. Imaging Studies: MRI of the lumbar spine obtained on [**2131-2-27**], demonstrates a disc protrusion at L4-L5, and severe spinal canal stenosis at this level. At L5-S1, there is a left foraminal disc extrusion impinging the left L5 and left S1 nerve root. This was read by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Assessment and Plan: Mr. [**Known lastname 29175**] is a 73-year-old male who since [**2130-11-2**] has had severe right-sided leg pain. Symptoms are consistent with neurogenic claudication. Although he does have a large foraminal disc extrusion on the left, his symptoms are more right-sided. Symptoms are more consistent with severe canal narrowing at L4-L5. Dr. [**Last Name (STitle) 1352**] reviewed surgery with him, which would be a L5 laminectomy and L4 partial laminectomy. He understands the goal of surgery is to alleviate his right leg pain and increase his walking tolerance. His personal goal is to be able to walk on the beach in [**Location (un) **], [**State 1727**] with his grandchildren. Surgical details were reviewed and consents signed. He will be scheduled at a mutually convenient time. I will be in contact with Dr. [**Last Name (STitle) **] to ensure that he can be off aspirin during the periop period. Past Medical History: Coronary Artery Disease s/p NSTEMI Hypertension Hypercholesterolemia Diabetes Mellitus Dilated Cardiomyopathy Peripheral Vascular Disease s/p Right Fem-[**Doctor Last Name **] Bypass Left foot ulcer (healed) Chronic Renal Insufficiency s/p Left Lung Resection d/t Tuberculosis s/p Right Breast Tumor removal (benign) Social History: -Tobacco, +ETOH (2 gin/d), -IVDA Lives with wife Family History: Non-contributory Physical Exam: see HPI Pertinent Results: [**2131-4-17**] 08:15PM GLUCOSE-72 UREA N-32* CREAT-1.5* SODIUM-142 POTASSIUM-4.3 CHLORIDE-107 TOTAL CO2-27 ANION GAP-12 [**2131-4-17**] 08:15PM estGFR-Using this [**2131-4-17**] 08:15PM CALCIUM-8.8 PHOSPHATE-4.3 MAGNESIUM-2.3 [**2131-4-17**] 08:15PM WBC-5.9 RBC-3.69* HGB-11.4* HCT-34.3* MCV-93 MCH-30.9 MCHC-33.2 RDW-13.0 [**2131-4-17**] 08:15PM PLT COUNT-244 [**2131-4-17**] 03:55PM TYPE-[**Last Name (un) **] TEMP-37 PO2-47* PCO2-46* PH-7.43 TOTAL CO2-32* BASE XS-4 COMMENTS-RA [**2131-4-17**] 03:55PM GLUCOSE-110* NA+-140 K+-5.0 [**2131-4-17**] 03:55PM HGB-12.7* calcHCT-38 Brief Hospital Course: Patient was admitted to the [**Hospital1 18**] Spine Surgery Service and taken to the Operating Room for the above procedure. Refer to the dictated operative note for further details. The surgery was without complication and the patient was transferred to the PACU in a stable condition. TEDs/pnemoboots were used for postoperative DVT prophylaxis. Intravenous antibiotics were continued for 24hrs postop per standard protocol. Initial postop pain was controlled with a PCA. Diet was advanced as tolerated. The patient was transitioned to oral pain medication when tolerating PO diet. Foley was removed on POD#2. Drain out POD2, then restarted [**Last Name (un) **]. [**Hospital **] clinic was consulted and helped managed his sugars. Sugars well controlled on insulin pump. . POD3 patient developed low grade temp. U/A was negative for infection. Chest xray was normal. . [**Last Name (un) **] was consulted for management of Inslin pump. . Physical therapy was consulted for mobilization OOB to ambulate. Hospital course was otherwise unremarkable. On the day of discharge the patient was afebrile with stable vital signs, comfortable on oral pain control and tolerating a regular diet. Medications on Admission: atenolol 50 mg Tablet one Tablet(s) by mouth once a day doxercalciferol [Hectorol]2.5 mcg Capsule 1 Capsule(s)every day fexofenadine [[**Doctor First Name **]] 180 mg Tablet 1 Tablet(s) by mouth as needed furosemide 40 mg Tablet 1 Tablet(s) in morning and 1 tab in evening rosuvastatin [Crestor]40 mg Tablet 1 (One) Tablet(s) once a day Kayexalate Powder 15 grams Powder(s) by mouth once a day valsartan [Diovan]80 mg Tablet 1 (One) Tablet(s) once a day ascorbic acid 500 mg Capsule, Sustained Release 1 Capsule(s) daily Aspirin Oral 81 mg every day last dose [**2131-4-6**] ferrous sulfate 325 mg (65 mg Elemental Iron) Tablet 1 daily [Centrum Silver] Tablet 1 Tablet(s) by mouth daily folic acid Oral 400 mcg every day p.m Crestor Oral 40 mg every day p.m(dinner) Metamucil Oral 1 tsp every day as needed for constipation oxyCODONE Oral 5 mg as needed as needed for pain Glucagon Subcutaneous 1 mg emergency dose as needed for hypoglycemia . Apidra Subcutaneous 100 unit/mL dose varies at meals and as needed for snacks or based on activity administer within 15 minutes before breakfast, lunch, and supper correction=BS level-120 divided by 30 then based on [**Doctor Last Name **] and bld glucose/a.m=14u bolus,noon=6-7u bolus,dinnertime =approx 12u) . Indomethacin Oral 50 mg 3 times per day as needed for gout flare alpha lipoic acid 300mg daily as needed for gout flare dinnertime Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): take while on narcotics to prevent constipation. Disp:*60 Capsule(s)* Refills:*2* 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for constipation. Disp:*30 Tablet(s)* Refills:*0* 3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: [**1-15**] Tablet, Delayed Release (E.C.)s PO DAILY (Daily) as needed for constipation. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 4. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**4-20**] hours as needed for fever, pain. 5. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain: no driving or alcohol. Disp:*90 Tablet(s)* Refills:*0* 6. doxercalciferol 2.5 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). Capsule(s) 7. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. sodium polystyrene sulfonate 15 g/60 mL Suspension Sig: One (1) PO DAILY (Daily). 14. Insulin Pump IR1250 Miscellaneous 15. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Discharge Disposition: Home With Service Facility: VNA of [**Location (un) 270**]-East & Visiting Nurse Hospice Discharge Diagnosis: lumbar central stenosis, neurogenic claudication Discharge Condition: good Discharge Instructions: You have undergone the following operation: Lumbar Decompression Without Fusion Immediately after the operation: ?????? Activity: You should not lift anything greater than 10 lbs for 2 weeks. You will be more comfortable if you do not sit or stand more than ~45 minutes without moving around. ?????? Rehabilitation/ Physical Therapy: ◦ 2-3 times a day you should go for a walk for 15-30 minutes as part of your recovery. You can walk as much as you can tolerate. ◦ Limit any kind of lifting. ?????? Diet: Eat a normal healthy diet. You may have some constipation after surgery. You have been given medication to help with this issue. ?????? Wound Care: Remove the dressing in 2 days. If the incision is draining cover it with a new sterile dressing. If it is dry then you can leave the incision open to the air. Once the incision is completely dry (usually 2-3 days after the operation) you may take a shower. Do not soak the incision in a bath or pool. If the incision starts draining at anytime after surgery, do not get the incision wet. Cover it with a sterile dressing and call the office. ?????? You should resume taking your normal home medications. ?????? You have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so please plan ahead. You can either have them mailed to your home or pick them up at the clinic located on [**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic prescriptions (oxycontin, oxycodone, percocet) to your pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. ?????? Follow up: ◦ Please Call the office and make an appointment for 2 weeks after the day of your operation if this has not been done already. ◦ At the 2-week visit we will check your incision, take baseline X-rays and answer any questions. We may at that time start physical therapy. ◦ We will then see you at 6 weeks from the day of the operation and at that time release you to full activity. Please call the office if you have a fever>101.5 degrees Fahrenheit and/or drainage from your wound. Physical Therapy: No restrictions Treatments Frequency: dressing only if draining Followup Instructions: Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2131-5-7**] 1:20 Provider: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 8603**] Date/Time:[**2131-5-7**] 1:40 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7779**], MD Phone:[**Telephone/Fax (1) 3241**] Date/Time:[**2131-8-16**] 10:00

[ "724.03", "443.9", "357.2", "414.00", "429.9", "715.90", "585.3", "V58.67", "425.4", "379.90", "250.63", "412", "250.53", "403.90", "722.10", "V45.81", "721.42", "V10.46", "V12.01", "272.0" ]

icd9cm

[ [ [] ] ]

[ "03.09", "80.51" ]

icd9pcs

[ [ [] ] ]

9977, 10068

5872, 7078

333, 352

10161, 10168

5253, 5849

12591, 13064

5192, 5210

8521, 9954

10089, 10140

7104, 8498

10192, 10275

5225, 5234

12503, 12519

12541, 12568

11947, 12485

10309, 10523

2658, 3479

270, 295

10908, 11935

380, 1879

4791, 5109

5125, 5176

3497, 4769

4,300

179,995

25961

Discharge summary

report

Admission Date: [**2200-1-13**] Discharge Date: [**2200-1-18**] Date of Birth: [**2150-5-4**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1283**] Chief Complaint: Chest pressure Major Surgical or Invasive Procedure: CABGx3 LIMA-> LAD, SVG->RCA, SVG->OM CPB 91' Cross clamped 43' History of Present Illness: 49year old male s/p MI on [**2199-11-18**] with [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] and angioplasty to RCA. Patietn with 2VD not amenable to PCI. He denies SOB but had chest pressure the morning of MI. Past Medical History: GERD, hiatal hernia, s/p PTCA Social History: denies Tobacco, Etoh, IVDA. Lives with parents. Family History: father and grandfather with CAD s/p CABG Physical Exam: in bed NAD Neuro AA&Ox3, nonfocal Chest CTAB resp unlab median sternotomy stable, c/d/i no d/c, RRR no m/r/g chest tubes and epicardial wires removed. Abd S/NT/ND/BS+ EXT warm with trace edema, LLE EVH c/d/i Pertinent Results: Cardiology Report ECHO Study Date of [**2200-1-13**] PATIENT/TEST INFORMATION: Indication: Intra-op TEE, CABG Weight (lb): 300 Status: Inpatient Date/Time: [**2200-1-13**] at 14:02 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2006AW582-: Test Location: Anesthesia West OR cardiac Technical Quality: Suboptimal REFERRING DOCTOR: DR. [**First Name (STitle) 412**] [**Last Name (Prefixes) 413**] MEASUREMENTS: Left Ventricle - Inferolateral Thickness: 1.0 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 4.7 cm (nl <= 5.6 cm) Left Ventricle - Ejection Fraction: 50% (nl >=55%) Aorta - Ascending: 3.1 cm (nl <= 3.4 cm) INTERPRETATION: Findings: RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Normal LV wall thicknesses and cavity size. Mild global LV hypokinesis. LV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior - hypo; mid anterior - hypo; basal anteroseptal - hypo; mid anteroseptal - hypo; basal inferoseptal - hypo; mid inferoseptal - hypo; basal inferior - hypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral - hypo; basal anterolateral - hypo; mid anterolateral - hypo; anterior apex - hypo; septal apex - hypo; inferior apex - hypo; lateral apex - hypo; apex - hypo; RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic root diameter. Normal ascending aorta diameter. Simple atheroma in ascending aorta. Simple atheroma in descending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). AVR leaflets move normally. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Abnormal MVR leaflet/disc motion. Systolic motion of the mitral chordae (normal variant). No resting LVOT gradient. Mild to moderate ([**12-23**]+) MR. Normal LV inflow pattern for age. TRICUSPID VALVE: Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. No TEE related complications. The patient was under general anesthesia throughout the procedure. Conclusions: PRE-CPB Left ventricular wall thicknesses and cavity size are normal. There is mild global left ventricular hypokinesis. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the ascending aorta. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. The aortic prosthesis leaflets appear to move normally. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. The anterior mitral leaflet displays restricted systolic motion resulting in. mild to moderate ([**12-23**]+) anteriorly directed mitral regurgitation. There is no pericardial effusion. POST-CPB Normal biventricular systolic function. MR is now trace. No other changes from pre-CPB Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD on [**2200-1-13**] 15:55. [**Location (un) **] PHYSICIAN: ([**Numeric Identifier 64528**]) Cardiology Report ECG Study Date of [**2200-1-14**] 12:14:14 PM Sinus rhythm. Early anterior precordial R wave progression may be normal variant. Compared to the previous tracing of [**2200-1-3**] no major change. Read by: [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 975**] Intervals Axes Rate PR QRS QT/QTc P QRS T 82 164 86 396/434.42 39 -5 35 RADIOLOGY Final Report CHEST (PORTABLE AP) [**2200-1-15**] 9:46 AM CHEST (PORTABLE AP) Reason: r/o effusion [**Hospital 93**] MEDICAL CONDITION: 49 year old man s/p cabg REASON FOR THIS EXAMINATION: r/o effusion INDICATION: Status post CABG, rule out effusion. TECHNIQUE: Single portable AP radiograph, compared with most recent examination dated [**2200-1-14**]. FINDINGS: There is a right IJ central venous catheter, extending to the brachiocephalic confluence/SVC. Cardiac silhouette remains within normal limits, and there is persistent widening of the mediastinum. Persistence of retrocardiac opacity is most likely atelectasis. No evidence of pneumonia, new opacities, or pneumothorax. There is probably a small left pleural effusion. IMPRESSION: No significant change in retrocardiac atelectasis and postoperative mediastinal widening. The study and the report were reviewed by the staff radiologist. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DR. [**First Name (STitle) 7204**] [**Name (STitle) 7205**] Approved: WED [**2200-1-15**] 4:42 PM Brief Hospital Course: Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2200-1-10**] for further management of his coronary artery disease. He had been previously catheterized at [**Location (un) 47**] in [**10-26**] where he was found to have three vessel disease that was not amenable to PCI. Given the severity of his disease, the cardiac surgical service was consulted for surgical revascularization. He was worked-up in the usual preoperative manner. On [**2200-1-13**] he successfully underwent CABGx3 (LIMA->LAD, SVG->RCA, SVG->OM). Afterward he was transferred to the Cardiac surgery recovery unit in stable condition and awakened neurologically intake. He was weaned from ventilator support, extubated, and pressors were weaned. On POD 2 he was then transferred to the Stepdown unit for further recovery. His chest tubes were removed without complication. He was gently diuresed to his preoperative weight, beta blockade and aspirin therapy were resumed, and physical therapy service was consulted to assist with his postoperative strength and mobility. He was transfused two units of PRBC's for a hematocrit of 21.3 which was associated with lightheadedness with sitting up. A chest Xray did not show evidence of hemothorax. Electrolytes were repleted as needed. On POD 3 his epicardial pacing wires were removed without complication, he continued to improve his ability to ambulate including climbing stairs without respiratory distress or chest pain. On POD 5 Mr. [**Known lastname **] was 2kg above his preop weight with good exercise tolerance, no SOB, or chest pain. His blood pressure was stable. His sternotomy and leg incision were clean, dry, and intact without evidence of infection. He was discharged home on POD 5 with services in good condition, cardiac diet, sternal precautions, and instructed to follow up with his PCP and cardiologist in [**12-23**] weeks. He will follow up with Dr. [**Last Name (STitle) 1290**] in four weeks. Medications on Admission: Plavix 75' Lipitor 80' Lisinopril 5' Metoprolol 25'' ASA 325' Discharge Medications: 1. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H (every 12 hours) for 7 days. Disp:*14 Packet(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. 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* 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:*14 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: CAD, GERD, hiatal hernia, Discharge Condition: Good Discharge Instructions: Shower, wash incisions with mild soap and water and pat dry. No lotions, creams or powders to incisions. Call with fever >101, redness or drainage from incision, or weight gain more than 2 pounds in one day or five pounds in one week. No lifting more than 10 pounds for 10 weeks. No driving until follow up with surgeon. Followup Instructions: follow up with Dr. [**Name (NI) **] in four weeks [**Telephone/Fax (1) 170**] follow up with Dr. [**Last Name (STitle) 11427**] in [**12-23**] weeks [**Telephone/Fax (1) 8058**] follow up with Dr. [**Last Name (STitle) 1295**] in [**12-23**] weeks ([**Telephone/Fax (1) 64154**] Completed by:[**2200-1-18**]

[ "412", "V15.02", "414.01", "V45.82", "278.00", "V17.3", "553.3", "285.9", "530.81", "440.0", "272.4", "693.1", "518.0" ]

icd9cm

[ [ [] ] ]

[ "39.61", "39.64", "36.12", "34.04", "88.72", "38.91", "89.64", "36.15" ]

icd9pcs

[ [ [] ] ]

9360, 9431

5902, 7872

335, 399

9501, 9508

1075, 1131

9878, 10188

789, 831

7984, 9337

4910, 4935

9452, 9480

7898, 7961

9532, 9855

1157, 4292

846, 1056

281, 297

4964, 5879

427, 654

4326, 4873

676, 707

723, 773

71,174

127,050

53474

Discharge summary

report

Admission Date: [**2137-5-22**] Discharge Date: [**2137-5-29**] Date of Birth: [**2063-3-9**] Sex: F Service: MEDICINE Allergies: Iodine-Iodine Containing / Codeine / Zoloft Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Abdominal Pain, Hematemesis, Diverticulitis, Tremor/Myoclonus Major Surgical or Invasive Procedure: intubation [**2137-5-22**] central line [**2137-5-26**] intubation [**2137-5-26**] History of Present Illness: 74 year old Female who initially presented with abdominal pain, and an abdominal CT in the ED was significant for concern for diverticulitis/colitis at the splenic flexure with some concern for chronic mesenteric ischemia. She was occult blood positive on rectal exam. She was started on ciprofloxacina and metronidazole in the ED. She also notes that the day prior to admission she had nasuea and vomitting after drinking some water. She was also noted with a whole body coarse tremor, with occaisional myoclonic jerking motions. The family notes this has begun within the last 3 months, with initiation of steroids for her ILD, but markedly worsened over the last several weeks. This has also been accompanied with some cognative decline and some delerium. A neurology consult was obtained. The morning after admission however during rounds she proceeded to have frank hematemesis. Nasogastric lavage was performed with return of approximately 500ml of blood. The patient has been undergoing workup and treatment for interstitial lung disease of unknown etiology. She also has a history of supraventricular tachycardia, and has been on antyarrythmics for over 10 years. Past Medical History: CAD - 40% mid LAD on cath in [**2124**], stress echo [**2137-3-11**] Hyperlipidemia Tobacco Dependence Gastritis COPD - PFTs [**2137-5-8**] FVC 75% FEV1 89% FVC/FEV1 118% Interstitial Lung Disease - UIP vs NSIP on prednisone SVT on flecainide since [**2116**]'s AAA, <4cm followed by Dr. [**Last Name (STitle) **] at [**Hospital1 18**] Restless Leg Syndrome Low Back Pain Social History: She is a widow. Her two children currently reside in [**Location (un) 86**]. Previously worked as a cafeteria manager in the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] School system. No ETOH or drug use. Active smoker: [**3-31**] cigarettes/day, max history 10/day. Requires helps for ADLs. Walks with walker at baseline. Family History: Mother - stroke; Father - stroke; Brother - CAD at age 65 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, + Hematemasis PULM: - Dyspnea, + Cough, - Hemoptysis HEME: + Bleeding, - Lymphadenopathy GU: - Dysuria, - hematuria, - Incontinence SKIN: - Rash ENDO: - Heat/Cold Intolerance MSK: - Myalgia, - Arthralgia, - Back Pain NEURO: - Numbness, - Weakness, - Vertigo, - Headache PHYSICAL EXAM: VSS: Tmax 101.2, T 101.2, 118/60, 75, 18, 96%2L GEN: NAD Pain: 0/10 HEENT: EOMI, MMM, - OP Lesions PUL: Fine Crackles bibasilar COR: RRR, S1/S2, - MRG ABD: obese, NT, ND, +BS, - CVAT, - Rebound, - Guarding EXT: - CCE NEURO: CAOx2, Coarse motor tremor, worse in LE, myoclonic jerks every 1-2 minutes involving all extremities, Motor [**5-30**] UE/LE/Finger spread Pertinent Results: [**2137-5-23**] 07:00AM BLOOD WBC-10.1 RBC-3.31* Hgb-11.2* Hct-33.2* MCV-100* MCH-33.7* MCHC-33.7 RDW-13.6 Plt Ct-218 [**2137-5-22**] 08:00PM BLOOD WBC-17.0*# RBC-3.86* Hgb-13.0 Hct-38.7 MCV-100* MCH-33.6* MCHC-33.5 RDW-13.7 Plt Ct-238 [**2137-5-23**] 07:00AM BLOOD Neuts-80.4* Lymphs-17.2* Monos-1.9* Eos-0.1 Baso-0.5 [**2137-5-22**] 08:00PM BLOOD PT-12.8 PTT-20.0* INR(PT)-1.1 [**2137-5-23**] 07:00AM BLOOD Glucose-96 UreaN-33* Creat-1.8* Na-135 K-4.8 Cl-101 HCO3-26 AnGap-13 [**2137-5-22**] 08:00PM BLOOD Glucose-109* UreaN-34* Creat-2.0* Na-136 K-5.0 Cl-97 HCO3-24 AnGap-20 [**2137-5-23**] 07:00AM BLOOD LD(LDH)-210 [**2137-5-22**] 08:00PM BLOOD ALT-33 AST-40 CK(CPK)-32 AlkPhos-105 TotBili-0.3 [**2137-5-23**] 07:00AM BLOOD Albumin-3.2* Calcium-8.4 Phos-5.1* Mg-1.7 CT HEAD W/O CONTRAST Study Date of [**2137-5-23**] 2:35 AM IMPRESSION: 1. No acute intracranial abnormality. 2. Chronic microangiopathic ischemic disease and age-related involutional changes. CT ABD & PELVIS W/O CONTRAST Study Date of [**2137-5-22**] 9:39 PM WET READ AUDIT # 3 MLHh WED [**2137-5-22**] 10:22 PM Ltd w/o IV contrast. Fat stranding around dist tv colon and splenic flexure suggests acute colitis or diverticulitis. FLuid-filled large and small bowel loops suggesting reactive ileus or superimposed gastroenteritis. Relatively featureless bowel could be seen in chronic mesenteric ischemia. Mod hiatal hernia. Severe emphysema. Roughly stable infrarenal AAA msr 3.3 cm. Brief Hospital Course: #. Hypoxic Resipratory Failure: The patient was transferred to the floor after her GI bleed was explored and treated with an endoscopy done by the GI service as described below. Two days after she was transferred to the floor, the patient was ambulating with physical therapy. Afterwards she developed hypoxic respiratory failure becoming tachypneic, with low oxygen saturations. She was triggered on the floor also for her hypotension. She was transferred back to the ICU. The patient was placed on non-rebreather mask and continued to have oxygen saturations in the low 90s. She developed fatigue and stated that she was tired. She also started having changes in her mental status becoming more somnolent. The patient's family as well as the patient had discussion about code status. It was determined that she was okay to be resucitated and intubated however the patient did not want prolong intubation. She was intubated for airway protection. A central line was also placed for CVP monitoring as well as pressor administration. She was kept on pressors. The patient was maintained on the ventilator and was given diuresis as well as antibiotics with limited clinical improvement. On the second day after intubation, the decision was made to terminally extubate the patient and make the patient CMO with all family members present. The patient was extubated and in 2 hours because asystolic with no pulses or respirations. The patient's family declined autopsy. NEOB was notified. The patient was transferred to the morgue. . #. Acute Blood Loss Anemia due to GI Bleeding. High risk for GIB given long term prednisone, aspirin, and aspirin containing medications. Patient was found to have reddish-brown coffee ground hematemesis. Hct was noted to have dropped about 5 points but also in the setting of getting maintenance fluid since admission. NGT was placed with continuous brown-red aspirate of about 500cc as GI was called to evaluate patient for likely upper GIB, such as [**Doctor First Name **]-[**Doctor Last Name **] tear, given recent retching, nausea, and vomiting prior to admission. No BM since admission. She has active type and screen until [**5-25**], and a second IV was placed (18g, 20g). Aspirin containing medications were stopped. She received bolus of pantoprazole then transitioned to drip. MICU was called to evaluate for patient given active bleeding and need for urgent endoscopy by GI with anesthesiology for possible need for MAC. Plan to have at least q8h Hct check with 2 units of crossmatched pRBC standby. She was transferred to the MICU and underwent endoscopy, which showed + erosive esophagitis. She was kept on high dose PPI with the plan to have repeat endoscopy in 8 weeks. . #. Ischemic Colitis. History is somewhat difficult to obtain from patient. Initial read of CT abd/pelvis suggested diverticulitis and then later read as colitis. She was placed on ciprofloxacin and metronidazole empirically, and kept NPO initially. She was noted to have diffuse tenderness in her abdomen during round with + guarding. Surgery was consulted prior to her transfer to the MICU. She was transferred back on Unasyn and Flagyl, with unclear reason to the change from [**Name (NI) **] and Flagyl, ? concern for C. diff, but C. diff was negative. MRA/MRI showed suggestive of acute on chronic ischemic colitis. The patient was evaluated by the surgical service previous to be a poor operative candidate and would unlikely be able to tolerate the procedure. It was felt likely that the GI bleed which was the original chief complaint was caused by the ischemic colitis. #. Acute Renal Failure. Likely in the setting of acute bleeding. IV hydration. Renally dose medications. Held lisinopril. Avoid nephrotoxins. # Spastic Movement- per daughter, new over past few days. Strength intact, and left lower extremity weakness at baseline after spine surgery per patient. No confusion. Given spastic movements, recent falls will pursue CT Head to rule-out subacute process such as subdural. General weakness worsened while on prednisone, concerning for steroid induced myopathy. CK nl. Neurology was consulted and was unclear to the cause of her myoclonus because her symptoms reportedly resolved prior to the discontinuation of her prednisone. Her prednisone was discontinued by MICU team after their discussion with her primary pulmonologist. PT consult. #. Interstitial Lung Disease. Continue on steroid initially. However, given the tremor and myoclonus, there was a concern that these involuntary movements were induced/exacerbated by the steroid. Given the concern and after discussion between MICU and primary pulmonologist, her prednisone was stopped. She continued on home inhalers and was kept on supplemental O2 while in house. #. COPD. Continue albuterol nebs, spiriva, symbicort #. CAD Native Vessle. Holding aspirin given acute GIB. Once stabilized, can restart aspirin. Continue statin and betablocker. Hold ACE inhibitor given ARF. Nitroglycerin prn. #. Supraventricular Tachycardia. Continue flecainide. Check ECG for prolonged QTc. #. Mental health. Continue citalopram. # FEN: NS at 125cc/h overnight / replete lytes prn / NPO # PPX: heparin SQ, bowel regimen # ACCESS: PIV # CODE: presumed FULL # CONTACT: patient, daughter [**Name (NI) **] [**Telephone/Fax (1) 109950**]. [**Name2 (NI) **]r [**Name (NI) **]. Medications on Admission: - Symbicort (nedsonide-formoterol) 1 puff daily - Firoicet daily prn headache - Citalopram 40 mg qhs - Flecainide 100 mg q8h - Neurontin 800 mg [**Hospital1 **] - Lisinopril 5 mg daily - Metoprolol Tartrate 100 mg [**Hospital1 **] - Nitrospray prn - Oxycodone 5 mg TID-QID prn breakthrough pain - Oxycodone/acetaminophen 2 tabs QID for pain - Prednisone 10 mg daily - Rosuvastatin 40 mg daily - Bactrim DS 1 tab QMWF - Spiriva 18mcg 1 puff daily - ASA 81 mg daily - Calcium 600 + Vitamin D 200 daily - Colace 100 mg daily prn constiptation - Multivitamin daily Discharge Disposition: Expired Discharge Diagnosis: NA Discharge Condition: NA Discharge Instructions: NA Followup Instructions: NA [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

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icd9cm

[ [ [] ] ]

[ "96.71", "38.93", "96.04", "33.24", "38.91", "45.13", "99.62" ]

icd9pcs

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372, 456

10971, 10976

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11027, 11169

2435, 2494

10945, 10950

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67,835

146,069

37432

Discharge summary

report

Admission Date: [**2197-1-10**] Discharge Date: [**2197-1-19**] Date of Birth: [**2129-4-11**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2777**] Chief Complaint: Periurethral abscess, concern for Fournier's Gangrene Major Surgical or Invasive Procedure: Debridement of scrotal and periurethral abscess and open placement of suprapubic urinary catheter, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 770**], [**2197-1-10**]. [**2197-1-17**] 1. Ultrasound-guided puncture of the left common femoral artery. 2. Contralateral 3rd order catheterization of a branch of the right hypogastric artery. 3. Abdominal aortogram. 4. Selective arteriogram of the right hypogastric artery. 5. Coil embolization of the right hypogastric artery. 6. Closure of the left common femoral arteriotomy. [**2197-1-17**] Right hypogastric a. coil emobilization History of Present Illness: 67M who presented from OSH with 5 days of worsening scrotal pain and swelling. He states he was in his usual state of health when he started having worsening scrotal pain which made it difficult to walk, prompting him to be evaluated at OSH. He underwent a scrotal ultrasound which showed scrotal wall thickening with a WBC 15k, and he was transfered to [**Hospital1 18**] ED. He received Vancomycin and Unasyn prior to transfer. On arrival, he appears hemodynamically stable, and he has no SOB, CP, N/V, leg pain. He has had decreased appetite since yesterday evening. His last oral intake was cabbage yesterday evening. He denies dysuria, hematuria, incomplete voiding, or other urinary symptoms. Past Medical History: PMH: DM, HTN, ? Acute MI PSH: Per pt has Hx of "stenting" of vessel after left Arm pain, but does not believe stent in heart, thinks in arm. Social History: Lives at home with wife Family History: Non-contributory Physical Exam: Temp: 98.1-99 HR: 61 BP: 144/75 RR: 16 Spo2: 94% RA Gen: NAD, Alert and oriented x3 Neuro: CN II-XII Cardiac: RRR, no mrg, + S1, S2 Lungs: CTA bilaterally, no resp distress Abd: soft, NT, ND, no rebound/guarding Suprapubic catheter intact and draining L groin puncture site without bleeding or hematoma. Extremities warm and well perfused Dressing intact to periurital abcess Pertinent Results: [**2197-1-18**] 06:20AM BLOOD Hct-32.7* [**2197-1-15**] 05:40AM BLOOD WBC-7.7 RBC-3.49* Hgb-10.7* Hct-30.8* MCV-88 MCH-30.6 MCHC-34.7 RDW-14.2 Plt Ct-236 [**2197-1-10**] 07:54PM BLOOD Neuts-88.8* Lymphs-5.7* Monos-4.4 Eos-1.0 Baso-0.2 [**2197-1-15**] 05:40AM BLOOD Plt Ct-236 [**2197-1-11**] 01:56AM BLOOD PT-14.4* PTT-28.9 INR(PT)-1.3* [**2197-1-18**] 06:20AM BLOOD UreaN-16 Creat-1.6* K-4.0 [**2197-1-16**] 06:15AM BLOOD Glucose-108* UreaN-20 Creat-1.6* Na-144 K-4.0 Cl-105 HCO3-31 AnGap-12 [**2197-1-11**] 08:03AM BLOOD CK(CPK)-131 [**2197-1-11**] 08:03AM BLOOD CK-MB-3 cTropnT-<0.01 [**2197-1-16**] 06:15AM BLOOD Calcium-7.9* Mg-2.0 [**2197-1-10**] 12:45PM BLOOD %HbA1c-6.3* [**2197-1-14**] 06:05AM BLOOD Vanco-16.0 [**2197-1-12**] 01:47AM BLOOD Type-ART pO2-196* pCO2-49* pH-7.33* calTCO2-27 Base XS-0 [**2197-1-10**] 06:00PM BLOOD Hgb-11.0* calcHCT-33 [**2197-1-12**] 01:47AM BLOOD freeCa-1.07* Radiology Report CTA AORTA/BIFEM/ILIAC RUNOFF W/W&WO C AND RECONS Study Date of [**2197-1-16**] 10:23 AM [**Last Name (LF) **],[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] 12R [**2197-1-16**] 10:23 AM CTA AORTA/BIFEM/ILIAC RUNOFF W Clip # [**Clip Number (Radiology) 84126**] Reason: pre-op eval for large iliac artery aneurysms. Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 67 year old man with large bilateral iliac artery aneurysms. Please get CTA of ENTIRE aorta with bilateral runoff. REASON FOR THIS EXAMINATION: pre-op eval for large iliac artery aneurysms. CONTRAINDICATIONS FOR IV CONTRAST: None. Final Report CLINICAL INDICATION: Bilateral iliac artery aneurysms. TECHNIQUE: MDCT was performed from the upper abdomen through bilateral feet prior to and following the uneventful administration of nonionic intravenous contrast and oral contrast. Curved multiplanar reformations and volume rendered images were performed in the 3D imaging lab. Comparison is made to prior CT of the pelvis performed [**1-10**], [**2196**]. FINDINGS: The liver is diffusely decreased in attenuation, consistent with hepatic steatosis. There are no focal lesions within the visualized portions of the liver and spleen. The kidneys, adrenal glands, pancreas are unremarkable. The gallbladder is contracted. There are no pathologically enlarged lymph nodes by size criteria. The abdominal bowel loops are grossly unremarkable and there is no free fluid. PELVIS: There are new midline surgical staples and there is a new suprapubic catheter. Prostatic calcifications are noted. There has been interval debridement of the perineum with interval resolution of previously seen fluid collections. New foci of gas are noted, likely post-surgical. There is no pelvic free fluid. There are large bilateral inguinal lymph nodes, likely reactive. Bone windows demonstrate degenerative changes of the spine. There are no focal suspicious lesions. CTA: There is mild atherosclerotic change at the origins of the celiac artery and SMA, which remain patent. The renal arteries are patent bilaterally. There is a small area of focal ulcerating plaque adjacent to the left renal artery. There is a large infrarenal aortic aneurysm, measuring 7.3 cm in maximum transverse dimension. AAA volume is 704 mL. Again noted are large bilateral common iliac artery aneurysms, right greater than left. There are multifocal areas of high density within the right common iliac artery aneurysm sac seen on pre-contrast images, consistent with calcification. No definite areas of contrast leak are identified on post-contrast images. The right common iliac artery aneurysm measures 8.4 x 8.2 cm, and the left common iliac artery aneurysm measures 5.4 x 5.3 cm. There is aneurysmal dilatation of the proximal right internal iliac artery measuring 2.0 cm. Both external and internal iliac arteries are patent, as are the common femoral arteries. There is suboptimal contrast within the superficial femoral arteries, but these do appear grossly patent bilaterally, with scattered areas of atherosclerotic calcification. The right popliteal artery is patent, as are the anterior and posterior tibial and peroneal arteries. The right plantar and dorsal arches are patent. The left popliteal, posterior tibial and peroneal arteries are patent throughout. The left anterior tibial artery is patent proximally then occludes in its mid portion. The left plantar arch is patent and there is a very small left dorsal arch. IMPRESSION: 1. Large infrarenal aortic and bilateral common iliac artery aneurysms. 2. Three-vessel runoff on the right and two-vessel runoff on the left. 3. Interval debridement of the perineum with interval resolution of previously seen fluid collections. New small foci of gas are likely post- surgical. 4. Hepatic steatosis. The study and the report were reviewed by the staff radiologist. DR. [**First Name4 (NamePattern1) 674**] [**Last Name (NamePattern1) 20058**] DR. [**First Name (STitle) 8913**] SUN Approved: TUE [**2197-1-17**] 8:41 AM Imaging Lab [**2197-1-12**] Echo [**Known lastname 84127**], [**Known firstname 84128**] [**Hospital1 18**] [**Numeric Identifier 84129**]Portable TTE (Complete) Done [**2197-1-12**] at 2:08:18 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Hospital1 **] C [**Location (un) 830**], [**Hospital Ward Name 452**] 440 [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2129-4-11**] Age (years): 67 M Hgt (in): 64 BP (mm Hg): 113/55 Wgt (lb): 210 HR (bpm): 100 BSA (m2): 2.00 m2 Indication: Mitral valve disease. Murmur. ICD-9 Codes: 785.2, 424.1, 424.2 Test Information Date/Time: [**2197-1-12**] at 14:08 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**First Name4 (NamePattern1) 1022**] [**Last Name (NamePattern1) **], RDCS Doppler: Full Doppler and color Doppler Test Location: West SICU/CTIC/VICU Contrast: None Tech Quality: Adequate Tape #: 2009W078-0:58 Machine: Vivid [**7-27**] Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 3.6 cm <= 4.0 cm Left Atrium - Four Chamber Length: *6.4 cm <= 5.2 cm Left Atrium - Peak Pulm Vein S: 0.8 m/s Left Atrium - Peak Pulm Vein D: 0.6 m/s Right Atrium - Four Chamber Length: *5.2 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 5.3 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 3.6 cm Left Ventricle - Fractional Shortening: 0.32 >= 0.29 Left Ventricle - Ejection Fraction: >= 55% >= 55% Left Ventricle - Stroke Volume: 111 ml/beat Left Ventricle - Cardiac Output: 11.08 L/min Left Ventricle - Cardiac Index: 5.54 >= 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': 15 < 15 Aorta - Sinus Level: 3.2 cm <= 3.6 cm Aorta - Ascending: 3.3 cm <= 3.4 cm Aortic Valve - Peak Velocity: *4.2 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: *71 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 36 mm Hg Aortic Valve - LVOT pk vel: 1.50 m/sec Aortic Valve - LVOT VTI: 32 Aortic Valve - LVOT diam: 2.1 cm Aortic Valve - Valve Area: *1.2 cm2 >= 3.0 cm2 Aortic Valve - Pressure Half Time: 204 ms Mitral Valve - E Wave: 1.1 m/sec Mitral Valve - A Wave: 1.2 m/sec Mitral Valve - E/A ratio: 0.92 Mitral Valve - E Wave deceleration time: 210 ms 140-250 ms TR Gradient (+ RA = PASP): *38 mm Hg <= 25 mm Hg Findings LEFT ATRIUM: Elongated LA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and global systolic function (LVEF>55%). Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. AORTIC VALVE: ?# aortic valve leaflets. Severely thickened/deformed aortic valve leaflets. Moderate AS (area 1.0-1.2cm2) Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. PERICARDIUM: No pericardial effusion. Conclusions The left atrium is elongated. 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 number of aortic valve leaflets cannot be determined. The aortic valve leaflets are severely thickened/deformed. There is moderate aortic valve stenosis (valve area 1.0-1.2cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Moderate calcific aortic stenosis. Mild symmetric left ventricular hypertrophy with normal global biventricular systolic function. Moderate pulmonary hypertension. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2197-1-12**] 16:13 Time Taken Not Noted Log-In Date/Time: [**2197-1-10**] 8:39 pm SWAB PERINEAL FLUID SWAB TRANSPORT. **FINAL REPORT [**2197-1-14**]** GRAM STAIN (Final [**2197-1-10**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS. FLUID CULTURE (Final [**2197-1-13**]): 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.. STAPH AUREUS COAG +. RARE GROWTH. SENSITIVITIES PERFORMED ON CULTURE # 287-9905S [**2197-1-10**]. ANAEROBIC CULTURE (Final [**2197-1-14**]): NO ANAEROBES ISOLATED. Time Taken Not Noted Log-In Date/Time: [**2197-1-10**] 8:19 pm ABSCESS Site: URETHRA PERI-URETHRAL/SCROTAL ABSCESS. GRAM STAIN (Final [**2197-1-10**]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS, CHAINS, AND CLUSTERS. 3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). SMEAR REVIEWED; RESULTS CONFIRMED. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ANAEROBIC CULTURE (Final [**2197-1-16**]): Mixed bacterial flora-culture screened for B. fragilis, C. perfringens, and C. septicum. None isolated. FLUID CULTURE (Final [**2197-1-15**]): 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.. STAPH AUREUS COAG +. SPARSE GROWTH OF TWO COLONIAL MORPHOLOGIES. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. Please contact the Microbiology Laboratory ([**7-/2493**]) immediately if sensitivity to clindamycin is required on this patient's isolate. SENSITIVITIES: MIC expressed in MCG/ML [**1-11**] Urine cx- neg Blood cx x2 - neg [**2197-1-10**] MRSA Screen negative Brief Hospital Course: The patient was transferred to [**Hospital1 18**] with concern for Fournier's Gangrene. He underwent a CT scan with IV contrast which showed periurethral abscess with additional collection in the perineum. Incidental finding of large bilateral iliac artery aneurysms was noted. He was taken emergently to the OR for debridment of periurethral and perineal abscess and open placement of suprapubic urinary catheter. The case was uncomplicated - please see dictated operative note for full details. Postoperatively, he was brought to the T-SICU for aggressive dressing changes. He continued on Vancomycin and Zosyn while he was inpatient. He did well and was eventually transferred to the floor in stable condition. He underwent twice-daily dressing changes with wet to dry dressings in the area of debridement. His suprapubic catheter continued to drain well. The Cardiology consult service saw the patient for pre-operative clearance for future management of his bilateral iliac artery aneurysms. He underwent a CT angiogram of the entire Aorta with bilateral runoff at the request of the vascular surgery service. He continued to do well, and after his CT scan was reviewed by the vascular surgery team, they felt that he required an immediate coiling procedure. He was transferred to the vascular surgery service with the recommendations that he continue to have twice daily dressing changes with wet to dry dressings and be sent out on a 2 week course of oral Bactrim. Medications on Admission: MEDS: Lisinopril 5 mg po qday, Metoprolol 25 mg po qday, Glyburide 2.5 mg po qday, Simvastatin 20 mg po qday. Discharge Medications: 1. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO twice a day for 2 weeks. Disp:*28 Tablet(s)* Refills:*0* 2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 4. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 7. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual QID (4 times a day) as needed for bladder spasms. Disp:*30 Tablet, Sublingual(s)* Refills:*0* 8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Large bilateral iliac artery aneurysms on CT pelvis for Fournier's gangrene Acute on chronic renal failure Past Medical History: Diabettes Hypertension MI Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: Division of Vascular and Endovascular Surgery Angioplasty/Stent Discharge Instructions Medications: ?????? Take Aspirin 325mg (enteric coated) once daily ?????? If instructed, take Plavix (Clopidogrel) 75mg once daily ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort What to expect when you go home: It is normal to have slight swelling of the legs: ?????? Elevate your leg above the level of your heart (use [**2-23**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated ?????? It is normal to feel tired and have a decreased appetite, your appetite will return with time ?????? Drink plenty of fluids and eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal) ?????? After 1 week, you may resume sexual activity ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate ?????? No driving until you are no longer taking pain medications ?????? Call and schedule an appointment to be seen in [**3-23**] weeks for post procedure check and ultrasound What to report to office: ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site) ?????? Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call vascular office [**Telephone/Fax (1) 1237**]. If bleeding does not stop, call 911 for transfer to closest Emergency Room. Twice daily dressing changes with wet to dry dressings to the Periurethral abscess. You should take your full course of antibiotics. You should call Dr. [**Last Name (STitle) 770**] for a follow-up appointment appointment. be sent out on a 2 week course of oral Bactrim. Followup Instructions: Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2197-2-1**] 11:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 2625**] Date/Time:[**2197-2-1**] 1:15 Call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 770**] for wound check appointment in [**1-22**] weeks. Completed by:[**2197-1-19**]

[ "584.9", "585.9", "441.4", "442.2", "414.01", "424.1", "403.90", "608.83", "598.9", "597.0", "250.00", "V45.82" ]

icd9cm

[ [ [] ] ]

[ "88.47", "39.79", "57.18", "58.39", "88.42" ]

icd9pcs

[ [ [] ] ]

17151, 17209

14633, 16118

368, 982

17411, 17411

2380, 3690

20403, 20816

1939, 1957

16279, 17128

3730, 3848

17230, 17340

16144, 16256

17556, 19530

19556, 20380

1972, 2361

13438, 14610

275, 330

3880, 13405

1010, 1716

17425, 17532

17362, 17390

1898, 1923

3,459

191,904

18511+18512

Discharge summary

report+report

Admission Date: [**2121-10-31**] Discharge Date: Date of Birth: [**2074-4-17**] Sex: F Service: BONE MARROW TRANSPLANT CHIEF COMPLAINT: Burkitt's lymphoma. For HISTORY OF PRESENT ILLNESS, PHYSICAL EXAMINATION on arrival to [**Hospital1 69**] and original laboratory evaluations, please refer to the note from Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] from the [**2121-10-31**]. The current dictation will described the hospitalization course of the patient between that day and the [**2121-11-29**]. Between the 19th and the [**2121-11-3**], the patient remained in the Medical Intensive Care Unit of [**Hospital1 346**] where her respiratory and cardiovascular status was stabilized and chemotherapy was initiated according to the protocol designed by Dr. [**First Name (STitle) **]. The patient was transferred to the floor on the [**2121-11-3**], at which point she was in no acute distress. She had a clear mental status and her main complaints were abdominal pain status post exploratory laparotomy. Her renal function was adequate with a creatinine of 0.9 and a uric acid of 5.7. Tumor lysis and prophylaxis was ongoing with allopurinol and aggressive intravenous fluid hydration. PROBLEMS BY SYSTEM: 1. HEMATOLOGY: The patient was diagnosed with Burkitt's lymphoma. Kinetic studies performed on bone marrow aspiration material obtained at [**Hospital1 188**] showed an 8; 22 translocation involving the .....gene. Based on this diagnosis, it was decided that the patient should be treated with the Codex-M protocol. However, the treatment protocol was compromised by the patient's physical status and several other factors. Methotrexate was never administered because of the patient's large pleural effusions. Also, a phosphoamide treatment was discontinued after original administration resulted in a significant change in mental status. As a result, as of now, the patient's chemotherapy protocol has been compromised by poor tolerance and performance status. 2. PANCREATITIS: The patient exhibited abdominal pain on admission which was attributed to infiltration of her colon by lymphoma. Moreover, treatment with chemotherapy was expected to result in a high risk of bowel perforation because of melting of the large tumor mass that had infiltrated her colon. Upon her admission, the patient complained of abdominal pain. Laboratory results showed an elevated amylase and lipase level which continued to rise and was associated with increased abdominal pain. By hospitalization day six, the blood amylase levels peaked at 486 and the blood lipid levels peaked at 558. The patient was already n.p.o. and treated and supported with intravenous fluids and morphine. Gradually, the amylase and lipase blood levels dropped and the patient's abdominal pain subsided. A repeat abdominal CT scan showed improvement in her status with a regulation of lymphoma and radiographic features of pancreatitis. 3. RESPIRATORY STATUS: Throughout her second week of hospitalization, the patient complained of increased shortness of breath. By that time, the pleural effusions that had accumulated in her chest cavity were quite sizable and on the right side calculated as greater than 2 liters. A thoracentesis was performed on the [**2121-11-11**], and two liters of bloody fluid were aspirated. A cytology revealed the presence of the lymphoma cells. The patient tolerated the actual procedure well, however, shortly afterwards, she exhibited hypotension and had to be transferred to the Medical Intensive Care Unit for blood pressure support. Her blood pressure normalized quickly, but unfortunately, at the same time, the pleural effusions reaccumulated within one day and had reached the original before thoracentesis size. The patient was then transferred again to the floor and it was decided to hold off on further thoracentesis. As a result, it was decided that methotrexate would not be administered to the patient, because pleural effusions contained adequate medication for methotrexate administration. 4. CARDIOVASCULAR: In addition to the above described episode of hypotension, the patient remained tachycardic throughout her hospitalization. Original evaluation on the [**11-4**] revealed that the patient's left ventricular ejection fraction was 55%. However, upon institution of chemotherapy her left ventricular ejection fraction dropped to less than 25% within five days. The cause of this change is still unclear, but potential toxicity from the chemotherapy regimen cannot be excluded. The decline in her left ventricular function continued and on the [**2121-11-14**], her left ventricular ejection fraction was less than 20% with severe global left ventricular hypokinesis identified by echocardiogram. Fortunately, her cardiovascular status improved during the next days with her left ventricular ejection fraction improving to approximately 30% on the [**2121-11-20**]. However, as of the time of this dictation, [**2121-11-29**], the patient continues to be consistently tachycardic. 5. INFECTIOUS DISEASE: The patient was transferred to [**Hospital1 1444**] status post exploratory laparotomy, and at that time she was treated with Levofloxacin, Metronidazole and Cefepime because of her post surgical status and her high risk for bowel perforation because of her treatment for lymphoma that had infiltrated her colon. Following the initiation of chemotherapy, the patient's white blood cell count dropped, she became neutropenic, and soon afterwards, she exhibited fever, as her antibiotic coverage was modified to include meropenem and Vancomycin. However, blood cultures drawn on the [**2121-11-9**] revealed [**Female First Name (un) 564**] albicans. Following this result, the patient was treated with AmBisome as well. However, her fever persisted and growth of [**Female First Name (un) 564**] from serial blood cultures persisted as well. At that point, it was decided to remove the Hickman catheter that had been placed in the outside hospital. That was done on the [**2121-11-14**], and the culture of the catheter tip grew [**Female First Name (un) **] albicans as well. Following the removal of the Hickman catheter, the patient's fevers subsided. Her mental status and her general performance status improved, and the patient became afebrile for a period of three days. However, due to the need for intravenous access, a PICC line was placed. Subsequently, the patient exhibited fevers again, at which point the PICC line was removed and blood cultures that were drawn revealed again the presence of [**Female First Name (un) 564**] albicans. Throughout this period, the patient was being treated with antibiotics including AmBisome. As of the time of this dictation, the patient's temperature has been within normal limits with the possible exception of a temperature of 100.1 F., on the morning of the [**2121-11-29**]. It should also be noted that the patient has currently a double lumen PICC placed which, given her prior repeated candidemia, predisposes her to future development of fungal infection. However, the risk for future fungal infection must be weighed against the need for intravenous access for this patient who needs several intravenous medications and total parenteral nutrition. 6. MENTAL STATUS: The patient's mental status throughout her hospitalization fluctuated with altered mental status during the period when she was afebrile and she had positive blood cultures for [**Female First Name (un) **] albicans. Her mental status improved when her Hickman line was removed and her fevers subsided. However, when her mental status and general performance status somewhat recovered from the fungal infection, she was treated with additional chemotherapy including Ifosfamide. Following this treatment, the patient exhibited altered mental status and became quite somnolent. A radiographic imaging of her brain was negative for acute events. Her change in mental status was attributed to the Ifosfamide (Ifosfamide encephalopathy), and during the next few days, her mental status improved with the only specific treatment being administration of thiamine (100 mg of thiamine four times a day). Following the patient's reaction to this medication, it was decided to stop any further chemotherapeutic treatment. 7. GASTROINTESTINAL: Upon arrival, the patient had Burkitt's lymphoma with abdominal presentation, including infiltration of her appendix, cecum, and terminal ileum. She also developed pancreatitis following her exploratory laparotomy in the outside hospital. During her first week of hospitalization at the [**Hospital1 69**] the patient was complaining of significant abdominal diffuse pain and was at severe risk for bowel perforation as her Burkitt's lymphoma was expected to respond to her chemotherapeutic regimen. Fortunately, her pain subsided with a very temporary support with morphine and her abdominal examination normalized. Follow-up abdominal CT scan without intravenous contrast performed on the [**2121-11-14**], revealed no bowel dilatation and no bowel wall thickening which was interpreted as a favorable response of her lymphoma to chemotherapy. The patient remained without abdominal complaints for an additional two weeks of her hospitalization. However, on the [**2121-11-27**], the patient complained of mild tenderness to abdominal palpation for the first time during the last three weeks of her hospitalization. This was worrisome of recurrence of lymphoma in the abdominal cavity or bowel obstruction caused either by the lymphoma or by adhesions from her exploratory laparotomy or also there was the possibility of an intra-abdominal infection. A KUB performed at the bedside did not show evidence of obstruction. The patient was suggested to have an abdominal CT scan which was not possible because the patient could not tolerate the p.o. intake of the p.o. contrast and it was decided to avoid using a nasogastric tube because the patient was at the time neutropenic with a very low platelet count. As of now, the patient has not had this CT scan of her abdomen and she has been managed supportively. It has been decided to avoid an aggressive management of her complaint of abdominal tenderness to palpation. The patient exhibits no rebound or guarding. Her abdomen is soft and nondistended, and she has been able to hold her bowel movements indicating probable complete bowel obstruction is not probable. In brief, this is a very frail patient who has been in this hospital for one month and has exhibited a very aggressive manifestation of Burkitt's lymphoma with several complications, including large pleural effusions, hypotension following thoracentesis, Candidemia, with fever and cardiovascular instability, cardiac toxicity with a low left ventricular ejection fraction, changes in her mental status following her fungal infection and administration of Ifosfamide as well as pancreatitis and currently abdominal tenderness to palpation. Because of the poor performance status of this patient, it has been decided that further chemotherapy should be held off. The original chemotherapy regimen for this patient was designed to be the Codex-M regimen, however, the patient was never given methotrexate because of her persistent pleural effusions and the patient has had a poor reaction to Ifosfamide with altered mental status, and at this point, further Ifosfamide is being held off. The patient has received an intrathecal administration of ARA-C. CT scan of the abdomen following one cycle of her chemotherapy has demonstrated a favorable response to her chemotherapy; however, given the aggressive nature of her disease, it is expected that she is at a high risk of relapse unless she can continue further chemotherapy treatment, which at this point is not considered appropriate given her very poor performance status. Evaluation of the patient for continuation of her chemotherapy protocol in the near future is recommended. As of the [**2121-11-29**], the patient's medications include: Acyclovir 400 mg intravenous three times a day; Vancomycin 1 gram intravenously q. 12 hours; meropenem 1 gram intravenously q. eight hours; Captopril 25 mg p.o. three times a day; Thiamine 100 mg intravenously q. day; AmBisome 300 mg intravenous q. 24 hours; Protonix 40 mg p.o. q. day; Nystatin swish and swallow; Peridex swish and swallow; supportive care with anti-fungal skin creams. The patient has received so far several transfusions of packed red blood cells and platelets and has had bone marrow aspiration and biopsy as well as one intrathecal administration of ARA-C and a second lumbar puncture to evaluate her altered mental status which was negative for infection. At this point, further plans for this patient may include continuation of her chemotherapy once her performance status allows that, and/or transfer to the outside hospital where she was originally seen ([**Hospital3 **]) as of the [**2121-11-29**], the disposition for this patient remains undecided. Further dictation for this patient will continue from the new intern taking over the medical service on Monday, the [**12-1**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4380**], M.D. [**MD Number(1) 10999**] Dictated By:[**Last Name (NamePattern1) 10203**] MEDQUIST36 D: [**2121-11-29**] 16:48 T: [**2121-11-29**] 22:31 JOB#: [**Job Number 50875**] Admission Date: [**2121-10-31**] Discharge Date: [**2121-12-4**] Date of Birth: [**2074-4-17**] Sex: F Service: Bone marrow transplant service Again, this was a 47-year-old female admitted with Berkitt's lymphoma. HOSPITAL COURSE OVER THESE PREVIOUS DAYS: 1. Liver lesions: The patient went for a repeat MRI which showed no change in the previously noted enumerable hepatic cyst in her liver. A Hepatology consult was obtained who felt that the most likely etiology of these cysts were from hepatic candidiasis, although one could not rule out lymphoma involving from Burkitt's. She will be discharged on AmBisome 300 mg IV q.d. for treatment of her hepatic candidiasis. This regimen, that being AmBisome, was recommended by the Infectious Disease physicians, who felt that AmBisome was a better drug of choice as compared to fluconazole. 2. Heme: The patient's platelets, white count, and hematocrit have all been stable. Her white count remained elevated despite discontinuing her G-CSF. However, the patient is not febrile and her white count should be continued to be watched. 3. On the morning of [**12-4**], the patient had some transient episodes of hypotension with SBPs in the 70s. Her captopril was discontinued, and she was given two IV fluid boluses with appropriate response. Her blood pressures and all of her vital signs are stable. 4. FEN: The patient was continued on TPN over the past couple days. She is also started on marinol 2.5 mg p.o. b.i.d. and encouraged p.o. intake. CONDITION ON DISCHARGE: Guarded, but stable. DISCHARGE DIAGNOSES: 1. Burkitt's lymphoma. 2. Hepatic candidiasis. DISCHARGE STATUS: The patient will be discharged to an outside hospital. DISCHARGE MEDICATIONS: 1. AmBisome 300 mg IV q.d. 2. Marinol 2.5 mg p.o. b.i.d. before breakfast and dinner. 3. Atarax 25 mg IV/p.o. q.4-6h. prn for itching. 4. Colace 100 mg p.o. b.i.d. 5. Protonix 40 mg p.o./IV q.d. 6. Nystatin [**6-21**] mL swish and swallow q.6. prn. 7. Peridex 15 mL swish and swallow prn. [**First Name8 (NamePattern2) 1730**] [**Last Name (NamePattern1) **], M.D.12.699 Dictated By:[**Name8 (MD) 8288**] MEDQUIST36 D: [**2121-12-4**] 13:09 T: [**2121-12-4**] 13:20 JOB#: [**Job Number 50876**]

[ "349.82", "996.62", "577.0", "200.20", "560.1", "V58.1", "112.5", "584.8", "428.0" ]

icd9cm

[ [ [] ] ]

[ "03.92", "99.25", "99.15", "38.91", "03.31", "41.31", "38.93", "34.91", "86.09" ]

icd9pcs

[ [ [] ] ]

15126, 15249

15272, 15805

157, 7342

7358, 15058

15083, 15105

24,947

157,332

20883

Discharge summary

report

Admission Date: [**2181-7-9**] Discharge Date: [**2181-7-12**] Date of Birth: [**2158-8-15**] Sex: M Service: CSURG Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1283**] Chief Complaint: 22M s/p CVA w/ PFO. Major Surgical or Invasive Procedure: Closure of PFO [**2181-7-9**]. History of Present Illness: This 22 y/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4746**] had a R peripheral cerebellar hemispheric infarct in [**2181-5-9**] and an echo on [**2181-5-16**] revealed a patent foramen ovale with a hypermobile atrial septum. He is now admitted for closure of PFO. Past Medical History: H/O PFO H/O migraines S/P R cerebellar infarct. H/O ADD S/P ORIF of R thumb Social History: Cigs: 1 ppd x 8 yrs. ETOH: none Works as landscaper and lives with mother. Family History: unremarkable Physical Exam: Gen: WDWN [**Male First Name (un) 4746**] in NAD AVSS HEENT: NC/AT, EOMI, PERRLA, oropharynx benign Neck: Supple, FROM, no lymphadenpathy or thyromegaly, carotids 2+, no bruits Lungs: Clear to A+P CV: RRR w/out R/G/M, nl. S1, S2 Abd: +BS, soft, nontender, w/out masses or hepatomegaly. Ext: w/out C/C/E pulses 2+ = bil. throughout. Neuro: nonfocal. Brief Hospital Course: Pt. was admitted on [**7-9**] and underwent elective closure of PFO by a minimally invasive approach w/ a R ant. mini-thorocotomy. He tolerated the procedure well and was tranferred to the CSRU in stable condition on propofol. He was quickly extubated and had a stable post op night. He was transferred to the floor on POD#1, had his chest tubes d/c'd on POD#2 and continued to progress. He was discharged on POD#3 in stable condition. Medications on Admission: Plavix 75 mg PO qd Ativan PRN 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. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*30 Tablet(s)* Refills:*2* 3. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO every [**4-24**] hours as needed. Disp:*50 Tablet(s)* Refills:*0* 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 5. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain: Take medication with food. Disp:*120 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 1110**] VNA Discharge Diagnosis: Patent foramen ovale. s/p CVA Discharge Condition: Good. Discharge Instructions: Follow medications on discharge instructions. You may not drive for 4 weeks. You may not lift more than 10 lbs. for 2 months. You may shower, let water flow over wounds, pat dry with a towel. Followup Instructions: Make an appointment with Dr. [**Last Name (STitle) 2472**] for 1-2 weeks. Make an appointment with Dr. [**Last Name (STitle) 1290**] for 4 weeks. Completed by:[**2181-7-12**]

[ "745.5", "V12.59", "314.00" ]

icd9cm

[ [ [] ] ]

[ "35.71" ]

icd9pcs

[ [ [] ] ]

2431, 2490

1283, 1723

331, 364

2564, 2571

2811, 2988

881, 895

1803, 2408

2511, 2543

1749, 1780

2595, 2788

910, 1260

272, 293

392, 674

696, 773

789, 865

62,717

167,258

46243

Discharge summary

report

Admission Date: [**2145-1-26**] Discharge Date: [**2145-1-31**] Date of Birth: [**2069-7-18**] Sex: F Service: MEDICINE Allergies: IV Dye, Iodine Containing Attending:[**First Name3 (LF) 2279**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Pericardiocentesis History of Present Illness: Ms. [**Known lastname 98305**] is a 75 year-old female with CAD s/p LAD stent, diastolic CHF, h/o breast cancer s/p L mastectomy, and ongoing evaluation for cystic neoplasm of pancreas who presents with about two weeks of dyspnea, chills and productive cough. She has also had orthopnea requiring her to sleep on two pillows last night and reports increased PND. She has not had dependent swelling. She reports chest pain (pleuritic vs. MSK) with deep inspiration that she feels is connected to her recent complaint of left shoulder, neck, and chest wall pain; this was evaluated by Dr. [**Last Name (STitle) **] of Ortho as an outpatient and ascribed to glenohumeral arthritis and outlet impingement syndrome. In the past two days, she states her cough has become productive. She thinks this is at times related to difficulty swallowing or choking on food although she denies any globus sensation; she is also unsure if the coughing sometimes causes difficulty swallowing. Today, she developed a low grade fever and notes that she actually has been experiencing night sweats for "months." . In the ED, initial vs were: T 99.2, P 93, BP 128/88, RR 16, O2sat 100%, pain [**8-30**]. Pt breathing comfortably at rest and speaking in full sentences. She was given ASA 81mg x 3 due to initial concern for cardiac etiology. Labs notable for WBC 16.8 with 87.8 N but on bands. EKG was NSR at 89, low voltage. Cardiac enzymes have been < assay. PA/lateral CXR showed a markedly increased cardiac sillouette with bilateral L>R pleural effusions and left atelectasis. A lateral decub CXR demonstrated loculation. Cardiology was called for a bedside ultrasound to evaluate for pericardial effusion; there was no evidence of tamponade. Blood cultures were drawn. Pt was given levofloxain 750mg IV and later tylenol 1000mg for fever to 100.3. She is being admitted for further workup of the cardiac and pleural effusions. On transfer, vs: T 100.1, P 97, BP 109/81, RR 20, O2sat 93 RA. . On the floor, pt complains mostly of pain involving her left shoulder, neck, chest wall, and back. This is exacerbated by deep breathing and is also positional. She has taken tylenol without much efficacy and states a lidoderm patch is helpful. She further says is not "allowed" to take NSAIDs. She is not currently dyspneic at rest and is off O2. . Review of sytems: No recent weight loss or gain. Orthostatic lightheadedness on Sunday which improved by the next day without intervention - none currently. Occasional headache and recent left ear pain with hearing changes. No rhinorrhea or congestion. Denies palpitations. Periodic nausea which led to finding of cystic neoplasm in the uncinate process of the pancreas with negative (limited) cytology but elevated CEA concerning for mucinous neoplasm (IPMN vs. CMN); undergoing active surveillance as outpatient with Dr. [**Last Name (STitle) 468**]. She also has noted a possible left neck cyst and is to follow up with ENT. No anorexia. No constipation, diarrhea, or abdominal pain; no recent change in bowel or bladder habits. No dysuria. Diffuse arthralgias or myalgias chronically. Longstanding pruritis of extremities which has increased recently. Past Medical History: CAD: PCI of sequential proximal and mid LAD lesions in [**4-/2135**] Hiatal hernia: thoracic stomach, GERD C2 fx after fall [**2138**] (s/p anterior internal screw fixation 06 by [**Doctor Last Name 363**]) Breast Ca s/p L mastectomy Cervical fracture requiring surgery Thrombocytopenia Mesenteric Ischemia Hypertension Thyroglossal Cyst Cataract Surgery [**11-29**] CHF with diastolic failure Osteoporosis Sciatica B/L knee osteoarthritis Social History: Patient lives alone, works at [**Company 2486**]. Son helps with some ADLs, but able to bathe, feed and toilet herself. Denies tobacco, alcohol other drugs. Family History: Non contributory Physical Exam: Admission Exam: Vitals: Tm 100.3, Tc 99.0 BP 96-102/66-71, pulsus 9 (110 -> 101) P 96 , RR 20, O2sat 92 RA. General: Alert, oriented, uncomfortable due to shoulder pain but in no acute distress, speaking in full sentences. HEENT: Sclera anicteric, MMM, oropharynx clear. Neck: Supple, JVP , no LAD, unable to appreciate significant left-sided cyst. Chest: Exam limited as pt refused to sit up due to shoulder pain but decreased breath sounds at bases L>R with mild rales, no wheezes or rhonchi. TTP over left chest wall. 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, nonpitting edema at bilateral ankles. Neuro: AAO x 3, able to say months of year backwards with frequent prompting, days of week backwards more easily recited. Pertinent Results: On Admission: [**2145-1-26**] 12:40PM BLOOD WBC-16.8* RBC-4.62 Hgb-13.9 Hct-42.0 MCV-91 MCH-30.2 MCHC-33.2 RDW-15.0 Plt Ct-128* [**2145-1-26**] 12:40PM BLOOD Plt Ct-128* [**2145-1-26**] 12:40PM BLOOD Glucose-101* UreaN-23* Creat-0.9 Na-141 K-3.5 Cl-102 HCO3-26 AnGap-17 [**2145-1-27**] 06:00AM BLOOD TotProt-6.3* Albumin-3.5 Globuln-2.8 Calcium-8.8 Phos-3.4 Mg-2.2 On discharge: [**2145-1-31**] 07:00AM BLOOD WBC-9.3 RBC-4.19* Hgb-12.4 Hct-37.8 MCV-90 MCH-29.7 MCHC-32.8 RDW-14.5 Plt Ct-315 [**2145-1-31**] 07:00AM BLOOD Glucose-84 UreaN-25* Creat-1.1 Na-141 K-4.1 Cl-108 HCO3-31 AnGap-6* [**2145-1-31**] 07:00AM BLOOD Calcium-8.5 Phos-2.5* Mg-2.3 [**2145-1-27**] 06:00AM BLOOD [**Doctor First Name **]-POSITIVE * Titer-1:80 [**2145-1-27**] 06:00AM BLOOD C3-146 C4-36 Imaging: Cardiac Echo: -The left atrium is moderately dilated. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is moderately dilated. The mitral valve leaflets are mildly thickened. There is a moderate to large sized pericardial effusion. The effusion appears circumferential. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. Stranding is visualized within the pericardial space c/w organization. No right ventricular diastolic collapse is seen. There is sustained right atrial collapse, consistent with low filling pressures or early tamponade. -Compared with the prior study (images reviewed) of [**1-26**]/201, sustained right atrial collapse is now seen, consistent with possible early tamponade physiology. The overall size of the effusion is unchanged. Chest CT: IMPRESSION: 1. Small left pleural effusion has simple fluid characteristics and does not demonstrate CT findings associated with empyema. However, direct correlation with thoracentesis may be helpful to better ascertain the etiology of the effusion if warranted [**Date Range 10015**]. 2. Pericardial fluid and pneumopericardium, the latter reportedly related to recent drainage procedure. 3. Bilateral lower lobe atelectasis, right greater than left, with near complete collapse of right lower lobe. Cardiac Cath: COMMENTS: 1. Pericardiocentesis was performed with needle entry from the subxiphoid position. 2. Subsequent removal of 640cc of pericardial fluid (all sent for studies) and confirmation by bedside echocardiogram of sucessful removal of fluid with appropriate catheter position. FINAL DIAGNOSIS: 1. Pericardial tamponade with improvement of pericardial pressure after removeal of 640 cc fluid. Brief Hospital Course: Mrs. [**Known lastname 98305**] was admitted to the [**Hospital1 18**] on [**2145-1-27**] with symptoms of dyspnea. Her hospital course by system is summarized below. # Pericardial effusion: Etiology remains unclear but malignancy on the differential. Pt is undergoing work-up of mucinous pancreatic neoplasm with elevated CEA (likely IPMN or MCN) as well as presumed recurrent thyroglossal cyst (with ENT). She additionally has a h/o breast cancer although most recent mammogram from [**6-/2144**] was birads-2; nl colonoscopy in 5/[**2142**]. Greatest pulsus was 8. Echo showed possible early tamponade with moderate to large pericardial effusion. On [**2145-1-27**] she underwent pericardiocentesis with drain placement and removal of 400cc bloody pericardial fluid. Her CCU stay is summarized below. . CCU Course ([**Date range (1) 60917**]): Patient was transferred to the CCU on [**2145-1-27**] after placement of pericardial drain. Initial drain placement put out 640 cc serosanginous fluid and subsequently drained 400 cc of serosanginous. Pulsus on admission to CCU was 4 mm Hg and was checked q4h. A repeat echo was performed on [**2145-1-28**] and showed no effusion. Drain was removed later in day on [**2145-1-27**]. She was started on ibuprofen and morphine prn for pleuritic chest pain. Pericardial fluid cytology was negative for malginancy. [**Doctor First Name **] came back positive with a titer of 1:80 (which can be see in [**9-9**]% of healthy individuals). C3/C4 and TSH were WNL and notably Cytology was negative for malignant cells. . # Dyspnea: Resolved after Pericardiocentesis though lungs sounds remain distant. Chest CT showed small left pleural effusion has simple fluid characteristics not consistent with empyema. Also with bilateral lower lobe atelectasis, right greater than left, with near complete collapse of right lower lobe. She was treated with levofloxacin for 7 days for a possible pneumonia and her home dose of Lasix. Her respiratory status improved and was not hypoxic. She will follow up with her PCP for further evaluation of her respiratory status. . # Anaphylaxis: Chest CT with contrast was obtained and while patient received IV dye, she became acutely short of breath and hypotensive to the 70s. She was given an epi pen along with steroids and anti-histamines and her symptoms resolved. She never lost her pulse. She was monitored for nearly 72 hours post event and had no further reactions. . # Left shoulder/chest pain: Most likely MSK due to outlet impingement syndrome & glenohumeral arthritis per Ortho eval. Markedly improved s/p pericardiocentesis. [**Month (only) 116**] have had some component of referred pain. Thsi was best treated with a lidocaine patch and 650 mg PO Tylenol. We discharged her with a prescripton for outpatient physical therapy to work on periscapular stabilization, postural retraining, and range of motion of the cervical spine and shoulder as per Dr. [**Last Name (STitle) **]' note. . # Dysphagia: Improved after pericardioncentesis . # Lightheadedness: Intermittent, and the patient had negative orthostasis. Patient denied any change in fluid intake or fluid loss and was never anemic. . # CAD: Had negative troponin and was continued on all her home cardiac medications . # HTN: Was controlled on her home medications . # HL: Dr/ [**Last Name (STitle) **]' note suggests Lipitor was discontinued . # Chronic dCHF: Was compensated. Patient was continued on home lasix several days after pericardiocentesis. . # Gout: Never flared and was treated with home allopurinol. . # Depression/anxiety: Treated with home citalopram . # Reflux esophagitis: Treated with home pantoprazole . # Pruritis: Pt reports this increased recently, LFTs were negative. Patient was discharged with follow-up with primary care in one week and cardiology with Dr. [**Last Name (STitle) 911**] in two weeks. Medications on Admission: Alendronate 70 mg qweekly Allopurinol 400 mg daily Amlodipine 5 mg daily Ammonium lactate 12% lotion [**Hospital1 **] to arms and legs Atorvastatin 80 mg daily - pt says recently stopped for unclear reason although not documented in most recent PCP note Citalopram 20 mg daily Furosemide 40 mg daily Pantoprazole 40 mg daily Potassium Chloride 10 mEq daily Valsartan 320 mg daiy Aspirin 81 mg daily Calcium-Vitamin D daily Discharge Medications: 1. allopurinol 100 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 3. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 5. ammonium lactate 12 % Lotion Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). Disp:*1 1* Refills:*2* 6. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 8. Outpatient Physical Therapy Please work on periscapular stabilization, postural retraining, and range of motion of the cervical spine and shoulder. 9. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week. 10. Calcium Antacid 200 mg (500 mg) Tablet, Chewable Sig: Two (2) Tablet, Chewable PO once a day. 11. Vitamin D 1,000 unit Capsule Sig: One (1) Capsule PO once a day. 12. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever or pain. 13. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Pericaridal effusion Community Acquired Pneumonia Small Pleural Effusions Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mrs. [**Known lastname 98305**], It was a pleasure taking care of you while you were an inpatient at the [**Hospital1 18**]. You were admitted [**2145-1-26**] for shortness of breath. We found that there was fluid around your heart. The cardiologists drained this fluid and you were monitored in the Cardiac Care Unit. It is unclear why you had this fluid around your heart but we will continue to investigate this. During your admission you had a CT scan with contrats dye. You had an allergic reaction to this and you should never receive CT dye again. 1. Please avoid CT scan contrast in the future and always let you doctors know about this reaction. 2. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than three lbs. You should continue all of your medications with the following important changes: START Atorvastatin 80 mg daily STOP potassium chloride pills. Your potassium levels were normal during this hospitalization and you currently do not need further supplementation. STOP Valsartan (blood pressure medication). Your blood pressure was well controlled during your admission - please follow-up with your primary care doctor on re-starting this medication. Followup Instructions: Dr.[**Name (NI) 5786**] office will call you for an appointment. You should see your cardiologist in the next 1-2 weeks. If you do not hear from his office please call them at: [**Telephone/Fax (1) 42006**]. You should have a repeat echo at this appointment. . It is also very important that you see Dr. [**Last Name (STitle) **], or one of his associates this week. If you do not hear from the office on [**Last Name (STitle) 766**], you should call [**Telephone/Fax (1) 250**] for an appointment. We have also emailed the office to let them know you need an appointment. . Here are other appointments that you have approaching: Department: [**Hospital3 249**] When: [**Hospital3 **] [**2145-2-1**] at 9:00 AM With: [**First Name8 (NamePattern2) 2747**] [**Last Name (NamePattern1) **], LICSW [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: RHEUMATOLOGY When: TUESDAY [**2145-2-9**] at 9:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 4900**], MD [**Telephone/Fax (1) 2226**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: ORTHOPEDICS When: TUESDAY [**2145-3-2**] at 7:45 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 1228**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**]

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icd9cm

[ [ [] ] ]

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icd9pcs

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30691

Discharge summary

report

Admission Date: [**2103-9-20**] Discharge Date: [**2103-9-25**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7708**] Chief Complaint: BRBPR Major Surgical or Invasive Procedure: [**2103-9-24**] Colonoscopy History of Present Illness: Ms. [**Known lastname 72724**] is a [**Age over 90 **] y/oF with history of remote colon ca s/p resection ~23 years ago, and mild hypertension who is admitted night of [**2103-10-21**] with BRBPR. She has noticed some change in her stools for the last few days, but brought to her daughter??????s attention last night with maroon stool in the toilet. She had another episode of red blood this morning, moderate quantity. She has not had this problem before. She has no abdominal pain, but has had occasional nausea but no vomiting. Her only other change in bowel habits was a few days earlier, when she ahd some constipation and had to use her finger to aid in evacuation of stool. She has no history of hemorrhoids. . She has DJD and had been taking more naproxen PRN, and more of one analgesic more recently, that the daughter thinks is Tylenol. . In the ED: her initial vitals were T 97.6, HR 72, BP 127/48 RR 18 Sat 98% 2L. She received 2L of normal saline. She had an episode of BRBPR in the ED of about 500cc. Vitals however remained stable without tachycardia or hypotension. Her rectal exam was frankly bloody, but no hemorrhoids appreciated. She was seen by GI with decision to not scope immediately and see if this clears, with back-up plan of IR scan/embolism likely preceded by endoscopy. . In the ICU: She presented with a Hct of 27.4, but dropped to 24.7 that same night. She subseqently received 2 units on [**9-20**], and 1 unit PRBC on [**9-21**]. Her Hct has remained stable in the 30s since then. Past Medical History: - Colon Ca s/p resection 23 years ago in [**Last Name (un) 51768**], FL - Hypertension - Depression - Degenerative Joint Disease Social History: lives at home with daughter and son-in-law, denies etoh, smoking Family History: NC Physical Exam: Vitals: 96.8, 121/48, 65, 18, 98%RA HEENT: NC/AT, clear oropharynx, MMM Neck: supple, no LAD CV: RRR s m/g/r Chest: CTAB Abd: +BS NT/ND, soft Ext: no c/c/e Skin: no rashes, lesions, or jaundice Neuro: A&Ox3 Pertinent Results: LABS: [**2103-9-20**] WBC-8.8 RBC-3.05* HGB-9.0*# HCT-27.4*# MCV-90 MCH-29.6 MCHC-33.0 RDW-13.4 [**2103-9-20**] 02:50PM CALCIUM-9.2 PHOSPHATE-2.6* MAGNESIUM-2.1 [**2103-9-20**] 02:50PM cTropnT-0.02* [**2103-9-20**] 02:50PM CK(CPK)-94 [**2103-9-20**] 02:50PM GLUCOSE-117* UREA N-47* CREAT-1.0 SODIUM-140 POTASSIUM-5.0 CHLORIDE-103 TOTAL CO2-30 ANION GAP-12 [**2103-9-20**] 03:35PM URINE RBC-0-2 WBC-<1 BACTERIA-RARE YEAST-NONE EPI-0-2 [**2103-9-20**] 03:35PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2103-9-20**] 07:47PM WBC-7.8 RBC-2.76* HGB-8.6* HCT-24.7* MCV-89 MCH-31.1 MCHC-34.8 RDW-13.5 [**9-21**] 5:18pm - Hct 30.2 [**9-22**] 1:35pm - Hct 30.7 [**2103-9-23**] 03:02PM BLOOD Hct-32.1* [**2103-9-24**] 05:25AM BLOOD WBC-6.2 RBC-3.44* Hgb-10.3* Hct-30.7* MCV-89 MCH-30.1 MCHC-33.7 RDW-13.9 Plt Ct-249 [**2103-9-25**] 05:15AM BLOOD WBC-8.5 RBC-3.39* Hgb-10.4* Hct-30.3* MCV-90 MCH-30.7 MCHC-34.2 RDW-13.8 Plt Ct-263 [**2103-9-25**] 05:15AM BLOOD Glucose-105 UreaN-12 Creat-0.9 Na-139 K-3.8 Cl-104 HCO3-28 AnGap-11 . Imaging: CXR: no acute CP process ECG: Sinus 1:1 at 70 bpm, normal axis, intervals. No e/o ischemia Colonoscopy: Diverticulosis of the sigmoid colon and descending colon Two small polyps in the sigmoid and ascending colon 1.5 cm penduculated polyp in the sigmoid colon. (polypectomy) Erythema and petechiae on several colonic folds in the sigmoid colon Otherwise normal colonoscopy to cecum Brief Hospital Course: [**Age over 90 **] y/oM with remote h/o semi-colectomy for colon ca a/w likely lower GI bleed in the absence of abdominal pain. # GIB: Patient reported painless hematochezia and maroon stools x 2-3 days prior to admmission and then BRBPR on morning of admission. Differential included diverticulosis, AVM, colon CA, or colonic ischemia. Pt's Hct nadired to 24.7. She received 3 units PRBC in ICU. She remained hemodynamically stable during floor hospital course. For the remainder of her hospital course and she did not require any further transfusions after [**2103-9-21**]. The day after [**Hospital **] transfer to floor she reported two bloody bowel movements and [**Hospital1 **] hematocrit checks were continued but HCT remained stable around 30. She reported no further bloody or maroon bowel movements. She had a colonoscopy on [**2103-9-24**] which showed diverticulosis as well as polyps. She had a polypectomy and pathology is pending. Although initially started empirically on IV PPI [**Hospital1 **], this was changed to PO daily dosing prior to discharge. # HTN- Norvasc initially held but restarted prior to discharge at home dose 5 mg daily. # [**Name (NI) 1068**] Pt Remained stable on zoloft. # Code: Full Medications on Admission: Allergies: NKDA Home medications: Zoloft 50mg PO daily Norvasc 5mg PO daily Naproxen PRN Tylenol PRN Aspirin PRN Discharge Medications: 1. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 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:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary Diagnosis 1. Gastrointestinal Bleed 2. Diverticulosis 3. Sigmoid/Colon Polyps. Biopsy reports pending Secondary Diagnosis 1. Depression 2. Osteoarthritis 3. Hypertension Discharge Condition: Hemodynamically stable, stable hematocrit x 3 days, afebrile Discharge Instructions: You were admitted to the hospital with maroon colored stools and bleeding from your gastrointestinal tract. Your blood counts were initially low so you were transfused 3 units of blood. After this, your blood counts remained stable and you did not have any further bleeding. You had a colonoscopy on [**2103-9-24**] which showed diverticulosis, which are small outpouchings in the colon, and polyps. One polyp was removed and a biopsy was sent for pathology. The results of the biopsy were pending at the time of discharge. We made the following changes to your medications 1. We added Pantoprazole 40mg by mouth daily Please take all medications as prescribed and follow up with your primary care doctor as below. Please return to the ED or call your primary care physician if you develop bloody, maroon or dark tarry stools or notice bleeding from you rectum. Also call if you develop nausea, vomiting, lightheadedness, dizziness, chest pain, shortness of breath or any other concerning symptoms. Followup Instructions: Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] on Thursday [**10-4**] at 5:15pm. Call [**Telephone/Fax (1) 14825**] if you have any questions regarding your appointment. A repeat hematocrit should also be checked at this time. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7476**] MD [**MD Number(1) 7715**]

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icd9cm

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2013, 2080

25,574

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5170

Discharge summary

report

Admission Date: [**2162-12-30**] [**Month/Day/Year **] Date: [**2163-1-3**] Date of Birth: [**2094-10-7**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1865**] Chief Complaint: dark stools, shortness of breath. Major Surgical or Invasive Procedure: small bowel enteroscopy History of Present Illness: The patient is a 68M with h/o CAD s/p CABG '[**48**], AS , ischemic CM with EF 45% and h/o GI due to AVMs in the past who now p/w 4 days of maroon colored stool, stomach upset and also with increased weight. The patient reports being in his usual state of health until 3 days ago when he noticed that his stool had been becoming darker and had some bright red blood. He has been noticing some exertional CP (stabbing pain in chest) and dyspnea when walking around the house and from the house to the car. He also had an episode 2 days ago of stabbing chest pain when lying down to go to sleep. His symptoms were relieved with a SL nitroglycerin. Also noticed dizziness and lightheadedness over the past 24 hours. . ROS: weight prior to [**Holiday **] was 184. over past month has been creeping up up to between 195-200 over last few days. pt reports he "gets in trouble with SOB when over 190". + throbbing pain in left hand over last few days. . In the ED an NGL was negative, he was given a PPI. Two 18g peripheral IV's were placed. His SBP's remained approximately 100-110's with HR in the 60's. Original EKG was without ischemic changes. While in the ED, the patient began to experience jaw pain and a repeat EKG showed new ST depressions and T wave inversions. He was transfused 2 units of [**Holiday **]. Also the patient had a K=6 and was treated with insulin/amp D50/ bicarb/and calcium gluconate. Past Medical History: -- CABG '[**48**] (LIMA-LAD, SVG LAD, SVG OM) -- Cath [**10/2162**]: Three vessel native coronary artery disease, patent grafts, moderate aortic stenosis, patent previously placed stents, elevated left sided filling pressure. -- Stress test [**2162-5-24**]: Poor functional status. 3.5 minutes of exercise on [**Doctor Last Name 4001**] protocol. EF 30% and multiple fixed perfusion defects and minor inferior defect. -- multiple coronary stents in [**2160**],[**2161**], and [**2162**] -- Aortic stenosis: [**Location (un) 109**] 0.8 mm Hg. -- Ischemic CM/CHF - diastolic, systolic EF 45%, recent admit for diuresis in late [**6-8**]. -- DM2, last HgA1c in [**2162-10-3**] of 7.1 -- Anemia: baseline HCT 31-33 -- Hypothyroidism -- OSA on CPAP -- Depression -- CKD- with baseline Cr 1.5-2.0 -- hypercholesterolemia -- OA -- Gout -- IBS-diarrhea predominant -- Obesity -- PVD -- UGI and LGI bleeding secondary to AVMs Social History: Lives with his wife in [**Name (NI) 5110**]. Retired [**Doctor Last Name **], worked for [**Location (un) 86**] Globe for >45 years. Denies smoking, ETOH, or "other funny stuff". Has 1 daugther who lives in [**State 4260**] and 2 sons who live locally. Family History: There is no family history of premature coronary artery disease or sudden death Physical Exam: PE: T: BP:104/31 HR:81 RR: 22 O2 100% RA Gen: Pleasant, well appearing, NAD HEENT: No conjunctival pallor. No icterus. MMM. OP clear. NECK: Supple, No LAD, No JVD. No thyromegaly. CV: 3/6 SEM LUNGS: good breath sounds b/l, minimal crackles at bases ABD: NT/ND, small areas of ecchymosis from insulin injections EXT: no c/c/e; discoloration consistent with chronic venous stasis NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. Pertinent Results: [**2162-12-30**] 05:30PM BLOOD WBC-6.7 RBC-2.81* Hgb-9.3* Hct-26.2* MCV-93 MCH-33.3* MCHC-35.7* RDW-15.7* Plt Ct-176 [**2162-12-31**] 12:29AM BLOOD Hct-26.5* [**2163-1-1**] 03:09AM BLOOD WBC-7.3 RBC-3.59* Hgb-11.6* Hct-32.7* MCV-91 MCH-32.2* MCHC-35.4* RDW-16.1* Plt Ct-144* [**2163-1-2**] 09:35AM BLOOD WBC-7.0 RBC-3.76* Hgb-12.3* Hct-34.2* MCV-91 MCH-32.8* MCHC-36.1* RDW-16.4* Plt Ct-147* [**2163-1-3**] 06:35AM BLOOD WBC-7.4 RBC-3.46* Hgb-11.9* Hct-32.0* MCV-93 MCH-34.5* MCHC-37.3* RDW-18.6* Plt Ct-153 [**2163-1-3**] 03:15PM BLOOD WBC-8.5 RBC-3.51* Hgb-11.4* Hct-32.0* MCV-91 MCH-32.4* MCHC-35.6* RDW-15.8* Plt Ct-126* [**2162-12-30**] 05:30PM BLOOD Plt Ct-176 [**2163-1-1**] 09:15PM BLOOD Plt Ct-161 [**2163-1-3**] 03:15PM BLOOD Plt Ct-126* [**2162-12-30**] 05:30PM BLOOD Glucose-97 UreaN-112* Creat-2.9*# Na-133 K-6.3* Cl-104 HCO3-19* AnGap-16 [**2163-1-1**] 09:15PM BLOOD Glucose-130* UreaN-66* Creat-2.0* Na-136 K-4.8 Cl-103 HCO3-19* AnGap-19 [**2163-1-2**] 09:35AM BLOOD Glucose-181* UreaN-53* Creat-1.8* Na-138 K-5.0 Cl-103 HCO3-24 AnGap-16 [**2163-1-3**] 06:35AM BLOOD Glucose-165* UreaN-52* Creat-1.5* Na-134 K-4.7 Cl-104 HCO3-20* AnGap-15 [**2162-12-30**] 05:30PM BLOOD CK(CPK)-105 [**2162-12-31**] 12:29AM BLOOD CK(CPK)-104 [**2162-12-31**] 09:06AM BLOOD CK(CPK)-98 [**2162-12-31**] 07:56PM BLOOD CK(CPK)-94 [**2162-12-30**] 05:30PM BLOOD CK-MB-8 cTropnT-0.11* [**2162-12-31**] 12:29AM BLOOD CK-MB-7 cTropnT-0.07* [**2162-12-31**] 09:06AM BLOOD CK-MB-NotDone cTropnT-0.11* [**2162-12-31**] 07:56PM BLOOD CK-MB-NotDone cTropnT-0.12* . . [**2163-1-1**] EKG: NSR, 78BPM, no STE, STD, normal axis, intervals. TWI in avL only. . [**2162-12-31**] EGD - single nonbleeding 18mm dudoneal ulcer. Brief Hospital Course: Pt was admitted to the medical intensive care unit in hemodynamically stable condition, with ongoing dark stools. . . # GI bleeding. Pt is a a 68 M with h/o recurrent GI bleeding from AVMs, CAD s/p CABG, CHF (EF45%) who presented [**12-30**] with 4d of dark colored stools, stomach upset, and dyspnea, found to have HCT of 26. He was felt to be hemodynamically stable (97.2 94/39 64 18 98%RA). NGL was negative in ED, initial EKG showed ST depression and TWI. Creatinine was slightly elevated, K was 6 on admission. Pt received insulin/bicarb/calcium gluconate, 2U PRBC, and 2L NS in the Emergency Department. He was then transferred to the MICU (HR 65 BP 119/32 100%2L), seen by the GI service, and transfused 2U [**Name (NI) **] (pt received a total of 4U PRBC), with hct stabilizing at 32. EGD performed on [**12-31**] revealed a non-bleeding duodenal ulcer. . Pt was transferred to the general medical floor. Repeat HCT was stable 32-34. He continued to have dark stools without frank bleeding, despite stable HCT and SBPs. H. pylori serologies were obtained which were unremarkable. Pt was treated with sucralfate and [**Hospital1 **] protonix as per GI service recommendation. He was discharged home on [**2163-1-3**] with instructions to follow-up with his gastroenterologist within 2-3 weeks. In addition, he was instructed to follow-up with his primary care physician [**Name Initial (PRE) 176**] 2 weeks regarding restarting his Bumex and xaroxolyn as below. . . # cardiac: # ischemia - pt presnted with dynamic EKG changes while in ED (deeping of inverted T's and ST depressions), this was felt likely to represent demand ischemia in the setting of GI bleeding and anemia. His symptoms of SOB were resolved s/p 2U PRBC, and did not recur during his admission. Pt was seen by the cardiology service in the ED who recommended correcting his anemia, and managing him medically. . Pt's aspirin and plavix were initially held, but were restarted once pt's hematocrit stabilized in light of his s/p recent placement of cypher stent in [**5-8**]. Pt was instructed to follow-up with his cardiologist within 4 weeks regarding the specific duration of his plavix therapy in light of his multiple recurrent GI bleeding episodes. Pt was otherwise discharged on his prior cardiac regimen of toprol 50mg qdaily, imdur 60 mg qdaily, zetia 10mg po qdaily, and simvastatin 80 mg po qdaily. . # pump - pt with h/o CHF (EF 45%), on standing bumex, zaroxlyn and zestril at home. these medications were held in the MICU [**2-4**] UGIB and ARF. Zestril was restarted prior to [**Month/Day (2) **]. Pt was discharged home with instructions not to take his bumex or zaroxlyn until seen by his PCP, [**Name10 (NameIs) 151**] whose nurse practitioner he had an appointment 2d after [**Name10 (NameIs) **], given his lack of clinical volume overload and still resolving ARF. . # rythym - pt remained in NSR during his hospitalization. . . # Acute on Chronic Renal Failure - etiology of pt's ARF was felt most likely hypoperfusion/prerenal in the setting of GI bleeding. Creatinine peaked at 2.9, and came down to 1.5 at time of [**Name10 (NameIs) **] (baseline 1.4-1.7) with IVF hydration. Pt restarted on his Zestril, but discharged with instructions not to take his prior bumex and zaroxlyn until seen by PCP who will assess volume status and follow pt's CRI. Pt has an appointment with his [**Name8 (MD) 6435**] NP 2-3d after [**Name8 (MD) **]. . . # DM2: pt was continued on his previous regimen of NPH 60qam/50qpm and humalog 30qam/20qpm. He was given additional coverage as needed with humalog sliding scale. . # Hypothyroidism: pt was continued on his home regimen of synthroid 200mcg qd. . # Hyperlipidemia: pt was continued on his home regimen of pravastatin 60 qhs. . # Gout: pt has a h/o of gout for which he is treated with allopurinal. He was continued on this regimen, though initially dosed QOD [**2-4**] ARF. As his renal function improved, this was switched to daily dosing. On [**1-2**] pt developed right knee pain. Ultrasound and doppler studies were obtained to rule out [**Hospital Ward Name **] cyst and aneurysm. Pt was afebrile without elevated WBC count, thus septic arthritis was felt unlikely. Pt was treated with oxycodone 5mg prn with good releif. NSAIDs, colchicine, and prednisone were avoided given pt's ARF and GIB respectively. Pt was discharged home with a 7d supply of oxycodone. Should his pain persist, he was instructed to follow-up with his PCP. . # Depression: cont Zoloft. . # OSA: pt continued to use his own CPAP at night. . # dispo - pt discharged home with strict instructions to follow-up with GI within 2-3 weeks regarding his chronic GI bleeding, and ongoing dark stools despite stable HCT. he was instructed to follow-up with cardiology regarding duration of plavix therapy. he was instructed to follow-up with his PCP/PCP nurse [**Name9 (PRE) 3525**] regarding restarting bumex and zaroxlyn and future follow-up of his creatinine. Medications on Admission: allopurinol 150mg po qday ambien 5mg qhs prn asa 325mg qday bumex 0.5mg [**Hospital1 **] calcitriol 0.25mg qday carafate 1 gram qid ferrous sulfate 325mg qday insulin humulin N as directed insulin humulin R as directed isosorbide mononitrate 60mg qday levoxyl 200mcg qday NTG 0.4mg sl q5 minutes prn chest pain x3 plavix 75mg qday protonix 40mg qday simvastatin 80mg qday spironolactone 25mg qday toprol xl 50mg qday zaroxlyn 2.5mg prn for increasing weight zestril 5mg qday zetia 10mg qday zoloft 50mg qday [**Hospital1 **] Medications: 1. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. 6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Allopurinol 300 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 9. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a day). 10. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 11. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 13. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO three times a day as needed for hand or knee pain for 5 days. Disp:*15 Tablet(s)* Refills:*0* 14. Humalog (insulin) Please take 30 Units with breakfast and take 20 Units with dinner. 15. NPH (insulin) please take 60 Units with breakfast and take 50 Units with dinner. 16. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO once a day. 17. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual PRN CHEST PAIN as needed for chest pain: place one tablet under toungue if you develop chest pain, may repeat up to three times, take 5 minutes apart. if used, please call your PCP or the emergency department. . 18. Levoxyl 200 mcg Tablet Sig: One (1) Tablet PO once a day. 19. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a day. [**Hospital1 **] Disposition: Home [**Hospital1 **] Diagnosis: upper gi bleeding [**Hospital1 **] Condition: stable [**Hospital1 **] Instructions: please continue to take all of your medications as prescribed. you were discharged with a new perscription for oxycodone for knee pain x 5 days. your protonix was increased to twice daily. Please continue to weigh yourself every morning, [**Name8 (MD) 138**] MD if weight increases by > 3 lbs. Adhere to 2 gm sodium diet . your bumex and zaroxylyn were discontinued, you should wait until you are seen by dr. [**Last Name (STitle) **] or her nurse practitioner to restart these if you have more edema. . if you have recurrent vomitting of blood, or bloody stools, chest pain, shortness of breath, fevers, chills, or other worrisome symptoms, please contact your primary care physician or the emergency department. Followup Instructions: upon arriving home, please contact your gastroenterologist and arrange to be seen within 2-3 weeks regarding your ongoing GI bleeding. . please contact your primary care physician and arrange to be seen within 2-3 weeks regarding restarting your bumex. . please contact your cardiologist and arrange to be seen within 4-6 weeks regarding continuing to take aspirin and plavix. Provider: [**First Name8 (NamePattern2) 674**] [**Last Name (NamePattern1) 11298**], RN,BSN,MSN Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2163-1-6**] 12:00 . Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2163-1-11**] 1:00 . Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 2310**], MD Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2163-2-3**] 2:30

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icd9cm

[ [ [] ] ]

[ "45.13", "99.04" ]

icd9pcs

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Discharge summary

report

Admission Date: [**2190-9-5**] Discharge Date: [**2190-9-9**] Date of Birth: [**2132-10-15**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2782**] Chief Complaint: Nausea, vomiting, abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: 57M w/PMHx IDDM, heavy EtOH use who presented to [**Hospital1 18**] [**Location (un) 620**] with nausea, emesis and abdominal pain found to be in DKA. He reported that he developed nausea after eating a [**Location (un) 6002**] on his night shift 1.5 days ago. Subsquently he has vomited >15 producing nb/nb emesis. He denies fevers. He reports suprapubic abdominal pain that was well controled with advil. He denies changes in his bowels or bladder habbits. After arriving to [**Hospital1 18**] [**Location (un) 620**], initially had a lactate of 15, WBC 15.8 with potassium of 5.7 and AG metabolic acidosis of 39. Received 3L IV NS, Insulin gtt started and Vanc, Zosyn IV received. Last FSG 328 mg/dL. His lipase was nearly 1100. He was then transferred to [**Hospital1 18**] for futher management. On arrival to [**Hospital1 18**], he was continued on Insulin gtt [**First Name8 (NamePattern2) **] [**Last Name (un) 387**] protocol, D5 NS +40 mEq and electrolytes were repleted. He was quickly transfer to the MICU for futher managmenet of his DKA, presume pancreatitis, and alcohol withdrawal. His inital vitals in the ED were 99.8 110 138/78 18 98% RA. Past Medical History: 1. Diabetes mellitus type 2. 2. Dyslipidemia. 3. Psoriasis. 4. Gout. 5. Elevated transaminases. 6. Anemia (macrocytic) 7. Vitamin D deficiency. 8. History of right rotator cuff injury. 9. History of carpal tunnel syndrome. 10. Last colonoscopy in [**2188-4-7**] at which time the patient was noted to have a colon polyp and diverticulosis. Pathology was consistent with a hyperplastic polyp. 11. Status post right and left inguinal hernia repairs. Social History: The patient is married. He has 2 children He states that he does not smoke cigarettes. Last drink Friday, [**5-14**] drinks daily, sometimes more. He acknowledges that he drinks "heavily." He works for the highway system for the state. He denies use of illicit drugs. Family History: The patient's mother died from ovarian cancer he believes in her early 70s. The patient's father died from heart disease in his 70s. The patient has 4 sisters who he believes are in goodhealth. He is not aware of any family history of iron overload. Physical Exam: MICU EXAM T 37.7 HR: 104 BP: 132/66 RR: 25 SpO2: 96% General: Alert, oriented, no acute distress HEENT: Sclera anicteric, horizontal nystamus MMM, oropharynx clear Neck: supple CV: Regular rate normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, ttp suprapubic, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, tremor in hands bilaterally Discharge Exam: VS: 98.8 117/97 90 18 100 ra General: Sitting up in bed, NAD, aoX3 HEENT: Sclera anicteric, PERRL, OP clear Neck: supple, no JVD CV: RRR, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, nontender, nondistended, no rebound/guarding, no CVA tenderness Ext: WWP, 2+ DP/PT/radial, no edema, psoriasis patches on wrists, and left calf, no asterixis Neuro: CNII-XII intact, moving all extremities, no asterixis, AOx3, [**4-10**] recall, gait not observed Pertinent Results: Admission Labs: [**2190-9-4**] 11:55PM BLOOD WBC-5.5 RBC-2.30* Hgb-7.8* Hct-23.8* MCV-104* MCH-34.0* MCHC-32.8 RDW-12.8 Plt Ct-133* [**2190-9-4**] 11:55PM BLOOD Neuts-90.6* Lymphs-4.6* Monos-4.5 Eos-0.2 Baso-0.1 [**2190-9-4**] 11:55PM BLOOD PT-13.2* PTT-26.6 INR(PT)-1.2* [**2190-9-4**] 11:55PM BLOOD Glucose-236* UreaN-29* Creat-1.7* Na-138 K-4.0 Cl-103 HCO3-17* AnGap-22* [**2190-9-5**] 02:50AM BLOOD ALT-61* AST-96* AlkPhos-55 Amylase-511* TotBili-1.8* [**2190-9-5**] 02:50AM BLOOD Lipase-1251* [**2190-9-5**] 06:39AM BLOOD CK-MB-3 cTropnT-<0.01 [**2190-9-4**] 11:55PM BLOOD Calcium-5.9* Phos-1.6* Mg-1.1* [**2190-9-5**] 02:50AM BLOOD VitB12-1273* [**2190-9-5**] 02:50AM BLOOD Triglyc-77 [**2190-9-5**] 12:12AM BLOOD Type-[**Last Name (un) **] Temp-37.1 O2 Flow-2 pO2-35* pCO2-30* pH-7.39 calTCO2-19* Base XS--5 Intubat-NOT INTUBA Vent-SPONTANEOU [**2190-9-5**] 12:02AM BLOOD Lactate-3.6* [**2190-9-5**] 03:07AM BLOOD Lactate-2.2* [**2190-9-6**] 04:33AM BLOOD Lactate-1.1 [**2190-9-4**] 11:55PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.013 [**2190-9-4**] 11:55PM URINE Blood-TR Nitrite-NEG Protein-30 Glucose-300 Ketone-80 Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG [**2190-9-4**] 11:55PM URINE RBC-1 WBC-6* Bacteri-FEW Yeast-NONE Epi-1 [**2190-9-4**] 11:55PM URINE CastHy-17* Relevent MICU Labs: [**2190-9-6**] 03:55AM BLOOD WBC-5.2 RBC-2.97* Hgb-10.4* Hct-30.2* MCV-102* MCH-34.8* MCHC-34.3 RDW-13.0 Plt Ct-109* [**2190-9-7**] 04:17AM BLOOD WBC-3.8* RBC-2.60* Hgb-8.8* Hct-28.0* MCV-107* MCH-33.7* MCHC-31.4 RDW-12.7 Plt Ct-103* [**2190-9-6**] 03:55AM BLOOD PT-12.0 PTT-27.7 INR(PT)-1.1 [**2190-9-6**] 03:55AM BLOOD Plt Ct-109* [**2190-9-7**] 04:17AM BLOOD PT-12.2 PTT-30.3 INR(PT)-1.1 [**2190-9-7**] 04:17AM BLOOD Plt Ct-103* [**2190-9-6**] 03:55AM BLOOD Glucose-152* UreaN-18 Creat-1.1 Na-135 K-3.8 Cl-98 HCO3-23 AnGap-18 [**2190-9-7**] 04:17AM BLOOD Glucose-546* UreaN-9 Creat-1.0 Na-132* K-3.1* Cl-97 HCO3-25 AnGap-13 [**2190-9-6**] 03:55AM BLOOD ALT-53* AST-72* LD(LDH)-251* CK(CPK)-104 AlkPhos-62 Amylase-517* TotBili-1.0 [**2190-9-7**] 04:17AM BLOOD ALT-57* AST-86* LD(LDH)-218 AlkPhos-75 TotBili-1.0 [**2190-9-6**] 03:55AM BLOOD Lipase-1303* [**2190-9-7**] 04:17AM BLOOD Lipase-1337* Discharge Labs; [**2190-9-9**] 08:00AM BLOOD WBC-4.2 RBC-2.99* Hgb-10.2* Hct-30.5* MCV-102* MCH-34.0* MCHC-33.3 RDW-13.1 Plt Ct-169 [**2190-9-9**] 08:00AM BLOOD Glucose-176* UreaN-16 Creat-1.0 Na-137 K-3.4 Cl-103 HCO3-25 AnGap-12 [**2190-9-9**] 08:00AM BLOOD Calcium-8.1* Phos-2.7 Mg-1.6 [**2190-9-8**] 07:00AM BLOOD %HbA1c-8.3* eAG-192* Micro: Blood culture [**9-4**]- PENDING x 2 Imaging: EKG [**2190-9-5**]: Sinus tachycardia. RSR' pattern in lead V1 (normal variant). Left atrial abnormality. Non-specific ST segment changes. No previous tracing available for comparison. Rate 114, QTc 424 CXR [**2190-9-5**]: Lung volumes are low and there are patchy bibasilar opacities which may reflect patchy lower lobe atelectasis, although aspiration or pneumonia cannot be entirely excluded. Clinical correlation is advised. No pneumothorax. No evidence of pulmonary edema. No acute bone abnormality appreciated. CT abd/pelvis [**2190-9-5**]: 1. Peripancreatic fluid and fat stranding suggestive of pancreatitis. No evidence of organized fluid collection. 2. Hepatic steatosis. 3. Diverticulosis without evidence of diverticulitis Brief Hospital Course: 57 yo Male with history of poorly controlled DM, transferred from [**Hospital1 **] [**Location (un) 620**] for managment of DKA, pancreatitis and EtOH withdrawal #DKA- came in with gap of 18, glucose of 230s. Patient endorse medication non-compliance. While in the ICU, patient was treated with fluid and electrolyte resuscitation and subcutaneous insulin, with good response. [**Last Name (un) **] Diabetes Center was consulted. His insulin drip was stopped on [**2190-9-7**]. He was called out to the medicine floor where he remained quite stable. He was seen by PT on whose recommendation he was dc-ed to rehab. # Acute pancreatitis- Nausea and abdominal pain were present on admission, as well as a lipase to 1098 at [**Hospital1 **] [**Location (un) 620**] 1251 at [**Hospital1 18**]. He was treated conservatively with NPO diet, pain control with tylenol. A CT abdomen showed uncomplicated pancreatitis, without pseudocyst, necrosis, or fluid collection. Pt improved quickly and was toelrating regular diet, with pain controlled on tylenol at dc to rehab. # Alcohol withdrawal- Patient reports his last drink was on friday morning before admission. Patient reports that he drinks [**5-14**] hard alcoholic drinks daily. He denies any withdrawal symptoms in the past, however while in the ICU he required more than 100mg of PRN Diazepam on a CIWA scale. He was treated with Diazepam and breakthrough lorazepam per CIWA protocol, and given thiamine and multivitamin supplementation. A social work consult was placed regarding his substance abuse, as well. He did not score on CIWA after transfer to floor. #Anemia: HCT has remained stable throughout MICU stay. Has macrocytic anemia consistent with history of alcohol abuse. He did not require transfusion, and had guaiac negative stools. We continued home b12 and added on folate supplementation. #[**Last Name (un) **]- Presented with serum Cr of 1.9 on admission, which is elevated from baseline. Was given aggressive fluid resuscitation and responded well with normalization of serum Cr. Normalised at time of dc. Transitional Issues: - Will need ETOH abuse council if amenable - f/u with [**Last Name (un) 387**] as outpt-set up as high risk through care connection seen w/in 2 days of discharge; decision to refer to [**Last Name (un) **] deferred to PCP Medications on Admission: Lisinopril 10 mg daily simvastatin 40 mg daily Levemir Flexpen [**Hospital1 **] (10 units, but patient is unsure) Spectravite Senior multivitamin Discharge Medications: 1. Simvastatin 40 mg PO DAILY 2. Lisinopril 10 mg PO DAILY 3. FoLIC Acid 1 mg PO DAILY 4. Multivitamins W/minerals 1 TAB PO DAILY 5. Levimir 8 Units Bedtime 6. Insulin SC Sliding Scale Insulin SC Sliding Scale using HUM Insulin Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Doctor Last Name 5749**] [**Doctor Last Name **] Village - [**Location (un) **] Discharge Diagnosis: PRIMARY DIAGNOSIS: 1. ACUTE PANCREATITIS 2. DIABETIC KETOACIDOSIS SECONDARY DIAGNOSIS: 1. TYPE 2 DIABETES MELLITUS 2. HYPERLIPIDEMIA 3. PSORIASIS Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr [**Known lastname **], It was a pleasure participating in your care while you were admitted to [**Hospital1 69**]. As you know you were admitted because you were experiencing abdominal pain and were ultimately found to have pancreatitis. This was caused by drinking too much alcohol and it is very important that you decrease the amount you are drinking. Your blood sugars were also extremely high and you develop a condition called Diabetic Ketoacidosis. This can be extremely dangerous and it is very important that you take insulin as instructed. Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) 6715**] H. Location: [**Hospital1 **] FAMILY MEDICINE OF [**Location (un) **] Address: [**Street Address(2) 31531**], [**Location (un) **],[**Numeric Identifier 31532**] Phone: [**Telephone/Fax (1) 31529**] Please discuss with the staff at the facility a follow up appointment with your PCP when you are ready for discharge.

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

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336, 342

10139, 10139

3607, 3607

10869, 11247

2323, 2578

9511, 9747

9969, 9969

9340, 9488

10290, 10846

2593, 3060

3076, 3588

9090, 9314

264, 298

370, 1537

10057, 10118

3623, 6958

9988, 10036

10154, 10266

1559, 2019

2035, 2307