ChanBeDu/relevant_section_length · Datasets at Hugging Face

12,763

111,190

44436

Discharge summary

report

Admission Date: [**2104-6-23**] Discharge Date: [**2104-7-2**] Service: CSU HISTORY OF PRESENT ILLNESS: This is an 84-year-old man admitted [**2104-6-23**] being discharged today, [**2104-7-2**], who has a past medical history significant for coronary artery disease, hypertension, hypercholesterolemia, prostate cancer, status post a radical prostatectomy ten years ago, with chronic urinary tract infections, status post hernia repair times two and status post bilateral knee repairs. PREOPERATIVE MEDICATIONS: 1. Procardia XL 60 mg p.o. q d. 2. Imdur 60 mg p.o. q d. 3. Lescol 80 mg p.o. q d. 4. Aspirin 81 mg p.o. q d. 5. Ditropan 5 mg p.o. q d. 6. Macrobid 50 mg p.o. q h.s. ALLERGIES: No known drug allergies. SOCIAL HISTORY: History of a 20 pack per year history of smoking quitting 40 years ago denying alcohol use. HOSPITAL COURSE: The patient had a known history of coronary artery disease with a history of percutaneous transluminal coronary angioplasty to his left circumflex coronary artery in 199. He presented to an outside hospital with complaints of chest pain and was found to have an elevated troponin. He was then transferred to [**Hospital6 256**] on [**2104-6-23**] for cardiac catheterization at which time, he continued to complain of intermittent mild chest pain. Cardiac catheterization was performed that day, [**2104-6-23**], which revealed severe two-vessel coronary artery disease with a fifty percent distal stenosis of his left main coronary artery, 80-90 percent stenosis of his left anterior descending coronary artery, 80 percent stenosis of his left circumflex coronary artery with moderate left ventricle dysfunction with an ejection fraction of 40-45 percent. The patient underwent coronary artery bypass grafting times two with the left internal mammary artery to left anterior descending coronary artery and saphenous vein graft to the obtuse marginal on [**2104-6-25**]. Total cardiopulmonary bypass time was 48 minutes. Total cross-clamp time was 37 minutes. The patient was discharged in stable condition to the Cardiac Surgery Recovery Unit on propofol and phenylephrine. The patient was extubated the evening of surgery without complication. The patient continued to be constipated during his course, however, stating that he had been constipated four days prior to his admission to the hospital. He was transferred to [**Hospital Ward Name 121**] two [**2104-6-27**] in stable condition. The patient went into atrial fibrillation on postoperative day three with a heart rate in the 90s. He was administered Lopressor with good effect and he was converted back to sinus rhythm with a heart rate in the 50s. The patient's Foley catheter was discontinued on postoperative day two and his own condom catheter was placed secondary to incontinence, which he had been wearing at home prior to admission. The patient was found to have a urinary tract infection. Urine cultures were sent out which grew out E. Coli for which he was treated with ceftriaxone 1 gm intravenously b.i.d. On postoperative day four, he was also found to have a hematocrit of 25.3 for which he was transfused one unit of packed red blood cells. The patient continued to remain in normal sinus rhythm. His heart rate was in the 50s to 70s progressing to level five for physical therapy on postoperative day six and was ready to be discharged to a rehabilitation facility on [**2104-7-2**]. PHYSICAL EXAMINATION: The patient's examination on discharge revealed the patient to be neurologically intact. The chest was clear to auscultation bilaterally with no wheezing, rhonchi or rales. The sternum was stable. The incision was clean, dry and intact. His heart was regular with no murmurs, rubs or gallops. Abdomen was soft, nontender and nondistended. Extremities were warm with 1+ pedal edema bilaterally. Vital signs 98.7 was his current temperature, blood pressure 107/59, heart rate 58, respirations 20, saturation 94 percent on room air. Chest x-ray performed [**2104-7-1**] revealed a small left pleural effusion, otherwise, unremarkable. DISCHARGE MEDICATIONS: 1. Potassium chloride 20 mEq p.o. q d for two weeks. 2. Lasix 20 mg p.o. q d for two weeks. 3. Colace 100 mg p.o. b.i.d. 4. Protonix 40 mg p.o. q d. 5. Aspirin 325 mg p.o. q d. 6. Acetaminophen 325 mg, two tablets p.o. q four hours p.r.n. 7. Plavix 75 mg p.o. q d for three months. 8. Ditropan 5 mg p.o. q d. 9. Lipitor 40 mg p.o. q d. 10. Multivitamin p.o. q d. 11. Ascorbic acid 500 mg p.o. b.i.d. 12. Iron complex 150 mg p.o. q d. 13. Metoprolol 25 mg p.o. b.i.d. 14. Ceftriaxone 1 gm intravenously b.i.d. for ten days. 15. Darvon for pain 100-650 mg p.o. q six hours p.r.n. DISPOSITION: The patient was discharged in good condition to a rehabilitation facility with discharge instructions to follow-up with Dr. [**Last Name (STitle) 1295**] in [**1-29**] weeks and Dr. [**Last Name (STitle) 70**] in [**4-1**] weeks. DISCHARGE DIAGNOSIS: Coronary artery disease, status post coronary artery bypass grafting times two. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**] Dictated By:[**Last Name (NamePattern4) 28488**] MEDQUIST36 D: [**2104-7-2**] 11:04:42 T: [**2104-7-2**] 11:46:55 Job#: [**Job Number **]

[ "E878.2", "410.71", "427.31", "997.1", "287.5", "412", "599.0", "414.01", "041.4" ]

icd9cm

[ [ [] ] ]

[ "99.04", "99.20", "36.15", "88.56", "39.61", "99.05", "37.22", "36.11", "88.53" ]

icd9pcs

[ [ [] ] ]

4106, 4961

4983, 5329

862, 3425

527, 734

3448, 4083

117, 501

751, 844

10,366

171,456

48333

Discharge summary

report

Admission Date: [**2165-8-26**] Discharge Date: [**2165-9-29**] Service: GEN [**Doctor First Name 147**] PAST MEDICAL HISTORY: 1. Paroxysmal atrial fibrillation. 2. Hypertension. 3. Coronary artery disease with ejection fraction of 20% per echocardiogram in [**2158**]. 4. Coronary artery disease status post myocardial infarction times three, status post coronary artery bypass graft in [**2156**]. 5. Diabetes mellitus type 2. 6. Benign prostatic hypertrophy. 7. Gout. 8. Primary biliary cirrhosis, complicated by thrombocytopenia and splenomegaly. 9. Right femoral patellar fracture, post open reduction and internal fixation. 10. Gastroesophageal reflux disease. 11. Status post cholecystectomy. 12. History of gastrointestinal bleed. 13. Chronic renal insufficiency with baseline creatinine of 2.2. 14. Anemia. ALLERGIES: Penicillin and erythromycin. MEDICATIONS 1. Zosyn 1 mg p.o. q. day. 2. Lopressor 12.5 mg p.o. q. day. 3. Lasix 40 mg p.o. q. day. 4. Glipizide 5 mg p.o. q. day. 5. PhosLo two tablets p.o. with meals. 6. Bicitra 30 cc., p.o. twice a day. 7. Moexipril 5 mg p.o. q. day. 8. Epogen 5000 units subcutaneously every Monday and Friday. 9. Calcium carbonate 500 mg p.o. four times a day. 10. Ambien 5 mg p.o. q. h.s. 11. Tylenol p.r.n. 12. Lentus 20 units subcutaneously q. h.s. HISTORY OF PRESENT ILLNESS: The patient is an 86 year old man with diabetes mellitus, chronic renal insufficiency, biliary cirrhosis, with a recent upper gastrointestinal bleed from multiple duodenal ulcers seen on endoscopy two weeks prior to admission. The patient presented with worsening of his baseline epigastric pain, nausea and vomiting of coffee grounds. The patient was assessed in the Emergency Room and underwent CT scan which showed free air in the area of the second portion of the duodenum along with a large amount of free air and ascites. Because of the patient's significant co-morbid conditions along with peritoneal signs and free air, the options were discussed and the decision was made to admit the patient and proceed with an operation. HOSPITAL COURSE: The patient was taken to an Operating Room on [**2165-8-26**], where exploratory laparotomy and suture repair of perforated duodenal ulcer, gastrostomy and feeding jejunostomy was performed. The operation was complicated by diffuse oozing from the liver surface, a large amount of ascitic fluid which was drained, proximal atrial fibrillation, rate controlled, and a couple of episodes of hypertension down to 60 which resolved promptly. At the end of the operation, the patient was hemodynamically stable and was transferred to the Intensive Care Unit, intubated. 1. Cardiovascular: The patient remained hypotensive, dropping his mean arterial pressure down to the 40s. He was started on Levophed. Throughout his admission, we were not able to wean patient off Levophed. He, in a matter of fact, required increasing doses of Levophed to keep his mean arterial pressure above 60. A Cardiology consultation was also obtained which agreed with the management already provided. The patient was tried on digoxin which did not improve his condition and we were still not able to wean him off of Levophed. Throughout his admission, the patient remained in rate controlled atrial fibrillation with heart rate between 70 and 120. 2. Respiratory: Postoperatively, when it was clear that the patient will require a long term ventilator support, his intubation was converted to tracheostomy. He eventually progressed from CIMV to [**Hospital1 **]-C-PAP which he tolerated well throughout his admission with only small amounts of yellow secretion that came out of his tracheostomy tube. The patient's saturation remained good. 3. Renal: The patient's chronic renal failure got worse after the operation. His creatinine increased between 2.5 and 3.5. The patient eventually became aneuric, required hemodynamically. However, sessions were frequently interrupted because of the patient's hypotension. Throughout his admission his renal status has not improved. The patient remained aneuric with a high creatinine. 5. Gastrointestinal: The patient has a G-tube and J-tube placed interoperatively. He was very quickly times two. His goal tube feeds which he remained throughout his admission resolved any complications. No gastrointestinal bleeds. The patient's primary biliary cirrhosis is probably contributing significantly to his multiple system failure. 6. Endocrine: Throughout his admission, the patient required an insulin drip. All attempts to wean him off resulted in the patient's blood sugars staying above 200. 7. Hematology: The patient remained thrombocytopenic throughout his admission with platelet level less than 100, but he did not have any active episodes of bleeding as indicted above. The patient required red blood cell transfusion intermittently to improve his hematocrit. 8. Infectious Disease: The patient grew Methicillin resistant Staphylococcus aureus out of his sputum culture in the beginning of his postoperative course. He was placed on Vancomycin on which he remained throughout that admission. All cultures were negative. 9. Wound: Clean, dry and intact. 10. Neurological: After the patient's sedation was weaned off, he was a alert, oriented, pain free, responding appropriately to the environment, following commands and answering questions. DISPOSITION: During the course of his admission, the patient's status was changed to "Do Not Resuscitate" "Do Not Intubate". On [**9-28**], a family meeting was held with members of the following teams present. Due to lack of progress in the patient's recovery and worsening of his cardiovascular and renal status, the decision was made to change the patient's status to comfort measures only. His Levophed dosing was cut in half which resulted in immediate drop in his mean arterial pressure. The patient was started on a morphine drip on comfort measures and expired in the morning of [**2165-9-29**], with patient's family present. DISCHARGE STATUS: The patient expired. DISCHARGE DIAGNOSES: 1. Perforated duodenal ulcer. 2. Gastrointestinal bleed status post repair. 3. Heart failure. 4. Atrial fibrillation. 5. Tracheostomy dependent. 6. Diabetes mellitus. 7. Methicillin resistant Staphylococcus aureus. 8. Acute renal failure. 9. Biliary cirrhosis. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3799**], M.D. [**MD Number(1) 3800**] Dictated By:[**Last Name (NamePattern4) **] MEDQUIST36 D: [**2165-9-29**] 16:12 T: [**2165-9-29**] 16:45 JOB#: [**Job Number **]

[ "571.6", "567.2", "532.60", "428.0", "427.31", "287.5", "789.5", "584.9" ]

icd9cm

[ [ [] ] ]

[ "46.39", "38.95", "89.64", "44.42", "43.19", "39.95", "96.6", "38.91", "31.1" ]

icd9pcs

[ [ [] ] ]

6137, 6676

2119, 6116

1363, 2100

139, 1333

10,551

170,033

7052

Discharge summary

report

Admission Date: [**2110-3-5**] Discharge Date: [**2110-3-10**] Date of Birth: [**2056-7-20**] Sex: M Service: O-MED ADMISSION DIAGNOSIS: Melena. HISTORY OF PRESENT ILLNESS: The patient is a 53-year-old Asian male with a history of metastatic cancer of unknown primary who presented with melena. The patient reports that he had two black stools on the day prior to admission. He had four bowel movements that day. The patient states he has been having abdominal pain for approximately two months. He had an abdominal computed tomography which showed a cecal mass and liver lesions. The computed tomography was done one month prior to admission. Since that time, he has had right upper quadrant pain and right lower quadrant pain that has persisted. He describes it as dull with occasional knife-like episodes. He was started on a Fentanyl patch. The patient had a course of chemotherapy one week prior to admission and had some vomiting after the chemotherapy. He denies any coffee-grounds emesis or hematemesis. He denies chest pain, shortness of breath, or fever. He had felt lightheaded and dizzy. He denied the use of nonsteroidal antiinflammatory drugs. The patient was due for his second round of chemotherapy today. He had routine laboratories drawn which showed a hematocrit of 14.2. Therefore, he was sent to the Emergency Department for evaluation. In the Emergency Department, he was seen by the Gastrointestinal Service as well as the Surgery Service and was given intravenous fluids and packed red blood cells. PAST MEDICAL HISTORY: 1. Metastatic cancer of unknown primary; with a cecal mass and hepatic lesions. Biopsy of the cecal mass in [**2110-4-15**] showed poorly differentiated carcinoma that was CK-7 positive, positive for CK-20, negative for S-100. Suggestive of lung adenocarcinoma, pancreatic cancer, or lower urinary tract. He had a biopsy of an ileocecal lesion which showed poorly differentiated adenocarcinoma. He was started on cisplatin and irinotecan for presumptive gastric carcinoma. 2. Appendicitis in [**2110-1-15**]. 3. Right inguinal hernia repair in [**2108**]. 4. Ileocecectomy after appendicitis. MEDICATIONS ON ADMISSION: 1. Fentanyl patch 25 mcg transdermally q.72h. 2. Tylenol p.o. as needed. 3. Antiemetic (the patient does not recall the name). ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient was born in [**Last Name (un) 26340**]. He has been in the United States since [**2081**]. He works as a cook. He is married. He has a young child. He quit smoking two months prior to this admission. He rarely drinks alcohol. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on admission revealed temperature was 98.7, blood pressure was 106/72, heart rate was 118, respiratory rate was 20, and oxygen saturation was 100% on room air. Head, eyes, ears, nose, and throat examination revealed extraocular movements were intact. The patient was pale. His mucous membranes were moist. The neck was supple with no lymphadenopathy. The chest was clear to auscultation bilaterally. Cardiovascular examination revealed normal first heart sounds and second heart sounds. There were no murmurs, rubs, or gallops. The patient was tachycardic. The abdomen revealed a surgical medial abdominal scar. Bowel sounds were present. The abdomen was soft but diffusely tender with most tenderness being in the right lower quadrant. There was no guarding. The patient did have some rebound tenderness over the right lower quadrant. Extremity examination revealed there was no peripheral edema. There was no clubbing. The patient had tattoos on both upper extremities. Neurologically, the patient was alert and oriented times three. Cranial nerves II through XII were intact. There was no focal neurologic deficits on examination. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories revealed white blood cell count was 7.8, hematocrit was 14.2, and platelets were 559. Absolute neutrophil count was 7630. Sodium was 138, potassium was 4.3, chloride was 102, bicarbonate was 26, blood urea nitrogen was 11, creatinine was 1.1, and blood glucose was 159. INR was 1 and partial thromboplastin time was 25.8. PERTINENT RADIOLOGY/IMAGING: A computed tomography of the abdomen from [**2110-1-15**] showed dilated small-bowel loops with multiple air/fluid levels. There was edematous small bowel. There was a cecal soft tissue mass. There was carcinomatosis of the stomach. There was a soft tissue mass in the mesentery near the pancreas. There were hypodense lesions in the liver. A KUB showed no free air or evidence of obstruction. An electrocardiogram showed a rate at 100 with a normal axis. There were no ST-T wave changes. A colonoscopy in [**2110-1-15**] showed a cecal mass. HOSPITAL COURSE: The patient was initially admitted to the Medical Intensive Care Unit for an upper gastrointestinal bleed causing blood loss anemia. He was transfused 4 units of packed red blood cells, and his hematocrit bumped to 29. The Gastrointestinal Service was consulted. The patient underwent an esophagogastroduodenoscopy which showed diffuse ulceration and oozing of the gastric mucosa, compatible with linitis plastica. Once the patient was stabilized, he was transferred to the O-MED Service. His hematocrit was checked twice per day and remained stable. He was maintained on intravenous Protonix twice per day. The patient received chemotherapy while he was in house. He received cisplatin and irinotecan on [**3-7**]. The patient was monitored in the hospital for a stable hematocrit. He developed some nausea and vomiting after his chemotherapy; however, this resolved by the time of discharge. At the time of discharge, the patient's hematocrit was stable at 27 to 29. DISCHARGE DIAGNOSES: 1. Upper gastrointestinal bleed secondary to metastatic cancer; likely gastric in origin with possible 2. Blood loss anemia. 3. Hypovolemic shock. 4. Status post appendectomy. 5. Right inguinal hernia repair in [**2108**]. 6. Ileocecectomy after appendicitis. MEDICATIONS ON DISCHARGE: 1. Percocet p.o. as needed. 2. Fentanyl patch 50 mcg transdermally q.72h. 3. Protonix 40 mg p.o. once per day. 4. Compazine p.o. as needed. DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was to be seen in the [**Hospital **] Clinic in three days' time. He was to have his hematocrit checked at that time. [**First Name11 (Name Pattern1) 396**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 9758**] Dictated By:[**Last Name (NamePattern1) 222**] MEDQUIST36 D: [**2110-5-7**] 14:47 T: [**2110-5-10**] 03:55 JOB#: [**Job Number 26341**]

[ "578.1", "584.9", "197.8", "151.9", "285.1" ]

icd9cm

[ [ [] ] ]

[ "99.25", "45.13" ]

icd9pcs

[ [ [] ] ]

5838, 6105

6131, 6276

2210, 2379

4836, 5817

6310, 6749

155, 164

193, 1560

1582, 2184

2396, 4817

15,397

111,830

30649

Discharge summary

report

Admission Date: [**2133-4-30**] Discharge Date: [**2133-5-1**] Date of Birth: [**2133-4-30**] Sex: F Service: NB IDENTIFICATION: Baby Girl [**Known lastname 2433**] is a 1 day old former 31 [**3-21**] week infant with recurrent Atrial Flutter and Hydrops who is being transferred from [**Hospital1 18**] NICU to [**Hospital3 1810**] Cardiac Intensive Care Unit. HISTORY: Baby girl [**Known lastname 2433**] is a 31-4/7 week gestation female infant admitted to the newborn intensive care unit because of prematurity and a prenatal diagnosis of fetal tachycardia and hydrops. This mother is a 35-year-old gravida 2 para 0 now 1 mother. Prenatal screens: Blood type A positive, antibody negative, hepatitis B surface antigen negative, RPR nonreactive, rubella immune, group beta strep status unknown. Chlamydia, HIV and GC cultures negative. This pregnancy was complicated by the development of maternal hypertension noted 3 days prior to delivery when she was admitted to [**Hospital **] Hospital. Fetal assessment revealed fetal tachycardia and hydrops and the mother was transferred to [**Hospital1 346**] for further care. A fetal echo done after admission to [**Hospital1 69**] revealed intermittent fetal tachycardia sometimes with rates into the 270 range. Also noted was moderately severe ascites, mild pleural effusions and scalp edema and polyhydramnios. The mother was evaluated by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] of the cardiology electrophysiology team at [**Hospital3 1810**] and maternal treatment with digoxin was initiated. The mother was also treated with flecainide. Because of worsening pregnancy induced hypertension and concern for persistent fetal tachycardia, the baby was delivered by cesarean section. The infant emerged with cry and some good respiratory effort. She was bulb suctioned and intubated orally and was noted to have equal breath sounds. Apgar scores were 7 at one minute and 8 at 5 minutes of age. EXAM: Initial exam notable for an LGA infant with moderate edema and significant ascites. Wt was 2765 gm, length was 41.5 cm, and HC was 33.5 cm, all greater than the 90th%ile. Infant was tachycardic with a systolic murmur. Lungs were coarse and moderately aerated. Abdomen was distended. Tone and activity were grossly normal. Infant was non-dysmorphic. HOSPITAL COURSE: CARDIOVASCULAR: Upon admission to the NICU, the baby was noted to have a heart rate in the 230s. An EKG at that time revealed a diagnosis of atrial flutter with 2:1 conduction. After placement of umbilical venous and umbilical arterial lines, as well as treatment with surfactant, an attempt to cardiovert the infant with transesophageal pacing was attempted but was unsuccessful. The infant was then treated with 2 joules of synchronized cardioversion with immediate conversion to normal sinus rhythm. The baby was also treated with 1 dose of procainamide IV infusion over 1 hour around that time. Overnight, during placement of umbilical venous catheter, the infant converted back into atrial flutter. There was a subsequent successful conversion back to normal sinus rhythm with a procainamide bolus at that time. The infant once again returned to atrial flutter this morning with EKG revealing aberrant conduction. Attempts were made to convert back to sinus rhythm with adenosine boluses which were unsuccessful but with subsequent successful conversion to normal sinus rhythm this morning with esophageal pacing. The infant remained in normal sinus rhythm for the majority of the day of [**5-1**] from about 8 a.m. in the morning until 5 p.m. at night but with physical stimulation during chest x-ray, the infant was noted to convert back into atrial flutter. At that time, she received a 5 per kilo bolus of procainamide, without effect. Esophageal pacing was attempted, also without effect. Sinus rhythm was eventually obtained with direct cardioversion. Of note, infant was maintained on procainamide infusion of 30 mcg/kg/min throughout. Procainamide level this morning was 9.1 with a NAPA level of 2.3. Blood pressures have remained borderline, with MAPs 25-30 by A-line and 30-35 by cuff. The infant has received 1 normal saline bolus for low blood pressures this morning, has not received any further boluses today. An echocardiogram was performed earlier in the day of [**5-1**]. The results of that echocardiogram are pending. Preliminary findings showed a moderately depressed ventricular function, AV regurgitation and a patent ductus arteriosus. Respiratory: Upon admission to the newborn intensive care unit, the infant was placed on a conventional ventilator and has received a total of 2 doses of surfactant. Blood gases have been stable. The last blood gas showed a pH of 7.36 with a PCO2 of 43. She is currently on settings of 24/6 with a rate of 26 and an FIO2 of 31-50%. Chest x-ray was notable for mild RDS. FEN: Upon admission to the NICU, the infant was started on IV fluids of D10W at 60 cc per kilogram per day. Initial D stick was 22 for which she received a 2 per kilo D10W bolus. Subsequent D stick was 36. She received another 2 per kilo D10W bolus with subsequent blood sugars in the 70 to 90 range. Electrolytes at 2 p.m. this afternoon showed a sodium of 134, potassium 5.2, chloride 105, bicarb 22, BUN 14, creatinine 1. Albumin level 1.9. Bilirubin 4.5 with a direct bilirubin of 0.3. Ionized calcium this morning was 1.15. Urine output has been minimal throughout the day. Foley placement would likely be beneficial. ID: Upon admission to the NICU, a CBC and blood culture were drawn. White blood cell count was 5500, hematocrit 46.1, platelet count 230 with 40% polys and 1% bands. A blood culture that was drawn at that time has no growth so far. The infant was started on Ampicillin and cefotaxime and she continues to be on those antibiotics. GI: Infant has been maintained NPO. Moderate ascites is notable on exam, and an abominal ultrasound can be considered in the future. LFTs this afternoon revealed AST 4, ALT 32, Bili 4.5/0.3, and albumin 1.9. NEUROLOGY: The infant is currently receiving fentanyl 2 mcg per kilogram q.4 hours for sedation. A head ultrasound has not been performed, but likely should be considered within first week of life. The infant is currently n.p.o., receiving IV fluids of D10W with 2 mEq of sodium per 100 cc via the umbilical venous catheter. The infant has [**12-16**] normal saline with 1/2 unit of heparin per ml running through the umbilical artery catheter. The infant is n.p.o. Total fluids are 60 cc/kg/day. State newborn screen was sent just prior to discharge. The infant has not received any immunizations. DISPOSITION: Due to recurrent atrial flutter thus far not amenable to medical therapy, infant was transferred to [**Hospital3 18242**] Cardiac Intensive Care Unit. Transfer was discussed with parents, who agree. DISCHARGE DIAGNOSES: 1. Prematurity at 31-4/7 weeks. 2. Respiratory distress syndrome. 3. Rule out sepsis. 4. Atrial flutter, status post cardioversion. 5. Hydrops. [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**MD Number(2) 56682**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2133-5-1**] 18:29:17 T: [**2133-5-2**] 10:46:38 Job#: [**Job Number 72666**]

[ "427.32", "765.19", "745.5", "763.83", "779.89", "V30.01", "779.82", "765.26", "770.6", "V29.0", "766.1", "782.3" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.04", "99.61" ]

icd9pcs

[ [ [] ] ]

6913, 7312

2363, 6892

13,943

168,467

30352

Discharge summary

report

Admission Date: [**2166-4-27**] Discharge Date: [**2166-4-28**] Date of Birth: [**2114-6-13**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5438**] Chief Complaint: tx from [**Hospital 1281**] Hospital for resp failure Major Surgical or Invasive Procedure: None History of Present Illness: 51 yo m with h/o IPF was in USOH at home until 7 days PTA when he developed inc brown sptum, SOB, and chills. Developed diarrhea 3 days PTA. last few days SOB got worse. During the last few days, his pulm increased steroids ans stated on a Zpack. Over the next day, had decreased eating and inc weakness. He is normally on 1.5 L NC O2 at home since his DC from [**1-26**]. Wife called EMS at midnight of [**4-27**]. who brought him to [**Hospital 1281**] Hosp ED. EMS was unable to obtain an O2 sat and placed him on NRB. On presentation to the ED, his O2 sat was 55% on arrival and then 79% on NRB. ABG pn NRB was 7.44/27/72. He was given tylenol, ativen, rochephin, solumedrol 125 IV, Bactrim, flagyl, and azithro in the ED. Was intubated in the ICU at [**Hospital1 1281**] at 0245. While intubated, becamse hypotensive and was started on neo and given fluids. Was switched to levophed and vasopression in the ICU. BP reported at 60's systolic. Under sterile conditions, placed L IJ and L art groin line [**2-21**] him being clamped down. Gave aggressive IVF (4L). CVP went from 10 -> 30 with fluids. ABG after intubation 7.05/40/86 on AC 500/30/10/100. He was noted to have WBC of 29 with 8% bands and given ceftax, vanc, flagyl (?cdiff) in the ICU. Also wanted to give bactrim for PCP, [**Name10 (NameIs) **] did not get b/f transfer. Got a DFA for flu which is neg. Also noted to be in ARF with Cr 2.1. Also . Transfered via [**Location (un) **] to [**Hospital1 18**]. On route, required vecuronium an fentanyl bolus. Stopped propofol for hypotension. On presentation to the ICU, gas was 6.98/66/84 on AC 500/18/13/100. Was on levophed and vasopression and bicarb gtt. Past Medical History: 1. NIDDM 2. HTN 3. Intersitial pulm fibrosis - Starting in [**9-25**], the patietn started to have some SOB. Admitted to OSH [**12-25**] and CT showed pulm infilatrates and honeycoming. VATs-bx at [**Hospital 1281**] hosp showed diffuse aveolar damage. Felt to have rapidly accerleating IPF. That admission was started on steroids and went into rehab. DC from rehab in [**1-26**] on 1.5 L home O2. on a VERY slow pred taper. 4. hyperchol Social History: non smoker, worked at GE. According to wife, never had been sick before this. Is an avid golfer. In the last few weeks, has been using his arms to climb stairs, some SOB. Family History: NC Physical Exam: PCV 31, PEEP 13 rate 27 Fio2 100% levophed 0.09 vaso 2.4 General: unarousable, sedated. HEENT: NC/AT, pinpoint pupils, fixed and symmetric, EOMI without nystagmus, no scleral icterus. Mucous membranes dry. Neck: supple, no JVD or carotid bruits appreciated. Echymoses and erythema at sight of IJ. Pulmonary: diminished breath sounds bilaterally, + bibasalar crackles, or no wheezing heard. Cardiac: RRR, nl. S1S2, no M/R/G noted, soft heart sounds Abdomen: soft, NT/ND, distant bowel sounds Extremities: AKA, no lesions, echymoses. ext very cool, mottled. distal pulses dopplerable Skin: no rashes or lesions noted. Neurologic: sedated Pertinent Results: Labs from OSH: BNP 956 picograms/ml NA 137 K 4.3 Cl 101 Bicarb 22 BUN 19 Cr 2.1 ca 8, alt P, ast 40, ap 68, alb 2.2, chol 139, INR 1.5, PTT 35 WBC 29 with 8 band, 74 neut, HCT 41, plt 352 Trop I 0.96 (normal < 0.06) Ddimer 3.69 ug/ml (normal 0 - 0.49) UA 1030, 2+ prot, -LE, +nit . notable for INR 2.9, K 6.3, elevated LFTs, elevated Ddimer. . EKG: sinus tach, normal axis, ST depressions V5 - V6, Q in III and TWI III, Q and TWI in III and F . Reports: No radiology sent from OSH. CXR on admission here: diffuse bilateral interstial markings eparing the LUL. No effusions, ETT 8CM from carina. . [**2166-4-27**] 08:38AM FIBRINOGE-667* D-DIMER-6285* [**2166-4-27**] 08:38AM WBC-20.0* RBC-4.06* HGB-12.1* HCT-39.0* MCV-96 MCH-29.8 MCHC-31.1 RDW-13.4 [**2166-4-27**] 08:38AM ALBUMIN-2.3* CALCIUM-7.1* PHOSPHATE-9.1* MAGNESIUM-2.2 URIC ACID-8.9* [**2166-4-27**] 08:38AM CK-MB-3 cTropnT-0.17* [**2166-4-27**] 08:38AM ALT(SGPT)-133* AST(SGOT)-197* LD(LDH)-860* CK(CPK)-78 ALK PHOS-64 AMYLASE-52 TOT BILI-1.6* [**2166-4-27**] 08:55AM LACTATE-7.8* [**2166-4-27**] 08:55AM TYPE-ART RATES-18/0 TIDAL VOL-500 PEEP-13 O2-100 PO2-84* PCO2-66* PH-6.98* TOTAL CO2-17* BASE XS--17 AADO2-576 REQ O2-93 -ASSIST/CON INTUBATED-INTUBATED [**2166-4-27**] 05:15PM LACTATE-11.1* K+-4.5 [**2166-4-27**] 11:03PM O2 SAT-88 [**2166-4-27**] 11:54PM TYPE-ART PO2-69* PCO2-45 PH-7.11* TOTAL CO2-15* BASE XS--15 . CHEST (PORTABLE AP) [**2166-4-27**] 6:50 PM Slight worsening of bilateral interstitial/alveolar opacities bilaterally, which may represent pulmonary edema. . [**2166-4-27**] EKG Sinus tachycardia. Compared to the previous tracing of [**2166-4-27**] the T wave inversions in the inferior leads are slightly more prominent. . Brief Hospital Course: Assessment: 51 yo m with h/o IPF dx at [**Hospital 1281**] hospital in [**12-25**] here with septic shock and acute resp failure who expired shortly after presentation to the hospital given profound shock. . # Resp failure: Most likley [**2-21**] to acceleration of IPF. Was on steroids with a long taper and no PCP [**Name9 (PRE) **] that can be ascertained from records we have. Therefore, at increased risk for pathogens such as PCP, [**Name10 (NameIs) 14616**], [**Name11 (NameIs) **], Aspergillus, coccidioidomycosis, and nocardia, given his immunocompromised state. Diagnostics: sputum cultures, viral screen, U leg antigen. Considered bronch but unable to decrease FiO2. Family was to bring the path slides and CT scans from [**Hospital1 1281**] hosptial pathology and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] will review them to give second opnion on diagnosis of IPF. Theraputics: continued abx which included cefepime for gram pos and pseudomonas coverage; azithro for leginella and mycoplasma coverage; Vanc by level for MRSA (no history of MRSA); bactrim for PCP and nocardia. Ventilation and oxygenation: esopheal balloon to measure trans plumonary pressures. Pt with high chest wall compliance, but very low lung compliance. Continued on PCV to limit peak pressures, need to limit PEEP as well. was initially having very low sats on 100% Fio2 and 13 PEEP. Attempted to wean FiO2. . # Septic Shock: Most concerning for pulmonary etiology. Pan culture and f/u OSH cultures. Broad spectrum abx. Stress dose steroids. Attempted to keep CVP > 20 given high PEEP. Monitored UO which slowly decreased to anuria at time of demise. Continued levophed and vasopressin. . # Gap metabolic acidosis and respiratory acidosis: was on bicarb gtt for most of the day. Elevated lactate, which continued to trend up until the patients demise. . # DM: insulin gtt . # ARF: Cr 2.1 on presentation. No h/o renal failure. could be related to sepsis, volume depletion. Fluid repletion, but patient with lactic acidosis, renal failure, anuric at time of demise. . # Coagulopathy: Concerning for DIC. D-dimer high and INR increasing. PE lower on differential since has clear infectious signs and labs. Avoided heparin. . # Diarrhea, has a h/o ciff in the past and has had 3 days diarrhea since starting zpack. Flagyl emperically. c-diff toxin was to be checked x3 . # HTN: Held HCTZ while in shock # Hyperchol: Held statin while has shock liver # FEN: NPO, bolus for low UO . # Communication/Code: had family discussion on [**4-27**] about expectations. Told family that his IPF is a terminal disease and that his chance of making it though this illness is very low. The family was unaware of the severity of the diagnosis and its natural progression for unclear reasons. The patient did not share much of his medical history with the family. Of note, he told his wife that he did not want to go to the hospital though he had been very ill for the last few days. The outcome of the meeting was to proceed with very aggressive care for the next 48 hours and then reassess his status if it has not improved for withdrawl of care. Unfortunately pt's condition continued to deteriorate. 11:30 PM [**2166-4-28**], in discussion with the family members- decision was made that no chest compressions, or shocks would be delivered in the event of cardiac arrest. The implications of this decision were discussed in detail and decision was confirmed. No chest compressions, defibrillation etc to be delivered to the patient in the event of code. Family would like abx, fluids, pressors and other aggressive measures to be continued at this time. Soon therafter patient became bradycardic, overwhleming acidosis, renal failure and shock, and pt expired with family by his side. Medications on Admission: Meds on transfer: levophed vasopressin ceftaz 1gm azithrom 500 solumedrol 80 IV flagyl 250 ativan 1mg vanc 1gm heparin SC insulin gtt bicarb gtt . Meds at home: pred 25 protonix 40 seroquel 50 simvastain 10 HCTZ Discharge Medications: Pt expired Discharge Disposition: Expired Discharge Diagnosis: respiratory failure metabolic acidosis septic shock IPF Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired

[ "518.81", "V46.2", "401.9", "787.91", "V58.67", "276.7", "584.9", "486", "515", "250.00" ]

icd9cm

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icd9pcs

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2747, 2751

9227, 9239

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42369

Discharge summary

report

Admission Date: [**2137-4-7**] Discharge Date: [**2137-4-15**] Date of Birth: [**2055-3-1**] Sex: F Service: NEUROLOGY Allergies: Ultram Attending:[**First Name3 (LF) 65686**] Chief Complaint: syncope Major Surgical or Invasive Procedure: None History of Present Illness: 82F with HTN and GBM s/p resection, chemo, and radiation discharged 2 days ago from OMED admitted to the MICU for syncopal episode with NSTEMI and relative hypotension. The patient has a history of GBM s/p resection [**2136-12-30**] and chemo/radiation who was admitted to the OMED service for pancytopenia. She was discharged home on [**2137-4-5**] on new medications for neutropoenia: Ciprofloxacin 500mg [**Hospital1 **], Fluc 200mg qd and Acyclovir 400mg TID. She was instructed to stop hctz, Lisinopril and Keppra (because they thought this contributed the cytopoenia). . Last night, per ED history, the patient was walking to the bathroom and prior to reaching the toilet had a sudden syncopal event with fall and headstrike to bathroom wall with +LOC. Per the patient, she was sitting on the toilet and felt an overwhelming "warmth" and premonition of illness. She does not recall falling off the toilet or striking her face but she does know that this happened. Of note, she had incontinence to stool but no frank seizure-like movements or tongue biting (witnessed by her daughters). She was sent to hospital for syncope workup. . ED COURSE: In the ED, initial VS were 97.4, 100, 106/63, 18, 96%. EKG revealed STD in V2-V6 as well as II, III, and AVF. Labs were significant for a white count of 2.9 with differential of 48% neutrophils, hematocrit of 26.0, and platelet count of 21. Serum chemistries were unremarkable. Troponin-T was 0.56, CK 291, MB 36. Cardiology was consulted and felt her elevated trop without cardiac symptoms was likely the result of demand-like ischemia in the setting of possible hypotension. She also underwent multiple radiographic investigations: 1. CTA Chest With and Without Contrast: no PE. 2. CT C-Spine Without Contrast: no acute process. 3. CT Head Without Contrast: no acute intracranial process. 4. Pelvic XR: ordered and pendin Her UA was significant only for an elevated Sp.Gravity. . Of note, patient entered to ED with BP's in the 100's systolically which dropped to the 80's. She had two peripheral IV's placed and was fluid responsive to 2LNS. She was also initiated on vanc/cefepime for concern of possible sepsis. Discussion between cardiology team and Dr. [**Last Name (STitle) 60181**] (her neuro-oncologist) felt that patient would be best served on on the West MICU given her multiple comorbidities. . On arrival to the MICU, she is pleasant and conversant. Denies any pain. She is noted to desaturate to 85 on shovel mask with laboured breathing. Past Medical History: Past Medical History: 1. Glioblastoma 2. Hypertension 3. Colon Cancer s/p surgical resection in [**2111**] 4. Gall bladder removal 5. Appendectomy 6. Tonsillectomy 7. Right knee replacement surgery . Oncologic History: [**2111**] Diagnosed with colon cancer and underwent resection [**2136-12-17**] Developed left facial droop [**2136-12-29**] Developed forgetfulness and acute confusion [**2137-1-1**] Brain MRI showed right frontal lesion [**2137-1-7**] Right frontal craniotomy for resection of lesion Pathology: glioblastoma [**2137-2-4**] - [**2137-2-25**] IMRT 6 MeV 4000 Gy in 15 fr by Dr. [**First Name (STitle) 13014**] with TMZ 100 mg/m2 [**2137-4-1**] - Admission for pancytopenia Social History: Patient is widowed. She is also retired and lives alone. She has 7 children. She smoked between [**2070**] and [**2104**], half PPD Family History: FAMILY HX: Her brother died from lymphoma. Physical Exam: Triage: 97.4 100 106/63 18 96% Arrival to MICU: 109-120, SpO2 89% General: AAOx3, laboured breathing HEENT: right upper lip abraision without continued bleeding, MMM, supple neck Neck: no lad CV: tachy without notable murmurs or gallops Lungs: diffuse wheeze and occasional crackles Abdomen: soft and benigh GU: foley Ext: no c/c/e, warm. 1+ Radial and DP pulse Neuro: Cn2-12 intact, moving all extremities DISCHARGE EXAM O: 98.2 106/60 86 18 97%RA GEN: NAD HEENT: PERRL, EOMI, MMM NECK: No JVD CV: RRR, distant heart sounds, unable to appreciate for MRG Resp: CTAB Abd: +BS soft NTND -HSM, -HJR Ext: -c/c/e Neuro: grossly intact Pertinent Results: [**2137-4-7**] 05:08AM BLOOD WBC-2.9*# RBC-2.93* Hgb-8.5* Hct-26.0* MCV-89 MCH-29.0 MCHC-32.8 RDW-17.8* Plt Ct-21* [**2137-4-8**] 04:00AM BLOOD WBC-3.7* RBC-2.72* Hgb-8.1* Hct-24.4* MCV-90 MCH-29.7 MCHC-33.1 RDW-18.6* Plt Ct-62* [**2137-4-8**] 04:20PM BLOOD WBC-3.1* RBC-2.63* Hgb-7.8* Hct-23.9* MCV-91 MCH-29.8 MCHC-32.7 RDW-18.8* Plt Ct-50* [**2137-4-9**] 03:34AM BLOOD WBC-3.1* RBC-2.41* Hgb-7.0* Hct-21.2* MCV-88 MCH-29.2 MCHC-33.1 RDW-18.1* Plt Ct-47* [**2137-4-7**] 05:08AM BLOOD Neuts-48* Bands-1 Lymphs-38 Monos-12* Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0 [**2137-4-8**] 04:00AM BLOOD Neuts-58 Bands-1 Lymphs-25 Monos-14* Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-1* NRBC-1* [**2137-4-9**] 03:34AM BLOOD Neuts-55 Bands-0 Lymphs-30 Monos-14* Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0 [**2137-4-7**] 05:08AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-NORMAL [**2137-4-8**] 04:00AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-OCCASIONAL [**2137-4-9**] 03:34AM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-OCCASIONAL Macrocy-2+ Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL MacroOv-OCCASIONAL [**2137-4-7**] 05:08AM BLOOD PT-11.6 PTT-27.4 INR(PT)-1.1 [**2137-4-7**] 05:08AM BLOOD Plt Smr-VERY LOW Plt Ct-21* [**2137-4-7**] 06:16PM BLOOD Plt Ct-75*# [**2137-4-8**] 04:00AM BLOOD PT-12.2 PTT-28.1 INR(PT)-1.1 [**2137-4-8**] 04:00AM BLOOD Plt Smr-VERY LOW Plt Ct-62* [**2137-4-8**] 04:20PM BLOOD Plt Ct-50* [**2137-4-9**] 03:34AM BLOOD Plt Ct-47* [**2137-4-7**] 05:08AM BLOOD Glucose-162* UreaN-22* Creat-1.0 Na-140 K-3.6 Cl-108 HCO3-22 AnGap-14 [**2137-4-7**] 09:45PM BLOOD Glucose-136* UreaN-23* Creat-1.2* Na-140 K-3.9 Cl-109* HCO3-20* AnGap-15 [**2137-4-8**] 04:00AM BLOOD Glucose-136* UreaN-22* Creat-1.2* Na-139 K-3.5 Cl-105 HCO3-24 AnGap-14 [**2137-4-8**] 04:20PM BLOOD Glucose-118* UreaN-24* Creat-1.1 Na-138 K-3.6 Cl-104 HCO3-26 AnGap-12 [**2137-4-9**] 03:34AM BLOOD Glucose-116* UreaN-23* Creat-1.0 Na-139 K-3.9 Cl-107 HCO3-28 AnGap-8 [**2137-4-7**] 05:08AM BLOOD CK(CPK)-291* [**2137-4-7**] 02:42PM BLOOD CK(CPK)-768* [**2137-4-7**] 09:45PM BLOOD CK(CPK)-787* [**2137-4-8**] 04:00AM BLOOD CK(CPK)-613* [**2137-4-8**] 04:20PM BLOOD CK(CPK)-360* [**2137-4-8**] 09:50PM BLOOD CK(CPK)-230* [**2137-4-9**] 03:34AM BLOOD LD(LDH)-431* CK(CPK)-207* TotBili-0.5 [**2137-4-7**] 05:08AM BLOOD CK-MB-39* MB Indx-13.4* [**2137-4-7**] 05:08AM BLOOD cTropnT-0.56* [**2137-4-7**] 02:42PM BLOOD CK-MB-108* MB Indx-14.1* cTropnT-1.22* [**2137-4-7**] 09:45PM BLOOD CK-MB-91* MB Indx-11.6* cTropnT-2.03* [**2137-4-8**] 04:00AM BLOOD CK-MB-61* MB Indx-10.0* cTropnT-2.01* [**2137-4-8**] 10:01AM BLOOD CK-MB-41* MB Indx-8.9* cTropnT-2.03* [**2137-4-8**] 04:20PM BLOOD CK-MB-26* MB Indx-7.2* cTropnT-1.99* [**2137-4-8**] 09:50PM BLOOD CK-MB-15* MB Indx-6.5* cTropnT-1.98* [**2137-4-9**] 03:34AM BLOOD CK-MB-13* MB Indx-6.3* cTropnT-2.35* [**2137-4-7**] 05:08AM BLOOD Calcium-9.3 Phos-3.4 Mg-1.8 [**2137-4-7**] 09:45PM BLOOD Calcium-8.9 Phos-4.1 Mg-2.0 [**2137-4-8**] 04:00AM BLOOD Calcium-8.9 Phos-4.2 Mg-1.8 [**2137-4-9**] 03:34AM BLOOD Calcium-8.5 Phos-2.9 Mg-2.1 [**2137-4-9**] 03:34AM BLOOD Hapto-167 [**2137-4-7**] 09:51PM BLOOD Type-MIX Temp-36.7 pH-7.38 [**2137-4-8**] 04:13AM BLOOD Type-MIX Temp-37.1 pH-7.43 [**2137-4-8**] 10:20AM BLOOD Type-MIX Temp-36.8 pH-7.38 Comment-GREEN TOP [**2137-4-8**] 04:35PM BLOOD Type-[**Last Name (un) **] Temp-37.2 pO2-31* pCO2-42 pH-7.42 calTCO2-28 Base XS-1 [**2137-4-7**] 05:13AM BLOOD Lactate-1.6 [**2137-4-7**] 09:51PM BLOOD Lactate-1.2 [**2137-4-8**] 04:13AM BLOOD Lactate-1.0 [**2137-4-8**] 10:20AM BLOOD Lactate-1.6 [**2137-4-7**] 09:51PM BLOOD O2 Sat-49 [**2137-4-8**] 04:13AM BLOOD O2 Sat-61 [**2137-4-8**] 10:20AM BLOOD O2 Sat-95 [**2137-4-7**] 09:51PM BLOOD freeCa-1.18 [**2137-4-8**] 04:13AM BLOOD freeCa-1.15 [**2137-4-8**] 10:20AM BLOOD freeCa-1.14 Urine GENERAL URINE INFORMATION Type Color Appear Sp [**Last Name (un) **] [**2137-4-7**] 07:03 Yellow Clear >1.050* DIPSTICK URINALYSIS Blood Nitrite Protein Glucose Ketone Bilirub Urobiln pH Leuks [**2137-4-7**] 07:03 NEG NEG TR NEG NEG NEG NEG 5.5 NEG MICROSCOPIC URINE EXAMINATION RBC WBC Bacteri Yeast Epi TransE RenalEp [**2137-4-7**] 07:03 1 1 NONE NONE <1 URINE CASTS CastHy [**2137-4-7**] 07:03 4* OTHER URINE FINDINGS Mucous [**2137-4-7**] 07:03 RARE MICRO [**2137-4-7**] MRSA SCREEN MRSA SCREEN-PENDING INPATIENT [**2137-4-7**] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [**Hospital1 **] [**2137-4-7**] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [**Hospital1 **] EKG: [**Known lastname **],[**Known firstname **] [**Medical Record Number 91761**] F 82 [**2055-3-1**] Cardiovascular Report ECG Study Date of [**2137-4-7**] 11:21:00 PM Sinus tachycardia. Delayed R wave progression. Diffuse extensive ST segment depression consistent with possible ischemia/injury. Clinical correlation is suggested. Compared to the previous tracing of earlier the same date the ventricular rate has increased and the extensive ST segment depression has returned. TRACING #3 Intervals Axes Rate PR QRS QT/QTc P QRS T 117 158 74 316/415 63 8 85 [**Known lastname **],[**Known firstname **] [**Medical Record Number 91761**] F 82 [**2055-3-1**] Cardiovascular Report ECG Study Date of [**2137-4-7**] 7:52:20 AM Sinus rhythm. Early R wave transition. Diffuse ST segment flattening consistent with possible ischemia. Clinical correlation is suggested. Low voltage in the limb leads. Compared to the previous tracing of earlier the same date the severity and extent of ST segmenet depression has decreased. TRACING #2 Read by: FISH,[**Doctor First Name **] E. Intervals Axes Rate PR QRS QT/QTc P QRS T 95 174 76 398/459 70 42 63 Cardiovascular Report ECG Study Date of [**2137-4-7**] 6:06:58 AM Sinus tachycardia. Early R wave transition. Extensive ST segment depression most pronounced in the anterior leads consistent with myocardial injury/ischemia. Clinical correlation is suggested. Low voltage in the limb leads. Compared to the previous tracing of [**2137-4-7**] the extent and severity of ST segment depression has increased. TRACING #1 Read by: FISH,[**Doctor First Name **] E. Intervals Axes Rate PR QRS QT/QTc P QRS T 106 170 74 366/446 65 39 47 [**Known lastname **],[**Known firstname **] [**Medical Record Number 91761**] F 82 [**2055-3-1**] Cardiovascular Report ECG Study Date of [**2137-4-7**] 5:15:04 AM Sinus tachycardia is slower compared to tracing #1. ST segment depression in the inferolateral leads is less pronounced, new compared to tracing of [**2137-2-5**]. TRACING #2 Read by: [**Last Name (LF) **],[**First Name3 (LF) **] I. Intervals Axes Rate PR QRS QT/QTc P QRS T 104 164 80 384/461 64 33 64 Cardiovascular Report ECG Study Date of [**2137-4-7**] 4:58:40 AM Sinus tachycardia. ST segment depression in the inferolateral leads, new compared to earlier tracing of [**2137-2-5**], possibly representing ischemia. TRACING #1 Read by: [**Last Name (LF) **],[**First Name3 (LF) **] I. Intervals Axes Rate PR QRS QT/QTc P QRS T 108 166 78 366/450 66 32 79 ECG Study Date of [**2137-4-8**] 8:08:18 AM Sinus tachycardia. Early R wave transition. ST segment depressions diffusely. Compared to the previous tracing of [**2137-4-7**] the ventricular rate is slower and the extent and severity of ST segment depression is less, athough some still persist. TRACING #4 Read by: FISH,[**Doctor First Name **] E. Intervals Axes Rate PR QRS QT/QTc P QRS T 100 162 76 386/456 61 18 75 CT HEAD W/O CONTRAST Study Date of [**2137-4-7**] 4:59 AM IMPRESSION: 1. No findings related to recent trauma. 2. Expected postsurgical changes at the right frontal lobe and continued vasogenic edema. CT C-SPINE W/O CONTRAST Study Date of [**2137-4-7**] 5:00 AM IMPRESSION: 1. No evidence of fracture or subluxation. 2. Severe right carotid bifurcation calcifications. CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2137-4-7**] 5:13 AM IMPRESSION: 1. No evidence of pulmonary embolism. 2. Pulmonary edema. 3. No focal lung consolidation or evidenc of pneumonia. 4. Moderate-to-severe atherosclerotic calcifications and soft plaques at the descending thoracic aorta and significant calcifications of the coronary arteries. Portable TTE (Complete) Done [**2137-4-8**] at 3:00:00 PM FINAL Conclusions The left atrium and right atrium are normal in cavity size. The estimated right atrial pressure is 5-10 mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild to moderate regional left ventricular systolic dysfunction with hypokinesis of the anterior septum and mild dyskinesis of the distal inferior wall and apex. The apex is mildly aneurysmal. The remaining segments contract normally (LVEF = 35 %). No masses or thrombi are seen in the left ventricle. There is no left ventricular outflow obstruction at rest or with Valsalva. 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. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Suboptimal image quality. Mild symmetric left ventricular hypertrophy with regional systolic dysfunction suggestive of multivessel CAD. Mild mitral regurgitation. Pulmonary artery hypertension. CXR CHEST (PORTABLE AP) Study Date of [**2137-4-7**] 10:25 AM FINDINGS: Cardiac silhouette is upper limits of normal in size, accompanied by pulmonary vascular engorgement, new bilateral perihilar alveolar opacities and peripheral interstitial septal thickening. Findings are consistent with widespread pulmonary edema. Note is made of an accompanying small right pleural effusion. CHEST PORT. LINE PLACEMENT Study Date of [**2137-4-7**] 5:20 PM IMPRESSION: AP chest compared to [**4-1**] and [**4-7**] at 10:11 a.m.: Moderately severe pulmonary edema has worsened slightly. Small right pleural effusion has increased and tiny left pleural effusion may have developed. Heart size and mediastinal caliber are normal. Tip of the new right PIC line is in the right atrium, would need to be withdrawn 5.5 cm to move it to the low SVC. No pneumothorax. CHEST (PORTABLE AP) Study Date of [**2137-4-8**] 3:27 AM IMPRESSION: Moderate pulmonary edema has improved since [**4-7**] at 5:05 p.m.: Right PIC line has been partially withdrawn, tip projecting at the level of the superior cavoatrial junction. Withdrawing the catheter 2.5 cm would ensure that it is in the low third of the SVC. Small right pleural effusion persists. There is no pneumothorax. Heart size is normal. Mediastinal vascular caliber is unremarkable. CHEST (PORTABLE AP) Study Date of [**2137-4-9**] 2:50 AM Brief Hospital Course: Assessment and Plan: 82F with HTN and GBM s/p resection, chemo, and radiation discharged 2 days ago from OMED admitted to the MICU for syncopal episode with NSTEMI, hypotension. A unifying cause is either vasovagal syncope or seizure complicated by takotsubo/catecholaminergic myocardial toxicity and heart failre . # Hypoxic Respiratory Failure -The patient's initial CXR showed interval development of pulmonary edema in the setting of global myocardial hypokinesis and fluid resuscitation (2L). Patient was initially placed on BIPAP and she was found to be fluid overloaded on imaging. She had a CTA which showed no evidence of pulmonary embolism, no focal lung consolidation or evidenc of pneumonia and moderate-to-severe atherosclerotic calcifications and soft plaques at the descending thoracic aorta and significant calcifications of the coronary arteries. She was initially on neosynephrine then changed to levophed and by HD2 was weaned off pressors completely. She had a TTE which showed LVEF of 35%, mild symmetric left ventricular hypertrophy with regional systolic dysfunction suggestive of multivessel CAD, mild mitral regurgitation, and pulmonary artery hypertension. She was gently diuresed with significant improvement of her respiratory status. She was satting in the high 90s on 3L NC before transfer to the floor. Upon transfer, she improved without further diuresis needs and upon discharge was on room air without signs of volume overload. # Hypotension - Secondary to cardiogenic shock. As stated above patient was quickly weaned off pressors. Her O2 sats, CVO2 were monitored with improvement. She had a TTE as above. As there was initially some concern for sepsis, Vancomycin/Cefepime were intially continued but were stopped on [**2137-4-9**] after patient's imaging revealed no infection and her respiratory status improved with diruesis. She also has been afebrile with no leukocytosis. Cardiology recommendations were to continue the full dose aspirin and patient did not require further antiplatelet/anticoagulation. # Syncope: Patient recently had an admission for as-yet-idiopathic (chemotherapy-related vs keppra related) panyctopenia and has been neutropenic until as late as [**2137-4-5**]. She was initially felt to have had a seizure by the MICU team, and lacosamide was started per recommendations of Dr [**Last Name (STitle) 60181**] (her neuro-onc). Based upon history, seizure was quickly ruled out, and the lacosamide was stopped. She likely had a vasovagal event that preciptated her syncope. # GBM/Neutropenia/Pancytopenia: Patient with pancytopenia thought to be related to chemo, last cycle [**2-25**]. Patient in category of mild neutropenia, thrombocytopenia to 21, and moderate anemia to 26. Patient's neutrophils were trended and they improved to where patient was no longer neutropenic. Upon discharge, her counts were beginning to recover well, without requiring transfusions for support. Transitional Issues: - Will require a stress test as an outpatient to eval for cardiac disease Medications on Admission: Medications: Ciprofloxacin 500mg [**Hospital1 **], Fluc 200mg qd and Acyclovir 400mg TID DOCUSATE SODIUM 100 mg by mouth as needed for constipation SENNOSIDES dosage uncertain Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) Powder in Packet PO DAILY (Daily) as needed for constipation. Disp:*30 Powder in Packet(s)* Refills:*0* 4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 5. Toprol XL 50 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* Discharge Disposition: Home With Service Facility: [**Location (un) 8930**] Home Care Discharge Diagnosis: Vasovagal syncope Cardiogenic shock ?Takostubo's cardiomyopathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted after a fall at home. Likely due to low blood pressure after the fall, you went into cardiogenic shock, which is to say that your heart was not functioning normally and you required medications to help it pump effectively. This resolved after 2-3 days. After this, you were observed to make sure no further issues with your heart continued. We started some new medications for your heart. Please note the following new medications: START Colace 100mg by mouth twice per day Senna 1 tab by mouth twice per day Miralax 17g packet by mouth once per day as needed for constipation Aspirin 81mg by mouth once per day Toprol XL 50mg by mouth once per day Otherwise please stop taking your previous medications (cipro, fluconazole, acyclovir) as you no longer need these for low blood counts. Followup Instructions: Department: NEUROLOGY When: TUESDAY [**2137-4-16**] at 11:00 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12567**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1844**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Please call ([**Telephone/Fax (1) 2037**] to schedule an appointment with a cardiologist. You will probably need a stress test as an outpatient at some point in the future.

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icd9cm

[ [ [] ] ]

[ "38.97" ]

icd9pcs

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20960

Discharge summary

report

Admission Date: [**2108-10-10**] Discharge Date: [**2108-10-16**] Date of Birth: [**2042-8-4**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: [**2108-10-10**] Coronary artery bypass graft x3(Left internal mammary artery > left anterior descending, saphenous vein graft > posterior descending artery, saphenous vein graft > RPLB) History of Present Illness: 66 y/o male c/o chest pain with h/o CAD s/p multiple stents over several years. Underwent cath on [**9-14**] which revealed several vessel disease. Past Medical History: s/p Multiple PCI/stents, Hypertension, Elevated cholesterol, Chronic back pain s/p surgery, sleep apnea, skin cancer s/p removal Social History: Quit smoking 25yrs ago. Denies ETOH use. Family History: Brother with CAD and CABG in 50's Physical Exam: VS: 66 12 134/84 5'[**11**]" 218# Gen: WDWN male in NAD, uses cane Skin: W/d intact with mult. bruises bilat. arms and abd. HEENT: EOMI, PERRL, NCAT Neck: Supple, FROM, -JVD, -carotid bruit Chest: CTAB -w/r/r Heart: RRR -c/r/m/g Abd: Soft, NT/ND +BS Ext: Warm, well-perfused, 1+edema, superficial l thigh varicisities Neuro: A&O x 3, MAE, non-focal Pertinent Results: [**2108-10-10**] Echo: PRE-BYPASS: No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). There is a PFO with left to right shunt at rest Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. There is some calcification of right coronary cusp and non coronary cusp. There is mild aortic valve stenosis (area 1.5cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is no pericardial effusion. Post_Bypass: Preserved biventricular systolic function. LVEF 55%. Thoracic aortic contour is intact. Trivial MR. Mild AS. PFO. [**10-14**] CXR: Persistent linear atelectasis at the left base. No other acute findings. [**2108-10-10**] 01:32PM BLOOD WBC-13.5* RBC-3.76* Hgb-12.4*# Hct-35.8* MCV-95 MCH-32.9* MCHC-34.5 RDW-14.3 Plt Ct-187 [**2108-10-15**] 05:22AM BLOOD WBC-10.6 RBC-3.39* Hgb-10.9* Hct-31.8* MCV-94 MCH-32.1* MCHC-34.2 RDW-14.8 Plt Ct-231 [**2108-10-10**] 01:32PM BLOOD PT-13.1 PTT-32.9 INR(PT)-1.1 [**2108-10-16**] 06:50AM BLOOD PT-11.3 INR(PT)-1.0 [**2108-10-10**] 02:00PM BLOOD UreaN-25* Creat-0.9 Cl-107 HCO3-24 [**2108-10-15**] 05:22AM BLOOD Glucose-83 UreaN-37* Creat-1.0 Na-148* K-3.6 Cl-109* HCO3-33* AnGap-10 [**2108-10-15**] 05:22AM BLOOD Calcium-8.1* Phos-2.6* Mg-2.6 Brief Hospital Course: Mr. [**Known lastname 41238**] was a same day admit after undergoing all pre-operative work-up as an outpatient. On day of admission he was brought directly to the OR where he underwent a coronary artery bypass graft x 3. Please see operative report for surgical details. Following surgery he was transferred to the CSRU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. On post-op day one he was started on beta blocker and diuretics and gently diuresed towards his pre-op weight. Later on this day he was transferred to the SDU for further management. On post-op day two his chest tubes were removed. On post-op day three his epicardial pacing wires were removed and he was re-started on Plavix for previous stent placement. On this day his rhythm went into atrial fibrillation and he was started on Amiodarone. The following day his rhythm converted to sinus rhythm and remained in it through discharge. He worked with physical therapy for strength and mobility during post-op course. On post-op day six he appeared to be doing well and was discharge home with VNA services and the appropriate follow-up appointments. Medications on Admission: Aspirin, Lisinopril, Toprol XL, HCTZ, Crestor, Plavix, Isosorbide, Nitro prn, Darvocet, Ativan Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 4. Rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* 5. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks. Disp:*14 Tablet(s)* Refills:*0* 6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): please take 400mg twice a day for 7 days then decrease to 400mg daily for 7 days, then decrease to 200mg daily and follow up with Dr [**Last Name (STitle) 11250**] . Disp:*120 Tablet(s)* Refills:*0* 7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* 9. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO once a day for 2 weeks. Disp:*28 Capsule, Sustained Release(s)* Refills:*0* 10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 55719**] [**Hospital **] Home Health and Hospice Discharge Diagnosis: Coronary artery disease s/p Coronary Artery Bypass Graft PMH: Hypertension, Elevated cholesterol, Chronic back pain s/p surgery, sleep apnea, skin cancer s/p removal 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: Please call to schedule all appointments Dr. [**Last Name (STitle) 11250**] in [**1-31**] week [**Telephone/Fax (1) 11254**] Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**] Completed by:[**2108-10-16**]

[ "411.1", "427.31", "V45.82", "414.01", "424.1", "724.5", "780.57", "401.9", "272.0" ]

icd9cm

[ [ [] ] ]

[ "36.15", "36.13", "39.61" ]

icd9pcs

[ [ [] ] ]

5604, 5695

2865, 4070

333, 521

5904, 5910

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924, 959

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5716, 5883

4096, 4192

5934, 6398

974, 1324

283, 295

549, 698

720, 850

866, 908

23,469

172,927

25105

Discharge summary

report

Admission Date: [**2183-11-5**] Discharge Date: [**2184-1-12**] Date of Birth: [**2131-8-16**] Sex: M Service: LIVER TRANSPLANT SURGERY CHIEF COMPLAINT: End stage liver disease, encephalopathy. HISTORY OF PRESENT ILLNESS: A 52 year-old male with HCV cirrhosis, HIV, alcohol use, presenting with increased confusion and change in mental status. Patient had increasing confusion since [**2183-11-23**] with symptoms of fatigue and decreased energy. He had decreased function, was not performing activities of daily living well and had decreased appetite. Patient saw his primary care physician 1 week prior to admission. His ammonia level was checked as well as a chest x-ray. At that time the patient denied any fever, chills, urinary symptoms or abdominal pain. He did have a cough for approximately 1 week and was compliant with taking his lactulose 4x a day. Dr. [**Last Name (STitle) 497**] saw the patient in the liver clinic on the day of admission. At that time the patient was combative and agitated. He was transferred to the emergency department and admitted to the Intensive Care Unit for observation. In the emergency department an abdominal ultrasound was performed which was a suboptimal study secondary to agitation and movement. A small amount of fluid anterior to the liver was noted. Blood and urine cultures were sent off and patient was given lactulose with rifaximin. He was also given a dose of ceftriaxone and some Haldol. On admission patient was confused but cooperative. PAST MEDICAL HISTORY: HCV cirrhosis. He was diagnosed 15 years prior to admission and was never treated for this. Questionable history of diabetes. Past hospitalizations for encephalopathy. History of IV drug abuse. HIV diagnosed 14 years prior to admission on HAART therapy, in the past 5 to 6 year period off medications, recently restarted. Diabetes on insulin. Polysubstance abuse. Low back pain. Hypertension. Upper gastrointestinal bleed approximately a year ago. SOCIAL HISTORY: Lives with wife and 13 year-old son. Former alcohol counselor. IV drug abuse but quit 20 years prior to admission. Recent cocaine injection use approximately 4 to 5 months ago. Prior heavy alcohol use but none x 20 years ago. Smoked 2 packs per 20 years and quit approximately 13 years prior to admission. Originally from [**Male First Name (un) 1056**]. Currently not working. FAMILY HISTORY: No liver disease. PHYSICAL EXAMINATION: Temperature 98.8, heart rate 82, blood pressure blood pressure 139/99, respiratory rate 13, O2 saturation 96% on room air. Patient was pleasant in mild distress and agitation. Alert and oriented to the date. Head, eyes, ears, nose and throat: Pupils equal, round and reactive to light, scleral icteric, mucous membranes moist. Facial and cheek wasting. Neck: No jugular venous distension, no LAD. Lungs clear to auscultation bilaterally, slight bibasilar crackles. Heart: Regular rate and rhythm, tachycardia, S1, S2, no murmurs, regurgitation, gallop. Abdomen: Positive distention but soft, nontender, no rebound, no guarding, no flank dullness bilaterally. Liver edge not palpated. Neurologic: Positive asterixis. Skin: Jaundice, mild erythematous areas over anterior chest, no spider angiomas and palmar erythema. Rectal: Guaiac negative as per emergency department. Electrocardiogram on admission was normal sinus rhythm with a left axis, no change from prior electrocardiogram. Chest x- ray demonstrated minimal bibasilar atelectasis, no infiltrates. Abdominal ultrasound: Hepatopetal flow through the main portal vein. White count on admission 18.1, hematocrit 35.7, creatinine 0.9, BUN 11, potassium 4.9, lactate 2.3. mono 86. BRIEF HOSPITAL COURSE: The patient was admitted under the medical service. He was given lactulose and rifaximin. Hepatology was consulted and followed along throughout this course. He had a low sodium of 117. This was felt to be secondary to volume depletion. IV fluids were restricted. He underwent a diagnostic paracentesis on [**2183-11-3**]. He underwent liver transplant. The surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] assisted by Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] and Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]. Estimated blood loss was 6 liters. Please see operative report for further details. Postoperatively patient was maintained in the Surgical Intensive Care Unit. Liver function tests trended down. Baseline AST was 2,081. ALT 1723, alkaline phosphatase 67 with a total bilirubin of 2.6. This trended down on postoperative day 3 to AST of 448, ALT 1120, alkaline phosphatase 99, total bilirubin of 1.3. Duplex of the liver demonstrated patent portal vein and hepatic arteries. Postoperatively he was moving extremities and tracking with eyes. He was doing well. Liver function tests started to climb. He suffered an acute severe rejection of the liver transplant. He was relisted and received on [**11-15**] and ABO incompatible liver transplant. He underwent a second liver transplant on [**2183-11-17**]. The surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Indication was for hyperacute severe cellular rejection of first liver transplant. Biopsy of the explant demonstrated severe rejection. He had been treated with OKT3 plasmapheresis but steroids but despite those he continued to have allograft failure with fresh frozen plasma and cryo requirements. On [**11-16**] he was taken t the operating room for a second liver transplant. He received induction of immunosuppression again intraoperatively. Postoperatively he received Solu-Medrol with taper CellCept 1 gram b.i.d. Anti-A titers were followed and he received plasmapheresis, approximately 8 plasmapheresis treatments on alternating days. He received IVIG as well as OKT3 for a total of 8 treatments. Prograf was started on postoperative day 3 at 2 mg p.o. b.i.d. Prograf levels ranged between 4 to 10.7. Prograf was gradually increased to 7 mg b.i.d. Anti-A titers continued to 1 to 4. Absolute CD3 was 0. Vital signs were stable until postoperative day 3 when he spiked a temperature to 102. Blood and urine cultures were done. He was started on IV antibiotics, linezolid and meropenem. Blood and urine cultures were subsequently negative. Sputum culture demonstrated greater than 25 PMNs and greater than 10 epithelial cells. Gram stain indicated extensive contamination with upper respiratory secretions. Yeast was demonstrated. Patient underwent a bronchoscopy. This demonstrated Klebsiella that was pansensitive. He received linezolid and meropenem for a total of 14 days. On postoperative day 8 on [**11-23**] sputum cultures demonstrated gram negative rods and staph aureus coag positive moderate growth. An HIV viral load at this time was done and demonstrated 626 copies. White count ranged between 12.5 and 13.7. Hematocrit was fairly stable at 26 to 30. He did have 2 [**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 1662**] drain as well a nasogastric tube. Liver function tests trended down nicely to as AST of 20, ALT 51, alkaline phosphatase 115, total bilirubin of 0.9 and amylase of 47. Throughout this hospital course he was maintained on IV ganciclovir for CMV prophylaxis. The CMV viral load was negative. He also received IV Lasix to diurese the edema. Duplex ultrasound demonstrated the portal vein and hepatic artery. Chest x-ray demonstrated left lower lobe atelectasis. Postoperative day 3 the patient was still fairly sleepy and he underwent a head CT. Head CT demonstrated slight progression of prominence of petechial appearing hemorrhage within the left and right frontal regions, consistent with hemorrhagic products in the region of the prior infarct and continued sinus opacification in the setting of intubation. Head MRI was done that demonstrated no evidence of superior saggital sinus thrombosis. Bifrontal brain infarction near the vertex with adjacent small foci of parenchymal hemorrhage was noted. He was very sleepy. Neurology was consulted. An EEG was recommended. EEG demonstrated evidence for basically 2 electrophysiological states, 1 that seemed to be associated with the patient sleeping and that consists of suppressive bursts lasting up to 4 seconds in duration. The other was the background rhythm which was fairly well sustained in the beta range following vigorous stimulation. No focal or lateralized signs were noted. No seizure activity was seen but in comparison to the previous tracing that was done the second EEG was performed and slightly improved. Neurologically throughout this hospital course he gradually awakened after being transferred out of the Intensive Care Unit. He became agitated at times, restless and pulled out various tubes including his post pyloric feeding tube that had to be replaced various times. Psychiatry was consulted for management of what appeared to be metabolic encephalopathy. He received Haldol b.i.d., initially 1 mg b.i.d. and then 2 mg b.i.d. with improvement of agitation. It was recommended that the patient follow up with neurology for behavioral neurology, neuropsychiatry evaluation. During the Surgical Intensive Care Unit course the patient was intubated on respirator and it was difficult to wean the patient from the ventilator. He underwent tracheostomy on [**12-5**]. An open tracheostomy was performed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Please see operative report. Estimated blood loss was minimal. There were no complications. He was maintained on the ventilator. Gradually he was weaned from the ventilator and his tracheostomy was downsized. Subsequently the tracheostomy was removed on [**12-31**]. Tracheostomy site was covered with a dry dressing. He was evaluated by speech and swallow as his mental status started to clear and this demonstrated aspiration. A post pyloric feeding tube was placed and he was transitioned off of hyperalimentation and placed on post pyloric feeding tube nutrition using 3/4 strength Mepro at 60 cc per hour. He was able to tolerate this well. This provided 2160 K calories/76 grams of protein. His weight preoperatively was 72.9. This had trended down and has stabilized around 53 to 54 kilograms. He was evaluated by speech and swallow and had a video swallow that demonstrated silent aspiration with thin and clear fluid during the week of [**1-4**]. He was gradually advanced using honey thickened liquids with constant 1 to 1 with feeding for observation and he tolerated this well. The patient has been followed by physical therapy secondary to long prolonged hospital course. It was felt that he would benefit from rehabilitation. He was able to transfer with maximum assist to the chair. Physical therapy assessment included steady progress in all areas. Findings included balance moderate but assist required to attain and maintain weight. Gait was narrow, BOS, decreased WF to the left with mid stance, decreased step length on the right. Throughout the physical therapy session heart rate was steady at 70 to 74, respiratory rate 20, 99 to 120% on room air. He was able to ambulate left upper extremity of patient around the shoulder of the physical therapist. Needed maximum assistance to ambulate. Plan was to continue physical therapy at rehabilitation with 3 to 4 times a week sessions for therapeutic exercises, transfer, gait, and pulmonary monitoring. Hepatology followed throughout the hospital course making recommendations. Infectious disease followed along throughout the hospital course given management for HIV medications. Patient completed a 14 day course of Vancomycin for methicillin resistant Staphylococcus aureus tracheobronchitis. Vancomycin was stopped on [**2184-1-7**]. Patient was diagnosed with a Klebsiella urinary tract infection and received a 14 day course of meropenem. This finished on [**2184-1-6**]. Chest x-ray on [**12-30**] demonstrated left lower lobe atelectasis without any infiltrate. Given his HIV medications, his need for Prograf was diminished. Of note, the patient is on Protease inhibitors that affect the Prograf level. He was dosed with Prograf 0.25 mg for a total of 3 days on [**12-23**], [**12-24**] and [**12-25**]. This Prograf was then stopped until [**1-6**]. He maintained a Prograf level of 9.4 to up to 14.7 and then back down to 10.8. He received Prograf 0.5 mg on [**1-6**] and then Prograf was held and he has maintained the Prograf level in the range of 15.6 to 9.5 with the 9.5 being on [**1-12**]. He continued on CellCept [**Pager number **] mg t.i.d. This was decreased to b.i.d. on [**1-9**]. Solu- Medrol was tapered down to prednisone and was decreased at 10 mg p.o. q.d. Liver function tests remained stable with an AST of 32, ALT of 37, alkaline phosphatase of 286 and total bilirubin of 2.5. He underwent an ultrasound on [**1-1**] that demonstrated normal flow with hepatic and portal veins and arterial flow being normal. The liver biopsy on [**12-30**] was normal. No acute rejection. Creatinine increased during this hospital course to 2.9 and up as high as 4.6. His HIV medication doses were adjusted by infectious disease and his creatinine gradually decreased and returned to baseline of 1.2. Nephrology followed during this time making medication adjustments. Nutrition consult was obtained and patient was monitored by dietitian throughout the hospital course. Of note, on [**2184-1-11**] patient was able to take in approximately 590 calories with 12 grams of protein. He was continued on his tube feeding. Occupational therapy followed the patient. Occupational therapy was recommended at rehabilitation 1 to 5 times a week to address activities of daily living, mobility, and cognition. Patient was able to cooperate with occupational therapy intervention. As of this date on [**1-12**] the patient was doing well. He was alert, oriented to place. Rate was regular rhythm. Lungs were clear to auscultation. Tracheostomy site was covered by gauze. He was decannulated as previously mentioned. Abdomen was soft. Of note, the patient has a wound VAC at the upper portion of his chevron incision. This wound measures approximately 5-1/2 cm x 2 cm x 3 cm in the wound bed. There are visible blue sutures. The wound is filling in, is granulating. Wound VAC drains very small amount of serous fluid. Extremities: No edema. Vital signs: 98.1, 89, 195/68 to 131/72, respiratory rate 20, 97% on room air. Weight is 53 kilos. He is pleasant. He is able to verbalize his needs. Abdomen is soft. He does have loose stools. Stools were sent for C difficile and these were negative on [**12-2**], [**12-6**] and [**12-24**]. Patient was able to have his Foley removed and voided sufficiently. On [**1-9**] patient was noted to not have voided for approximately 6 hours. A bladder scan was done. This demonstrated a residual of approximately 700 cc. Patient was catheterized for 500 cc. Foley was left in place for 2 days. Foley was removed and patient was started on finasteride 5 mg p.o. q.d. He was able to void independently. Urine output is typically 2300 cc of urine. Patient was followed by [**Hospital **] Clinic for management of blood sugars. Blood sugars ranged from 79 to 225. NPH insulin 10 units q A.M. and q P.M. have helped maintain blood sugars in the low 100 range. He has received intermittent sliding scale regular insulin. On [**2184-1-2**] an HIV viral load demonstrated less than 50 copies per ml. On [**2184-1-12**] patient was ready for discharge to [**Hospital 13698**] Hospital. He was alert and oriented, conversant and appropriate. Haldol had been decreased to p.r.n. Psychiatry saw the patient on [**2184-1-9**] and recommended outpatient neuropsychiatric testing followed up by behavioral neurology. Of note, the patient required Haldol for delirium, agitation that had resolved and he did not receive any Haldol since converting from a b.i.d. dosing to p.r.n. dosing for the last 5 days. DISCHARGE DIAGNOSES: HIV hepatitis C virus cirrhosis. Insulin dependent diabetes mellitus. Hypertension. Depression. Bifrontal intraparenchymal hemorrhages. Abdominal incision wound infection requiring VAC. Adrenal insufficiency. Status post orthotopic liver transplant [**2183-11-7**] complicated by severe acute rejection, [**2183-11-17**] orthoptic liver transplant with an ABO incompatible liver. The patient underwent a splenectomy at that time. Klebsiella urinary tract infection. Methicillin resistant Staphylococcus aureus pneumonia. Malnutrition. Dysphagia with aspiration risk. Tracheostomy [**2184-1-5**]. DISCHARGE MEDICATIONS: CellCept 1 gram p.o. b.i.d., prednisone 10 mg p.o. q.d., linizudine 300 mg p.o. q.d., lopinavir-ritonavir 400-100 mg/5 ml solution, 5 ml p.o. b.i.d., tenofovir, disoproxil fumarate 300 mg tablets 1 tablet p.o. q.d., fluconazole 400 mg p.o. q.d., Bactrim single strength 1 p.o. q.d., Valsate 900 mg p.o. q.d., azithromycin 1200 mg p.o. q Friday for MAP prophylaxis, metoprolol 75 mg p.o. b.i.d., hold if heart rate less than or blood pressure less than 100, Florinef 0.1 mg tablet p.o. 3 x a week on Monday, Wednesday and Friday for hyperkalemia, finasteride 5 mg p.o. q.d., lansoprazole 30 mg delayed release 1 p.o. q.d., ursodiol 300 mg capsule p.o. t.i.d., Neupogen 4,000 units per ml 1 ml injection sc q Monday, Wednesday and Friday, heparin 5,000 units per ml 1 ml sc b.i.d., Percocet 5/325 mg 5 to 10 ml p.o. 4 to 6 hours p.r.n. as needed. Albuterol 90 mcg per actuation 1 to 2 puffs p.r.n. q 6 hours. Insulin NPH 10 units sc b.i.d. Regular insulin sliding scale per finger check q.i.d. Please see sliding scale. For blood sugar less than 60 give juice, preferably not [**Location (un) 2452**] juice given hyperkalemia. Patient should receive laboratory work every Monday and Thursday for CBC, chem-10, AST, ALT, alkaline phosphatase, total bilirubin, albumin and trough Prograf level with results faxed immediately to the [**Hospital1 190**] transplant office at [**Telephone/Fax (1) 697**]. The transplant surgeon will monitor Prograf level and right dose the Prograf dose p.r.n. Please do not adjust heart medication or Prograf level. Please contact transplant office for adjustments. Patient is scheduled to follow up with Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]. Please call to make arrangements for follow up visit in 1 week. Phone number is [**Telephone/Fax (1) 673**]. Please have the patient followed by neuropsychiatry for neuropsychiatric testing and behavioral neurology as well as social service, physical therapy, occupational therapy and nutrition. Please call. DISCHARGE INSTRUCTIONS: Include call for fever, chills, nausea or vomiting, inability to tolerate tube feedings or medications, any purulence, redness, bleeding from abdominal incision. Please obtain a repeat video swallow within the next 1 to 2 weeks to re-evaluate ability to swallow. DISCHARGE CONDITION: Stable. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 02-366 Dictated By:[**Name8 (MD) 4664**] MEDQUIST36 D: [**2184-1-12**] 13:45:02 T: [**2184-1-12**] 15:52:20 Job#: [**Job Number 62972**]

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icd9cm

[ [ [] ] ]

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icd9pcs

[ [ [] ] ]

3708, 16034

19035, 19264

2406, 2425

16056, 16653

16677, 18723

18748, 19013

2448, 3684

175, 217

246, 1521

1544, 1993

2010, 2389

60,207

164,814

54825

Discharge summary

report

Admission Date: [**2101-7-19**] Discharge Date: [**2101-7-25**] Date of Birth: [**2016-8-28**] Sex: F Service: NEUROLOGY Allergies: sulfamethizole / Levaquin / Penicillins / aspirin / Cephalosporins Attending:[**First Name3 (LF) 5018**] Chief Complaint: Weakness and neglect concerning for stroke Major Surgical or Invasive Procedure: None. History of Present Illness: Ms. [**Known lastname **] is an 84 year-old right-handed woman with past medical history significant for multiple strokes (most recently had right occipital stroke 1 week ago; placed on Aggrenox), and recent grand mal seizure (started on Keppra), Hypertension, Hyperlipidemia, Melanoma, and vascular dementia who was transferred from OSH for a right frontal intraparenchymal hemorrhage. She presented from the skilled nursing facility where she had been placed on [**2101-7-18**] after discharge from hospital admission 1 week prior for stroke/seizure. Per the patient's granddaughter, Ms. [**Known lastname **] had been at baseline with normal conversational interaction and no notable motor deficit in any extremities. On [**7-19**], the skilled nursing facility staff reported Ms. [**Known lastname **] was last normal at 0530 hours, but was found at 0615 hours to be unresponsive, with no witnessed seizure activity. Of note, the skilled nursing facility staff reported a bite on tongue and obtained vitals (T 100.8F, BP 136/96, P 140, R 18 O2 88% RA). Upon transfer to outside hospital, she was found to have a right frontal intraparenchymal hemorrhage, was intubated for airway protection, and transferred to [**Hospital1 18**] for further evaluation. Neurosurgical evaluation s/p a repeat non-contrast head CT (unchanged from her outside hospital non-contrast head CT) noted no surgical evaluation was warranted at this time. Neurology evaluation demonstrated left sided weakness without withdrawl from painful stimuli in either the upper or lower extremity. The patient was intubated but followed commands directed to right motor activity. Her granddaughter provided additional information regarding previous hospitalizations and the history of her current presentation. Prior to initially being hospitalized for seizure/stroke, she began making paraphasic errors (words out of sequence), followed by her right arm coming up to her head, then generalizing with convulsions and foaming at the mouth. The Outside hospital MRI per their discharge summary which had been obtained on [**7-15**] showed acute/subacute right occipital infarct, old left occipital infarct, and a possible old right frontal lobe stroke. She was continued on Aggrenox during that admission and started on Keppra as an anti-epileptic. Past Medical History: - Right occipital stroke in addition to 3 prior strokes per family - Seizure disorder (reportedly has history of disease, but was off meds for three years without any event) - Hyponatremia - Hypertension - Hyperlipidemia - Glucose intolerance - Vascular dementia (+/- Alzheimers) - Monoclonal Gammopathy of Unknown Significance - Thrombocytopenia (Chronic) - Melanoma (s/p excision, lymph node dissection in [**2087**]) - Hiatal hernia Social History: Not obtained at the time of presentation Family History: Non-contributory Physical Exam: Physical Exam on Admission: Vitals: Tc=98.4, Tmax=99.5, BP=122/39-144/49, HR=57-78, RR=16-18, O2: 97% RA General: Awake, Cooperative, NAD. HEENT: NC/AT Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Rhonchorous, no Rales/Wheezes Cardiac: RRR, no M/R/G Abdomen: S/NT/ND +BS Extremities: no edema, ecchymoses scattered throughout. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, awake, oriented only to self. Able to follow commands with repetitive stimulation in R extremities, but not in L. Language is fluent with intact repetition and comprehension. Slow prosody with short answers. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation on right, with persistent R gaze preference. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: Left facial droop, L blunting nasolabial fold VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. [**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB L 3 3 3 3 2 2 2 2 3 3 3 3 3 3 R 5 5 5 5 5 5 5 5 5 5 5 5 5 5 -Sensory: No deficits to light touch, pinprick, cold sensation, vibratory sense, proprioception throughout. No extinction to DSS. -DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 2 2 3 2 1 R 2 2 2 2 1 Plantar response was upgoing on left, equivocal on right. -Coordination: Did not assess -Gait: Did not assess Physical Exam on Discharge: Neurologic: -Mental Status: Alert, awake, oriented only to self and hospital. Improved global perseveration (language and motor) Able to follow commands both extremities R more than left. Language is fluent with intact repetition and comprehension. Slow prosody with short answers. Unable to name months of the year backwards. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB L 5 5 5 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 5 5 5 -Sensory: No deficits to light touch -Coordination: Able to finger face finger grossly bilaterally -Gait: Did not assess Pertinent Results: SELECTED ADMISSION LABS: [**2101-7-19**] 01:40PM BLOOD PT-11.6 PTT-29.1 INR(PT)-1.1 [**2101-7-19**] 01:40PM BLOOD WBC-13.1* RBC-5.28 Hgb-14.8 Hct-44.6 MCV-85 MCH-28.0 MCHC-33.1 RDW-15.5 Plt Ct-151 [**2101-7-19**] 01:40PM BLOOD Glucose-135* UreaN-15 Creat-1.0 Na-130* K-4.5 Cl-98 HCO3-17* AnGap-20 [**2101-7-19**] 01:40PM BLOOD ALT-12 AST-36 AlkPhos-92 TotBili-0.3 [**2101-7-19**] 01:40PM BLOOD Albumin-3.6 Calcium-9.0 Phos-3.6 Mg-1.9 [**2101-7-19**] 01:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2101-7-19**] 01:43PM BLOOD Lactate-1.6 [**2101-7-19**] 03:56PM BLOOD Type-ART Rates-/14 Tidal V-450 PEEP-5 FiO2-50 pO2-186* pCO2-32* pH-7.49* calTCO2-25 Base XS-2 -ASSIST/CON Intubat-INTUBATED Relevant Labs: [**2101-7-22**] 06:10AM BLOOD Ret Aut-1.2 [**2101-7-20**] 10:18PM BLOOD CK-MB-4 cTropnT-0.06* [**2101-7-20**] 09:34AM BLOOD CK-MB-6 cTropnT-0.07* [**2101-7-20**] 03:10AM BLOOD cTropnT-0.07* [**2101-7-22**] 06:10AM BLOOD calTIBC-166* Hapto-171 TRF-128* [**2101-7-22**] 06:10AM BLOOD %HbA1c-5.9 eAG-123 [**2101-7-22**] 06:10AM BLOOD Triglyc-64 HDL-50 CHOL/HD-2.1 LDLcalc-43 Microbiology: [**2101-7-19**] 8:50 pm URINE **FINAL REPORT [**2101-7-21**]** URINE CULTURE (Final [**2101-7-21**]): CITROBACTER KOSERI. >100,000 ORGANISMS/ML.. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ CITROBACTER KOSERI | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 32 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Blood culture [**7-19**]: no growth SELECTED IMAGING STUDIES: - PORTABLE CHEST: [**2101-7-19**], IMPRESSION: Endotracheal tube tip 3.5 cm from the carina. No definite acute cardiopulmonary process. - CT HEAD W/O CONTRAST: [**2101-7-19**], IMPRESSION: Unchanged 4.5 x 3.1 cm right frontal intraparenchymal hemorrhage and intraventricular hemorrhage. - PORTABLE HEAD CT W/O CONTRAST: [**2101-7-20**], IMPRESSION: Interval decrease in size of right frontal intraparenchymal hemorrhage with no change in surrounding edema or midline shift. - MR HEAD W/ CONTRAST; MRA BRAIN W/O CONTRAST; MRV HEAD W/O CONTRAST; MRA NECK W&W/O CONTRAST: [**2101-7-20**], IMPRESSION: 1. Large intraparenchymal hemorrhage in the right frontal lobe with associated vasogenic edema. Hemorrhagic infarction is felt unlikely, as the overlying cortex is intact. Likely etiologies of this findings likely represent hypertensive hemorrhage or amyloid angiopathy. An underlying AV malformation, which is tamponaded by the overlying hemorrhages is also a differential consideration. 2. Multifocal stenoses of the intracranial vessels likely reflect atherosclerotic disease, however, inflammatory causes are also considered. It is unlikely to represent hemorrhage-related vasospasm due to distribution. 3. Cervical vessels demonstrate no stenosis. Labs on Discharge: [**2101-7-25**] 07:10AM BLOOD WBC-4.0 RBC-3.46* Hgb-9.6* Hct-29.3* MCV-85 MCH-27.6 MCHC-32.6 RDW-16.6* Plt Ct-250 [**2101-7-25**] 07:10AM BLOOD Glucose-103* UreaN-5* Creat-0.6 Na-140 K-3.3 Cl-111* HCO3-22 AnGap-10 [**2101-7-25**] 07:10AM BLOOD Calcium-7.7* Phos-2.8 Mg-1.7 Brief Hospital Course: Ms. [**Known lastname **] is an 84 year-old right-handed woman with past history significant for multiple strokes, grand mal seizure, HTN, HL, and vascular dementia who was transferred from OSH with new right frontal intraparenchymal hemorrhage. # Neuro: Ms. [**Known lastname **] presented from her skilled nursing facility, where she had been placed upon discharge for her previous right occipital stroke hospitalization on [**7-18**], with unresponsiveness, not moving her left side, and with a tongue bite. Upon transfer to the outside hospital, she was found to have a right frontal IPH, was intubated for airway protection, and transferred to [**Hospital1 18**] for further evaluation. In the ED, the patient was found to be responsive to commands on the right side with good strength in her upper and lower extremity; however, she had no antigravity left extremity movement and of note, had a right gaze preference without crossing the midline. She had two non-contrast head CT imaging studies for comparison, one performed at the outside hospital initially presented to from her skilled nursing facility and two studies performed at [**Hospital1 18**] which redemonstrated the 3.1 x 4.5 cm right frontal intraparenchymal hemorrhage with surrounding vasogenic edema that causes minimal shift of the anterior falx towards the left approximately 3 mm with effacement of the adjacent sulci. This studies were not significantly changed from each other. Ms. [**Known lastname **] was brought to the ICU for further monitoring given her intubation and ventilator dependant respiratory failure. Due to her recent hospitalization for seizures and questionable presence of a seizure leading to being found down by her skilled nursing facility, her Keppra dosage was increased from 500mg twice a day to 750mg twice a day. On repeat evaluation in the ICU, the patient was seen to have decreased responsiveness to commands, but was moving her left lower extremity more spontaneously, more evident distally. On [**2101-7-20**], the patient was extubated after passing her spontaneous breathing trial. She was awake, and oriented only to self. She was able to follow basic commands including squeezing hands with the right upper extremity, lift her right lower extremity, and lift also her left lower extremity with much effort. She progressed in terms of strength and comprehension over the next 24 hours and was able to grasp fingers with either hand, as well as demonstrate anti-gravity strength in both upper extremities. She remained oriented only to self during this time. Over the next few days she continued to immproved so that upon discharge on *** she was oriented to self and location, she was able to follow commands, she was fluent with good repitition, was poorly innattentive in that she could not do the months of the year backwards, her strength improved to [**5-14**] bilaterally throughout. She passed her swallow study [**2101-7-23**] and was tolerating PO intake. From an anticoagulation perspective, her Aggrenox was held due to her hemmorhage. However, on [**7-25**] her aspirin of 325mg was restarted as head CT was stable. On [**7-22**] subcut heparin DVT prophylaxis was started. Of note, on imaging, she had a right frontoparietal lesion which was most likely ischemic stroke, but somewhat concerning for mass lesion. She will have a repeat MRI 6 weeks after discharge to assess for interval change. She will f/u with Dr. [**Last Name (STitle) **] in stroke clinic. # Cardiac: On presentation, patient was allowed to autoregulate blood pressure if systolic blood pressure remained below 160 mmHg with Nicardipine IV for any elevated blood pressure. In the ICU, the Nicardipine was changed to by mouth antihypertensives which continued maintaining the patient in the desired blood pressure range. On the floor she was started on lisinopril of 20mg daily to control her BP. Continued her home Norvasc. Her LDL was found to be 43 and she was started on her simvistatin 10mg daily. Her troponins peaked at 0.06. # ID: While in the ICU, blood and urine cultures for Ms. [**Known lastname **] were obtained with the latter coming back positive for a urinary tract infection. Given the patients allergies, 2 doses of Fosfomycin was administered. She will need 1 more dose to complete full course of treatment for complicated UTI. Of note, an outside hospital blood culture from [**7-11**] grew GNR in 1 of 2 samples as well as strep viridans. The strep viridans was thought to be a contaminant. The GNRs were not able to be speciated at [**Hospital3 **] and were sent to a reference lab. Results not availabe at time of discharge. VERY low suspicion for bacteremia as multiple repeat blood cultures were negative. # Endocrine: Fingerstick glucose checks were performed on a regular basis to ensure Ms. [**Known lastname **] remained euglycemic. Any elevation was treated with insulin based on hospital protocol sliding scale. Her HgBA1c was noted to be 5.9 # GI: Ms. [**Known lastname **] experienced no gastrointestinal complaints during her inpatient stay. She was prophylaxed with a H2-Blocker in accordance with protocol. After extubation, given her orientation only to self, there was concern for aspiration with by mouth feeding. The patient had a nasogastric tube placed, which was repositioned due to questionable confirmatory imaging complicated by her known hiatal hernia. The patient pulled out her NG tube on [**7-23**], but she plassed her swallow study and was started on PO nutrition. # Heme: Ms. [**Known lastname **] was found to have a hemoglobin drop, in part due to hemodilutional effect of providing IV fluids and also because she was tranfused with blood products shortly before transfer to [**Hospital1 18**], thus, admission hct was above her baseline. Anemia labs were ordered for the patient which revealed low Fe & TIBC, TF. retics inapprop low; low TIBC which is c/w Anemia of chronic disease. No ferritin was sent. TRANSITIONS OF CARE: -will need 1 dose of Fosfomycin 3g to complete treatment for UTI -will have MRI w/ and w/o contrast of the brain to assess for interval change -will f/u with Dr. [**Last Name (STitle) **] in stroke clinic -pt with questionable allergy to aspirin, will need to be monitored (LOW suspicion for allergy as was on aggrenox and tolerated) 1. Dysphagia screening before any PO intake? (x) Yes - () No 2. DVT Prophylaxis administered? (x) Yes - () No 3. Antithrombotic therapy administered by end of hospital day 2? (x) Yes - () No 4. LDL documented? (x) Yes (LDL =43 ) - () No 5. Intensive statin therapy administered? (for LDL > 100) () Yes - (x) No (if LDL >100, Reason Not Given: ) 6. Smoking cessation counseling given? () Yes - (x) No (Reason (x) non-smoker - () unable to participate) 7. Stroke education given? (x) Yes - () No 8. Assessment for rehabilitation? (x) Yes - () No 9. Discharged on statin therapy? (x) Yes - () No (if LDL >100, Reason Not Given: ) 10. Discharged on antithrombotic therapy? (x) Yes (Type: (x) Antiplatelet - () Anticoagulation) - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? () Yes - () No - (x) N/A Medications on Admission: -Aggrenox by mouth twice a day -Keppra 500mg by mouth twice a day (to be increased to 750 mg [**Hospital1 **] in 2 weeks) -Norvasc 5mg by mouth daily -Zocor 40mg by mouth each evening -Celexa 20mg by mouth daily -Aricept 5mg by mouth daily -Doxycycline 1000mg by mouth twice a day (to be completed [**2101-7-21**]) Discharge Medications: 1. Amlodipine 5 mg PO DAILY 2. Citalopram 20 mg PO DAILY 3. Donepezil 5 mg PO HS 4. Fosfomycin Tromethamine 3 g PO ONCE Duration: 1 Doses Dissolve in [**3-13**] oz (90-120 mL) water and take immediately; please administer on [**7-26**] 5. LeVETiracetam 750 mg PO BID 6. Lisinopril 20 mg PO DAILY 7. Nystatin Oral Suspension 5 mL PO QID 8. Simvastatin 10 mg PO DAILY 9. Aspirin 325 mg PO DAILY Discharge Disposition: Extended Care Facility: [**Location (un) 1459**] Care and Rehabilitation Center Discharge Diagnosis: right frontal parenchymal hemorrhage Discharge Condition: Neurologic: -Mental Status: Alert, awake, oriented only to self and hospital. Improved global perseveration (language and motor) Able to follow commands both extremities R more than left. Language is fluent with intact repetition and comprehension. Slow prosody with short answers. Unable to name months of the year backwards. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB L 5 5 5 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 5 5 5 -Sensory: No deficits to light touch -Coordination: Able to finger face finger grossly bilaterally -Gait: Did not assess Discharge Instructions: Dear Ms. [**Known lastname **], You were transferred to the [**Hospital3 **] Medical Center from [**Hospital3 2783**] with a small bleed in your brain. We monitored you carefully and you did well. Gradually, your symptoms improved. We have made the following changes to your medications: STOP Aggrenox Zocor Doxycycline INCREASE Keppra to 750mg twice per day START Lisinopril 20mg daily Simvastatin 10mg daily Nystatin oral suspension 4 times per day as needed for mild thrush Fosfomycin 3g for 1 dose on [**7-26**] You have been schedule to follow up with your stroke neurologist, Dr. [**Last Name (STitle) **] on in the [**Hospital 23**] clinic on the [**Location (un) **] of [**Hospital1 18**] [**Hospital Ward Name 516**] as scheduled below. On the same day of your appointment with Dr. [**Last Name (STitle) **] you are scheduled for an MRI of your head. It was a pleasure taking care of you, we wish you all the best! Followup Instructions: Department: RADIOLOGY When: MONDAY [**2101-9-26**] at 8:35 AM With: XMR [**Telephone/Fax (1) 590**] Building: CC [**Location (un) 591**] [**Hospital 1422**] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: NEUROLOGY When: MONDAY [**2101-9-26**] at 1:30 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 [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**] Completed by:[**2101-7-25**]

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icd9cm

[ [ [] ] ]

[ "96.71", "96.6", "38.91" ]

icd9pcs

[ [ [] ] ]

17847, 17929

9870, 15864

371, 378

18010, 18023

6001, 6010

19809, 20529

3264, 3282

17429, 17824

17950, 17989

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3952, 5135

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6026, 8270

3325, 3702

18038, 18829

15885, 17063

2753, 3190

3206, 3248

8287, 9552

3,575

175,797

46147

Discharge summary

report

Admission Date: [**2129-6-22**] Discharge Date: [**2129-6-23**] Date of Birth: [**2072-5-1**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 8404**] Chief Complaint: CC: Low Blood Pressure Major Surgical or Invasive Procedure: None. History of Present Illness: 57 y.o. Female with HCV cirrhosis, ESRD on HD s/p failed renal transplant, seizure, HTN, recently dx ovarian mass, hypothyroidism s/p thyroidectomy referred to the ED from HD for hypotension. Admitted to ICU for hypotension. . Ms. [**Known lastname 3671**] states over the past few days she has noted intermittent episodes of lightheadedness particularly orthostasis symptoms, she denies any episodes of syncope. She was in dialysis today with a reported (per pt) systolic BP 108 laying down and mid 90s sitting she thinks she fell asleep during dialysis. She woke up at the end of dialysis and not her dialysis run was finished, the HD RNs were also next to her telling her her BP was low. Per report from the ED her BPs in dialysis were in ther 70s after her run, she was given 1L of NS with no improvement with her BPs which is why she was referred to the ED. She denies any consitutional symptoms such as nausea, vomiting, fevers, chills. She does endorse a 5 day history of sore throat, rhinorrhea which has now improved. She has also had a dry cough x 3 days. She denies any SOB or DOE. She states that she has been under a lot of stress over the passt few days, she lives at home with her sister who is 'unstable' and lead to them having to move out. She has been trying to move out of her place for the past few days. Due to the stress she states she is not eating or drinking as much but denies feeling dehydrated. . In the ED initial VS were noted to be T97.8, HR 87, BP 102/47, RR 16, Sat 96% RA. In the room however she was noted to be '[**Name6 (MD) 98153**] [**Name8 (MD) **] RN note and triggered for a BP 78/47, HR 82, RR 12, Sat 100% on RA. Per ED signout pt was noted to have foggy thinking but no evidence of chest pain, lightheadedness. Given the level of hypotension which trended down to systolic of 69 a rt femoral line was placed. Pt was given 1gm of Vancomycin, 2L NS with a BP improvement to 89-93 systolic. An EKG showed SR 74 bpm, STD V3-V4, TWI V3-V6. Pt received and additional 2 L of NS in the ED with BPs remaining 92/48, BP improved to 92/48 after 2 more litres of NS her BP was noted to be 101. In total pt received 1L NS at HD and an extra 4L NS in the ED. . CXR in the ED showed linear scarring in lung bases that was unchanged from priors. His initial labwork was notable for WBC 5.9, Hgb/Hct 12.1/35.4, plt 146. chem panel was notable for K of 6.2, BUN/Cr 13/3.3. Repear K was then 3.6 and then 2.9, lactate 1.7. Pt also 750mg Levofloxacin in addition to Vancomycin for empiric coverage. . Of note she has been admitted twice over the past 2 months for hypotension pre and post dialysis. Her first admission was [**2129-4-23**] and was thought to be [**2-16**] aggressive BP regimen as well as the pt inappropriately taking her medications. She was taking nitroglycerin every day as opposed to PRN. She was also noted to be hypothyroid, likely not adherent to her snythroid medication. She was ruled out for adrenal insufficiency. Outpt Nephrologist reports dry weight as 74kg. On [**5-12**] she was referred to the ED for abdominal pain and triggered in the ED for a BP in the 70s. Again her hypotension was easily corrected with fluid and thought to be [**2-16**] BP regimen. Past Medical History: -HTN -ESRD on hemodialysis -HCV cirrhosis -spinal stenosis with back pain -seizure disorder -depression -hypothyroidism -substance abuse -Lumbar laminectomy -status post failed renal transplant -cholecystectomy -thyroidectomy -Rt ovarian mass Social History: Retired special education teacher. Widowed, lives at home with sister, who is primary caregiver. [**Name (NI) **] one son, who is healthy. # Tobacco: 3 packs per week since teenager # Alcohol: Denies # Drugs: Past IVDU, but not in several years Family History: Father: ESRD and hypertension Mother: lung cancer Physical Exam: GEN: African American Female laying down in bed tearful, comfortable, NAD HEENT: PERRL, EOMI, anicteric, mildly dry MM Neck: No thyroid palpated, no cervical LAD RESP: Bibasilar inspiratory crackles otherwise CTA CV: S1, S2, II/VI murmur referred from the graft ABD: Soft, mild tenderness over RLQ, tympanetic to percussion, old surgical scars noted midline EXT: No edema, no asterixis. Left arm fistula +bruits/+thrills SKIN: no rashes/no jaundice/dry skin NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. Pertinent Results: [**2129-6-22**] 11:20PM SODIUM-142 POTASSIUM-4.6 CHLORIDE-106 [**2129-6-22**] 11:20PM CK(CPK)-59 [**2129-6-22**] 11:20PM CK-MB-3 cTropnT-0.05* [**2129-6-22**] 07:01PM PT-16.4* PTT-28.1 INR(PT)-1.4* [**2129-6-22**] 05:58PM LACTATE-1.7 [**2129-6-22**] 05:52PM GLUCOSE-109* UREA N-10 CREAT-3.0* SODIUM-144 POTASSIUM-2.9* CHLORIDE-106 TOTAL CO2-28 ANION GAP-13 [**2129-6-22**] 05:52PM TSH-0.45 [**2129-6-22**] 05:04PM GLUCOSE-130* K+-3.6 [**2129-6-22**] 05:00PM GLUCOSE-130* UREA N-13 CREAT-3.3*# SODIUM-137 POTASSIUM-6.2* CHLORIDE-95* TOTAL CO2-31 ANION GAP-17 [**2129-6-22**] 05:00PM estGFR-Using this [**2129-6-22**] 05:00PM WBC-5.9 RBC-3.86* HGB-12.1 HCT-35.4* MCV-92 MCH-31.4 MCHC-34.3 RDW-17.0* [**2129-6-22**] 05:00PM NEUTS-66.4 LYMPHS-24.6 MONOS-5.9 EOS-2.6 BASOS-0.5 [**2129-6-22**] 05:00PM PLT COUNT-146* CXR [**2129-6-22**]: Stable scarring of bilateral lower lungs. No acute process. EKG [**2129-6-22**]: Sinus rhythm. Extensive ST-T wave changes are non-specific although cannot exclude myocardial ischemia. Compared to the previous tracing of [**2129-5-20**] the ST-T wave changes are slightly more prominent in the precordial leads. The other findings are similar. EKG [**2129-6-23**]: Sinus rhythm. Non-specific inferior and anterior T wave changes. Cannot exclude ischemia. Compared to the previous tracing of [**2129-6-22**] no diagnostic interim change. TTE [**2129-6-23**]: The left atrium is elongated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Normal left ventricular cavity size and wall thickness with preserved global and regional biventricular systolic function. No clinically significant valvular regurgitation or stenosis. Normal pulmonary artery systolic pressure. Compared with the prior study (images reviewed) of [**2128-2-20**], mild mitral regurgitation is no longer present and the pulmonary artery systolic pressure has normalized. Brief Hospital Course: 57 y.o. Female with a history of HTN, HCV cirrhosis, ESRD on HD s/p failed renal transplant, seizure d.o., depression, hypothyroidism, substance abuse referred to the ED for hypotension at dialysis. Admitted to the ICU for hypotension. . # Hypotension: Pt admitted with systolic BPs in the 70s with improvement to 100s after 5L of NS. On review of Ms. [**Known lastname 21913**] history in OMR this is the 3rd time she has presented to the ED with BPs in the mid 70s requiring ICU care. On review of the discharge summaries, her prior work ups have included infectious (with neg cx), adrenal insufficiency ([**4-/2129**] [**Last Name (un) 104**] stim to 32.1 from 7.8). She has been noted to have TSH >100 and 5.6 in the past; however most recent TSH was improved. There concerns that this may be medication-related given she is taking multiple medications for pain which may cause hypotension, but the patient reports compliance with her medication regimen. During this admission, the patient's episode occurred during HD and she was given fluid back which was initially removed but still became hypotensive to the 70's following HD. It is believed that the fluid shifts and hypoveolemia [**2-16**] dialysis. She endorsed decreased PO intake, orthostatic symptoms and her BP and symptoms improved with IVF. She was placed on Levo/Vanc to cover for possible HAP vs CAP initially, but antibiotics were subsequently discontinued as she had no infectious symptoms, was afebrile, and had no leukocytosis. Renal felt her hypotension was again related to overuse of pain medications, and the patient was informed the that strict medication compliance is essential. Her blood pressures remained stable in the MICU back at her baseline and she was discharged the following day. . # EKG Changes/CAD: Pt had acute on chronic non-specific ST changes on EKG in the ED. She denied any chest pain or tightness and her prior cath in [**2128-12-15**] showed non obstructive CAD. Repeat EKG was unchanged, CE's were negative, and the patient underwent a TTE which showed no wall motion abnormalities. She was continued on ASA 81mg, Simvastatin and was closely monitored without incident. . # Hypokalemia: Unclear as to the etiology, pt had dialysis but her K bath is unlikely to have been as low as 2.9. The pt received K in the ED, and her K+ was rechecked. . # Hypothyroidism: Continued levothyroxine 188mcg. TSH was wnl. . # ESRD on HD: Will notify renal of admission, continue on home regimen of Calcium Acetate . # HCV Cirrhosis: Last liver bx [**2121**] grade 1 fibrosis. No evidence of asterixis, hepatic decompensation on examination. Pt has underlying mild coagulopathy with INR 1.4-1.5, thought [**2-16**] depressed hepatic synthetic function. . # Thrombocytopenia: Pt has chronic thrombocytopenia likely [**2-16**] cirrhosis, splenomegaly. . # Seizure Disorder: Continued on Keppra 250 mg [**Hospital1 **]. . # Depression/Anxiety: Continued on fluoxetine 60 mg daily. . # Rt Ovarian Mass: Pt recently diagnosed with rt ovarian mass which was thought to be benign, pt on Dilaudid PRN for RLQ pain. Home Dilaudid PRN was continued. . # Methadone: Called Habit OpCo and confirmed Methadone dose was 54mg daily, and she was given a dose at 2pm the day of discharge. Unclear if this is for her IVDU history vs chronic pain. Was contact[**Name (NI) **] by the [**Hospital 228**] [**Hospital 2514**] Clinic following her discharge and informed them of the hospital course. . ## Code status: FULL CODE Medications on Admission: 1. Levetiracetam 250 mg [**Hospital1 **] 2. Fluticasone-salmeterol 250-50 mcg/dose INH [**Hospital1 **] 3. Gabapentin 300 mg qHD 4. Clonazepam 0.5 mg [**Hospital1 **] PRN 5. Methadone 44mg daily 6. Fluoxetine 60 mg daily 7. ASA 81 mg daily 8. Simvastatin 20 mg daily 9. Omeprazole 20 mg daily 10. Folic acid 1 mg daily 11. Trazodone 50 mg qHS PRN 12. B complex-vitamin C-folic acid 1 mg Daily 13. Calcium acetate 667 mg 2 Capsule TID W/MEALS 14. Levothyroxine 188 mcg daily 15. calcium carbonate 200 mg calcium (500 mg) PO BID 17. Vitamin D 1,000 unit daily 18. Hydromorphone 4-8 mg q4hrs PRN Discharge Medications: 1. methadone 10 mg/5 mL Solution Sig: Fifty Four (54) mg PO DAILY (Daily). 2. levetiracetam 250 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: [**1-16**] Disk with Devices Inhalation [**Hospital1 **] (2 times a day). 4. gabapentin 300 mg Capsule Sig: One (1) Capsule PO QHD (each hemodialysis). 5. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as needed for anxiety. 6. fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily). 7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 10. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 12. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Capsule PO once a day. 13. calcium acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 14. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily): Total of 188mcg daily. 15. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO once a day: Total of 188mcg daily. 16. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 17. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 18. hydromorphone 2 mg Tablet Sig: 2-4 Tablets PO every four (4) hours as needed for pain. Discharge Disposition: Home Discharge Diagnosis: Hypotension (low blood pressure) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Discharge Instructions: You presented to the hospital for low blood pressures during your hemodialysis sessions. Your electrocardiogram tracings of your heart rhythm showed changes which were concerning for insufficient blood supply to your heart when your blood pressures were low. You underwent an echocardiogram which did not show any concerning abnormalities, and a repeat electrocardiogram showed improvement of the abnormalities in the setting of improved blood pressures. Your low blood pressures may be due to decreased fluid content in your body following dialysis, or from some of your medications. You were seen by the kidney specialists in the ICU and you will resume dialysis according to your usual schedule when you leave the hospital. No changes were made to your home medications. Please discuss your medications, particularly your pain medications, with your primary care physician to determine whether they may be causing low blood pressure. Followup Instructions: Department: ENDO SUITES When: FRIDAY [**2129-7-1**] at 3:00 PM Department: DIGESTIVE DISEASE CENTER When: FRIDAY [**2129-7-1**] at 3:00 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],MD [**Telephone/Fax (1) 463**] Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3202**] Campus: EAST Best Parking: Main Garage Department: ADVANCED VASC. CARE CNT When: TUESDAY [**2129-9-6**] at 2:00 PM With: [**Name6 (MD) 5536**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 5537**] Building: [**Street Address(2) 7298**] ([**Location (un) 583**], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: Free Parking on Site [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 8405**]

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Discharge summary

report

Admission Date: [**2100-12-21**] Discharge Date: [**2101-1-2**] Date of Birth: [**2030-1-26**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 2969**] Chief Complaint: Lung mass Major Surgical or Invasive Procedure: 1. Bronchoscopy. 2. Reoperative right thoracotomy with right upper lobectomy and en bloc right chest wall resection (ribs 3,4 and 5) with [**Doctor Last Name 4726**]-Tex chest wall reconstruction and decortication of right middle and right lower lobes History of Present Illness: Mr. [**Known lastname 75713**] was initially evaluated for resectability of a locally-advanced right lung cancer. The patient has a 60-pack-year smoking history and has a complex history for a right-sided lung mass beginning back in 04/[**2100**]. At that time, he appeared to have a right chest abnormality which on fiberoptic bronchoscopy was cytologically positive for malignancy. He underwent cervical and anterior mediastinoscopy that did not show any involvement of the mediastinal lymph nodes followed by a thoracoscopy and subsequent exploratory thoracotomy which defined a chest wall invasive lesion felt to be T3 if not, T4 because I presume a diffuse pleural involvement. He was deemed unresectable and then begun on chemotherapy, which has consisted of a weekly carboplatin and Taxol with Avastin under the care of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at the Cancer Center of [**Location (un) 86**]. He now presents for resection of localy advanced tumor. Past Medical History: Significant for a traumatic blindness in the left eye, hypertension, appendectomy, and alcohol-induced gastric ulcers. He has been alcohol-free for almost two decades. Social History: Quit smoking 18 years ago. No alcohol x 20 years. Family History: Notable for cerebral hemorrhage. His father had lung cancer. He had a brother with gastric cancer and another brother with emphysema and a sister with cystic fibrosis. Physical Exam: HEENT: Ocular deformity on the left where he is blind . Anicteric sclerae. NECK: He has no adenopathy in the neck region or supraclavicular fossa. LUNGS: Decreased/coarse breathsounds right lung with soft crackles. Incisions clean, dry, intact. Some resolving ecchymoses. No hematoma. HEART: Regular rhythm and rate. ABDOMEN: Soft and nontender with normal bowel sounds. EXTREMITIES: He has trace peripheral edema. Pertinent Results: [**2101-1-2**] 05:30AM BLOOD WBC-9.1 RBC-2.96* Hgb-9.2* Hct-28.1* MCV-95 MCH-31.0 MCHC-32.7 RDW-18.1* Plt Ct-511* [**2101-1-1**] 10:25AM BLOOD WBC-10.3 RBC-3.13* Hgb-9.5* Hct-29.5* MCV-94 MCH-30.2 MCHC-32.1 RDW-17.0* Plt Ct-452* [**2100-12-22**] 11:53AM BLOOD WBC-8.8 RBC-3.41* Hgb-10.8* Hct-33.2* MCV-97 MCH-31.6 MCHC-32.5 RDW-20.1* Plt Ct-420 [**2100-12-21**] 04:08PM BLOOD WBC-6.6 RBC-3.77*# Hgb-12.0*# Hct-36.2*# MCV-96 MCH-31.9 MCHC-33.2 RDW-19.8* Plt Ct-381# [**2101-1-2**] 05:30AM BLOOD Plt Ct-511* [**2101-1-1**] 10:25AM BLOOD Plt Ct-452* [**2100-12-21**] 04:08PM BLOOD Plt Ct-381# [**2100-12-21**] 04:08PM BLOOD PT-13.4 PTT-28.0 INR(PT)-1.1 [**2100-12-31**] 08:50AM BLOOD Glucose-171* UreaN-28* Creat-1.4* Na-140 K-4.0 Cl-107 HCO3-26 AnGap-11 [**2100-12-30**] 07:00AM BLOOD Glucose-97 UreaN-32* Creat-1.4* Na-141 K-4.4 Cl-107 HCO3-26 AnGap-12 [**2100-12-22**] 11:53AM BLOOD Glucose-191* UreaN-37* Creat-2.3* Na-137 K-4.3 Cl-102 HCO3-25 AnGap-14 [**2100-12-21**] 04:08PM BLOOD Glucose-120* UreaN-28* Creat-1.5* Na-140 K-4.2 Cl-105 HCO3-27 AnGap-12 [**2100-12-30**] 07:00AM BLOOD Calcium-8.4 Phos-3.9 Mg-2.0 [**2100-12-22**] 11:53AM BLOOD Calcium-7.9* Phos-4.6* Mg-2.4 [**2100-12-21**] 04:08PM BLOOD Calcium-9.0 Phos-5.0* Mg-1.3* [**2100-12-21**] 02:53PM BLOOD Type-ART pO2-183* pCO2-34* pH-7.45 calTCO2-24 Base XS-0 [**2100-12-21**] 02:53PM BLOOD Glucose-95 Lactate-1.1 Na-139 K-3.1* Cl-106 [**2100-12-21**] 12:36PM BLOOD Glucose-113* Lactate-1.3 Na-139 K-3.7 Cl-98* calHCO3-3012/22/07 1:05 pm BRONCHIAL WASHINGS **FINAL REPORT [**2100-12-27**]** GRAM STAIN (Final [**2100-12-25**]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 3+ (5-10 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final [**2100-12-27**]): 10,000-100,000 ORGANISMS/ML. OROPHARYNGEAL FLORA. SERRATIA MARCESCENS. >100,000 ORGANISMS/ML.. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ SERRATIA MARCESCENS | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S RADIOLOGY Final Report CT CHEST W/O CONTRAST [**2100-12-28**] 11:48 AM CT CHEST W/O CONTRAST Reason: white out of R lung - bronch clean, assess for effusions [**Hospital 93**] MEDICAL CONDITION: 70 year old man with REASON FOR THIS EXAMINATION: white out of R lung - bronch clean, assess for effusions CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 70-year-old male with right lung cancer status post right upper lobectomy and bronchoscopy. Evaluate for effusions. TECHNIQUE: Contiguous axial CT images of the chest are obtained without the administration of intravenous contrast [**Doctor Last Name 360**]. Multiplanar reformation images are reconstructed. COMPARISON: Chest CT dated [**2100-12-1**], and multiple prior chest radiographs dating between [**2100-12-13**] to [**2100-12-27**]. FINDINGS: The patient is status post right thoracotomy with right upper lobectomy for lung cancer with surgical sutures. Again note is made of large right pneumothorax occupying approximately half of the right hemithorax, with two chest tubes and hydropneumothorax at the base. The anterior chest tube terminates in the apex in the pneumothorax cavity, and posterior chest tube crosses posterior aspect of the pleura and terminates at the apex. There is a large pneumomediastinum surrounding trachea and esophagus, which extends somewhat to the left apex. The mediastinal structure is shifted to the right as noted on the plain radiograph. There is a large subcutaneous emphysema cavity extending from most of the visualized portion of the right chest and shoulder, overall unchanged since [**12-27**] comparing the scout image versus portable radiograph, however, is markedly increased since 23rd. Just above the anterior chest tube exit from the thoracic cavity, the pneumothorax cavity and the subcutaneous emphysema cavity appears to be communicated. There is evidence of prior right thoracotomy in the right upper ribs, with chest wall reconstruction with thin mesh. The evaluation of mediastinal structures and great vessels is limited due to lack of intravenous contrast [**Doctor Last Name 360**]. Atherosclerotic disease of the aorta is again noted. There is no significant mediastinal or hilar lymphadenopathy noted on this limited evaluation. The aerated portion of the right lung has patchy opacities especially at the bases with effusion, likely representing atelectasis and edema. There are postoperative changes as well, with opacity surrounding the surgical suture. In the left lung, there is dependent atelectasis and small effusion. There are patchy faint centrilobular opacities in the left lower lobe likely representing aspiration. There are degenerative changes of thoracolumbar spine. There is anterior ligamentous calcification. Multiplanar reformation images confirm above finding. There is a 3.2 x 2.7 cm left adrenal lesion, as seen on the prior study, measuring 15 [**Doctor Last Name **], likely representing adenoma. Otherwise, the rest of the upper abdomen is grossly unremarkable, however, evaluation is limited. IMPRESSION: 1. Limited study due to lack of intravenous contrast [**Doctor Last Name 360**] for assessment of mediastinum and great vessels. Persistent moderate-sized right pneumothorax and large pneumomediastinum with approximately 50% aeration of the right lung with post-operative changes and atelectasis and edema and small effusion. Hydropneumothorax on the right base. Two chest tubes as described above. Extensive subcutaneous emphysema, overall unchanged since 24th, however, has markedly increased since 23rd. 2. Post-right upper lobectomy for lung cancer, with surgical changes and prior thoracotomy and chest reconstruction changes, as well as soft tissue density surrounding the surgical suture likely postoperative, however, continued followup is recommended. The evaluation of the residual right lung is extremely difficult due to extensive pneumothorax and pneumomediastinum. 3. Patchy centrilobular opacity in the left lower lobe, likely representing aspiration. Atelectasis and small effusion. 4. 2.7-cm left adrenal lesion, likely adenoma. Please consider dedicated abdominal imaging for the assessment of metastatic disease. The finding was discussed with Dr. [**Last Name (STitle) **]. [**Doctor Last Name 3450**] and Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] telephone at the completion of the study. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) 7210**] [**Name (STitle) 7211**] [**Doctor Last Name 7205**] DR. [**First Name (STitle) 5432**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Approved: TUE [**2100-12-28**] 6:54 PM RADIOLOGY Final Report CHEST (PORTABLE AP) [**2101-1-1**] 5:49 AM CHEST (PORTABLE AP) Reason: interval xray [**Hospital 93**] MEDICAL CONDITION: 70y M s/p R Thoracotomy (Redo), RUL Lobectomy en block with chest wall resection (tumor invaded chest wall), chest wall reconstruction with Goretex mesh, decortication REASON FOR THIS EXAMINATION: interval xray HISTORY: Interval x-ray. CHEST, SINGLE AP VIEW. Compared with [**2100-12-31**], there is some interval increase in opacity at the right base, likely related to accumulation of pleural fluid. Otherwise, no significant change is detected. Deformity, volume loss, and degree of aeration in the right lung is stable. Subcutaneous emphysema present. Slight rightward shift of mediastinum unchanged. Left lung grossly clear, without CHF, focal infiltrate or effusion. IMPRESSION: Minimal increased opacity right base. Otherwise unchanged compared with one day earlier. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4343**] Approved: SAT [**2101-1-1**] 8:14 PM Brief Hospital Course: Patient underwent bronchoscopy and reoperative right thoracotomy with right upper lobectomy and en bloc right chest wall resection (ribs 3,4 and 5) with [**Doctor Last Name 4726**]-Tex chest wall reconstruction and decortication of right middle and right lower lobes (for further operative details, see dictated operative note dated [**2100-12-21**]). He tolerated the procedure well. He was extubated and transferred to the PACU for observation. Cardiovascular: Patient was cardiovascularly stable throughout his hospitalization. He was initially treated with IV Lopressor. Subsequently he was transitioned to PO Lopressor and eventually his home atenolol dose. His blood pressure was well controlled. No new cardiovascular medications were added during this hospitalization. Pulmonary: Patient was extubated. Aggressive pain control regiment and incentive spirometry was instituted. He was started on nebulizers as well as expectorants to help clear airway secretions. He did well and was transferred to the floor. Chest tubes were kept on suction as he had a significant air leak, which was expected from the extent of the surgery. On POD 3 he became more short of breath and his CXR showed white-out of the lower/middle lobe on right. He underwent bronchoscopy with clearing of mucus plug. Secretion were sent for culture and eventually grew Serratia (see ID section). On [**12-26**] he developed worsening SOB and brief desaturation to 80's. He was transferred to the ICU for closer observation and bronchoscopy. He subsequently underwent bronchoscopy on [**12-24**], and [**12-28**] for mucus plugging. Subsequent to this he required no further intervention. Over the next several days, air leak to chest tubes markedly decreased. His chest tubes were sequentially removed. On [**1-1**] the last chest tube was removed. CXR showed a pneumothorax. Serial x-rays showed the air collection to be stable > 24 hours. No further intervention was made. He continued to do well from a respiratory standpoint. GI: Diet was advanced on POD 1 without complications. ID: In light of worsening respiratory status and chest x ray with some lung collapse and mucus plugging, patient was started on Vanco/Zosyn. Following bronchoscopy on [**12-25**], BAL cultures returned with Serratia that was pan-sensitive. His antibiotics were tailored to include ciprofloxacin. He will complete a 14 day course. Because of continuing secretions, sputum cultures were sent on [**1-1**]. We will adjust antibiotics accordingly. Neuro: Pain was initially well controlled with an epidural. Over the initial weak, his epidural was stopped and he was started on PCA. This was then transitioned to Percocet with good pain control. He was discharged home on Percocet. He was discharged home with instructions for follow-up. Medications on Admission: Atenolol, cardura, HCTZ, lisinopril, doxazosin Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*40 Capsule(s)* Refills:*2* 2. Atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day. 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain: As needed for pain. Hold for oversedation. Disp:*50 Tablet(s)* Refills:*0* 4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 6. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days: Take until all pills are done. Disp:*14 Tablet(s)* Refills:*0* 7. Doxazosin Oral 8. Cardura 6 mg Discharge Disposition: Home Discharge Diagnosis: Lung cancer Discharge Condition: Stable to home, tolerating diet. Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * If you experience shortness of breath that is new or worsening. * 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. * Your pain is not improving within 8-12 hours or becoming progressively worse, or inadequately controlled with the prescribed pain medication. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * If you experience worsening pain, cloudy drainage or pain around your incisions. * Take antibiotics for the full course. Do not stop early unless specifically instructed to by your doctor. Incision Care: *You may shower. Pat incision dry. *Avoid swimming and baths until further instruction at your followup appointment. *Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. Followup Instructions: Please call Dr.[**Name (NI) **] office to schedule your follow up appointment. Your appointment should be in [**7-13**] days. ([**Telephone/Fax (1) 4741**]) Completed by:[**2101-1-2**]

[ "196.1", "934.1", "198.89", "162.3", "496", "585.9", "997.3", "518.0", "403.90", "482.83" ]

icd9cm

[ [ [] ] ]

[ "96.56", "32.6", "33.24" ]

icd9pcs

[ [ [] ] ]

14880, 14886

11277, 14083

288, 554

14942, 14977

2493, 5648

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239, 250

10525, 11254

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31,717

148,272

8035

Discharge summary

report

Admission Date: [**2145-9-5**] Discharge Date: [**2145-9-9**] Date of Birth: [**2094-10-10**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 800**] Chief Complaint: Hematemesis Major Surgical or Invasive Procedure: upper endoscopy History of Present Illness: Ms [**Doctor Last Name 28727**] is a 50 year old woman with poorly controlled type 1 diabetes, severe gastroparesis, end stage renal disease, on HD, presenting with one day of new hypertension, hyperglycemia and hematemesis. Patient reports she felt well on the night prior to admission, but felt very poorly this morning after waking up. She reports her fasting blood glucose was 500 and systolic blood pressure was approximately 240/140. She denies any chest pain, shortness of breath, diarrhea, but does report vomiting blood. She also reports this is not a new event for her and that she frequently vomits dark material with frank blood in it. In the ED, patient with Temp = 98.4 HR 130 BP 195/115 RR: 28 Os Sat: 99% RA. Patient continued to feel nauseated and became severely hypertensive to 240's and considered to be symptomatic (nausea), IV Labetalol 20mg x 1 was given and BP rapidly dropped to 96/55 in less than 1 hour, with ensuing global aphasia and acute mental status changes. Neurology was consulted in the ED for this and per their recommendation, BP was less agressively treated. Regarding the hematemesis, NG tube was placed and lavage with 500ml of NS without clearing of bloody, hemoccult positive contents. GI called, patient admitted to MICU for further management. Past Medical History: 1. Poorly controlled DM type 1, diagnosed in [**2117**]. Followed at the [**Last Name (un) **] (Dr. [**Last Name (STitle) 14116**]. Last HbA1c 9.8 in [**2-16**] at [**Last Name (un) **]. AV fistula on [**2145-1-20**], currently seeing Dr.[**Doctor Last Name 4849**] for evaluation of kidney transplant 2. Severe gastroparesis 3. Diabetic neuropathy, with Charcot joints 4. Chronic renal insufficiency baseline Cr ~4 .Started dialysis in [**2-16**] 5. Hypertension 6. Non-healing left foot ulcer with several foot surgeries 7. Hx. of MRSA 8. h/o UGIB 9. peripheral neuropathy 10. Diabetic retinopathy s/p laser surgery (blind right eye) Social History: Lives with her husband and two sons, remote smoking history and occasional ETOH. Currently on disability. Denies illicit / IVDU Family History: She has cousins, uncle, and grandmother with DM. No history of strokes. No GI malignancies or disorders. Physical Exam: Temp: 97.4 HR: 87 BP: 181/139 RR: 13 O2 Sat: 98% Gen: Ill appearing Woman, no acute distress HEENT: Dry mucous membranes, EOMI, PEERL CV: tachycardic, II/VI systolic murmur loudest at the LUSB. Lungs: CTA Bilaterally Abdomen: NTND, NABS Ext: no clubbing /cyanosis/edema, no splinter hemorrhages, no osler nodes, no [**Last Name (un) **] lesions. Pertinent Results: ================== ADMISSION LABS ================== WBC-12.0* RBC-4.34 Hgb-13.5 Hct-41.9 MCV-97 MCH-31.2 MCHC-32.3 RDW-14.7 Plt Ct-334 Neuts-85.5* Lymphs-9.4* Monos-3.4 Eos-1.2 Baso-0.5 PT-11.7 PTT-21.0* INR(PT)-1.0 Glucose-458* UreaN-30* Creat-5.4* Na-136 K-4.2 Cl-96 HCO3-26 AnGap-18 CK(CPK)-62 CK-MB-NotDone cTropnT-0.09* Calcium-9.2 Phos-5.2* Mg-2.3 Lactate-1.8 ======== ECG ======== NSR with evidence of LVH, TWI in V1 and 1mm ST elevation on V2. ============= Radiology ============= PORTABLE FRONTAL CHEST: Mild cardiomegaly persists, unchanged. Mediastinal and hilar contours are unchanged. There is no focal lung parenchymal consolidation, pleural effusion, or pneumothorax. There is no pneumomediastinum. The surrounding osseous structures are grossly unremarkable. IMPRESSION: No acute cardiopulmonary process. CT HEAD IMPRESSION: No acute intracranial hemorrhage or large area of acute infarction. However, MR [**Name13 (STitle) 430**] is more sensitive in the detection of acute infarction and can be considered if there is continued concern. Upper Extremity U/S IMPRESSION: No evidence of left upper extremity DVT. The study and the report were reviewed by the staff radiologist. ============= EEG ============= IMPRESSION: Abnormal EEG due to the slow background and occasional bursts of generalized slowing. These findings indicate a widespread encephalopathy affecting both cortical and subcortical structures. Medications, metabolic disturbances, and infection are among the most common causes. There were no areas of prominent focal slowing, and there were no clearly epileptiform features. ============= TTE ============= The left atrium and right atrium are normal in cavity size. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). The estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. 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. IMPRESSION: Trace aortic regurgitation with normal valve morphology. Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. ============= ECG ============= Sinus rhythm. Borderlne left axis deviation. Possible left ventricular hypertrophy. Leftward transition point, probably secondary to left ventricular hypertrophy. Compared to the previous tracing of [**2145-9-3**] multiple abnormalities as noted persist without major change. Brief Hospital Course: ASSESSMENT AND PLAN: Ms. [**Doctor Last Name 28727**] is a 50F with PMH s/f IDDM c/b ESRD on HD and gastroparesis. Presented to the ED with hematemesis, hyperglycemia, with cultures drawn yesterday growing GPC's. . #. Hematemesis: The patient reported. chronic hematemesis at home, with "coffee grounds", approximately 10 times and up to a cup full. The patient was typed and screened and followed with serial HCts that improved and no transfusion was needed. The patient was placed on an IV PPI and an Octreotide drip while she awaited an EGD. GI perfomed the EGD and found gastritis, but no active bleeding ulcers or evidence of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 329**] [**Last Name (NamePattern1) **] tear. GI also mentioned that she will need a colonoscopy in [**10-18**] to f/u polyp and poor prep onprior colonoscopy. The patient was transferred to the floor and her Hct remained stable until d/c home. . #. Gram positive Bacteremia: Although patient without fevers or chills, rapid growth on blood cultures in setting of hemodialsys was concerning. Given the patient's prior hx of MRSA, Vancomycin and Zosyn were started empirically. Zosyn was stopped prior to transfer from the MICU to the floor. On the floor, after a day of normal vital signs and reassuring CBCs, Vancomycin was stopped. Given the presence of a heart murmur on physical exam there was some concern for endocarditis, but a TTE did not reveal any concerning vegetations. In the end, the blood cxs great coagulase negative staph and it was felt by the medicine team that this was likely a contaminant. #. Hyperglycemia/DM: The patient was continued on Lantus and ISS. It was thought that her blood sugars may have been elevated in the setting of infection. There were no acute diabetic related issues during this hospitalization. . #. Hypertensive Urgency: Improved, Holding antihypertensives for now, would start metoprolol and amlodipine after patient begins taking PO's. Due to recent AMS from suddent BP drop but active GIB, would aim for goal SBP near 160-180 (30-40% decreased in first 24hrs) as a balance, unless actively symptomatic. The patient was restared on her antihypertensive medications on the medicine floor and she tolerated them well. She was frequently walked by nursing with no abnormal orthostatic vital signs. . #. Dysarthria / Altered mental status: It was thought that patient's altered mental status was due to over agressive BP lowering in the ED. Head CT was negative. Neurology was consulted and agree with this assessment, but prefered to do an EEG to r/o seizure. in setting of agressive BP lowering. At the time of d/c the final read on the EEG was pending, but neurology claimed they would be responsible to follow up with the patient's primary care doctor if any abnormalities were revealed that needed further workup. . #. Gastroparesis: The patient's home metoclopramide was held in the ICU and restarted on the medicine floor when she was tolerating po meals. There were no acute gastroperesis related issues during this hospitalization. . #. ESRD on HD: The patient received her regularly scheduled HD. There were no acute renal issues during this hospitalization. . #. Elevated cardiac enzymes: Likely demand ischemia in setting of hypertensive urgency / emergency during last admission. . #. Hyperlipidemia: Holding home pravachol while taking PO's. Statin was restarted on the medicine floor when the patient was tolerating po memals. . #. FEN: Diabetic diet . #. PPX: Pneumoboots, no heparin given bleeding. . #. ACCESS: PIV's, low threshold for central access if IV access is lost. . #. CODE STATUS: Presumed full . Medications on Admission: 1. Amitriptyline 25 mg PO HS 2. Amlodipine 5 mg PO BID 3. Metoprolol Succinate 25 mg (XL) PO DAILY (Daily). 4. Aspirin 81 mg Tablet 5. Pravastatin 20 mg 6. Metoclopramide 10 mg QIDACHS 7. Insulin Lantus 30 units at night; 8. Zantac 150 mg Tablet PO twice a day. Discharge Medications: 1. 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* 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 5. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Colace 100 mg Capsule Sig: [**2-10**] Capsules PO twice a day: for constipation . Disp:*30 Capsule(s)* Refills:*2* 7. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO twice a day as needed for constipation. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: 1) Insulin Dependent Diabetes Mellitus 2) End Stage Renal Disease on Dialysis 3) Acute Upper Gastrointestinal Bleed requiring endoscopy and serial hematocrit monitoring Discharge Condition: afebrile, good condition Discharge Instructions: You came to the hospital for hyperglycmeia and vomiting. In the ER your blood pressure was very elevated. After getting some medication to lower your blood pressure, you were confused and there was some concern for stroke. Your Head CT was negative. It was thought that you most likely experienced your symptoms secondary to a drop in blood pressure. Neurology performed an EEG as well to rule out any seizure activity. They will follow up with your primary care doctor regarding the results of this test. There was one specimen of your blood that grew bacteria, but it was thought that this was likely a contaminant. All of your other lab work indicated that you did not have a blood infection. You came in with some bleeding from the upper GI tract, but this seems to have resovled. Your blood counts were stable and you did not vomit on the floor. You were started on Pantoprazole, a proton pump inhibitor to decrease the acid secretion in your stomach and reduce your risk of stomach ulcers and bleeding from the stomach. Please seek immediate medical attention if you experience any light headedness, loss of concioussness, chest pain, dizziness, fevers, chills, vomitting, dark or red stools, belly pain or any change in your condition. Followup Instructions: Please follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 6431**] early next week and be sure to discuss with her your blood pressure medications. I have scheduled an appointment with a Nurse Practitioner ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1557**]) that works with Dr. [**Last Name (STitle) 14116**] to discuss your diabetes following this hospital admission on [**9-22**] at 11 am. You already have an appointment with Dr. [**Last Name (STitle) 14116**] scheduled for [**Month (only) 359**]. You also have an appointment for an upper endoscopy at [**2145-9-20**] at 10:30 am to evalaute the reason for your stomach bleeding. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**] Completed by:[**2145-9-13**]

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icd9cm

[ [ [] ] ]

[ "39.95", "45.13" ]

icd9pcs

[ [ [] ] ]

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31390

Discharge summary

report

Admission Date: [**2156-12-28**] Discharge Date: [**2157-2-4**] Date of Birth: [**2104-10-25**] Sex: F Service: MEDICINE Allergies: Talwin Nx Attending:[**First Name3 (LF) 1493**] Chief Complaint: Abdominal Pain Anasarca Transplant evaluation Major Surgical or Invasive Procedure: Ultrasound guided paracentesis [**2156-12-29**] Central Line Dialysis Catheter Placement History of Present Illness: 52-year-old female with history of alcoholic and hepatitis B cirrhosis, who was recently discharged from [**Hospital 1474**] hospital on [**12-15**] folling treatment for spontaneous bacterial peritonitis. She was seen in clinic today and was found with large ascites, profoundly distended, and notably jaundiced and in pain. She was admitted for a diagnostic and therapeutic paracentesis and further work up. . Recently she has had slightly worsening abdominal pain, increased [**Location (un) **] and some nausea and 1 episode of non-bloody emesis. Reports with weight gain 15 lbs. Past Medical History: # Alcoholic liver cirrhosis diagnosed in [**2134**] with ascites and esophageal varices. # Hepatitis B cirrhosis, which the patient states she contracted from her husband. Does not appear to have been completely treated in the past. The patient does report being enrolled in an interferon clinical trial at [**Hospital1 2025**] many years ago but was deemed to not be a "non-responder." # COPD. # Hypothyroidism. # Depression. # Status post cholecystectomy. # Sciatica status post back surgery x2 Social History: The patient has currently quit smoking for 2 weeks. She was previously smoking one pack per day for a total of 40 years. The patient is a former drinker with her last drink being on [**2155-3-29**]. She was drinking approximately four to six packs of beer per week along with binge-drinking with 40 beers on the weekends. She was drinking for a total of 30 years. Her last cocaine use was last year. Last marijuana use two years ago. She denies a history of IV drug abuse. She is not currently in substance abuse counseling or support, but states that she has not had any temptation to use illicits again. Family History: The patient reports alcoholism in both sides of her family. Mother deceased from bladder cancer at the age of 51. Father with heart disease and angina, but no history of myocardial infarction or coronary artery bypass grafts. The patient has three children with two girls at the ages of 23 and 21 with hepatitis B. the oldest son does not have hepatitis B Physical Exam: 98.6 112/69 72 20 94%RA GEN: illappearing, tearfull, obese HEENT: icteric sclera, jaundiced skin CV: rrr s1, s2, no M/g/R RESP: diffuse wheezing bilaterally ABD: tender to palpation, obese, +bs, site of paracentesis is still draining fluid EXT: tense pitting edema bilaterally Neuro: AAOx3, 5/5 strength, sensation intact, no flap. Pertinent Results: PARACENTESIS DIAG. OR THERAPEUTIC [**2156-12-29**] 4:45 PM PARACENTESIS DIAG. OR THERAPEU Reason: DIAGNOSTIC AND THERAPEUTIC paracentesis please send cell cou [**Hospital 93**] MEDICAL CONDITION: 52 year old woman with hep B/ETOH cirrhosis REASON FOR THIS EXAMINATION: DIAGNOSTIC AND THERAPEUTIC paracentesis please send cell count and differential, fluid for culture PARACENTESIS ON [**12-29**] CLINICAL HISTORY: ETOH cirrhosis. Diagnostic tap requested. PROCEDURE AND FINDINGS: A full discussion of pertinent risks, benefits, and alternatives to the procedure was performed, informed consent was obtained. Preprocedure timeout documents proper patient, site, and procedure. Using aseptic technique and ultrasound guidance, a 5 French [**Last Name (un) 11097**] centesis catheter was passed through anesthetized tissues in the left flank, to the peritoneal cavity from which approximately 1 liter of clear, straw-colored fluid was removed and sent for the requested labs. Hemostasis was then obtained, patient tolerated the procedure well without any immediate post-procedure complications. Dr. [**Last Name (STitle) 4401**] performed the procedure. IMPRESSION: Successful ultrasound-guided paracentesis. . CT ABDOMEN W/CONTRAST [**2157-1-1**] 5:41 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Reason: assess for loculation [**Hospital 93**] MEDICAL CONDITION: 52 year old woman with cirrhosis with large ascites, tap with only 1L removed, assess for loculation REASON FOR THIS EXAMINATION: assess for loculation CONTRAINDICATIONS for IV CONTRAST: not needed INDICATION: 52-year-old female with cirrhosis and large ascites with recent 1 liter of fluid removed via paracentesis. Assess for loculation. COMPARISON: [**2156-11-3**]. TECHNIQUE: MDCT acquired axial images of the abdomen and pelvis were obtained with IV contrast. Multiplanar reformations were performed. CT ABDOMEN WITH IV CONTRAST: There is a moderate right pleural effusion with associated atelectasis. There is airspace opacity within the left lung base, likely atelectasis. The liver is small and nodular consistent with cirrhosis. Metallic clips are present within the gallbladder fossa, consistent with prior cholecystectomy. The previously seen early enhancing lesions within the liver are not well demonstrated, given the lack of arterial phase timing. The pancreas and adrenal glands are unremarkable. The spleen is bulky, measuring 13 cm. The small bowel is filled with oral contrast with no evidence of obstruction. The large bowel is unremarkable. The rectum and sigmoid colon are stool filled. There is moderate amount of ascites located primarily along the pericolic gutters and extending down into the deep pelvis. There are no obvious septations or collection surrounded by soft tissue to suggest loculation. This examination is limited due to artifact created from the patient's body habitus, particularly on the right of the abdomen and pelvis. There is diffuse anasarca throughout the subcutaneous tissues of the abdomen and pelvis. CT PELVIS WITH IV CONTRAST: The uterus and adnexa are unremarkable. The urinary bladder is collapsed and contains a Foley catheter. There is no appreciable lymphadenopathy in the abdomen and pelvis. BONE WINDOWS: There are no suspicious lytic or sclerotic osseous lesions. IMPRESSION: 1. No loculation. Majority of fluid within the pericolic gutters and extending down into the deep pelvis. 2. Moderate right pleural effusion. 3. Cirrhotic liver and splenomegaly. . Echo: The left atrium is mildly dilated. The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%) Transmitral Doppler and tissue velocity imaging are consistent with normal LV diastolic function. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. An eccentric, posteriorly directed jet of Mild to moderate ([**12-15**]+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. The pulmonic valve leaflets are thickened. Significant pulmonic regurgitation is seen. There is no pericardial effusion. IMPRESSION: Normal left ventricular function. Normal right ventricular function. Moderately elevated estimated pulmonary pressures. Compared with the prior study (images reviewed) of [**2156-11-3**], the estimated pulmonary pressures are moderately elevated and the severity of mitral regurgitation has increased. . US ABD LIMIT, SINGLE ORGAN [**2157-1-7**] 9:16 AM US ABD LIMIT, SINGLE ORGAN Reason: EVAL FOR ASCITES AND MARK THE SPOT FOR PARACENTESIS [**Hospital 93**] MEDICAL CONDITION: 52 year old woman with EtOH, Hep B cirrhosis, refractory ascites. REASON FOR THIS EXAMINATION: Please assess for degree of ascites. Anasarca vs. ascites. LIMITED ABDOMEN ULTRASOUND COMPARISON: None. HISTORY: Ascites. FINDINGS: Limited [**Doctor Last Name 352**]-scale imaging of the abdomen was performed to assess for underlying ascites. Minimal amounts of fluid are seen in all four quadrants and midline pelvic view. Subsequently, no spot was marked due to limited quantity of free fluid. IMPRESSION: Minimal amount of abdominal ascites, unable to mark spot for paracentesis. . These findings were discussed with Dr. [**Last Name (STitle) 656**] at the time of review. Brief Hospital Course: # Cirrhosis: The patient reported recent onset of jaundice and acute exacerbation of peripheral edema and abdominal ascites. An ultrasound guided paracentesis was performed but could only drain 1L. CT abdomen showed ascites fluid in difficult to reach locations, along paracolic gutters and in pelvis. In addition, it showed much of the fluid was in her subcutaneous tissues. Hepatitis B was thought to be a precipitating factor. A viral load was checked and came back at 6700 copies. She was thus started on entecavir. On initial presentaiton her sodium was low at 123 and her creatinine was elevated to 1.3. She was placed on a fluid restriction and her diuretics were held. Her creatinine improved but her urine output and peripheral edema remained unchanged. In an effort to mobilize her fluid, she was adminstered 50g of albumin daily followed by IV lasix. Her creatinine, sodium, and urine output remained unchanged. . She was titrated up to albumin 25g [**Hospital1 **] followed by lasix 80mg [**Hospital1 **] 30 minutes after giving albumin, and she began to respond with increased urine output, increased sodium, and decreased creatinine. The patient also reported feeling less edematous. Her nadolol, lactulose, and midodrine were continued. Her cipro was continued for SBP prophylaxis. . The team attempted to aggressively diurese her with albumin cover, and was successful; unfortunately she then went into renal failure, and was oliguric. HD (ultrafiltration) was attempted in order to take off more fluid but her blood pressures did not tolerate much fluid loss. Eventually after much discussion with the team, the patient, and the patient's family, we decided to send the patient to the MICU where she could get CVVH and potentially be able to tolerate a greater degree of fluid removal over 24 hour fluid removal cycles. She did not tolerate the CVVH secondary to hypotension and after further family meetings she was made comfort measures only and transferred back to the medical floor for placement in an inpatient hospice setting. In terms of pain and discomfort, morphine solution was given with good effect. . #Dyspnea:Patient reporting increased dyspnea when changing position from lying down to sitting up. Reporting mild exertional dyspnea as well. CXR showed vascular congestion. She also had a mild O2 desaturation 97 to 95 with sitting up. Her history and presentation was suggestive of hepatopulmonary syndrome. She reported improvement with increased diuresis. She had stable oxygenation on room air. . #Hyperkalemia: Earlier in admission, in setting of hyponatremia. She did not have a history of DM, not on NSAIDS, ACEI, or spironolactone. A morning cortisol was measured and was found to be normal. Her ekg did not show changes consistent with hyperkalemia. She was given kayexalate to keep her potassium under 5.0; this was not an issue later in the admission. Once she was made comfort measures only her labs were no longer obtained. . # Transplant workup: To be finished during hospitalization. Much of her workup was completed at outside hospitals. She recived a transplant workup and psychiatry consult during this hospitalization. A colonoscopy is being considered. The ultimate problem are two issues, as above: pulmonary function, and BMI. Thus because the fluid issues above influenced both, we saw diuresis and then CVVH as one way to bring the patient towards the possibility of going onto the transplant list. Given she did not tolerate CVVH she was made comfort measures and was comfortable on time of discharge. . #:Anemia: Patient reported chronic BRBPR since her hemmorrhoid surgery 1 month ago, and she ocntinued with brbpr here. No vomiting, no hematemesis, no melena. She received 1 unit prbcs he day of admission, and received 2 units of prbc's a week later. Through most of her admission, despite ongoing BRBPR, she had stable Hcts. The source of the BRBPR was not clear, since she sometimes also had maroon stool; the possibility existed that some food dye or medicine could have been responsible for some of the color; however, a colonoscopy and workup for GI bleeding was secondary to trying to see if the patient might become eligible for a liver. Her hematocrit was stable at last check before suspending lab draws. . # Goals of care: the patient became more discouraged during this lengthy admission, and frustrated by the experience of waiting for an uncertain and potentially grim outcome. She decided to change her code status and a family meeting affirmed her decision to be DNR/DNI in the presence of her children, ex-husband and current partner. She eventually decided to give CVVH a try as one last strategy to attempt to advance towards transplant, but with the understanding that if this did not work she might be more interested in trying to move to the goal of comfort care. Given the ineffect of CVVH she was made CMO and transferred to inpatient hospice. Medications on Admission: Lasix 40 mg daily spironolactone 100 mg daily midodrine 10 mg t.i.d. nadolol 20 mg daily lactulose t.i.d. folic acid 1 mg daily ferrous sulfate 300mg po BID Multivitamin Thiamine 100mg daily Magnesium Oxide 400mg po TID with meals levothyroxine 25 mcg daily combivent 2 puffs every four hours oxycodone 5 mg Q4 p.r.n. ciproflox 250mg PO Daily Discharge Medications: 1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4 times a day) as needed. 3. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed. 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 5. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 7. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 8. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for anxiety. 9. Morphine Concentrate 20 mg/mL Solution Sig: 5-20mg PO Q2H (every 2 hours) as needed for pain. 10. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2 times a day). 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. Discharge Disposition: Extended Care Facility: [**Hospital 169**] Center Wedgemere Discharge Diagnosis: Liver Failure Cirrhosis End Stage Renal Disease Depression Discharge Condition: Fair, Hemodynamically Stable Discharge Instructions: You were admitted for your liver failure. Medical therapies were initiated and you also had hemodialysis which was ineffective. You are being discharged to a hospice center. If you experience increased pain, shortness of breath, nausea, vomitting or any other concerning symptom please contact your primary care doctor Followup Instructions:

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icd9cm

[ [ [] ] ]

[ "38.95", "54.91", "39.95" ]

icd9pcs

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Discharge summary

report

Admission Date: [**2187-10-26**] Discharge Date: [**2187-10-29**] Date of Birth: [**2117-11-22**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3326**] Chief Complaint: acute renal failure Major Surgical or Invasive Procedure: none History of Present Illness: 69 yr/o M who has received little previous medical care until one month ago when he was diagnosed on [**2187-10-11**] with liver mets indicative of diffuse metastatic disease - primary unknown. He had presented to his PCP with weight loss, jaundic, constipation, and anorexia of recent onset and PCP found and elevated Tbili leading to U/S and CT which showed hepatic mets and biliary dilation. Pt was referred to [**Hospital1 18**] for ERCP on [**2187-10-17**] which showed 1cm stricture of malignant appearance. A plastic biliary stent was placed (11cm by 10FR Cotton-[**Doctor Last Name **] biliary stent) and obtained cytology was negative. Pt was discharge home on 5 days of Cipro. Cr 0.9, Tbili 32.8, ALT 212, AST 198, and Alk Phos 868 at time of discharge. After this stent pt reported no improvement in his symptoms with persisting jaundice, constipation, and anorexia. Pt returned for other ERCP on [**10-24**] as he was having increase in LFTs. Another stent was placed, this time a metal stent (no records in OMR). Old plastic stent sent for cytology and found to be negative for malignant cells. Since [**10-24**] pt with generalized weakness and jaundice. Today he presented to [**Hospital **] hospital complaining of nausea. He was afebrile but appeared SOB although pt states he does not feel SOB. His BP showed systolics in the 70-80s and he was given an initial 60cc bolus followed by multiple 250cc boluses. Lungs were clear and sating 99% on RA. At [**Hospital1 **] he was afebrile with elevated WBC, BUN, and Cr. A foley was placed but only drained 75 cc of urine. Ct abd/pelvis showed narrowed stent. small ascites. He was given a dose of Daptomycin and Ertapenem at [**Hospital **] hospital before transfer. . On the floor, at presentation T 98.6 / BP 103/66 / HR 75 / RR 19 / sat 97% on RA. Pt describes and confirms above report of history with some additions. . Review of systems: (+) Per HPI and the following: mild HA that started today. mild cough for the last 2-3 days productive of occasional clear sputum. Pt also reports mild abdominal discomfort diffusely over the last few days along with continued abd pain as noted above. Pt denied any melana or BRBPR but also states that he is color blind and might not be able to note such a change in stool color. . (-) Denies fever, chills, Denies rhinorrhea or congestion. Denies shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations. Denies vomiting, diarrhea. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: None until recent liver troubles. Never really went to a doctor until the last month. Never has been hospitalized before and no previous surgeries. Social History: Married but does not live with wife (?estranged but still married). Lives with Son and daughter in law and wife has separate home. Before last month was very active and worked as trophy maker. Distant tob use for 10-15yrs in his 20s-30s. Occasional pipe use since that time. Current EtOh is 2-3 beers/day after work - none in last few weeks. Used higher amounts in the distant past >6 beers day most days. No IVDU/illicit drug use now or in the past. Family History: Father died of some heart disease in his 60-70s. Mom is alive in her 90s. Three siblings alive with no health problems. Physical Exam: T 98.6 / BP 103/66 / HR 75 / RR 19 / sat 97% on RA General: Alert, oriented, no acute distress, obviously icteric skin HEENT: Sclera icteric, slightly dry MM, oropharynx clear Neck: supple, no JVD, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: soft HS, Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, mild tenderness, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place draining small amount of bronze urine Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: Yellow throughout, reddish birthmark on R shoulder, some reddish discoloration under R elbow Psych/Neuro: limited work use, uses humor in conversation, appears to minimalize complaints, A&Ox3, no asterixis, no focal deficits Pertinent Results: [**2187-10-26**] 05:09PM WBC-30.9*# RBC-2.29*# HGB-7.8*# HCT-21.1*# MCV-92 MCH-34.1* MCHC-37.0* RDW-19.1* [**2187-10-26**] 05:09PM NEUTS-80* BANDS-2 LYMPHS-5* MONOS-10 EOS-0 BASOS-0 ATYPS-0 METAS-2* MYELOS-1* NUC RBCS-3* [**2187-10-26**] 05:09PM PT-18.2* PTT-43.0* INR(PT)-1.6* [**2187-10-26**] 05:00PM LACTATE-2.3* [**2187-10-26**] 05:09PM ALBUMIN-2.0* CALCIUM-7.1* PHOSPHATE-8.0* MAGNESIUM-3.4* [**2187-10-26**] 05:09PM ALT(SGPT)-235* AST(SGOT)-494* LD(LDH)-1395* CK(CPK)-316 ALK PHOS-852* TOT BILI-38.8* [**2187-10-26**] 05:09PM LIPASE-70* [**2187-10-26**] 05:09PM GLUCOSE-66* UREA N-149* CREAT-7.2*# SODIUM-132* POTASSIUM-5.0 CHLORIDE-97 TOTAL CO2-14* ANION GAP-26* [**2187-10-26**] CXR Cardiac size is normal. The aorta is elongated. There are low lung volumes. Opacities in the right perihilar and right lower lobe regions could be atelectasis but early infection cannot be totally excluded and followup is recommended. Minimally atelectasis is in the left base. There is no pneumothorax or pleural effusion. [**2187-10-27**] RUQ US IMPRESSION: 1. Markedly abnormal liver with multiple ill-defined masses throughout. Markedly dilated intrahepatic ducts within the left lobe of the liver. Moderate intrahepatic biliary dilatation in the right lobe of the liver. 2. Common bile duct stent seen and appears similar in configuration to the recent ERCP of [**2187-10-24**], with an area of focal narrowing in the upper aspect of the stent. 3. Small amount of ascites, mainly over the right lobe of the liver and also small amount seen within the left upper quadrant. 4. Normal-appearing kidneys bilaterally with no evidence of hydronephrosis. [**2187-10-27**] MRI Abdomen w/o Contrast 1. Multifocal intrahepatic duct diatation with proximal dominant strictures due to innumerable hepatic lesions in segments 2 and [**6-14**]. 2. Severe pancreatitis. 3. Asymmetric thickening of right lateral wall of distal esophagus with upper esophageal dilatation. Brief Hospital Course: Mr. [**Known lastname 87364**] is a 69 year-old gentleman with limited past medical history who was recently diagnosed with metastatic cancer to the liver from unknown primary and now s/p to ERCPs with 2 stent placements in the last 10 days presenting with elevated bili, hypotension, and acute renal failure. #. Liver metastases from unknown primary: causing acute liver failure with jaundice/icterus, encephalopathy, ascites, coagulopathy, poor liver synthetic function. The thickening of the esophagus seen on MRI may represent a possible primary, but patient's family declined further workup. Given the extent of his disease, including end-organ failure and lack of treatment options, the patient's family elected to make him Comfort Measures Only. He denied pain throughout admission, but was encephalopathic. At first he was treated with Lactulose for encephalopathy, but after discussions with the family, all meds were stopped except for medications for comfort/pain relief. He was discharged to [**Hospital1 656**] Family Hospice Home. #. Acute Renal Failure: Renal service was consulted; the exact etiology of his acute kidney injury was unclear. Possibly ATN related to meds or contrast, pre-renal state vs Hepatorenal Syndrome. CT at [**Hospital **] hospital showed no evidence of hydronephrosis or obstructive process. His renal function continued to decline but he did not require dialysis; his family decided that even if it was indicated, he would not undergo hemodialysis. He was made CMO, and nephrotoxic agents were held but no futher intervention was taken. At the time of discharge he was anuric. #. Hypotension: BPs low at [**Hospital1 **] and dipping down to systolics of 80-90s on presentation to [**Hospital1 18**]. Likely some element from anemia (see below) but might have also been related to hypovolemia due to poor po intake over last two weeks or secondary to sepsis with a very elevated WBC. He was responsive to initial fluid boluses but remained hypotensive at discharge to hospice. # Anemia: without obvious source of bleeding. He was initially transfused and workup pursued, but when he was made CMO, he received no further interventions. #. Leukocytosis: etiologies that were considered include cholangitis, UTI (in the setting of ARF, though urine culture was negative), pneumonia (though CXR was unconvincing). Arrived from [**Hospital1 **] on Daptomycin and Ertapenem, and he was switched to Vanc and Unasyn. These were discontinued when his goals of care were changed. Medications on Admission: none Discharge Medications: 1. Morphine Sulfate 2-4 mg IV Q2H:PRN dyscomfort sob 2. Lorazepam 0.5-2 mg IV Q4H:PRN agitation Discharge Disposition: Extended Care Facility: [**Hospital1 **] FAMILY HOSPICE HOUSE Discharge Diagnosis: metastatic cancer to liver, unknown primary acute liver failure acute renal failure Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were transferred from another hospital for worsening kidney function. You also had worsening liver function and you had test that showed large amount of tumor in your liver compressing your liver drainage system. It is unclear what the primary tumor is that caused the metastasis. Since we cannot offer curative or even palliative therapy for your disease, you and your family have elected for Comfort Measures Only status. You are being discharged to Hospice. . We have made the following changes to your medications: -STOP all prior medications -START Morphine and Lorazepam as needed for pain/discomfort Followup Instructions: You will be seen by healthcare professionals at the hospice center.

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icd9cm

[ [ [] ] ]

[ "51.10", "97.05" ]

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Discharge summary

report

Admission Date: [**2193-1-5**] Discharge Date: [**2193-1-11**] Date of Birth: [**2107-5-10**] Sex: F Service: MEDICINE Allergies: Avelox / Omeprazole Attending:[**First Name3 (LF) 663**] Chief Complaint: SOB, cough Major Surgical or Invasive Procedure: Right pleurex drain insertion [**2193-1-11**] History of Present Illness: 85 year old female with COPD on home O2 and recent left exudative pleural effusion who presents with cough, SOB and palpitations. . She reports 1 week of worsening cough productive of yellow sputum. Also has shortness of breath. She reports that at baseline she has difficulty walking from room to room in her house. She wears 3L home O2. However, in the last week, she has had significant cough and fits of cough. She hasn't been using her nebulizers often because they make her cough. Endorses occasional feelings of her heart double beating after a coughing spell. Denies fevers, chest pain, or nausea/vomiting. States her breathing sometimes requires her to sit upright, and she told the on-call pulmonary fellow that she has been sleeping in a chair due to her breathing. Denies worsening lower extremity edema, but does endorse waking up at night short of breath. . In late [**11-18**] she had a mild COPD exacerbation and her Symbicort was increased and she was given azithromycin. In [**12-19**] she was admitted to the [**Hospital 882**] Hospital with a new left pleural effusion. She was found to have an "undiagnosed lymphocytic, exudative effusion with negative cytology, AFB, bacterial and fungal cultures." It was felt that she may eventually need a pleuroscopy for diagnosis but the decision has not been made given her "respiratory frailty and DNR status." She also had a [**Hospital1 882**] admission in [**10-19**] and she had a sputum culture that reportedly grew cephalosporin-resistent pneumococcus. She was seen by Dr. [**Last Name (STitle) 1632**] (pulm) last week and had an echo that was unchanged from prior with normal EF >55% and boderline pulmonary hypertension. . In the ED, initial VS were 97 91 104/52 24 95% 3L. She was found to be wheezy and tachypneic. ECG showed NSR at rate 77 consistent with prior. She was given solumedrol, nebulizers, and azithromycin. CXR was normal. Labs were significant for an elevated lactate to 3.1. Vitals on transfer 97.4 77 126/55 19 96%3L. . Currently on the floor she feels much improved and denies current SOB. . Review of systems: (+) Per HPI. Endorses 3 episodes of bowel incontinence thought to be due to her Glucerna. (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied chest pain or tightness. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: COPD on home O2 Recent exudative pleural effusions Chronic sinusitis with secondary nasal drip and chronic cough. Hypothyroidism Chronic cough OA Glaucoma Cataracts Social History: Lives with her son. Smoked x 44 years, quit 25 years ago. Drinks one sombrero every evening (coffee flavored brandy plus milk and ice). Ambulates at baseline but can barely walk from room to room at baseline due to SOB. Former secretary. ET only 15 steps. Family History: Mother died 92 old age Brother died ? MI Other brother and sister well 5 children well Physical Exam: Vitals: 96.9 BP 121/70 HR 83 RR 24 92%2L 116.8 lbs General: Alert, oriented, no acute distress. Mild intention tremor L>R. HEENT: Sclera anicteric, MMM, oropharynx dry Neck: Supple, no LAD Lungs: Decreased breath sounds at the bases with very mild scattered wheeze CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops, JVP not elevated. Abdomen: Soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 1+ pulses, no clubbing, cyanosis. Trace bilat ankle edema. Neuro: GCS 15/15 A+Ox3. CN II-XII normal and UL/LL exam normal Pertinent Results: Admission labs [**2193-1-5**] 06:30PM BLOOD WBC-5.9 RBC-4.32 Hgb-13.6 Hct-39.4 MCV-91 MCH-31.4 MCHC-34.5 RDW-14.8 Plt Ct-263 [**2193-1-5**] 06:30PM BLOOD Neuts-66.7 Lymphs-23.0 Monos-4.4 Eos-5.3* Baso-0.7 [**2193-1-5**] 06:30PM BLOOD Glucose-133* UreaN-20 Creat-1.1 Na-137 K-4.3 Cl-104 HCO3-22 AnGap-15 [**2193-1-5**] 06:30PM BLOOD CK(CPK)-48 [**2193-1-6**] 06:10AM BLOOD ALT-13 AST-20 CK(CPK)-33 AlkPhos-60 TotBili-0.3 [**2193-1-6**] 06:10AM BLOOD Albumin-4.2 Calcium-9.0 Phos-3.2 Mg-2.0 . Other labs [**2193-1-6**] 06:10AM BLOOD TSH-0.90 [**2193-1-6**] 06:10AM BLOOD CRP-2.1 [**2193-1-5**] 06:42PM BLOOD Lactate-3.1* [**2193-1-6**] 07:54AM BLOOD Lactate-3.7* [**2193-1-6**] 07:31PM BLOOD Lactate-4.7* [**2193-1-7**] 12:23AM BLOOD Lactate-3.0* [**2193-1-7**] 06:37AM BLOOD Lactate-1.9 [**2193-1-8**] 07:13AM BLOOD Lactate-1.3 . Cardiac enzymes [**2193-1-5**] 06:30PM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-229 [**2193-1-6**] 06:10AM BLOOD CK-MB-2 cTropnT-<0.01 [**2193-1-6**] 08:25PM BLOOD CK-MB-3 cTropnT-<0.01 . Discharge labs [**2193-1-11**] 07:43AM BLOOD WBC-6.1 RBC-4.19* Hgb-13.2 Hct-39.2 MCV-94 MCH-31.6 MCHC-33.8 RDW-15.0 Plt Ct-267 [**2193-1-11**] 07:43AM BLOOD Glucose-80 UreaN-26* Creat-1.0 Na-140 K-5.1 Cl-105 HCO3-28 AnGap-12 [**2193-1-11**] 07:43AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.3 . . Microbiology: . BC [**1-6**] no growth . MRSA screen negative [**1-6**] . [**2193-1-7**] 12:00 pm Influenza A/B by DFA Source: Nasopharyngeal swab. **FINAL REPORT [**2193-1-7**]** DIRECT INFLUENZA A ANTIGEN TEST (Final [**2193-1-7**]): Negative for Influenza A. DIRECT INFLUENZA B ANTIGEN TEST (Final [**2193-1-7**]): Negative for Influenza B. . . Radiology . XR CHEST (PA & LAT) Study Date of [**2193-1-5**] 7:00 PM Frontal and lateral views of the chest were obtained. Lungs remain hyperinflated with flattening of the diaphragms and increased AP diameter ofthe chest on the lateral view, consistent with chronic obstructive pulmonary disease. Small bilateral pleural effusions are again seen. Small bilateral pleural effusions with overlying atelectasis are again seen. Superimposed bibasilar consolidation cannot be excluded. There is no pneumothorax. The aorta remains calcified and tortuous. Cardiac silhouette is not enlarged. Mild anterior wedging of a lower thoracic vertebral body is unchanged. IMPRESSION: Small bilateral pleural effusions with overlying bibasilar atelectasis. Underlying consolidation not excluded, particularly in the medial right lower lobe and infectious process not excluded. . XR CHEST (LAT DECUB ONLY) Study Date of [**2193-1-6**] 9:20 AM Right and left chest decubitus were obtained. There is minimal amount of left pleural effusion and moderate-to-large amount of right pleural effusion demonstrated on the decubital views. Otherwise, no change since the prior study has been demonstrated. . XR CHEST (PA & LAT) Study Date of [**2193-1-10**] 4:31 PM In comparison with the study of [**1-5**], there is no change in the degree and extent of the bilateral pleural effusions with compressive basilar atelectasis. Findings of chronic pulmonary disease persists. No evidence of acute focal pneumonia. . XR CHEST (PORTABLE AP) Study Date of [**2193-1-11**] 11:46 AM In comparison with study of [**1-10**], the patient has taken a much better inspiration and is now upright. This may be responsible for the apparent decrease in the effusions, especially on the right, though some of this may reflect the insertion of a right tunneled catheter. Opacification at the left base is consistent with volume loss in the left lower lobe. . . Cardiology ECG Study Date of [**2193-1-6**] 6:57:56 PM Sinus rhythm. RSR' pattern (probable normal variant). Anteroseptal ST-T wave changes consistent with possible ischemia. Clinical correlation is suggested. Compared to the previous tracing of [**2193-1-5**] the rate has increased. All other findings are similar. Intervals Axes Rate PR QRS QT/QTc P QRS T 99 140 78 362/430 69 0 48 Brief Hospital Course: 85 year old female with COPD on home O2 and recent left exudative pleural effusions, who presents with cough, SOB and questionable palpitations and orthopnea. Decompensation [**1-6**] requiring precautionary ICU transfer for consideration of BiPAP but did not necessitate this. Still tachypneic on transfer back to the [**Hospital1 **] [**1-7**]. Continued episodes of tachypnea, SOB and anxious ++ re these. Improved with new regime including morphine IR after palliative care consult. Had family meeting regarding disposition [**1-10**]. Right Pleurex drain was inserted [**1-11**] for symptomatic relief of effusions. She complained of pain at the drain. . #. Shortness of breath: Has increased cough production without fevers and worsening shortness of breath. Feel that this is most likely a bronchitis triggering a mild COPD exacerbation. Currently patient with baseline O2 requirement and appears comfortable and minimally wheezy. Also with recent h/o pleural effusions that were by report exudative. Always concern exists for empyema given this history, but CXR shows only small bilateral effusions and patient doesn't have leukocytosis or fever. There was no xray or clinical evidence of pneumonia although this could not be excluded on imaging. Also had a history of SOB worse when lying flat, although did not appear volume overloaded on physical exam and has had recent echo without evidence of CHF (JVP not elevated and trace akle edema). BNP 229. CEs -ve x2. She was treated with QID ipratropium and albuterol nebulisers, prednisone 40mg po daily and azithromycin. She had lateral decubitus CXR on [**1-6**] which showed a minimal left and moderate-large right pleural effusion. She was noted to have a rising lactate which was thought related to poor po intake. She latterly decompensated on the evening of [**1-6**] with a high RR, use of accessory muscles and feeling more SOB. Her ABG showed a respiratory alkalosis with a low pCO2. She was then started on IV ceftriaxone to cover for possibel infection although her WBC were notelevated, she remained afebrile and had no radiographic evidence of infection. Her lactate was seen to be increasing. As a precautionary measure, she was transferred to the ICU for consideration of BiPAP but this was not required. In the ICU she did not receive NIV and improved with nebs and lorazepam. The patient coped on baseline O2 requirement saturating well but was very anxiou regarding er breathing which was relieved by lorazepam. Her high lactate max 4.7 and was felt likely due to effort of breathing and some dehydration. Sh was seen by palliative care on [**1-8**] who recommended oral IR morphine 7.5mg Q4 PRN to as treatment of her anxiety regarding her pulmonary symptoms. She had a family meeting regarding her care and preferred to stay at home if possible and was adamant that she did not want to go to a nursing home. She had a family meeting on [**1-10**] regarding her care and was informed that her VNA services could also cover for hospice care. She worked with PT who felt she would benefit from a period of rehabilitation. She had ceftriaxone changed to oral cefpodoxime on [**1-10**] and this will be continued to complete a 5 day course ending [**1-11**]. She was seen by her pulmonologist Dr [**Last Name (STitle) 575**] on [**1-10**] who felt that a Pleurex drain may be of value to symptomatically treat her effusions as these effusions essentially excluded her best functioning lung tissue and were a considerable reason to account for her symptoms. She agreed to drain insertion and interventional pulmonology inserted a right Pleurex catheter on [**1-11**] and post procedure there was no evidence of pneumothorax on CXR but she did note pleuritic chest pain. This was relieved with oxycodone. She was discharged to rehabilitation on [**1-11**] and her leurex drain can be drained 3x/week. She will be seen by her PCP [**Last Name (NamePattern4) **] [**1-15**] and in due course by her pulmonologist. She will be seen for interventional pulmonology follow-up on [**1-24**] and by pulmonology in due course. Her wish was that if she were to worsen again that she would re-present to hospital as this would make her feel safe. . #. Pleural effusions: Currently with small bilateral pleural effusions on CXR and recent admission for exudative effusion of unclear etiology. DDx is broad but culture and workup have all been negative so far. Recent CT chest does show multiple pulmonary nodules but none changed from previous or suggesting malignancy. Could consider inflammatory /autoimmune causes. This could be contributing to her SOB. She went on to a lateral decub CXR on [**1-6**] which showed R>L effusions. She was resistant to the idea of diagnostic pleuroscopy on [**1-7**] when seen by interventional pulmonology following a brief stay in the ICU for a respiratory decompensation greatly worsened by extreme anxiety regarding her shortness of breath. She was changed to a regime to tackle her anxiety with breathing as above. She agreed to Pleurex drain insertion on [**1-11**] and this was inserted in teh right chest. 750ml was drained and limited by chest pain. Post procedure CXR showed no pneumothorax. She had pain at the site and this was relieved by oxycodone and a lidocaine patch can also be used. She will be seen by IP on [**1-14**]. She can have her Pleurex drained 3x per week on transfer to the community. . #. Elevated lactate: This rose from 3.1 on [**1-5**] to 4.7 on [**1-6**] with a normal anion gap and settled and remained down at 1.9-1.3 on [**1-7**] to [**1-8**]. This was felt most likely due to volume depletion in setting of poor po intake and increased work of breathing. She was treated with IV fluids, her breathing settled following anxiolytics and regular nebs and this fell to normal. . # Poor po intake: She noted little po intake past 2+ weeks. While in house, her intake improved. . #. Hypothyroidism: We continued home levothyroxine. TSH was normal. . #. Osteoporosis: Resumed alendronate. . #. Glaucoma: we continued home brimonidine and latanoprost eye drops. . #. Anxiety and Palliative Care: We continued home mirtazepine and increased lorazepam to 1mg PRN Q6H and she was seen by palliative care on [**1-8**] and they followed her during the rest pof her admission. They recommended adding morphine sulfate IR 7.5mg Q4H for anxiety regarding breathing. This considerably improved matters. She had a Pleurex drain placed on [**1-11**] for symptomatic relief of recurrent exudative effusions of unknown cause. She had a family meeting on [**1-10**] and her wish was to return home with services but not hospice at home although that would be an option if she worsens. In addition, her wish was that if she were to have another exacerbation again that she would re-present to hospital as this would make her feel safe. Medications on Admission: ALBUTEROL SULFATE - 2.5 mg/3 mL (0.083 %) Solution for Nebulization - 1 (One) vial(s) inhaled via nebulizaiton up to 4 times daily as needed for shortness of breath or wheezing ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2 (Two) puffs inhaled up to four times a day as needed for shortness of breath or wheezing when out of the house ALENDRONATE - (Not Taking as Prescribed) - 70 mg Tablet - 1 Tablet(s) by mouth weekly BRIMONIDINE [ALPHAGAN P] - (Prescribed by Other Provider) - Dosage uncertain BUDESONIDE-FORMOTEROL [SYMBICORT] - 160 mcg-4.5 mcg/Actuation HFA Aerosol Inhaler - 2 (Two) puffs inhaled twice a day FINGERTIP OXIMETER - - use as directed to assess home oxygen need FLUTICASONE - 50 mcg Spray, Suspension - 1 spray(s) in each nostril once or twice a day as needed for nasal allergy symptoms LATANOPROST [XALATAN] - (Prescribed by Other Provider) - 0.005 % Drops - LEVOTHYROXINE [LEVOXYL] - 75 mcg Tablet - one Tablet(s) by mouth once a day LORAZEPAM - 0.5 mg Tablet - 1 Tablet(s) by mouth four times a day as needed for anxiety MIRTAZAPINE - 15 mg Tablet - 2 Tablet(s) by mouth at bedtime OXYCODONE-ACETAMINOPHEN - 5 mg-325 mg Tablet - 1 Tablet(s) by mouth once a day For severe neck pain TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule, w/Inhalation Device - Contents of one capsule inhaled once a day Discharge Medications: 1. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 2. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 4. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 5. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain, fever. 6. dextromethorphan-guaifenesin 10-100 mg/5 mL Syrup Sig: Five (5) ML PO Q6H (every 6 hours) as needed for cough. 7. menthol-cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed) as needed for sore throat. 8. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as needed for wheeze and SOB. 10. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation QID (4 times a day). 11. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q2H (every 2 hours) as needed for sob, wheeze. 12. morphine 15 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours) as needed for anxiety and sob. 13. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. 14. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety. 15. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for constipation. 16. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 17. cefpodoxime 100 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 1 days. 18. Symbicort 160-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Inhalation twice a day. 19. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal [**Hospital1 **] (2 times a day) as needed for nasal congestion. 20. alendronate 70 mg Tablet Sig: One (1) Tablet PO QFRI (every Friday). 21. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for pain. 22. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. Discharge Disposition: Extended Care Facility: Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**] Discharge Diagnosis: Primary diagnoses: Chronic Obstructive Pulmonary Disease Exacerbation Exudative pleural effusions Pleurex drain insertion Anxiety regarding respiratory symptoms . Secondary diagnoses: Chronic sinusitis with secondary nasal drip and chronic cough. Hypothyroidism Chronic cough OA Glaucoma 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: It was a truly a pleasure looking after you during your stay at the [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **]. You presented with progressive shortness of breath and cough in addition to poor oral intake. You were treated for a COPD flare with oral steroids (to finish 5 days on [**1-11**]) and antibiotics in addition to regular and as needed nebulisers. You had worsening of your shortenss of breath and had a brief period of observation in the ICU. You have fluid collections at the base of your lungs (effusions) and you were seen by Interventional Pulmonology. You decided that you did not want any further intervention regarding these. You had considerable problems with anxiety regarding your shortness of breath and this was well controlled with lorazepam and latterly you were seen by Palliative Care to help with symptom control and we added oral morphine which also helped with your anxiety with breathing. You had a Pleurex drain inserted on [**1-11**] to help with the effusions (fluid around the lungs) and this can be drained at home 3x per week by VNA. You had some pain at the drain site and this settled with pain killers. By discharge, you were working with PT and discharged to rehab. . Changes to medications: We started oral cefpodoxime and should finish on [**1-11**] We started oral prednisone 40mg daily which should finish [**1-11**] We increased the frequency of your albuterol nebuliser to 4x daily and as required We stopped tiotropium and started ipratropium nebulisers 4x daily and as required We increased lorazepam to 1mg as needed up to every 6 hours We started oral morphine at 7.5mg as needed every 4 hours to help with distress and anxiety surrounding shortness of breath We started ondansetron as needed for nausea We started laxatives for constipation We started guaifenasin for your cough We started oxycodone for pain at the drain site If you need this, we have prescribed a lidocaine patch to help with pain at the drain site . Patient instructions: You will need to take your nebulisers regularly. Followup Instructions: We made the following appointments for you: We tried to make an appointment with Dr [**Last Name (STitle) 575**]. The secretary has put you on a wait list and discuss with Dr [**Last Name (STitle) 575**]. If he thinks you will need to be seen sooner, she will call pt at home with an appointment. You can also contact [**Name2 (NI) 28271**] office directly regarding this. . Department: [**Hospital3 249**] When: TUESDAY [**2193-1-15**] at 2:00 PM With: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**Telephone/Fax (1) 250**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: THURSDAY [**2193-1-24**] at 9:30 AM With: [**First Name8 (NamePattern2) 828**] [**Name8 (MD) 829**], MD [**0-0-**] 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

[ [ [] ] ]

[ "34.09" ]

icd9pcs

[ [ [] ] ]

18677, 18771

8154, 15003

289, 337

19113, 19113

4092, 8131

21442, 22446

3351, 3439

16408, 18654

18792, 18955

15029, 16385

19296, 21419

3454, 4073

18976, 19092

2466, 2874

239, 251

365, 2447

19128, 19272

2896, 3062

3078, 3335

5,453

171,739

19698

Discharge summary

report

Admission Date: [**2196-2-12**] Discharge Date: [**2196-3-9**] Date of Birth: [**2134-7-25**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 949**] Chief Complaint: Confusion Major Surgical or Invasive Procedure: Intubation/Mechanical Ventilation Arterial Line Lumbar Puncture History of Present Illness: 61yoM with hep C cirrhosis complicated with portal vein thrombosis on coumadin, known grade 1 varices, ascites on lasix 40mg, hepatic encephalopathy in past, on wait list for combined liver/kidney [**First Name3 (LF) **] with MELD 29, CKD from diabetic nephrosclerosis, and DM2 is admitted with confusion for 10 days and is transferred to the MICU for unresponsiveness. According to the report, he reported taking less lactulose then normal, usualy takes 3 a day but has been taking 1 a day for the last 2 weeks. As a result, he has noticed he is more confused and sleepy than usual. Has been oversleeping to 3PM daily. Says he has been struggling to use phones lately, ataxic gait (uses cane at baseline). Denies any fevers at home. Does report 2 episodes of emesis (brown tinge) in the last 10 days, non-bloody non-bilious. Last episode two days ago. No recent med changes. Denies chills, cough, SOB, chest pain, dysuria, no increase in abd girth. Was seen by PCP at [**Name9 (PRE) 53286**] and subsequently referred in for assessment. . Of note, pt admitted in [**12/2195**] for anemia and abdominal pain. He was managed conservatively with IV hydration and NPO, and vanco/zosyn-->cipro/flagyl, continued on cipro for prophylaxis. Transfused for HCT goal 27. Pt found to be pancytopenic due to hypersplenism. . In the ED, initial VS:97.2 62 136/63 18 100%. Ammonia 85. Lactate 2.1. Bicarb 19. Cr 2.2. WBC 2.9, HCT 28.9, PLT 66. INR 3.4. PTT 49. Head CT, no acute process. CXR no acute process. Bedside Abd U/S Scant ascites, not amenable to tap. Given 500cc IVF. Transfer vitals: 64 hr, 138/65, [**Last Name (un) **] 98 on RA, temp 97.6, rr 18 . On arrival to the floor, he reported confusion but was A+O x3, knows he is at [**Hospital1 18**]. He asked for narcotics and became angry when they were not given. He refused to take lactulose. At the time of 5AM morning vitals, he was unresponsive to pain, loud voice or sternal rub vitals were 112/56 62 18 100% on NRB (NRB placed despite o2 sat >95% on RA). ABG showed 7.50/28/91/23. He was then transferred to the MICU for closer monitoring. Past Medical History: - Hepatitis C cirrhosis genotype 1A (c/b h/o portal hypertension/ ascites/encephalopathy/SBP) awaiting combined liver/kidney [**Hospital1 **], Hepatitis C viral load [**3-/2192**]: 401,000 IU/mL; MELD 20 on [**2194-4-17**]. - Esophageal Varices: endoscopy [**2189**]: grade I varices - CKD (baseline Cr = 1.4-1.5): Diabetic Nephrosclerosis by biopsy - Diabetes (last HgA1C [**7-/2190**] 6%) with neuropathy - Ribavirin-induced Hemolytic Anemia - History of spontaneous bacterial peritonitis - Pancytopenia likely d/t hypersplenism - Chronic hyperkalemia - Hypertension - h/o IVDU with methadone maintenance, now off all therapy - DVT s/p IVC filter placement ([**10/2188**])- spontaneous in setting of hepatic encephalopathy - Hemmorhoids - Hx of PV thrombosis, restarted on coumadin Social History: Works as a carpenter. Lives with sister. Recently quit smoking, 30 pack year history. Sister is HPA. Prior history of IVDU heroin and cocaine quit 7 years ago. On methadone until 2 years ago. Denies alcohol, drugs recently. Lives in [**Location **] alone. Family History: Father died [**Name2 (NI) 53283**] at 55, no history of blood clots in family Physical Exam: Vitals: T:97.6 BP:112/56 P:62 R: 18 O2: 100% NRB General: eyes closed mouth open, snoring. not responsive to pain or loud voice HEENT: pupils 5mm and reactive PEERL sclera anicteric, MMM. Edontulous Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: chronic venous stasis changes on lower extremities BL. Warm, well perfused, No edema Neuro: positive corneal reflex. flacid upper and lower extremities. . Pertinent Results: [**2196-2-12**] 02:06PM BLOOD WBC-2.9* RBC-3.24* Hgb-9.8* Hct-28.9* MCV-89# MCH-30.4 MCHC-34.1 RDW-17.5* Plt Ct-66*# [**2196-2-12**] 02:06PM BLOOD Neuts-77.7* Lymphs-11.2* Monos-4.6 Eos-5.8* Baso-0.6 [**2196-2-12**] 02:06PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+ Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-2+ [**2196-2-12**] 02:06PM BLOOD PT-34.9* PTT-48.9* INR(PT)-3.4* [**2196-2-12**] 02:06PM BLOOD Glucose-315* UreaN-48* Creat-2.2* Na-141 K-3.9 Cl-110* HCO3-19* AnGap-16 [**2196-2-12**] 02:06PM BLOOD ALT-23 AST-40 TotBili-0.9 [**2196-2-13**] 10:43AM BLOOD Calcium-7.4* Phos-2.3* Mg-1.4* [**2196-2-16**] 02:11AM BLOOD Hapto-24* [**2196-2-12**] 02:06PM BLOOD Ammonia-85* [**2196-2-16**] 02:11AM BLOOD HIV Ab-NEGATIVE [**2196-2-15**] 04:21AM BLOOD Vanco-11.1 [**2196-2-13**] 10:43AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2196-2-13**] 06:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2196-2-13**] 05:22AM BLOOD Type-ART pO2-91 pCO2-28* pH-7.50* calTCO2-23 Base XS-0 [**2196-2-13**] 05:22AM BLOOD Glucose-129* Lactate-1.6 Na-140 K-4.5 Cl-113* [**2196-2-14**] 08:40PM BLOOD freeCa-1.23 [**2-12**] CT head: IMPRESSION: No acute intracranial process [**2-15**] MRI head: IMPRESSION: Predominantly cortical restricted diffusion. The most likely diagnosis would be diffuse hypoxic injury. Other alternate possibilities include CJD but the distribution is contiguous and would be less typical. The appearances are also not typical for posterior reversible encephalopathy syndrome. [**2-16**] CXR: The ET tube tip is 3.2 cm above the carina. The NG tube tip is in the stomach. The heart size and mediastinum are unremarkable. There is interval development of widespread parenchymal opacities, with perihilar and basilar distribution, most likely representing edema, although interval development of infection is a possibility. Reevaluation after diuresis is recommended if clinically warranted. There is no pleural effusion or pneumothorax. . [**2-23**] MRI head: IMPRESSION: Persistent areas of cortical restricted diffusion bilaterally, involving the frontal, temporal, parietal and insular regions as described above, persistent areas of restricted diffusion in the basal ganglia bilaterally. The possibility of diffuse hypoxic injury is a consideration, other causes cannot be completely excluded, including an infectious process. Bilateral fluid levels at the occipital ventricular horns, suggesting intraventricular hemorrhage. There is no evidence of hydrocephalus or mass effect. . [**2-26**] MR [**First Name (Titles) 41307**] [**Last Name (Titles) 53287**] [**Last Name (Titles) 41307**] was performed at the level of the centrum semiovale. This demonstrates what appears to be increased choline and decreased NAA. Findings are nonspecific and can be seen in inflammatory disease or neoplasm. Questionably increased lactate is noted in a few voxels IMPRESSION: Limited study due to motion. Nonspecific findings on MR [**Last Name (Titles) 41307**]. . [**3-9**] Opacification of the left lung has increased, there is now a complete opacification of the left hemithorax. The left lung is normal and shows normal ventilation. Unchanged course of the Dobbhoff tube. A wet read was delivered at the time of image acquisition. Brief Hospital Course: 61yoM with hep C cirrhosis complicated with portal vein thrombosis on coumadin, known grade 1 varices, ascites, hepatic encephalopathy in past, previously on wait list for combined liver/kidney [**Month/Day (4) **] with MELD 29, CKD from diabetic nephrosclerosis, and DM2 is admitted with confusion for 10 days now with persistent ams. # Altered mental status: Pt admitted initially with presumed hepatic encephalopathy as there was a history of decreased lactulose use. In the beginning of his admission he continued to refuse lactulose. Later he was found unresponsive and transferred to the MICU. His lactulose was restarted by NGT. His mental status improved however he was noted to have persistent confusion and significant moter deficits in non-vascular distribution and word finding difficulties. A lumbar puncture was performed which was unrevealing. Multiple MRIs were performed which showed restricted diffusion in b/l cortices most consistent with hypoxic brain injury. Neurology felt that this may still be hepatic encephalopathy though he had been stooling adequately for greater than two weeks without significant improvement in his mental status. A repeat lumbar was performed to rule out both CMV, in addition to prion disease. Only a few millilters of fluid were obtained despite the fact that the procedure was done under fluoroscopy. Due to the small volume only CMV PCR was sent which was negative. Prognosis was felt to be extremely poor. After prolonged discussion with the family the patient was made DNR/DNI. Neurological status failed to improve and ultimately the passed passed away as below. . #Seizure: He had a seizure during this hospitalization that was treated with IV ativan. Per report he has a had a prior seizure eight years ago. His ciprofloxacin was stopped to avoid seizure threshold lowering and he was started on keppra. A Video EEG did not show any seizure activity. Initially his mental status was thought to be a post-ictal state, however as it did not improve with time this was not felt to be related. He was continued on keppra without further seizure activity. . # Cirhosis: From hepatitis C, complicated by hepatic encephalopathy and h/o varices, portal vein thrombosis and ascites. He was presumptively treated for hepatic encephalopathy as this was felt to be a component of his AMS. Otherwise his liver was stable thoroughout this admission. However because of his mental deterioration he was de-activated and ultimately de-listed. . #Hypernatremia: His course was complcated by hypernatremia. He was intermittently given small boluses of D5 with careful monitoring to avoid rapidly correcting his sodium levels. His free water flushes were increased and his lactulose was decreased to keep his volume adequate. . #Portal Vein Thrombosis: he was initially on warfarin for anticoagulation. However, an [**Month/Day (4) 950**] showed patent portal veins and the decision was made that the risks of bleeding with continued anticoagulation outweighed the benfits and his warfarin was stopped. . # Respiratory status- On the evening of [**2196-3-9**] the patient was noted to become acutely dyspneic. Initial oxygen saturations remained stable in the high 90s. Chest xray was suggestive of lung collapse which was attributed to mucous plugging. The patient's family was contact[**Name (NI) **] and once again expressed desire to avoid invasive procedure such as intubation. The patient's saturations began to decrease despite face oxygen. He ultimately expired. Breath sounds and heart absent. Pupils were non reactive and the patient was pronounced dead with family at bedside. Medications on Admission: Propranolol 10 mg [**Hospital1 **] Lactulose 10 gram/15 mL (15) ML PO BID Ciprofloxacin 250 mg Daily Calcitriol 0.25 mcg PO MWF Amlodipine 10 mg Omeprazole 20 mg [**Hospital1 **] Procrit 40,000 unit/mL Solution once a week. Gabapentin 300 mg QAM Gabapentin 600 mg QPM Rifaximin 550 mg [**Hospital1 **] Furosemide 40 mg Daily Coumadin 1 mg currently taking 5mg a day for last week, but was taking 3mg daily prior oxycodone mg Q6H PRN Calcium 600 + D(3) 600 mg(1,500mg) -400 unit [**Hospital1 **] Ferrous sulfate 325 mg (65 mg iron) Ambien 5 mg Risendronate 35 mg Weekly Fish Oil 1,000 mg Daily Insulin glargine Ten (10) units Subcutaneous at bedtime. Discharge Disposition: Expired Discharge Diagnosis: Altered mental staus Hepatic encephalopathy Possible hypoxic brain injury . Secondary diagnosis Cirrhosis Discharge Condition: deceased

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icd9cm

[ [ [] ] ]

[ "96.71", "54.91", "03.31", "96.6", "96.04" ]

icd9pcs

[ [ [] ] ]

12016, 12025

7683, 8030

312, 378

12175, 12186

4349, 5529

3604, 3683

12046, 12154

11342, 11993

3698, 4330

263, 274

406, 2503

5538, 7660

8045, 11316

2525, 3312

3328, 3588

45,426

166,752

35889

Discharge summary

report

Admission Date: [**2144-1-3**] Discharge Date: [**2144-1-28**] Date of Birth: [**2066-8-10**] Sex: M Service: SURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 4691**] Chief Complaint: MVC requiring intubation Major Surgical or Invasive Procedure: 1. Exploratory laparotomy and packing of liver ([**1-3**]), external fixation of right tibia-fibula, traction pin of left femur ([**1-3**]) 2. exploratory laparotomy and removal of packing and abdominal fascial closure with skin staples, 3. placement of PEG and IVC filter ([**1-6**]), 4. Irrigation and debridement right tibiotalar dislocation, repair and tenodesis posterior tibial tendon to flexor hallucis, complex wound closure right open wound, open reduction internal fixation of left medial malleolar fracture, Open reduction internal fixation of left syndesmotic repair.([**1-6**]), 5. open Cricothyrotomy ([**1-17**]), Resection of total hip arthroplasty ([**1-17**]), Open reduction internal fixation femur with intramedullary nail 420 x 9 mm, unreamed, Open reduction internal fixation femur with cerclage and plating 6. Left ankle I+D [**1-27**] History of Present Illness: The patient is an elderly man who was in a motor vehicle crash, sustained multiple injuries including multiple lower extremity and pelvic fractures. Past Medical History: PMHx: HTN, DM2, CAD s/p MI [**2135**], RCA stent [**9-28**], ^lipid, DVT in [**1-1**], BPH, OA, L5 disc disease, THR b/l, Hernia, rotator cuff repair, back surgery for L4-L5 disc disease in [**2139**] [**Last Name (un) 1724**]: Atenolol 25', Simvastatin 40', Lisinopril 10', ASA 81', Diclofenac 75", Proscar 5', Metolazone 25', potassium 20' Social History: Unknown Family History: Unknown Physical Exam: On Discharge: Pertinent Results: Trends: WBC on admission-->WBC on discharge: 18.9--28.7--14.8--46.3--23.6--15.4--12 Hct on admission-->Hct on discharge: 33.9--22.8--28--31--28--27--24--25--24.1 INR on admission-->INR on discharge: 1.1--1.7--1.3 LFTs: (ALT/AST/AP/TB/DB): 3[**Telephone/Fax (5) 81547**]/3.5-->141/45/231/2.0/0.9-->28/24/166/1.0 [**1-3**] ECHO: 1. The left atrium and right atrium are normal in cavity size. No atrial septal defect or PFO is seen by 2D or color Doppler. 2. Left ventricular wall thicknesses and cavity size are normal. Left ventricular function is hyperdynamic and underfilled. 3. Right ventricular chamber size and free wall motion are normal. 4. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. No thoracic aortic dissection is seen. 5. There is mild aortic valve stenosis (area 1.2-1.9cm2). 6. The mitral valve appears structurally normal with trivial mitral regurgitation. 7. There is no pericardial effusion. There are no echocardiographic signs of tamponade. 8. A left pleural effusion and atelectasis is seen. 9. EF estimated to be 70% (ventricle is underfilled however) ECHO [**1-7**]: No atrial septal defect is seen by 2D or color Doppler. 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 diameters of aorta at the sinus, ascending and arch levels are normal. The descending thoracic aorta is mildly dilated. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (area 1.3 cm2). Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. Compared with the findings of the prior report (images unavailable for review) from [**2144-1-3**], findings are similar and the left ventricle is not hyperdynamic CTOH [**1-3**]: no ICH/fx CT C-spine: no fx CT Torso: Rib fx b/l [**3-31**], superior and inferior pubic rami on the L and ischium on the L, L acetabulum, vertical fracture of the R side of the sacrum, displaced fracture of the sternum and comminuted fractures of the femurs b/l, b/l small pleural effusions, b/l pelvic hematoms L-11X7cm, R-5.5X9cm CT Recon of spine: no Fx of T/L, tiny calcific density posterior to L5-S1 interspace is incompletely evaluated [**1-9**] RUQ US: Sludge and stones in distended gallbladder [**1-9**] CTOH: ? severe sinusitis and mastoiditis. [**1-9**] CT Torso: b/l pleural effusions and relaxation atelectasis, ascites, fractures of the ribs, pelvis and femurs unchanged, massive anasarca and scrotal edema including L > R hydrocele. [**1-15**] CT Torso: Increased b/l pulmonary consolidation, minimally changed study with numerous fractures, small ascites, cholelithiasis with pericholecystic fat stranding. [**1-21**] GJ tube study: Reflux of contrast into the stomach, however, contrast also progresses into the distal duodenum and proximal jejunum. No obstruction. **of note contrast was delivered into the G-tube port** [**1-16**] TibFib XR: 1. Massively comminuted fracture of the proximal femur with multiple butterfly fragments and loose fragments of cement in patient with a total left hip arthroplasty. 2. Acetabular component remains well seated in the acetabulum. No dislocation of the femoral head. 3. Transverse fracture through a minimally dorsally angulated mid-fibular shaft. 4. Status post ORIF of a distal tibial fracture with fracture line evident but no hardware-related complications. [**1-20**] Femur XR: LEFT FEMORAL, TWO VIEWS: The patient is status post periprosthetic fracture of the left proximal femur with interval placement of the intramedullary nails and screws and cerclage wires. Lateral plate of the proximal femur is also visualized. The acetabular cap is in place. Osseous fragments are noted in the medial thigh. Skin staples are noted within the lateral thigh. Cultures: [**1-3**] MRSA: negative [**1-4**] UCx: no growth final [**1-4**]: BCx: no growth [**1-5**] sputum: no growth [**1-6**] MRSA screen negative [**1-7**] BAL: normal flora growth [**1-9**] Cath Tip: no growth final [**1-9**] UCx: no growth final [**1-9**] BCx: no growth final [**1-9**] Cath Tip: no growth final [**1-9**] Nares Swab: no growth final [**1-13**] BAL: no growth-final [**1-13**] C.diff: negative [**1-15**] UCx: no growth final [**1-15**] Sput: no growth final [**1-15**] Cath Tip: no growth final [**1-15**] BAL: no growth final [**1-15**] BCx: no growth final [**1-18**] UCx: no growth final [**1-18**] BCx: no growth final [**1-18**] Sput: no growth final [**1-20**] MRSA screen [**1-20**] Cdiff negative Brief Hospital Course: 77M in MVC. Upon arrival to [**Hospital1 18**] ED, patient hypotensive despite fluids and blood given. Patient intubated but still hypotensive. Pressors started. Given his hypotension, the patient was quickly transferred to the ED for an emergent ex-lap. No obvious bleeders were found, however the liver bed was suspect. The liver was packed with gauze, the skin was closed, and the patient was taken to the TSICU for recussitation. After a few days, the patient was taken back to the OR for re-exploration and formal abdominal wall closure. During his time in the TSICU, orthopedics took him back to the OR for his lower extremity injuries. His course in the TSICU was complicated by prolonged ventilation ultimately requiring a tracheostomy. Please see below for more details during his TSICU stay. Events in TSICU [**1-3**]: Received bicarbonate infusion for acidosis. Had head, c-spine and torso CT. No acute source of bleeding found. overnight volume resuscitation with LR and albumin. [**1-4**]: multiple boluses (albumin and LR for SVV >15, MAP <65). cultured for fever. esoph P neg 6--> inc peep, able to [**Month (only) **] FiO2 to 80%. INR 1.6 (no improvement with IV vit K): per trauma hold on ffp. [**1-5**]: To OR AM [**1-6**] to remove packing and closure, ? ortho to fix ankle fractures [**1-6**], pt remains w/ stable bladder pressures and increased PEEPs. [**1-6**]: Went back to OR; had PEG, IVC filter, abdomen closed, no pelvic hematoma visible, L ankle ORIF, R knee washout. 1 unit prbc - EBL 250. Right SC CVL placed. ETT cuff leak, CXR indicated that it was shallow, advanced forward to 26cm. BP labile overnight, phenylephrine increased. Bladder pressure increased from 16 to mid 20's, UO trailing off - received increased IV fluid with LR (250/hr) plus boluses (1 L) [**1-7**]: bedside ECHO done -> pt. filled; cistracurium restarted; levo started and neo off; family meeting; bladder pressures in mid 20s -> to 15 early afternoon; esophageal balloon placed; bronch done -> many thick secretions Right lower; vanco/levo/aztreonam started -> changed to vanco/ceftriaxone; attempted inverse I:E with PEEP 15 -> SBP to 60s and O2sat to high 80s and trialed FiO2 80; given 2U PRBCs [**1-8**]: FiO2 weaned, weaning levophed, 1UpRBCs transfused, KVOed, making urine w/o lasix, ortho will wait to operate until next week, BPs labile overnight, WBC increasing [**1-9**]:Received RUQ US for elevated LFTs, Right CVL switched to quad lumen line, L SCV line removed, tips sent for culture. BC and UC sent. Started on Flagyl for C. diff coverage. Weaning Fi02. Had CT head, torso and lower extremities which showed fluid in the sinuses. Seen by ENT who took cultures but do not feel that infective source is sinusitis [**1-10**]: Vent changed to PEEP 18, prolonged I:E -> 1.4:1; placed on rotating bed; cisatracurium weaned off; abdominal incision partly opened and packed -> fat necrosis; one dose of demerol for shaking; Tube feeds changed to 3/4 strength [**1-11**]: PEEP weaned to 15, FiO2 50%, standing albumin Q8 ordered, lasix gtt cont, TFs switched to full strength @ 60cc/hr. [**2144-1-12**]: Switched to PS, srated on lactulose, given HCTZ in addition to lasix for diuresis. Albumin held. Weaning fentanyl and midazolam. Tired from PS, switched back to CMV at night. Copious pulmonary secretions. [**1-13**]: Lasix gtt for diuresis -> >2L negative [**1-14**]: lasix gtt/diuril d/ced, antibiotics d/ced, to OR [**1-15**], patient w large output from G-tube after TFs discontinued. [**1-15**]: temp to 101, tachy, hypotensive -> restarted levophed and cmv, pan cultured. G tube output elevated. CT torso negative. started vanc/levo/flagyl, given boluses LR. R SCVL removed and L SCVL placed. Bronched and BAL sent. [**1-16**]: tube feeds held, reglan started, g-tube clamped, plain films of femur in anticipation of OR [**1-17**] [**1-17**]: s/p OR - ORIF L femur, s/p tracheostomy (EBL 1500 - 3 units of blood, 1FFP in OR). [**1-18**]: DC'd midaz drip and given ativan prn; tightened RISS; TF to 60/hr. Checked urine lytes, osmol, FeNa. Has eosinophils in urine-UA sent for casts, ?cause of nephritis unclear. Have Dc'd famotidine and started sucralfate. Pancultured overnight. Have started metoprolol. [**1-19**]: lopressor increased; given 1U PRBC; TF to 125cc/hr; continuing to replace free water deficit; L aline looking erythematous -> attempted resiting overnight and wildly unsuccessful [**1-20**]: lopressor increased; methadone started; free water infusion stopped; fentanyl weaned [**1-21**]: TF noted when suctioning trach early am -> CXR taken and TF held; lopressor increased to 50mg [**Hospital1 **]; e-mycin started as promotility [**Doctor Last Name 360**]; tube study negative, ceftazidime dc'd. TF restarted at 30cc/hr and slowly increasing to goal 80/hr. IV Free water stopped. Trach mask trials started, patient did well for 8-10 hours. Placed back on the vent overnight to rest. [**1-27**]: Went to the OR for I+D, washout of his left ankle [**1-28**]: He resumed gentle diuresis with Lasix 40 Po BID. He is 20 kilograms over his admit weight, but also take into consideration his orthopedic hardware; he also bumped his creatinine with large amounts of Lasix and when on the Lasix drip, so while diuresis is needed, it should not be done too aggressively. Medications on Admission: Unknown Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: 71yo M MVC with prolonged ventilatory status s/p Cricothyrotomy, IVC filter placement, GJ placement, external fixation of right tib-fib, Left ORIF ankle, ORIF left femur Discharge Condition: Stable Discharge Instructions: You are being discharged to a facility that is equipped with a full respiratory staff. If you have problems breathing, feel that your chest is heavy, or suddenly have copious amounts of secretions, please inform the staff immediately. If you feel confused or dizzy, please notify the staff immediately as well. You will also work with physical therapy during your stay in this facility. They will help you get out of bed to your chair.

[ "V43.64", "864.02", "808.2", "958.4", "250.00", "825.31", "996.42", "E812.0", "518.5", "807.4", "824.4", "820.8", "278.01", "998.33", "E878.1", "461.9", "863.42", "401.9", "873.43" ]

icd9cm

[ [ [] ] ]

[ "38.7", "78.18", "46.32", "22.19", "84.72", "79.37", "31.1", "80.05", "46.75", "96.72", "79.67", "79.15", "79.35", "88.72", "27.59", "86.28", "83.88", "79.36" ]

icd9pcs

[ [ [] ] ]

12008, 12078

6636, 11950

295, 1156

12292, 12301

1799, 1831

1741, 1750

12099, 12271

11976, 11985

12325, 12767

1765, 1765

2001, 6613

231, 257

1184, 1334

1356, 1700

1716, 1725

11,040

142,139

43513

Discharge summary

report

Admission Date: [**2200-3-14**] Discharge Date: [**2199-3-17**] Service: HISTORY OF PRESENT ILLNESS: The patient is an 84-year-old Greek man who presented to the Emergency Room with an episode of large volume coffee ground emesis immediately following his dinner. He brought a sample of the emesis which was hemoccult positive. The patient also mentioned that he had He had no emesis once he got to the Emergency Room and he states this never happened to him before. He does occasionally take Pepcid but not chronically. He has no history of liver disease or alcoholism He does have a history of breast cancer which was resected ten years ago and without recurrence. The patient also noted decrease in feeling well for the last one to two weeks. No change in his stool to a darker color over the past few weeks. The son did state that his father appeared to have lost some weight. The patient denied any dizziness but had noted some fatigue. He had no chest pain, epigastric or abdominal pain. No nausea, short of breath, no fever or chills. He did have a upper respiratory infection three weeks ago. No other symptoms. PAST MEDICAL HISTORY: 1. Coronary artery disease, status post percutaneous transluminal coronary angioplasty greater than 10 years ago. 2. Type II diabetes mellitus. 3. Breast cancer, status post surgery ten years ago on the right. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Enteric coated aspirin q day. 2. Accupril 20 mg q day. 3. Amaril 1 mg twice a day. SOCIAL HISTORY: The patient is a retired shoemaker, he drinks occasional wine. He lives with his son in [**Name (NI) 11206**] (the sons name is [**Name (NI) **] [**Telephone/Fax (1) 93648**]). [**Name2 (NI) **] quit smoking 30 years ago. He has an active lifestyle. FAMILY HISTORY: No history of cancer. PHYSICAL EXAMINATION: The patient was afebrile at 98.3 degrees, heart rate of 84, blood pressure of 114/43, respiratory rate of 18, oxygen saturation of 96% on room air. On general exam he was alert and oriented but pale in no apparent distress. Head, eyes, ears, nose and throat exam showed normocephalic, atraumatic head with pupils being equal, round and reactive. His extraocular movements intact. His oropharynx was dry. Neck was supple with no thyromegaly and no lymphadenopathy, no jugular venous distention. His heart was regular rate and rhythm with a 1/6 systolic diastolic murmur at the right upper sternal border and normal S1 and S2. His lungs were clear to auscultation bilateral. His back showed no spinal tenderness and no CVAT. His abdomen was nondistended, nontender with hyperactive bowel sounds. His liver span was about 8 cm not palpable below the costal margin. He had no splenomegaly or tenderness, no caput medusa. Per the Emergency Room he was guaiac positive with brown stool. His extremities showed no cyanosis, clubbing or edema. 2+ radials and 2+ dorsalis pedis pulses bilateral. Neurologic exam: His cranial nerves 2 through 12 were intact. His motor and sensory examination was grossly intact. His deep tendon reflexes were 2+ and symmetrical. Skin showed no erythema, pale mucosa, no spider angiomata were appreciated. LABORATORY: The patient's white blood count was 9.4 with a hematocrit of 22.1 (over baseline of 36 to 38 in [**Month (only) 1096**]) and platelets of 357. Sodium was 133, potassium 4.7, chloride 99, bicarbonate 20, BUN 50 and creatinine 1.2. Electrocardiogram showed normal sinus rhythm at 88 with normal axis,normal intervals and T-wave inversion in AVR as well as Q's in V4 through V6, Tall R's in V2. HOSPITAL COURSE: The patient was admitted to the MICU initially for workup of an upper gastrointestinal bleed. He was transfused a total of three units of packed red blood cells with good results. He had no further episodes of hematemesis and his stool was brown throughout the hospitalization. Given the low hematocrit and the patient's history of coronary artery disease he was ruled out for myocardial infarction with CKs of 41, 27 and 30 and Troponin's less than .3 each time. On [**2200-3-14**] the patient underwent a esophagogastroduodenoscopy which showed a single crater of 3 cm ulcer in the stomach body (lesser curvature) with thickened edematous edges and stigmata of recent bleeding although no blood was seen in the stomach or duodenum. Cold forceps biopsies were taken both for histology and for H. pylori. Otherwise the patient's esophagogastroduodenoscopy was normal to the second part of the duodenum. The patient's non-steroidal anti-inflammatory drugs were stopped and these were not restarted. He was started on twice a day Protonix. The patient did well in the Intensive Care Unit and was sent out to the general medical floor in good condition on [**2200-3-15**]. He was hemodynamically stable, his hematocrit was stable in the 33 range. The patient did well but on the night of [**2200-3-15**] noted acute sudden onset of pain in his right first metatarsal pharyngeal joint felt to be most consistent with gout. Rheumatology consult was called who agreed this most likely represented an episode of gout. Given that the patient had no history of prior gout they did not feel that long-term treatment with Allopurinol was warranted at this time. Given the fact that the patient could not be started on non-steroidal anti-inflammatory drugs or systemic steroids and that Colchicine with its gastrointestinal toxicity should also be avoided at this time the Rheumatology service injected the metatarsal phalangeal joint with 40 mg of Depo Medrol with good effect. The patient's pain actually improved overnight. He was also given Ultram and Tylenol for pain and he was discharged with prescriptions for these medications. The physical therapy service walked with the patient and did not feel the patient needed any further intervention and he was able to walk well. For follow-up for the gastrointestinal issues the patient was scheduled for gastrointestinal follow-up with the Gastrointestinal service on [**2200-3-25**] and the patient was discharged to home in good condition on [**2200-3-17**] with the biopsy result and H. pylori results still pending. Following discharge the H. pylori antibody titer came back as negative. Later that day, the gastrointestinal service notified the primary team that biopsy of the stomach ulcer showed poorly differentiated adenocarcinoma. The patient has already had a scheduled follow-up with gastrointestinal on [**2200-3-25**] which is one week after discharge. The patient's PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) 401**] Salamis ([**Telephone/Fax (1) 11144**]) was contact[**Name (NI) **] with this diagnosis and he will contact the patient and set up him up with outpatient Oncology follow-up likely at [**Hospital6 **] and decisions for further care can be made at that time. DISCHARGE CONDITION: Good. DISCHARGE STATUS: Full Code. MEDICATIONS ON DISCHARGE: 1. Protonix 40 mg twice a day. 2. Accupril 20 mg q day. 3. Amaril 1 mg twice a day. 4. Ultram 50 mg p.o. q 4 to 6 hours p.r.n. for pain. DISCHARGE DIAGNOSIS: 1. Upper gastrointestinal bleed secondary to stomach ulcer from poorly differentiated gastric adenocarcinoma. 2. See past medical history. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10477**], MD [**MD Number(2) 11775**] Dictated By:[**Dictator Info **] MEDQUIST36 D: [**2200-3-17**] 15:34 T: [**2200-3-17**] 15:37 JOB#: [**Job Number 93649**] cc:[**First Name (STitle) 93650**]

[ "535.10", "274.0", "V45.82", "151.4", "531.40", "285.9", "V10.3", "276.5", "414.01" ]

icd9cm

[ [ [] ] ]

[ "81.92", "99.23", "45.16" ]

icd9pcs

[ [ [] ] ]

6915, 6953

1809, 1832

7142, 7589

6979, 7121

3625, 6893

1855, 2954

111, 1144

2972, 3607

1166, 1521

1538, 1792

78,995

124,007

25944

Discharge summary

report

Admission Date: [**2175-5-1**] Discharge Date: [**2175-5-4**] Date of Birth: [**2109-12-10**] Sex: F Service: ORTHOPAEDICS Allergies: Penicillins / Aspirin / Biaxin Attending:[**First Name8 (NamePattern2) 1103**] Chief Complaint: R knee pain Major Surgical or Invasive Procedure: [**2175-5-1**]: s/p right total knee replacement History of Present Illness: R knee OA Past Medical History: GERD Asthma Diabetes Mellitus (per patient - related to steroid use) HTN Dyslipidemia Rheumatoid Arthritis (per patient) Osteoporosis Depression S/p CCY [**9-27**] L4-L5 grade 1 spondylolisthesis, ?synovial cyst PSHx: umbilical hernia repair, tendon repair, left foot surgery, right rotator cuff repair [**10/2174**] Social History: Lives alone and is retired. Does not smoke, consume alcohol or use illicit drugs Family History: n/a Physical Exam: Well appearing in no acute distress Afebrile with stable vital signs Pain well-controlled Respiratory: CTAB Cardiovascular: RRR Gastrointestinal: NT/ND Genitourinary: Voiding independently Neurologic: Intact with no focal deficits Psychiatric: Pleasant, A&O x3 Musculoskeletal Lower Extremity: * Incision healing well with staples * Scant serosanguinous drainage * Thigh full but soft * No calf tenderness * 5/5 strength * SILT, NVI distally * Toes warm Pertinent Results: Imaging/diagnostics: - CT head: 1. No acute intracranial hemorrhage. 2. Bifrontal white matter hypodensity, left greater than right, which could be related to chronic small vessel ischemic disease, but mild acute edema cannot be excluded. If edema is present, it could be related to watershed infarction, given recent surgery, though other etiologies cannot be excluded.Since MRI is contraindicated in the immediate postoperative setting, shortinterval follow-up CT is recommended to assess for any progression of thesefindings. If clinically indicated, a CTA of the head may be obtained toexclude large vascular occlusion. . - CTA chest: No acute PE to the segmental level. . - Echocardiogram: The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. The right atrial pressure is indeterminate. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with infero-lateral akinesis. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No 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 mild pulmonary artery systolic hypertension. There is no pericardial effusion. [**2175-5-4**] 01:16PM BLOOD WBC-9.5 RBC-3.49* Hgb-11.0* Hct-31.6* MCV-91 MCH-31.4 MCHC-34.6 RDW-14.1 Plt Ct-203 [**2175-5-3**] 03:40AM BLOOD WBC-9.6 RBC-2.62* Hgb-8.2* Hct-24.2* MCV-92 MCH-31.4 MCHC-33.9 RDW-14.2 Plt Ct-192 [**2175-5-2**] 11:26AM BLOOD WBC-14.1* RBC-3.19* Hgb-10.0* Hct-29.5* MCV-93 MCH-31.5 MCHC-34.0 RDW-14.1 Plt Ct-213 [**2175-5-2**] 07:12AM BLOOD WBC-10.0 RBC-3.35* Hgb-10.3* Hct-30.8* MCV-92 MCH-30.6 MCHC-33.4 RDW-14.3 Plt Ct-230 [**2175-5-1**] 05:00PM BLOOD WBC-10.9# RBC-3.53* Hgb-10.8* Hct-32.8* MCV-93 MCH-30.6 MCHC-33.0 RDW-13.9 Plt Ct-236 [**2175-5-4**] 10:55AM BLOOD PT-15.1* INR(PT)-1.3* [**2175-5-3**] 04:25PM BLOOD PT-17.9* INR(PT)-1.6* [**2175-5-3**] 03:40AM BLOOD PT-16.7* PTT-28.3 INR(PT)-1.5* [**2175-5-2**] 11:26AM BLOOD PT-16.0* PTT-27.8 INR(PT)-1.4* [**2175-5-4**] 10:55AM BLOOD Glucose-108* UreaN-10 Creat-0.8 Na-138 K-3.8 Cl-103 HCO3-27 AnGap-12 [**2175-5-3**] 03:40AM BLOOD Glucose-92 UreaN-8 Creat-0.8 Na-142 K-3.7 Cl-105 HCO3-30 AnGap-11 [**2175-5-3**] 04:25PM BLOOD CK(CPK)-515* [**2175-5-3**] 03:40AM BLOOD ALT-82* AST-57* LD(LDH)-206 CK(CPK)-487* AlkPhos-68 TotBili-0.6 [**2175-5-2**] 11:26AM BLOOD ALT-127* AST-120* LD(LDH)-390* CK(CPK)-175 AlkPhos-81 TotBili-0.6 [**2175-5-3**] 04:25PM BLOOD CK-MB-3 cTropnT-<0.01 [**2175-5-3**] 03:40AM BLOOD CK-MB-3 cTropnT-0.03* [**2175-5-2**] 11:26AM BLOOD CK-MB-3 cTropnT-<0.01 proBNP-113 [**2175-5-3**] 03:40AM BLOOD Albumin-2.9* Calcium-8.1* Phos-3.2 Mg-1.9 [**2175-5-2**] 11:26AM BLOOD Albumin-3.5 Calcium-8.7 Phos-4.2 Mg-1.9 Brief Hospital Course: The patient was admitted to the orthopaedic surgery service and was taken to the operating room for above described procedure. Please see separately dictated operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Patient received perioperative IV antibiotics. Postoperative course was remarkable for the following: 1. [**Hospital Unit Name 153**] Course: On POD#1, patient developed sudden loss of consciousness with bilateral hand-twitching. Code Blue was called and patient was intubated for air protection. CT head was negative for acute bleed but showed bifrontal white matter hypodensity, left greater than right likely related to chronic small vessel ischemic disease. Patient had rapid recovery of mental status. Neurology was consulted and felt that patient's symptoms were more likely to be from transient hypotension and unlikely to be stroke. CTA of the chest of performed which ruled out PE. Patient was extubated the same afternoon. Mental status was throughout. Cardiac enzymes were stable and echocardiogram showed regional LV systolic dysfunction new compared to prior exam. Most likely cause of episode was transient hypotension post-operatively, likely from pain medications. Patient transferred back to the orthopedics service. 2. Post-op anemia - POD #2 Hct 24.2, asymptomatic -> Transfused 2 units PRBCs Otherwise, pain was initially controlled with a PCA followed by a transition to oral pain medications on POD#1. The patient received lovenox for DVT prophylaxis starting on the morning of POD#1. The foley was removed on POD#2 and the patient was voiding independently thereafter. The surgical dressing was changed on POD#2 and the surgical incision was found to be clean and intact without erythema or abnormal drainage. The patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was acceptable and pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact and the wound was benign. The patient's weight-bearing status is weight bearing as tolerated on the operative extremity. Ms. [**Known lastname 64515**] is discharged to rehab ([**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]) in stable condition. Medications on Admission: Advair 500/50 [**Hospital1 **], albuterol prn, Diltazem 300mg daily, fosamax 70mg weekly, glipizide 5mg prn, lisinopril 40mg daily, ativan 1mg prn, MVI, accolate 20mg [**Hospital1 **], pravastatin 20mg daily, prilosec 20mg [**Hospital1 **], roxicet prn, theophylline 300mg daily, Vit C, Vit D Discharge Medications: 1. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe Subcutaneous once a day for 4 weeks. Disp:*28 syringe* 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. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 4. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8 hours) as needed for anxiety. 5. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 7. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*90 Tablet(s)* Refills:*0* 10. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 11. multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 12. Calcium 600 + D(3) 600 mg(1,500mg) -400 unit Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] - [**Location (un) 538**] Discharge Diagnosis: right knee osteoarthritis Post-op anemia ***Anticipated length of stay < 30 days*** 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: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon or your primary physician. 6. Please keep your wounds clean. You may shower starting five (5) days after surgery, but no tub baths or swimming for at least four (4) weeks. No dressing is needed if wound continues to be non-draining. Any stitches or staples that need to be removed will be taken out at your follow-up visit in three (3) weeks after your surgery. 7. Please call your surgeon's office to schedule or confirm your follow-up appointment in three (3) weeks. 8. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as celebrex, ibuprofen, advil, aleve, motrin, etc). 9. ANTICOAGULATION: Please continue your lovenox for four (4) weeks to help prevent deep vein thrombosis (blood clots). [**Male First Name (un) **] STOCKINGS x 6 WEEKS. 10. WOUND CARE: Please keep your incision clean and dry. It is okay to shower five days after surgery but no tub baths, swimming, or submerging your incision until after your four (4) week checkup. Please place a dry sterile dressing on the wound each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed at your follow-up visit in three (3) weeks. 11. VNA (once at home): Home PT/OT, dressing changes as instructed, and wound checks. 12. ACTIVITY: Weight bearing as tolerated on the operative extremity. ROM as tolerated. No strenuous exercise or heavy lifting until follow up appointment. Physical Therapy: RLE WBAT ROM unrestricted CPM - 2-3x/day for 2-3hr session, advance flexion as tolerated Mobilize Treatments Frequency: Dry sterile dressing daily as needed for drainage Wound checks Ice and elevation TEDs Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], [**MD Number(3) 3261**]:[**Telephone/Fax (1) 1228**] Date/Time:[**2175-5-16**] 3:00 Provider: [**Name10 (NameIs) **] MAMMOGRAM [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 7976**] Date/Time:[**2175-10-3**] 10:00 Completed by:[**2175-5-4**]

[ "285.9", "401.9", "272.4", "518.81", "311", "250.00", "780.2", "530.81", "733.00", "493.90", "715.96", "714.0" ]

icd9cm

[ [ [] ] ]

[ "81.54", "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

8380, 8502

4357, 6837

316, 367

8630, 8630

1355, 1378

11849, 12207

861, 866

7180, 8357

8523, 8609

6863, 7157

8813, 10894

881, 1336

11618, 11717

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265, 278

10906, 11600

395, 406

1387, 4334

8645, 8789

428, 746

762, 845

22,169

140,144

13748

Discharge summary

report

Admission Date: [**2103-5-15**] Discharge Date: [**2103-5-22**] Date of Birth: [**2054-4-25**] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1271**] Chief Complaint: large left basal ganglia bleed Major Surgical or Invasive Procedure: placement of EVD History of Present Illness: HPI: Per reports/ OSH paperwork 49yr old female pt with PMH of back surgery and breast augmentation was found this evening by friends unable to speak with a flaccid right side. Purposeful movement of LUE only. Pt taken to [**Hospital **] Hospital where a Head CT showed a large Left Basal ganglia bleed 4.5 x 3.4cm with blood in left lateral, 3rd and 4th ventricles with approximately 5mm of midline shift. Upon admission to [**Name (NI) **] Hospital pt w/ BP of 222/139. Pt reportedly vomited and was intubated for airway protection. Pt transferred by [**Location (un) **] to [**Hospital1 18**] for further evaluation. Pt received versed succs and atomidate approx 2hrs prior to this exam. PMHx: back Surgery ? Breast Augmentation Allergies: Unknown Medications prior to admission: BCP's ?Oxycontin Naproxen Social Hx: (+)smoking Family Hx: Unknown ROS: Unable to assess PHYSICAL EXAM: T: BP:167/113 HR:105 RR: 14/14 O2Sats; 94% Gen: WD/WN, comfortable, NAD. HEENT: Pupils fixed bilat at 4mm Neck: Supple. Lungs: Coarse Cardiac: tachy Abd: Soft Extrem: Warm and well-perfused. Neuro: Mental status: No eye opening, intubated. Orientation: Intubated, no response to verbal stimuli Recall: Unable Language: Intubated. Cranial Nerves: I: Not tested II: Pupils fixed bilat @4mm bilat, No corneals III, IV, VI: No eye opening, V, VII: No obvious facial droop VIII: No response to voice. IX, X: Unable to participate [**Doctor First Name 81**]: Unable XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**5-19**] throughout. No pronator drift Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Toes downgoing bilaterally Labs: pending Head CT: large left basal ganglia bleed approx 4.5 x3.5cm w/ hydrocephalus Past Medical History: PMHx: back Surgery ? Breast Augmentation Social History: Social Hx: (+)smoking Family History: unknown Physical Exam: PHYSICAL EXAM: T: BP:167/113 HR:105 RR: 14/14 O2Sats; 94% Gen: WD/WN, comfortable, NAD. HEENT: Pupils fixed bilat at 4mm Neck: Supple. Lungs: Coarse Cardiac: tachy Abd: Soft Extrem: Warm and well-perfused. Neuro: Mental status: No eye opening, intubated. Orientation: Intubated, no response to verbal stimuli Recall: Unable Language: Intubated. Cranial Nerves: I: Not tested II: Pupils fixed bilat @4mm bilat, No corneals III, IV, VI: No eye opening, V, VII: No obvious facial droop VIII: No response to voice. IX, X: Unable to participate [**Doctor First Name 81**]: Unable XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**5-19**] throughout. No pronator drift Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Toes downgoing bilaterally Pertinent Results: Head CT: large left basal ganglia bleed approx 4.5 x3.5cm w/ hydrocephalus [**2103-5-15**] 02:50AM GLUCOSE-189* UREA N-9 CREAT-0.5 SODIUM-137 POTASSIUM-3.0* CHLORIDE-104 TOTAL CO2-23 ANION GAP-13 [**2103-5-15**] 02:50AM WBC-8.4 RBC-4.22 HGB-12.0 HCT-34.8* MCV-83 MCH-28.5 MCHC-34.4 RDW-16.2* [**2103-5-15**] 02:50AM NEUTS-81.0* LYMPHS-15.4* MONOS-3.2 EOS-0.3 BASOS-0.1 [**2103-5-15**] 02:50AM PT-12.6 PTT-30.0 INR(PT)-1.1 [**2103-5-15**] 02:50AM PLT COUNT-357 Brief Hospital Course: Pt was admitted to the ICU for close neurologic monitoring. She had EVD placed. repeat Ct showed extension of blood into the ventricles. Her neurologic status did not improve. Ultimaetely the family decided to make pt comfort measures only and she expired in the morning [**2103-5-22**]. Medications on Admission: Medications prior to admission: BCP's ?Oxycontin Naproxen Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Brain hemorrhage Discharge Condition: expired Discharge Instructions: none Followup Instructions: none [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**] Completed by:[**2103-5-22**]

[ "342.80", "780.01", "518.81", "305.1", "431", "331.4", "784.3", "401.0" ]

icd9cm

[ [ [] ] ]

[ "02.2", "96.72" ]

icd9pcs

[ [ [] ] ]

4226, 4235

3797, 4088

351, 369

4296, 4306

3302, 3302

4359, 4490

2377, 2386

4197, 4203

4256, 4275

4114, 4114

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280, 313

397, 1158

2774, 3283

3311, 3774

2640, 2758

2278, 2321

2337, 2361

63,637

116,537

40157

Discharge summary

report

Admission Date: [**2183-9-23**] Discharge Date: [**2183-9-24**] Date of Birth: [**2119-11-18**] Sex: F Service: MEDICINE Allergies: Penicillins / Tetracycline / IV Dye, Iodine Containing Contrast Media Attending:[**First Name3 (LF) 3565**] Chief Complaint: carboplatin desensitization Major Surgical or Invasive Procedure: none History of Present Illness: 63F with stage IIIC poorly differentiated primary peritoneal carcinoma, now with disease recurrence and participating in a [**Company 2860**] clinical trial. When she last received chemotherapy on [**2183-9-2**], a third of the way through the infusion of carboplatin, she developed an intense feeling of heat and generalized body tingling, tingling and numbness of the lips, and chest tightness. Carboplatin was discontinued and she received 100 mg hydrocortisone and 50 mg of Benadryl IV. Her vital signs remained stable, but she later had vomiting and headache. Given her allergic reaction, today she will receive paclitaxel followed by carboplatin per the desensitization protocol. On arrival to the MICU, patient's VS were T 98.8, 90, 124/84, 19, 98%RA. Patient appeared slightly anxious, but was in no respiraotry distress. Past Medical History: Past Oncologic History: - CT abd/pelvis on [**2182-2-28**] revealed a large mass centered in the sigmoid colon with pelvic lymphadenopathy, retroperitoneal lymphadenopathy, and peritoneal carcinomatosis. - A colonoscopy revealed a fungating, ulcerated mass within the sigmoid colon causing a partial obstruction. The biopsy of this mass revealed adenocarcinoma with papillary formation, suggestive of an ovarian primary. - [**2182-3-14**] underwent exploratory laparotomy, hysterectomy, bilateral salpingo-oophorectomy, rectosigmoid resection with colorectal re-anastomosis and diverting loop ileostomy. This was a suboptimal tumor debulking. Intra-operatively, the uterus and bilateral adnexal were unremarkable. Extensive firm retroperitoneal lymphadenopathy was appreciated. There was no evidence of carcinomatosis. The tumor was noted to involve the sigmoid colon and rectum. Pathology examination revealed serous carcinoma involving full thickness of the rectal wall. Seven of eight lymph nodes were positive for malignancy. Uterus, cervix, fallopian tubes, and ovaries were negative for malignancy. - [**4-26**] start chemotherapy with Carboplatin q21d and weekly Taxol - [**2182-5-30**] Cycle 3 Carboplatin and Taxol . Other Past Medical History: - Thalassemia. Social History: Imigrated from [**Country 3587**] in youth. Formerly employed in retail sales. No children, husband lives in [**Country 3587**]. Sister and [**Name2 (NI) 802**] in [**Name (NI) 86**] area. - Tobacco: Never - etOH: denies - Illicits: denies Family History: Uncle: diabetes. Mother and father lived in to 70's, she denies family history of cancer, CAD, hypertension. Physical Exam: ADMISSION PHYSICAL General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding GU: no foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, grossly normal sensation DISCHARGE PHYSICAL General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding GU: no foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, grossly normal sensation Pertinent Results: [**2183-9-22**] 08:10AM BLOOD WBC-5.4 RBC-4.00* Hgb-8.7* Hct-27.5* MCV-69* MCH-21.7* MCHC-31.6 RDW-19.2* Plt Ct-213 [**2183-9-24**] 05:03AM BLOOD WBC-10.9# RBC-4.01* Hgb-8.5* Hct-27.3* MCV-68* MCH-21.3* MCHC-31.3 RDW-19.6* Plt Ct-200 [**2183-9-23**] 11:20AM BLOOD Glucose-130* UreaN-23* Creat-0.8 Na-139 K-4.1 Cl-107 HCO3-25 AnGap-11 [**2183-9-24**] 05:03AM BLOOD Glucose-158* UreaN-25* Creat-0.9 Na-140 K-4.2 Cl-106 HCO3-21* AnGap-17 [**2183-9-23**] 11:20AM BLOOD Calcium-9.7 Phos-2.8 Mg-1.7 [**2183-9-24**] 05:03AM BLOOD Calcium-9.1 Phos-3.0 Mg-2.1 Brief Hospital Course: # Carboplatin desensitization: Patient was seen by Dr. [**First Name8 (NamePattern2) 2602**] [**Name (STitle) 2603**] from the department of allergy, who recommended that she receive carboplatin administered per the standard 12-step desensitization protocol. She also received Taxol. Pre-medication orders were entered by the pharmacist and co-signed by the [**Name2 (NI) 153**] team. The patient is understandably anxious given that she had an adverse reaction to carboplatin previously. Carboplatin desensitization was completed without incident. LFTs were stable. Patient was discharged home after discussion with oncology. # QTc monitoring: Because of large doses of ondansetron, QTc prolongation was monitored. Patient received electrolyte repletion and was monitored by serial EKG. QTc was 405 msec. Patient was discharged home on hospital day 2. Medications on Admission: Colace 100mg [**Hospital1 **] prn constipation Discharge Medications: Colace 100mg [**Hospital1 **] prn constipation Discharge Disposition: Home Discharge Diagnosis: Primary: Chemo desensitization Secondary: Primary peritoneal carcinoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 47639**], It was a pleasure to take care of you at [**Hospital1 18**]. You were admitted for a round of chemotherapy with carboplatin and paclitaxel. You were treated aggressively as per a desensitization protocol to prevent an allergic reaction. You tolerated the chemotherapy well and were discharged home. No changes were made to your home medications. Please follow-up with you hematologist-oncologist's office as noted below. Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: MONDAY [**2183-10-13**] at 11:00 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3240**], RN [**Telephone/Fax (1) 22**] Building: [**Hospital6 29**] [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: MONDAY [**2183-10-13**] at 11:00 AM With: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 22**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: MONDAY [**2183-10-13**] at 11:00 AM With: [**Name6 (MD) 5145**] [**Name8 (MD) 5146**], MD, PHD [**Telephone/Fax (1) 22**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2183-9-24**]

[ "V70.7", "V07.1", "275.2", "282.40", "197.5", "V14.8", "158.9", "196.2", "V58.11" ]

icd9cm

[ [ [] ] ]

[ "99.12", "99.25" ]

icd9pcs

[ [ [] ] ]

5656, 5662

4630, 5486

360, 367

5778, 5778

4055, 4607

6417, 7369

2795, 2905

5584, 5633

5683, 5757

5512, 5561

5929, 6394

2920, 4036

292, 322

395, 1229

5793, 5905

2505, 2521

2537, 2779

13,053

137,655

25768

Discharge summary

report

Admission Date: [**2118-10-18**] Discharge Date: [**2118-10-25**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2840**] Chief Complaint: cough and SOB Major Surgical or Invasive Procedure: None History of Present Illness: [**Age over 90 **]-year-old man with history of possible IPF diagnosed in [**2112**], on 2L home oxygen for seven years who is admitted with progressive shortness of breath after failing outpatient treatment for pneumonia. The patient was in his USOF until about 2 weeeks prior to admission. The patient was seen urgently in the clinic for evaluation on [**2118-10-5**] by [**First Name8 (NamePattern2) 714**] [**Last Name (NamePattern1) 715**] for right-sided chest pain and CXR done at that time revealed bilateral lower lobe opacities that could represent pneumonia as well as diffuse lung disease with peripheral and basilar distribution associated with honeycombing and punctate pulmonary calcifications suggestive of idiopathic pulmonary fibrosis. He was started on Levaquin 500 mg p.o. daily. He returned to clinic [**2118-10-10**] with general malaise, brown sputum, as well as fever to 100.8. At that time his Levaquin was increased to 750 mg po daily. Five days prior to the current admission Flagyl was also added per his [**Month/Day/Year 3390**]. [**Name10 (NameIs) **] had been on prednisone taper from 40 mg times three days, 30 mg times three days and then 20 mg which is his baseline dose. The patient had a routine appoitment with his [**Name10 (NameIs) 3390**] on the day of admission, who referred him to ED because of persistent symptoms and slow decline. . In addition to above symptoms, he also endorses occasional night sweats. No drenching sweats. Over the last month the patient reports SOB with walking only a few feet which is worsening from his baseline. He denies chest pain, palpitations, PND, orthopnea, diarrhea. He does have contipation and occasional lower extremity swelling. No weight loss. . On arrival to ED vital signs were AF, HR 100, 88/40, RR 20, 82% on 2L then was placed on 12L NRB with improvement in O2 sats. ABG ABG 7.45/28/127. CXR showed new focal opacity in the righ lung apex. In the ED, the patient given Vancomycin 1 gm IV once, Zosyn 4.5 gm IV once, Solumedrol 125 IV once, ASA 325 once, Combivent, Lasix 10 mg IV once. He then maintained O2 sats in mid 90's on 4L of NC. Past Medical History: 1. Idiopathic pulmonary fibrosis, diagnosed in [**2112**] after hospitalization for pneumonia. On home oxygen and chronic prednisone. Previously followed by a pulmonologist in Buffalo. The patient was recently seen by Dr. [**Last Name (STitle) **], and according to the patient, was told that the diagnosis of IPF is incorrect. p-ANCa borderline positive and ACE negative. - PFTs [**9-/2118**]: FVC 2.79 (81%) FEV1 2.1(108%) FEV1/FVC 78 (133%) 2. Hypertension 3. Colonic polyps 4. Basal cell carcinoma 5. Rectal cyst 6. S/p [**Year (4 digits) 4448**] ([**2110-4-1**]) for syncope and complete heart block 7. S/p TURP x 3 - patient self-catheterizes [**Hospital1 **] at home 8. Spinal stenosis 9. Degenerative arthritis 10. Hearing loss 11. An outside echo from [**2118-3-1**] showed ejection fraction of 45-50% with pulmonary arterial hypertension, TR gradient to 64 mmHg. Social History: He recently moved from Buffalo, [**State 531**] to [**Location (un) **], [**State 350**] where he lives with his son, [**Name (NI) **], [**Name (NI) **] smoked lightly and quit 20 years ago. He drinks alcohol only at social occasions. He is widowed since [**2092**]. He has three children, all of whom live in the [**Location (un) 86**] area, 11 grandchildren, and one great- grandchild. He is retired attorney and denies any occupational exposures. Family History: Positive for cardiac disease and hypertension Physical Exam: VITAL SIGNS: 95.5, 138/70, 81, 18, 92% on 4L GENERAL: elderly gentelman, alert and oriented, pleasant, cooperative, well appearing HEENT: NC, AT, pupils equal and small, sclera non-icteric, OP with thrush NECK: supple, no LAD, no thyromegaly LUNGS: dry bilateral crackles HEART: regular, nl S1, S2, [**2-6**] syst murmur at LUSB ABDOMEN: + Bs, soft, NT, ND EXTREMITIES: no edema, DP 2+ bilaterally NEUROLOGIC: Alert and oriented, appropriate, no gross motor and sensory deficits SKIN: no exanthems Pertinent Results: CXR [**2118-10-18**]: New focal opacity at the right lung apex, likely represents pneumonic consolidation. Additional bibasilar opacities consistent with continued superimposed pneumonia. Bilateral emphysematous change and interstitial opacities suggestive of interstitial pulmonary fibrosis. . EKG: V paced @ 82 . Admission Labs: [**2118-10-18**] 11:30PM LD(LDH)-239 CK(CPK)-67 [**2118-10-18**] 11:30PM CK-MB-NotDone cTropnT-0.25* [**2118-10-18**] 03:42PM TYPE-ART PO2-127* PCO2-28* PH-7.45 TOTAL CO2-20* BASE XS--2 INTUBATED-NOT INTUBA [**2118-10-18**] 03:42PM LACTATE-2.0 [**2118-10-18**] 03:30PM GLUCOSE-199* UREA N-28* CREAT-1.5* SODIUM-136 POTASSIUM-5.2* CHLORIDE-100 TOTAL CO2-20* ANION GAP-21* [**2118-10-18**] 03:30PM CK(CPK)-106 [**2118-10-18**] 03:30PM cTropnT-0.33* [**2118-10-18**] 03:30PM CK-MB-8 proBNP-5423* [**2118-10-18**] 03:30PM CALCIUM-8.5 PHOSPHATE-2.7 MAGNESIUM-1.7 [**2118-10-18**] 03:30PM WBC-20.2*# RBC-4.26* HGB-13.6* HCT-38.4* MCV-90 MCH-31.9 MCHC-35.4* RDW-14.0 [**2118-10-18**] 03:30PM NEUTS-95.0* BANDS-0 LYMPHS-3.4* MONOS-1.5* EOS-0.2 BASOS-0.1 [**2118-10-18**] 03:30PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2118-10-18**] 03:30PM PLT COUNT-447*# [**2118-10-18**] 03:30PM PT-13.7* PTT-25.8 INR(PT)-1.3 . Chest CT: 1. Ground-glass opacities in the right upper lobe which may represent superimposed infection. 2. Extensive inter and intralobular septal thickening with bilateral basal honeycombing consistent with UIP. 3. Bilateral severe emphysema with large emphysematous bullae in the lower lobes. 4. Mediastinal lymphadenopathy. 5. Small hypoechoic lesions in the liver, which are too small to characterize. [**2118-10-23**] 05:33AM BLOOD WBC-15.6* RBC-3.40* Hgb-10.9* Hct-31.7* MCV-93 MCH-32.1* MCHC-34.5 RDW-13.9 Plt Ct-404 [**2118-10-24**] 05:20AM BLOOD WBC-16.1* RBC-3.73* Hgb-11.4* Hct-33.5* MCV-90 MCH-30.6 MCHC-34.1 RDW-14.2 Plt Ct-498* [**2118-10-25**] 06:00AM BLOOD WBC-15.4* RBC-3.60* Hgb-11.4* Hct-33.3* MCV-93 MCH-31.6 MCHC-34.1 RDW-13.9 Plt Ct-472* [**2118-10-18**] 03:30PM BLOOD Neuts-95.0* Bands-0 Lymphs-3.4* Monos-1.5* Eos-0.2 Baso-0.1 [**2118-10-19**] 04:18AM BLOOD Neuts-91.4* Lymphs-5.7* Monos-2.3 Eos-0.5 Baso-0.1 [**2118-10-23**] 05:33AM BLOOD Glucose-71 UreaN-23* Creat-1.3* Na-136 K-4.6 Cl-101 HCO3-24 AnGap-16 [**2118-10-24**] 05:20AM BLOOD Glucose-85 UreaN-25* Creat-1.2 Na-134 K-4.5 Cl-101 HCO3-24 AnGap-14 [**2118-10-25**] 06:00AM BLOOD Glucose-88 UreaN-26* Creat-1.2 Na-135 K-4.5 Cl-99 HCO3-24 AnGap-17 [**2118-10-19**] 04:18AM BLOOD CK(CPK)-94 [**2118-10-21**] 12:35PM BLOOD CK(CPK)-23* [**2118-10-21**] 04:50PM BLOOD CK(CPK)-23* [**2118-10-18**] 03:30PM BLOOD cTropnT-0.33* [**2118-10-18**] 11:30PM BLOOD CK-MB-NotDone cTropnT-0.25* [**2118-10-19**] 04:18AM BLOOD CK-MB-NotDone cTropnT-0.22* [**2118-10-18**] 03:30PM BLOOD Calcium-8.5 Phos-2.7 Mg-1.7 [**2118-10-19**] 04:18AM BLOOD Calcium-8.0* Phos-4.0 Mg-2.0 [**2118-10-20**] 05:20AM BLOOD Calcium-7.5* Phos-2.8 Mg-1.7 BCx -; UCx -; Sputum Cx Pending, but direct AFB smear negative x 3 Legionella Ag - CXR [**10-24**]: IMPRESSION: Slight improvement in right upper lobe pneumonia and associated apparent superinfection of adjacent right apical bulla. Continued radiographic followup is recommended to ensure complete resolution. Brief Hospital Course: [**Age over 90 **]-year-old man with h/o possible idiopathic pulmonary fibrosis on chronic prednisone admitted with progression of DOE, low grade fevers and change in sputum color after failing outpatient empiric therapy for PNA. . 1. Shortness of breath. Most likely due to an acute infectious process superimposed on his underlying interstitial lung disease. The differential for this patient on chronic prednisone was considered to be broad, including atypical CAP as well as fungal infections, [**Age over 90 3390**], [**Name10 (NameIs) **] less likely MAC given upper lobe distribution. A-a gradient is elevated. Pt was covered for CAP with Ceftriaxone and Azithromycin. Bactrim was also continued for [**Name10 (NameIs) 3390**]. [**Name10 (NameIs) 3390**] stain in sputum Cx was negative. GM stain did reveal G+Rods 1+ quantity. ? contaminants. Pt initially required O2 but upon d/c he is sating well on 2L O2, which is his home dose. Pt was also continued on nebulizers as needed. He is restarted on his home dose of Advair and Spiriva before d/c. Patient's prednise was also continued at his usual dose (received Solumedrol IV bolus in the ED). There was no no evidence of bronchospasm and no evidence that this underlying interstitial lung disease was contributing to his decompensation. Pulmonary service was following the patient throughout his stay. Upon his d/c patient also had 3 sputum samples that were negative for AFB direct smear. It was decided that the pulmonary/TB precautions can be d/c. Pt is to follow up with Dr. [**Last Name (STitle) **] in dyspnea center, where he will also have repeat PFTs. It appears that patient underlying condition is more consistent with IPF rather than COPD . 2. Troponin elevation. Most likely in the setting of acute renal failure and demand ischemia. CKMB fraction normal x 2. No symptoms. EKG paced. NO events were observed on telemetry. EKG remained unchanged. . 3. Acute renal failure. Previous Cr 1.1. Most likely prerenal. Improved to baseline with gentle hydration. Cr. of 1.2 upon d/c. . 4. Leukocytosis. Most likely multifactorial secondary to steroid therapy and infectious process. . 5. Thrush. Most likely in the setting of chronic prednisone and inhaled steroids. Mouth hygeine and nystatin. . 6. FEN. Regular diet . 7. PPx. PPI and ISS with FS checks as the patient on steroids and received Solumedrol in the ED. Heparin SQ. Bowel regimen. Continue Actonel and Calcium/vitD. . Medications on Admission: 1. Prednisone 20 mg daily 2. Atenolol 25 mg daily 3. Actonel 35 mg q week 4. ADVAIR DISKUS 250-50 mcg twice a day 5. ALBUTEROL 90 mcg 1 puff inhaled prn 6. ATROVENT 18 mcg/Actuation--1 puff inhaled prn as needed 7. DUONEB 2.5-0.5 mg/3 mL-- via nebulizaiton 8. LEVAQUIN 750 mg po daily (started on [**2118-10-5**] and increased to 750 mg po daily dose on [**2118-10-10**]) 9. Stool Softener 30-100 mg--2 capsule(s) by mouth every other day 10. Bactrim 160-800 mg--one tablet(s) by mouth three times weekly 11. Tylenol prn Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Insulin Lispro (Human) 100 unit/mL Solution Sig: [**1-5**] units Subcutaneous ASDIR (AS DIRECTED): see sliding scale. 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 7. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): continue until advised by otherwise by your pulmonary doctor. 12. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours) for 5 days. 13. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO MWF (Monday-Wednesday-Friday). 14. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q4H (every 4 hours) as needed. 15. Albuterol Sulfate 0.083 % Solution Sig: [**1-2**] nebs Inhalation Q6H (every 6 hours). 16. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 17. Dextromethorphan Poly Complex 30 mg/5 mL Suspension, Sust. Release 12HR Sig: Ten (10) ML PO Q12H (every 12 hours) as needed. 18. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed for cough. 19. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: [**1-2**] Disk with Devices Inhalation [**Hospital1 **] (2 times a day). 20. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 21. Ipratropium Bromide 0.02 % Solution Sig: One (1) puff Inhalation Q6H (every 6 hours) as needed. 22. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day for 5 days. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: 1. RUL pneumonia - Gram positive rods 2. Acute renal failure 3. Pulmonary fibrosis 4. HTN 5. OA Discharge Condition: Stable. Tolerating PO. Afebrile. Resolving cough. Discharge Instructions: Please take all your medications as instructed. Please follow up with all your medical appointments. If you experience any fevers/chills and worsening of cough, please seek medical attention. If unable to eat and drink also seek medical attention. Followup Instructions: Provider: [**Name10 (NameIs) **] CALL Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2118-10-27**] 9:45 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3940**], MD Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2118-11-1**] 11:00 Provider: [**Name Initial (NameIs) 9484**]CC2 PULMONARY LAB-CC2 Date/Time:[**2118-11-21**] 11:00, followed by Dr.[**Name (NI) 6005**] appointment at 12:00 Completed by:[**2118-10-25**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

13022, 13101

7769, 10234

278, 284

13241, 13294

4403, 4718

13593, 14035

3822, 3869

10806, 12999

13122, 13220

10260, 10783

13318, 13570

3884, 4384

225, 240

312, 2441

4734, 7746

2463, 3338

3354, 3806

68,278

117,871

48099

Discharge summary

report

Admission Date: [**2119-7-14**] Discharge Date: [**2119-7-20**] Date of Birth: [**2059-5-24**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 922**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2119-7-14**] - Cardiac Catheterization and placement of an IABP [**2119-7-14**] - 1. Emergent coronary bypass grafting x3 on intra-aortic balloon pump with left internal mammary artery to left anterior descending coronary artery; reverse saphenous vein single graft from the aorta to the ramus intermedius coronary artery; as well as reverse saphenous vein single graft from aorta to posterior left ventricular coronary artery. 2. Endoscopic left greater saphenous vein harvesting. History of Present Illness: 60 year old gentleman with recent chest pain on exertion. Stress test was abnormal and he was scheduled for cath. Chest pain developed during cath today which revealed left main and multi-vessel coronary artery disease. He is now brought to the operating room urgently for CABG. Past Medical History: osteoarthritis lumbar disc disease hypercholesterolemia Social History: Lives with: wife, works at library Occupation: Tobacco: 1ppd x 30yrs, quit 13yrs ago ETOH: quit years ago Family History: Father died at 62 of heart disease Physical Exam: Pulse: 65 Resp: 18 O2 sat: B/P Right: 121/72 Left: Height: Weight: 74.8kg General: slightly anxious, but NAD Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact x Pulses: Femoral Right: IABP Left: 2+ DP Right: 2+ Left: 2+ PT [**Name (NI) 167**]: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit Right: Left: none Pertinent Results: [**2119-7-14**] ECHO Pre-bypass: The left atrium and right atrium are normal in cavity size. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. IABP seen in the descending aorta with tip 2 cm below the left subclavian artery. Post-bypass: The patient is A paced. IABP remains in good position. Preserved Biventricular function. Aortic contours intact. Remaining exam is unchanged. All findings discussed with surgeons at the time of the exam. [**2119-7-19**] 05:05AM BLOOD WBC-4.9 RBC-2.86* Hgb-8.6* Hct-25.4* MCV-89 MCH-30.3 MCHC-34.1 RDW-12.7 Plt Ct-209# [**2119-7-14**] 10:40AM BLOOD WBC-5.1 RBC-4.34* Hgb-13.0* Hct-37.7* MCV-87 MCH-30.0 MCHC-34.5 RDW-12.5 Plt Ct-208 [**2119-7-15**] 07:58AM BLOOD PT-14.0* PTT-33.2 INR(PT)-1.2* [**2119-7-14**] 10:40AM BLOOD PT-14.5* PTT-150* INR(PT)-1.3* [**2119-7-19**] 05:05AM BLOOD Na-140 K-4.5 Cl-101 [**2119-7-17**] 05:10AM BLOOD Glucose-110* UreaN-12 Creat-0.7 Na-136 K-4.2 Cl-101 HCO3-28 AnGap-11 [**2119-7-14**] 10:40AM BLOOD Glucose-134* UreaN-12 Creat-0.8 Na-138 K-3.6 Cl-106 HCO3-24 AnGap-12 Brief Hospital Course: Mr. [**Known lastname 101426**] was admitted to the [**Hospital1 18**] on [**2119-7-14**] for a cardiac catheterization. This revealed significant left main and three vessel coronary artery disease. As he developed chest pain during his catheterization, an intra-aortic balloon pump was placed. The cardiac surgical service was urgently consulted and surgical revascularization was recommended. Mr. [**Known lastname 101426**] was taken urgently to the operating room where he underwent coronary artery bypass grafting to three vessels. Please see operative note for details. Postoperatively he was taken to the intensive care unit for monitoring. The next morning, his intra-aortic balloon pump was weaned off and removed without incident. He then awoke neurologically intact and was extubated. On postoperative day two, he developed a right pneumothorax following removal of his chest tubes. A right pleural tube was thus placed with resolution of his pneumothorax. Later on postoperative day two, he was transferred to the step down unit for further recovery. He was gently diuresed towards his preoperative weight. After a water seal trial, the right pleural chest tube was removed and he subsequently developed a large right pneumothorax that required a chest tube to be reinserted. Follow up chest X-Ray revealed right lung rexpanded. This chest tube wsa pulled [**7-19**] without incident after clamping and serial CXR. The physical therapy service was consulted for assistance with his postoperative strength and mobility. Beta blockade, aspirin and a statin were resumed. Mr. [**Known lastname 101426**] continued to make steady progress and was cleared by Dr.[**Last Name (STitle) 914**] for discharge to home. He was in normal sinus rhythm and his chest xray showed a small pleural effusion with stable bilateral apical pneumothoraces. He will follow-up with Dr. [**Last Name (STitle) 914**], his cardiologist and his primary care physician as an outpatient. All follow up appointments were advised. Medications on Admission: Toprol 50 daily SL nitroglycerin simvastatin 20 daily Ascorbic acid 1000mg daily aspirin 325mg daily B complex vitamins Vit. D2 Folic acid MVI Omega 3 FA saw [**Location (un) 6485**] Vit E Discharge Medications: 1. 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* 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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 4. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 5. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*0* 6. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for itching . Disp:*qs qs* Refills:*0* 7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 9. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Centrus Home Care Discharge Diagnosis: Coronary artery disease Hyperlipidemia Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, with ecchymosis at knee and inner aspect of thigh Rash on Buttock, posterior thigh red and raised, resolving on back chest and groin area Discharge Instructions: 1) Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage 2) Please NO lotions, cream, powder, or ointments to incisions 3) Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart 4) No driving for approximately one month until follow up with surgeon 5) No lifting more than 10 pounds for 10 weeks 6) Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Appointment already scheduled [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2119-8-15**] 2:30 Please call to schedule appointments. Please follow-up with Dr. [**Last Name (STitle) 33746**] in 2 weeks. [**Telephone/Fax (1) 56771**] Please follow-up with Dr. [**Last Name (STitle) 101427**] in 2 weeks. **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2119-7-20**]

[ "414.01", "E878.2", "512.1", "E944.4", "272.4", "722.93", "715.96", "411.1", "693.0" ]

icd9cm

[ [ [] ] ]

[ "88.56", "37.22", "36.12", "97.44", "37.61", "39.61", "34.04", "36.15" ]

icd9pcs

[ [ [] ] ]

6985, 7033

3654, 5666

331, 818

7116, 7449

2061, 3631

8057, 8626

1348, 1385

5906, 6962

7054, 7095

5692, 5883

7473, 8034

1400, 2042

281, 293

846, 1128

1150, 1208

1224, 1332

81,660

131,477

29536

Discharge summary

report

Admission Date: [**2143-11-10**] Discharge Date: [**2143-11-16**] Date of Birth: [**2093-11-21**] Sex: F Service: MEDICINE Allergies: Codeine Attending:[**First Name3 (LF) 3276**] Chief Complaint: Flank pain, inability to flush nephrostomy tubes Major Surgical or Invasive Procedure: Replacement of percutaneous nephrostomy tubes. History of Present Illness: Ms. [**Known lastname 70847**] is a 49yo woman w/ rectal CA s/p surgery/chemo/XRT, HIV (last CD4 555 in [**5-25**]), LE DVT on lifelong Coumadin, obstructive uropathy [**1-16**] radiation fibrosis s/p bilat nephrostomy tube placement who p/w severe bilat flank pain. Patient/husband normally flush saline through both tubes, but last night at 11pm patient's husband unable to successfully flush the tubes. Scheduled to have routine tube change on [**2143-11-21**]. Last tube change by IR performed on [**2143-9-18**]. Began to have "excrutiating" bilat flank pain around site of nephrostomy insertion at 2AM today. Pain radiated to bilat groin. Tried taking her prescribed po Dilaudid 12mg, which did not help. The pain became progressively worse, so she came in to ED. She has minimal urethral urinary output and denies dysuria. Also denies fever/chills. Appetite has been fair. Patient and husband deny noticing any frank blood, pink tinge, or pus in drainage bags. 10-point ROS reviewed with assistance of husband and was otherwise negative. Denied sick contacts, recent illness, or recent medication changes. In ED, received IV Dilaudid 2mg x3, IV Zofran 4mg x1. Past Medical History: ONCOLOGIC HISTORY: 1) Rectal cancer: - late [**2139**]: 6 months of intermittent rectal bleeding, rectal pressure and a sensation of incomplete emptying. - [**2141-1-26**]: colonoscopy revealed a polyp in her sigmoid colon and a 2.5 cm distal rectal mass arising from the anal verge in the posterior rectum with a large area of induration. - [**2141-1-31**]: CT torso revealed an exophytic rectal mass measuring 4.8 x 3.8 cm, bulging posteriorly into the presacral space and anteriorly towards the uterus. There were enlarged lymph nodes in the perirectal fat adjacent to the mass, a 9-mm enhancing lymph node in the left pelvic sidewall, and enhancing lymph nodes in the right external iliac region. There was also a 7-mm hypodensity in the caudate lobe of the liver. Rectal ultrasound on [**2141-1-31**] and rectal MRI on [**2141-2-7**] were compatible with T3 disease. There were at least four abnormal perirectal lymph nodes seen on MRI, in addition to multiple bilateral enlarged pelvic sidewall lymph nodes, concerning for extensive disease. - [**2141-2-20**]: began chemoradiation - [**2141-3-10**]: 5-FU was discontinued due to mucositis, neutropenia, and abdominal cramping - [**2141-3-13**]: 5-FU was restarted at a reduced dose - [**2141-3-22**]: 5-FU was again stopped due to mucositis, perirectal skin changes, diarrhea, and electrolyte abnormalities. - [**Date range (3) 70844**]: Radiation was also held - [**2141-3-27**]: 5-FU was restarted at a further reduced dose - [**2141-3-31**]: completed radiation - [**2141-4-3**]: completed chemotherapy - [**Date range (3) 70845**]: hospitalized for bowel rest and the initiation of TPN due to presumed radiation enteritis. - [**2141-5-31**]: found to be HIV positive and began on HAART - [**Date range (1) 70846**]: required hospitalization for an SBO, underwent laparotomy, ileocecectomy, end-ileostomy, and placement of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] tube on [**2141-6-16**]. Pathology from this surgery revealed severe radiation-induced acute ischemic enteritis. She recovered from this surgery, but continued to require TPN. - [**7-/2141**]: Once her CD4 count had recovered, she underwent laparotomy, lysis of adhesions, ileal resection, proctosigmoidectomy, colonic jejunal pouch to near-anal anastomosis with EEA, takedown splenic flexure, resection of ileostomy and creation of new end-ileostomy. Pathology from the surgical specimen revealed no residual carcinoma and all 14 lymph nodes sampled were free of disease. - [**9-/2141**], [**10/2141**]: Subsequent imaging of the abdomen & pelvis showed no evidence of recurrence. - [**2142-2-14**]: CT abdomen showed "hyperdense thickening in the lumen near the anastomatic site, new since the earlier study. Local recurrence cannot be excluded, although possibly the appearance is associated with endoluminal debris." . OTHER MEDICAL HISTORY: 2) HIV CD4 count 555 on [**5-25**] 3) Short gut syndrome secondary to bowel surgery for CA. 4) Obstructive renal failure from radiation fibrosis, in the past necessitating b/l nephrostomy tubes which have required multiple revisions. 5) Lower extremity neuropathy, likely secondary to radiation fibrosis, uses a wheelchair since 4/[**2141**]. 6) Pancreatic insufficiency. 7) Anemia. 8) Chronic pain. 9) DVT in LE X2: requires lifelong coumadin, most recent [**4-24**] Social History: Lives with her husband and 4 children in [**Location (un) 17566**], does not smoke or drink alcohol. On long-term disability. Has [**First Name9 (NamePattern2) 269**] [**Location (un) 5871**], as well as [**Location (un) 511**] Home Therapy for Port maintenance. Family History: Her father died at 72 of MI. Her mother alive and well. Remote family history of breast, colon cancer. Her daughter has ulcerative colitis. Physical Exam: Admission exam: Vitals: 98.0 148/99 103 22 100% RA Gen: A&Ox3, in acute moderate pain distress, able to answer questions HEENT: dry MM, OP clear Neck: supple, no LAD CV: tachycardic, reg rhythm, no MRG appreciated Chest: R Port site c/d/i and non-tender, lungs CTAB Abd: soft, mild lower abdominal distention, NABS, ileostomy with non-bloody brown stool output Ext: mild bilat pedal edema, 1+ pulses, wearing Unna boots Neuro: chronic 0/5 strength in lower extremities, otherwise no other focal deficits Skin: no rashes Psych: appropriate, cooperative AT DISCHARGE: AF 97.8 110/60-70s 93-108 20 96%Ra lower extremity edema improved from mid-hospialization, only trace edema in lower legs. exam otherwise unchanged. Pertinent Results: Renal US ([**2143-11-10**]): The right kidney measures 12.7 cm, and the left kidney measures 10.9 cm. There is moderate right-sided hydronephrosis and mild left-sided hydronephrosis. The bilateral nephrostomy tubes appear to be within the collecting systems of both kidneys. Minimal perinephric free fluid is identified on the right. No suspicious renal mass or calculus is identified. Limited doppler evaluation of the right kidney demonstrates normal resistive indices. IMPRESSION: 1. Bilateral hydronephrosis, moderate on the right and mild on the left. 2. Nephrostomy catheters grossly appear to be located within the collecting systems. 3. Mild perinephric free fluid on the right. MICROBIOLOGY: [**2143-11-10**] 4:45 am BLOOD CULTURE Blood Culture, Routine (Preliminary): KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S [**2143-11-10**] 6:45 am URINE Site: CLEAN CATCH URINE CULTURE (Preliminary): GRAM NEGATIVE ROD(S). >100,000 ORGANISMS/ML.. GRAM NEGATIVE ROD(S). >100,000 ORGANISMS/ML.. [**2143-11-13**] 11:15 am FLUID,OTHER BLADDER WASHINGS 6. GRAM STAIN (Final [**2143-11-13**]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2143-11-16**]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. URINE CULTURE (Final [**2143-11-14**]): NO GROWTH. FINAL REPORT [**2143-11-13**]** CLOSTRIDIUM DIFFICILE TOXIN A & B TEST Feces negative for C.difficile toxin A & B by EIA. URINE CULTURE (Final [**2143-11-12**]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH FECAL CONTAMINATION. LABORATORY DATA: [**2143-11-10**] 04:45AM BLOOD WBC-11.6*# RBC-4.03* Hgb-11.2* Hct-35.0* MCV-87 MCH-27.7 MCHC-31.9 RDW-17.7* Plt Ct-287 [**2143-11-16**] 06:45AM BLOOD WBC-6.6 RBC-3.09* Hgb-8.7* Hct-27.4* MCV-89 MCH-28.2 MCHC-31.7 RDW-17.2* Plt Ct-262 [**2143-11-10**] 04:45AM BLOOD Neuts-81.0* Lymphs-15.1* Monos-2.6 Eos-1.2 Baso-0.2 [**2143-11-16**] 11:26AM BLOOD PT-22.5* INR(PT)-2.1* [**2143-11-10**] 04:45AM BLOOD Glucose-156* UreaN-20 Creat-1.2* Na-141 K-3.3 Cl-103 HCO3-26 AnGap-15 [**2143-11-10**] 10:01PM BLOOD Glucose-95 UreaN-24* Creat-1.7* Na-138 K-4.4 Cl-101 HCO3-27 AnGap-14 [**2143-11-16**] 06:45AM BLOOD Glucose-93 UreaN-9 Creat-1.1 Na-140 K-3.9 Cl-103 HCO3-30 AnGap-11 [**2143-11-10**] 04:43PM BLOOD Lactate-3.5* [**2143-11-11**] 01:54AM BLOOD Lactate-1.7 [**2143-11-10**] 06:45AM URINE Blood-MOD Nitrite-POS Protein-100 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG [**2143-11-12**] 10:29PM URINE Blood-LG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG [**2143-11-10**] 06:45AM URINE RBC-23* WBC->182* Bacteri-MANY Yeast-MANY Epi-1 [**2143-11-12**] 10:29PM URINE RBC-64* WBC-85* Bacteri-FEW Yeast-NONE Epi-<1 [**2143-11-10**] 06:45AM URINE UCG-NEGATIVE STUDIES: renal ultrasound [**2143-11-10**] IMPRESSION: 1. Bilateral hydronephrosis, moderate on the right and mild on the left. 2. Nephrostomy catheters grossly appear to be located within the collecting systems. 3. Mild perinephric free fluid on the right. . CXR [**2143-11-13**] IMPRESSION: Bibasilar atelectasis, slightly different in morphology and more severe today than on [**2143-6-28**]. Configuration of the right lung base suggests a small subpulmonic right pleural effusion. Upper lungs clear. Normal cardiomediastinal silhouette. No pneumothorax. Infusion port ends in the upper SVC. . KUB [**2143-11-15**] IMPRESSION: Multiple dilated loops of small bowel concerning for high grade obstruction. Brief Hospital Course: 49 y/o F w/ HIV on HAART, LE DVT on lifelong Coumadin, rectal CA s/p radiation, chemotherapy, and surgery. Course complicated by radiation-induced b/l urteral fibrosis requiring bil nephrostomy with history of recurrent tube obstruction. Presented with flank pain, found to have hydronephrosis and urosepsis. Obstruction relieved by tube replacemet with IR. # Sepsis: SIRS criteria + GNR bacteremia. Transiently requiring Levophed in the ICU. Patient at baseline with low BP (SBP ranging 80-100s, mostly in 80s when sleeping). Urinary origin [**1-16**] to obstruction. Underwent IR decompression of bil hydronephrosis and nephrostomy tube replacement. Initially covered with Daptomycin (has h/o of VRE in urine and MRSA in blood) + zosyn + cipro (for double GNR coverage in this patient with multiple healthcare exposures). Daptomycin DCed once urine and blood grew GNRs. Pt to complete a 14 day course of cipro. On the floor, no further episodes of hypotension or fevers. . #pyocystitis - frank pus seen coming from the bladder during perc neph tube placement. Foley was placed. Cultures showed no growth of organisms, likely as pt had begun antibiotics. Urine cleared and was serosanguinous while on the floor. Pt to go home with foley catheter to follow up with urology in 1 week for removal. Pt to follow up with infectious disease to explore possibility of prophylaxis as she frequently develops UTI/pyelonephritis in the setting of perc neph tubes. . # ARF/ bil obstructive hydronphrosis: pt had bilateraly nephrostomy replacement. Cr up to 1.9 from normal baseline. Of note patient has been followed by nephrology as outpatient for workup of proteinuria (1.5g) and edema and was planned for elective renal biopsy. Cr trended down after obstruction relieved, on discharge was 1.1. On the floor, pt was autodiuresing significantly, and the swelling in lower extremities that she had developed was much improved on discharge. Home lasix was restarted. . #abdominal obstruction - On [**2143-11-15**] pt developed severe abdominal pain, nausea and vomiting. She stated she gets obstructed like this at home and it eventually passes. Most likely [**1-16**] radiation induced intra-abdominal adhesions. KUB showed evidence of high grade obstruction. Pt soon afterwards felt a "[**Doctor Last Name **]/rushing feeling of things breaking free" and overnight her pain/nausea/vomiting resolved #tachycardia - HR persistently in the 90s-low 100s. Persisted without fever or signs of infection or dehydration. Felt to be pt's baseline. ECG showed normal sinus rhythm. I's and O's strictly monitored. . # h/o BLE DVT: Coumadin initially held for IR procedure. Restarted at home dose post procedure. . # HIV: VL [**3-/2143**] undetectable, CD4 [**5-/2143**] 555. Continued HAART at home dose. Pt to follow up in 1 week with Dr. [**Last Name (STitle) 13895**]. . # Peripheral neuropathy, functional LE paralysis. Continued lyrica- renal dosed. Continue home Methadone. . # Anxiety- Continued home Ativan 2mg QHS + 1-2mg PRN . # Proteinuria- Lisinopril initially held in the setting of renal failure, then restarted once renal failure improved. Pt to have renal biopsy as outpatient. . #Pt was maintained as DNR/DNI throughout the course of this hospitalization. . # Transitional issues: Pt should discuss idea for possible prophylaxis with Dr. [**Last Name (STitle) 13895**] her primary infectious disease physician. [**Name10 (NameIs) **] should restart lisinopril 2.5 (home dose) when creatinine is back to baseline, or per her PCP. Medications on Admission: CONFIRMED WITH PATIENT/HUSBAND: [**Name (NI) 70848**] 600 mg-300 mg 1 tab daily Darunavir 800mg daily Norvir 100mg daily Lasix 20mg daily Dilaudid 12-16mg Q2H for pain Lansoprazole 30mg daily Lisinopril 2.5mg daily Lorazepam 2mg Q2H + QHS PRN Methadone 50mg daily (split into 10mg, 15mg, 10mg, 15mg doses) Remeron 15mg QHS Lyrica 150mg TID Warfarin 4mg QHS Zolpidem 10mg QHS PRN Vitamin B12 1000mcg daily Ferrous sulfate 325mg [**Hospital1 **] Vit D 50,000 units daily Folic acid 1mg daily Loperamide 4mg PRN ADEKS 7.5mg daily Discharge Medications: 1. abacavir 300 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily). 2. lamivudine 150 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily). 3. darunavir 400 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily). 4. ritonavir 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO DAILY (Daily). 5. furosemide 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 6. hydromorphone 4 mg Tablet [**Hospital1 **]: 2-3 Tablets PO q2h as needed for pain. 7. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 8. lorazepam 2 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q2h and QHS as needed. 9. methadone 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). 10. methadone 10 mg Tablet [**Last Name (STitle) **]: 1.5 Tablets PO BID (2 times a day): please take at 1200 and 2200. 11. mirtazapine 15 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at bedtime). 12. zolpidem 5 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO HS (at bedtime) as needed for insomnia. 13. ferrous sulfate 300 mg (60 mg iron) Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). 14. ergocalciferol (vitamin D2) 50,000 unit Capsule [**Last Name (STitle) **]: One (1) Capsule PO DAILY (Daily). 15. folic acid 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 16. loperamide 2 mg Capsule [**Last Name (STitle) **]: Two (2) Capsule PO DAILY (Daily) as needed for diarrhea. 17. acetaminophen 500 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q6H (every 6 hours) as needed for headache/pain. 18. ciprofloxacin 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q12H (every 12 hours) for 7 days. 19. cyanocobalamin (vitamin B-12) 500 mcg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily). 20. simethicone 80 mg Tablet, Chewable [**Last Name (STitle) **]: 0.5-1 Tablet, Chewable PO QID (4 times a day) as needed for gas pain. 21. pregabalin 75 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO TID (3 times a day). [**Last Name (STitle) **]:*90 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**First Name5 (NamePattern1) 5871**] [**Last Name (NamePattern1) 269**] Discharge Diagnosis: PRIMARY urosepsis from obstruction of nephrostomy tubes SECONDARY HIV short gut syndrome Obstructive renal failure from radiation fibrosis Lower extremity neuropathy from radiation fibrosis Pancreatic insufficiency. Anemia. Chronic pain. history of DVT in both legs 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: It was a pleasure taking care of you during your recent hospitalization. You were admitted because your nephrostomy tubes were obstructed. We replaced those tubes. You also had a bloodstream infection which we treated with antibiotics. Your bladder appeared to be full of pus at the time the tubes were replaced, so a study was done to see if there were any fistulas (something else draining into the bladder) and there did not appear to be any abnormalities. We placed a foley catheter to collect urine. You also experienced an episode of bowel obstruction which passed on its own without need for intervention. You will keep the foley catheter in the bladder until your follow-up appointment with Dr. [**First Name (STitle) **]. We made the following CHANGES to your medications: CONTINUE ciprofloxacin STOPPED lisinopril (can restart when you see your PCP) STARTED simethacone for gas pain DECREASED lyrica to 75 TID in the setting of renal failure. Please talk to your PCP about increasing your lyrica and restarting lisinopril when your kidney function improves. Followup Instructions: Department: INFECTIOUS DISEASE When: WEDNESDAY [**2143-11-20**] at 11:30 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13896**], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: [**Hospital **] HEALTHCARE OF [**Location (un) **] When: THURSDAY [**2143-11-21**] at 11:50 AM With: [**First Name8 (NamePattern2) 3679**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 3070**] Specialty: Internal Medicine Building: [**Street Address(2) 8172**] ([**Location (un) 620**], MA) Ground Campus: OFF CAMPUS Best Parking: Parking on Site Department: [**Hospital **] HEALTHCARE OF [**Location (un) **] When: TUESDAY [**2143-12-17**] at 11:50 AM With: [**First Name8 (NamePattern2) 3679**] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 3070**] Building: [**Street Address(2) 8172**] ([**Location (un) 620**], MA) Ground Campus: OFF CAMPUS Best Parking: Parking on Site You will also have a follow up appointment with Dr. [**First Name (STitle) **] as he discussed with you. Please call his office on monday to confirm/schedule this. [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**]

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53406

Discharge summary

report

Admission Date: [**2178-1-20**] Discharge Date: [**2178-1-23**] Date of Birth: [**2129-10-5**] Sex: F Service: MEDICINE Allergies: Zosyn / Quinolones / Ceftriaxone / Flagyl / Keppra / Lisinopril / Naprosyn / Bactrim DS / Phenytoin / Nitrofurantoin / Sulfa (Sulfonamide Antibiotics) / Zofran / IV Dye, Iodine Containing Attending:[**First Name3 (LF) 6701**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: This is a 48-year-old female with PMHx of spina bifida, HTN, MR, paraperesis, non-epileptic [**First Name3 (LF) 54422**], and urostomy with chief complaint of abdominal pain. This occured 2 days prior to arrival, pain was diffuse (9.5/10), gradually increasing in severity. Associated with: nausea and vomiting (food contents, non-bloody); patient denies f/c, new n/t/w, HA/neck pain, change in vision, CP, SOB, cough, change in BM (1 on day prior, non-bloody), GU s/sx. Review of OMR reveals that the patient has been admitted several times for abdominal pain that presented similarly and had a negative work up including CT abdomen, RUQ U/S and HIDA scan. On her [**Month (only) 116**] admission she was treated with an aggressive bowel regimen and discharged after having daily stools. Also, the patient was recently admitted for spastic movements that were determined not to be [**Month (only) 54422**]. She then went to the ED again last week with spastic movements in renal ultrasound that neurology felt were consitent with her non-epileptic [**Month (only) 54422**]. In the neurology consult note from this ED visit her abdomen was noted to be diffusely tender and somewhat distended. . In the ED VS: 96.5 72 111/68 18 99% 2L. Exam was notable for distended abdomen that was mildly distended diffusely tender to palpation. She was guaiac negative. Labs notable for alk phos of 113 and U/A negative (bacteruira from ileal condiut). Patient had Abd Xray and CT scan which were unremarkable (stool present, no SBO, no abscess, no pancreatitis or other acute process). CXR showed no abnormality. Patient given morphine x2 and Zofran and admitted for pain control. . On the floor, patient was sleeping but when awoken states that her abdomen is painful and distended. (Of note, the above HPI is from the patient's presentation to the ED). She has since been admitted to the medical ICU for her diffuse fixed drug reaction/dermatologic condition). Past Medical History: 1. Asthma/COPD 2. Hypertension 3. GERD 4. Urostomy 5. h/o VRE pyelonephritis 6. Spina bifida (myelomengiocele) 7. Paraplegia (documented, though patient can walk) 8. Depression 9. Mild mental retardation 10. Psychogenic dysarthria and tremor 11. [**Month (only) **] vs. pseudoseizures - EEG work-up at [**Hospital3 **] in [**2165**] frequent runs of regular bifrontal sharp delta activity although the clinical events which occurred during the record were not associated with EEG change 12. Atopic dermatitis 13. Back pain 14. Genital herpes 15. Uterine fibroid 16. Uterine prolapse 17. Diverticulosis 18. External hemorrhoids Social History: Lives alone in an apartment in [**Location (un) 86**]. She is able to transfer w/ wheelchair. Reports [**Location (un) 269**] assistance once a week in her home. Tobacco: 1 PPD EtOH: Drinks 2-3 beers a day. Illicits: Denies IVDU ever. History of smoking crack cocaine, claims to have stopped using cocaine 3 years ago. Family History: 3 healthy children. Mother - died of lung cancer. Father - killed by his girlfriend. Not in contact with her brother and sister. Physical Exam: VS: 98.4 98.4 116/57 78 18 94% 2L. GEN: obese, awake HEENT: EOMI, PERRLA no scleral icterus CV: RRR nl S1 S2 LUNGS: CTAB/L ABD: +BS, distended and tympanic, diffusely TTP all over abdomen even with distraction, urostomy bag with small amount of urine, no rebound, +voluntary guarding. EXT: warm, well perfused 2+ distal pulses b/l NEURO: A&Ox3, able to answer questions appropriately On transfer: VS: afebrile, BP 111/67, HR: 71, SP02: 100% RA General: Intubated, sedated Chest: Coarse breath sounds throughout, no crackles Cardiac: Regular rate and rhythm, no murmurs, rubs, or gallops Abd: +BS, well-healed surgical incision, soft Pertinent Results: [**2178-1-22**] WBC-11.3*# Hgb-11.5* Hct-35.1* MCV-93 Plt Ct-226 Glucose-77 UreaN-9 Creat-0.8 Na-136 K-4.4 Cl-102 HCO3-25 Calcium-8.4 Phos-3.2 Mg-2.2 . [**2178-1-21**] ALT-10 AST-13 AlkPhos-119* TotBili-0.4 . [**2178-1-20**] Neuts-60.1 Lymphs-30.9 Monos-4.0 Eos-4.3* Baso-0.7 Lactate-1.4 . EKG ([**2178-1-21**]): Sinus rhythm. RSR' pattern in leads V1-V2 may be a normal variant. Baseline artifact in the limb leads makes assessment of those leads difficult. Since the previous tracing of [**2178-1-20**] there is probably no significant change but unstable baseline in the standard limb leads makes comparison difficult. . CXR 2V ([**2178-1-20**]): No acute cardiopulmonary pathology. . CT abdomen/pelvis with contrast ([**2178-1-22**]): 1. No acute abdominal pathology. 2. Status post urinary diversion with ileal conduit, with prominence of the lower ureters, unchanged since the prior study. Stable bilateral renal cortical scarring, stable. 3. Fibroid uterus. 4. Spina bifida with meningocele, unchanged. . Recent labs from [**2178-1-13**] at 1400: . 135 107 8 100 AGap=11 . 4.4 21 0.8 Comments: Glucose: If Fasting, 70-100 Normal, >125 Provisional Diabetes . Ca: 7.6 Mg: 1.9 P: 2.7 ALT: 8 AP: 89 Tbili: 0.4 Alb: 3.0 AST: 16 LDH: 257 Dbili: TProt: [**Doctor First Name **]: Lip: . Wbc: 11.2 Hgb: 10.9 Hct: 33.3 Plt: 218 N:76.5 L:17.2 M:1.8 E:4.2 Bas:0.4 PT: 13.1 PTT: 30.0 INR: 1.1 Lactate:1.6 [**2178-1-20**] 01:40PM URINE RBC-0-2 WBC-0-2 BACTERIA-MANY YEAST-NONE EPI-0 [**2178-1-20**] 8:18 pm URINE Site: CATHETER **FINAL REPORT [**2178-1-23**]** URINE CULTURE (Final [**2178-1-23**]): KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 64 I PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R Brief Hospital Course: This is a 48-year-old female with spina bifida and long standing urostomy, mild mental retardation, and prior bullos skin lesions admitted [**2178-1-20**] for abdominal pain, suspected related to constipation; overnight with fever to 103 and development of bullous skin lesions, concerning for drug reaction. Patient is being transferred to [**Hospital1 112**] for further burn care. . BULLOUS HYPERSENSITIVITY DRUG REACTION: New onset diffuse erythema and bullae in areas of friction noticed on hospital day 2, following fever to 103 evening prior. Progressive throughout the day, with increasing blistering, particular in axilla, neck folds, back, thighs, and shins. Dermatology was actively involved in patient's care. Zofran suspected to be causative [**Doctor Last Name 360**], with morphine and divalproex less likely. (Patient has had at least 4 previous bouts of drug reactions, and has required intubation for laryngeal and angioedema). Recommended transfer to [**Hospital6 **] Burn Unit for close monitoring due to rapid progression of bullae. Zofran was stopped. Skin biopsy performed by dermatology with path pending. Patient was given over 2 Liters of IV hydration in the ICU; hydration was stopped when IV access was lost. Pain control was with IV morphine, but then switched to PO after IV access was lost. Patient received 1 dose of IVIG (1g/kg/d); she was in the middle of her second dose before she lost IV access. She should get a total of 4 doses of IVIG over 4 days. She was given methyprednisolone 40mg IV once. . 2) ACCESS: Patient lost access on the morning of [**1-23**]. Peripherals and PICC were unable to be placed due to patient's extensive blistering. A right IJ was eventually placed for access. . 3) RESPIRATORY STATUS: On the morning of [**1-13**], patient had increasing stridor and increased work of breathing in addition to angioedema. She has required intubation in the past for respiratory decline in the setting of bullous hypersensitivity reaction. She was intubated prophylactically prior to transfer to [**Hospital1 112**]. Induction was with etomidate and succ, and sedation/pain control was maintained with midazolam and a morphine drip (to avoid further drug exposures). She remains on neo 0.9, but this can probably be weaned prior to transfer or right afterward. Initial abg showed 7.28/52/93 on Fi02 100%, TV 500, RR 16, PEEP 5. Subsequently, RR was increased to 18 and PEEP was increased to 10. Repeat gas is 7.35/43/94. . 3) KLEBSIELLA UTI: Noted on hospital day 2. Recurrent UTIs in this patient with urostomy due to spina bifida. Patient was seen by her primary care physician who thought that because recent u/a was negative, patient was probably colonized with klebsiella and antibiotics were not warranted at this time. If antibiotics are needed, patient can be started on meropenem. . (4) ASTHMA/COPD: Continued on montelukast per home regimen. . (5) NON-EPILEPTIC SEIZURE DISORDER: No concerning seizure activity during this hospital stay. Continued on divalproex 250mg PO BID per home regimen. . (6) DEPRESSION: Continued on citalopram 20mg PO daily and quetiapine 25mg PO QHS per home regimen. . If you have any questions, please call the [**Hospital Ward Name 121**] 7 MICU at: [**Telephone/Fax (1) 109836**] and ask for the resident on call. Medications on Admission: on last discharge [**2177-11-28**]: Miconazole Powder 2% 1 Appl TP [**Hospital1 **]:PRN skin irritation Montelukast Sodium 10 mg PO/NG DAILY Acetaminophen 325-650 mg PO/NG Q6H:PRN pain, fever Pantoprazole 40 mg PO Q24H Order date: [**6-15**] @ 1209 Citalopram Hydrobromide 20 mg PO/NG DAILY Quetiapine Fumarate 25 mg PO/NG HS Docusate Sodium 100 mg PO BID Senna 1 TAB PO/NG [**Hospital1 **]:PRN constipation Heparin 5000 UNIT SC TID Thiamine 100 mg PO/NG DAILY In addition per OMR notes: divalproex 250 mg Tab, Delayed Release Oral 1 Tablet, Delayed Release (E.C.)(s) Twice Daily - prescribed by PCP Discharge Medications: 1. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for skin irritation. 2. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. 4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for abdominal pain. 10. divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO BID (2 times a day). 11. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) dose PO DAILY (Daily) as needed for constipation. 12. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 13. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 14. immune globulin(hum),capr(IGG) 10 % Injectable Sig: One (1) Intravenous DAILY (Daily) for 4 days. 15. phenylephrine HCl 10 mg/mL Solution Sig: One (1) Injection TITRATE TO (titrate to desired clinical effect (please specify)). 16. pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours). 17. propofol 10 mg/mL Emulsion Sig: One (1) Intravenous TITRATE TO (titrate to desired clinical effect (please specify)). 18. midazolam 5 mg/mL Solution Sig: One (1) Injection TITRATE TO (titrate to desired clinical effect (please specify)). 19. morphine (PF) in D5W 100 mg/100 mL (1 mg/mL) Parenteral Solution Sig: One (1) Intravenous INFUSION (continuous infusion). 20. methylprednisolone sodium succ 40 mg Recon Soln Sig: One (1) Recon Soln Injection Q8H (every 8 hours). Discharge Disposition: Extended Care Discharge Diagnosis: Abdominal pain - Constipation. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Patient is being transferred to [**Hospital1 112**] Burn Care Unit, floor 8C. Number there is: [**Telephone/Fax (1) 109837**]. Accepting physician is [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 55378**]. Followup Instructions: Name: [**Last Name (LF) 5240**],[**First Name3 (LF) 5241**] Location: [**Hospital6 5242**] CENTER Address: [**Location (un) 5243**], [**Location (un) **],[**Numeric Identifier 2260**] Phone: [**Telephone/Fax (1) 798**] Appointment: [**Telephone/Fax (1) 766**] [**2178-2-2**] 11:20am [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6708**]

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icd9cm

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icd9pcs

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Discharge summary

report

Admission Date: [**2142-3-26**] Discharge Date: [**2142-4-12**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1253**] Chief Complaint: dyspnea on exertion Major Surgical or Invasive Procedure: Left sided Talc Pleurodesis Intubation [**2142-4-3**] Upper Endoscopy (EGD - esophagogastroduodenoscopy): [**2142-4-3**] and [**2142-4-11**]. History of Present Illness: Ms. [**Known lastname 7864**] is an 87 Russian-speaking woman from the [**Location (un) 3156**] with history of dCHF, Hypertension, Hypothyroidism, Hyperlipidemia, with >1yr history of exudative bilateral pleural effusions, presenting for elective admission for medical thorascopy with talc pleurodesis of left effusion. Bilateral pleural effusions initially attributed to CHF, did not respond completely to diuresis, found to be exudative and lymphocytic after multiple thoracenteses. Last [**Month (only) **], patient underwent medical thoracoscopy with talc pleurodesis on right side, which improved right sided effusion temporarily. Cytology and culture negative at that time, and effusion still exudative. Patient admitted now for elective mediastinal thorascopy on left in setting of recurrent Left sided pleural effusions and persistent fatigue and dyspnea on exertion. Thoracentesis was attempted [**12/2141**], but procedure was stopped after 500ml were removed in setting of discomfort and question of trapped lung. Patient underwent talc pleurodesis on left on day of admission, requiring ketamine for sedation. Received nerve block prior to procedure. Nonspecific inflammation, patchy erythema seen in pleura with no overt evidence of cancer. Fluid sent for AFB smear and culture, fungal culture, gram stain and culture, cytology. Pleural biopsy done for pathology as well. She was given 800 cc LR in the OR and 250cc bolus in PACU. Pleurex catheter and chest tube in place to suction. Vitals in PACU post-op as follows: BP 120/80 HR 60-80s RR SaO2 96% 6L NC. She took a few hours to recover from sedation and ketamine, but on arrival to the floor, she felt well overall. She denied any pain in her chest/lungs. Denied shortness of breath at rest. Past Medical History: CHRONIC BILATERAL PLEURAL EFFUSIONS, S/P TALC PLEURODESIS [**9-/2141**] HYPERTENSION HYPERLIPIDEMIA HYPOTHYROIDISM Gastritis - per EGD [**2134**] H/O NEPHROLITHIASIS H/O BASAL CELL CARCINOMA [**2135**] *S/P SPLENECTOMY [**2133**] *S/P CHOLECYSTECTOMY CHRONIC CONSTIPATION URINARY INCONTINENCE OSTEOPOROSIS CHRONIC UTI on methenamine Social History: Prior to admission, she was living in her own apartment [**Location 7865**]in [**Location (un) **]. Her daughter lives [**Name2 (NI) 3592**] [**Last Name (NamePattern1) 7866**]. Her grandson is the HCP. Retired factory worker from the [**Location (un) 3156**]. Widowed with adult children. She has no history of tobacco, alcohol, or illicit drug use. Walks with the assist of a cane or walker. Mobile every day. Family History: Mother had hypertension. Physical Exam: ADMISSION EXAM: Vitals: 97.8 128/78 70 16 95% on 3L NC General: Alert, oriented, no acute distress HEENT: Sclera anicteric, mild conjunctival pallor, MMM, oropharynx clear Neck: supple, JVP ~ 9cm Lungs: Bilateral crackles halfway up posteriorly CV: Regular rate and rhythm, + systolic murmur and S4 loudest at apex Chest: chest tube and pleurex catheter from left lower back draining serosanginous fluid Abdomen: soft, very mild LLQ tenderness, non-distended, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 1+ bilateral lower extremity edema DISCHARGE EXAM: afebrile 130/55 p59 R18 94%RA GEN: well appearing, comfortable. RESP: CTA B. L Pleurex in place. Good AE. Breathing comfortably. CV: RRR. JVP wnl. Pertinent Results: Microbiology: [**2142-3-29**] 10:13 am URINE Source: Catheter. **FINAL REPORT [**2142-3-30**]** URINE CULTURE (Final [**2142-3-30**]): YEAST. 10,000-100,000 ORGANISMS/ML.. Pathology: Pathology Examination SPECIMEN SUBMITTED: Left Parietal Pleura. DIAGNOSIS: Pleura (left parietal), biopsy (A): Pleura with lymphoid infiltrate consistent with reactive inflammatory process (see note). Pathology Examination SPECIMEN SUBMITTED: Cell block of pleural fluid DIAGNOSIS: Pleural fluid, cell block: Negative for carcinoma; [**Year/Month/Day **] and scattered mesothelial cells. Note: See cytology (C12-7517V). Cytology Report PLEURAL FLUID Procedure Date of [**2142-3-26**] NEGATIVE FOR MALIGNANT CELLS. Mesothelial cells, macrophages and [**Date Range **]. Radiologic Studies: Radiology Report CHEST (PORTABLE AP) Study Date of [**2142-3-26**] IMPRESSION: 1) Tiny left apical pneumothorax. New left thoracostomy tubes. 2) Improved left lung aeration. 3) New right mediastinal contour may reflect a new loculated effusion. Radiology Report CHEST (PORTABLE AP) Study Date of [**2142-3-27**] IMPRESSION: Moderate right pleural effusion with adjacent compressive atelectasis is unchanged from the prior exam. Radiology Report CHEST (PORTABLE AP) Study Date of [**2142-3-29**] 12:12 AM IMPRESSION: 1. Interval development of a hazy left upper zone opacity, which may signify focal atelectasis or pneumonia. 2. No pneumothorax. 3. Worsening left lower lobe collapse. 4. Unchanged moderate right pleural effusion with adjacent atelectasis. Radiology Report CHEST (PORTABLE AP) Study Date of [**2142-3-30**] UPRIGHT AP VIEW OF THE CHEST: A left-sided chest tube terminates in the left upper lung as before. Severe left basilar atelectasis is similar to prior. Moderate left increased and moderate right pleural effusions are again seen. right basilar atelectasis is present. Subtle left upper lung opacity is little changed from the prior study. There is no new consolidation. Cardiomediastinal silhouette is unchanged. Radiology Report CT CHEST W/CONTRAST Study Date of [**2142-3-30**] IMPRESSION: 1. Dilated esophagus with oral contrast retained proximally, aerosolized material filling the remainder, and distal tapering, concerning for distal obstruction. Although no mass like lesions is identified, differential diagnosis includes malignancy, benign stricture, and achalasia. Severe dysmotility is less likely. Oral contrast is also sequestered in the oropharynx. 2. Interval placement of left chest tube with new small left anterior pneumothorax. 3. New right flank subcutaneous soft tissue edema. 5. Decreased size of right axillary fluid collection. 6. Loculated bilateral pleural effusions, with left pleural calcifications. Radiology Report CT NECK W/CONTRAST (EG:PAROTIDS) Study Date of [**2142-3-30**] IMPRESSION: 1. Dilated esophagus with oral contrast retained proximally, aerosolized material filling the remainder, and distal tapering, concerning for distal obstruction. Although no mass like lesions is identified, differential diagnosis includes malignancy, benign stricture, and achalasia. Severe dysmotility is less likely. Oral contrast is also sequestered in the oropharynx. 2. Interval placement of left chest tube with new small left anterior pneumothorax. 3. New right flank subcutaneous soft tissue edema. 5. Decreased size of right axillary fluid collection. 6. Loculated bilateral pleural effusions, with left pleural calcifications. Radiology Report CHEST (PORTABLE AP) Study Date of [**2142-3-31**] 3:17 AM FINDINGS: Comparison is also made to prior CT scan from [**2142-3-30**]. Heart size is enlarged. There are bilateral pleural effusions, right side worse than left. There is a left retrocardiac opacity. There is faint if any density projecting over the mid upper esophagus. This could correlate with the retained barium seen in this location on the prior CT scan; however, it is better assessed on the CT. There is no pneumothoraces. These findings have been discussed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7867**] with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Radiology Report CHEST PORT. LINE PLACEMENT Study Date of [**2142-3-31**] IMPRESSION: 1. Interval placement of right subclavian PICC line with its tip near the junction of the brachiocephalic vein with the superior vena cava. Dr. [**Last Name (STitle) 7868**] discussed this with [**First Name8 (NamePattern2) 1785**] [**Last Name (NamePattern1) **] by phone on [**2142-3-31**] at 8:30 p.m. There is a small-to-moderate sized layering right effusion which may have slightly increased in size since the previous study. In addition, there is persistent opacity at the left base with a suggestion of some air bronchograms which may represent lower lobe collapse, although a pneumonia in this vicinity should also be considered. Interval improvement in mild perihilar edema. No pneumothorax. Heart remains enlarged. Mediastinal contours are within normal limits. Radiology Report CT ABD & PELVIS WITH CONTRAST [**2142-4-1**] IMPRESSION: 1. Stranding surrounding the second portion of duodenum is nonspecific. No free air. 2. Stable loculated bilateral pleural effusions. Left PleurX catheter in stable location. 3. Stable cardiomegaly and small pericardial effusion. 4. Stable dysmorphic appearing liver, perihepatic ascites, and periportal edema. 5. Bilateral non-obstructing nephrolithiasis and renal hypodensities, some of which too small to fully characterize, but most likely cysts. 6. Improved lower esophageal dilation since two days prior. 7. Unchanged fat and fluid-containing ventral hernia. 8. Splenosis status post splenectomy. 9. Stable left adrenal thickening. [**2142-4-2**] 9:00:00 AM - EGD report Impression: An adherent clot was seen in the esophagus at 35cm from the incisors. This was unable to be washed or suctioned off. There appeared to be an ulcer in the clot. No active bleeding was seen. Normal mucosa in the stomach Two openings were noted in the proximal duodenum (D1). They were consistent with either duodenal diverticula or potentially hepaticoduodenostomy. Otherwise normal EGD to third part of the duodenum Recommendations: The clot in the esophagus is the likely etiology of the coffee ground emesis and odynophagia. Would keep NPO today and advance to slowly to soft solids. Continue [**Hospital1 **] PPI Can stop fluconazole as no evidence of [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] need repeat endoscopy. F/u with inpatient GI team to determine exact timing. [**2142-4-11**] - EGD report Impression: Ulcer in the lower third of the esophagus Granularity and erythema in the stomach body and antrum Previous choledochoduodenostomy of the first part of the duodenum Otherwise normal EGD to third part of the duodenum Recommendations: Continue PPI therapy. Further recommendations as per inpatient GI consult team. Additional notes: The procedure was performed by the attending and the GI fellow. The attending was present for the entire procedure. The patient's home medication list is appended to this report. FINAL DIAGNOSES are listed in the impression section above. Estimated [**Year (4 digits) **] loss = zero. No specimens were taken for pathology. [**2142-3-26**] 09:40PM [**Year/Month/Day 3143**] WBC-10.3 RBC-2.65* Hgb-9.7* Hct-27.5* MCV-104* MCH-36.6* MCHC-35.3* RDW-15.5 Plt Ct-206 [**2142-4-12**] 02:05AM [**Month/Day/Year 3143**] WBC-6.6 RBC-2.45* Hgb-8.1* Hct-25.6* MCV-105* MCH-33.2* MCHC-31.8 RDW-18.0* Plt Ct-285 [**2142-3-26**] 09:40PM [**Year/Month/Day 3143**] Glucose-116* UreaN-24* Creat-0.9 Na-145 K-4.3 Cl-108 HCO3-29 AnGap-12 [**2142-4-2**] 02:27AM [**Year/Month/Day 3143**] Glucose-677* UreaN-31* Creat-0.8 Na-125* K-3.6 Cl-96 HCO3-25 AnGap-8 [**2142-4-8**] 07:00AM [**Month/Day/Year 3143**] Glucose-87 UreaN-21* Creat-1.6* Na-136 K-4.6 Cl-104 HCO3-25 AnGap-12 [**2142-4-12**] 02:05AM [**Month/Day/Year 3143**] Glucose-67* UreaN-19 Creat-0.9 Na-138 K-3.7 Cl-103 HCO3-27 AnGap-12 [**2142-4-1**] 05:34AM [**Year/Month/Day 3143**] Hapto-<5* [**2142-4-1**] 05:34AM [**Year/Month/Day 3143**] LD(LDH)-206 TotBili-1.2 MICRO: ____________________________ Time Taken Not Noted Log-In Date/Time: [**2142-3-26**] 12:15 pm PLEURAL FLUID LEFT PLEURAL FLUID. GRAM STAIN (Final [**2142-3-26**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white [**Year/Month/Day **] cell count.. FLUID CULTURE (Final [**2142-3-29**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2142-4-1**]): NO GROWTH. ACID FAST SMEAR (Final [**2142-3-27**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. ________________________________ Time Taken Not Noted Log-In Date/Time: [**2142-3-26**] 12:15 pm TISSUE LEFT PARTIAL PLEURA. GRAM STAIN (Final [**2142-3-26**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Final [**2142-3-29**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2142-4-1**]): NO GROWTH. ACID FAST SMEAR (Final [**2142-3-27**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. Brief Hospital Course: Ms. [**Known lastname 7864**] 87F Russian speaking woman from [**Location (un) 3156**] with history of chronic diastolic congestive heart failure, chronic bilateral exudative pleural effusions of unclear etiology, admitted after elective talc pleurodesis of left side, who developed severe odynophagia during hospitalization and hematemesis, found to have a clot on esophageal ulcer, without evidence of active bleeding or candidal esophagitis. # BILATERAL EXUDATIVE PLEURAL EFFUSIONS: Unclear etiology of exudative pleural effusions which have been present for the past year. She is s/p talc pleurodesis of right side in [**9-/2141**] which worked temporarily. She underwent medical thoroscopy and talc pleurodesis of left side [**2142-3-26**], and she required repeat talc placement [**2142-3-28**] because mild fluid overload made the talc less effective the first time. Procedure was done under conscious sedation, also given ketamine. She was not intubated for procedure. Chest tube was removed [**2142-3-30**], and pleurex catheter remained for drainage. Pleural studies again showed exudative effusion, negative gram stain and culture. Cytology was negative. Pleural biopsies also showed negative gram stain, culture and lymphoid infiltrate consistent with reactive inflammatory process. The pleurex catheter was managed by IP team. The volume of her pleural effusions was noted to trend with the status of her heart failure, with significantly decreased output after diuresis to euvolemia. She was discharged with home VNA services with daily Pleurex drainage. # ODYNOPHAGIA/HEMETEMESIS/ESOPHAGEAL ULCER: Patient developed severe odynophagia roughly 1-2 days after procedure and was unable to tolerate po intake. ENT was consulted and did not see enlargement of tonsils or any source of bleeding from the cervical portion of esophagus. Flovent was stopped in setting of potential candidal esophagitis, though patient did rinse mouth out after every Flovent use and there was no evidence of thrush. She was also complaining of epigastric tenderness and was spitting up food and drink tinged with [**Last Name (LF) **], [**First Name3 (LF) **] IV PPI was started for potential acute gastritis, as she does have a history of gastritis as seen on EGD in [**2134**]. She was given oral viscous lidocaine PRN throat pain with some relief. GI was consulted, and patient was started empirically on sucralfate and fluconazole for potential candidal esophagitis, though she was unable to tolerate any PO medications at this point. She began to spit up gross [**Year (4 digits) **] several times per day. Hematocrit trended downwards slowly from 29 to 22, and patient was transfused 1u pRBCs with appropriate bump in Hct. Of note, she very difficult to crossmatch due to her autoimmune hemolytic anemia and multiple antibodies. CT neck and chest showed very dilated esophagus, gastrografin unable to pass through because of food and [**Year (4 digits) **] stuck in esophagus. She was transferred to [**Hospital Ward Name 332**] ICU for high risk EGD with intubation and underwent the procedure on [**2142-4-2**], which showed an adherent clot over a likely ulcer base, no active bleeding and no evidence of candidal esophagitis. Fluconazole was stopped and patient was continued on Protonix. Her diet was restarted on [**2142-4-3**] and patient underwent repeat EGD which showed a clean based superficial ulcer. She will continue on [**Hospital1 **] ppi at discharge. # INTERMITTENT HYPOXIA: Patient was having intermittent hypoxia, requiring up to 5L O2 by nasal canula while on the floor. This is likely secondary to significant atelectasis, as visualized on CXR with RLL collapse and likely atelectasis also on left above heart. Hypoxia improved when she was seated in upright position and made to breathe deeply. No clear pneumonia on CXR and no coughing clinically. She is encouraged to use incentive spirometry. Her oxygen requirement stabilized throughout her hospital stay. # ANEMIA: Hematocrit trended down slowly in setting of serosanguinous chest tube drainage and spitting up gross [**Hospital1 **]. She remained hemodynamically stable on the floor. She was transfused 1u pRBCs with good response in Hct. She has known history of gastritis, as seen on EGD in [**2134**]. Initial EGD showed showed an adherent clot over a ulcer base, no active bleeding and no evidence of candidal esophagitis. Of note, patient was difficult to crossmatch because of multiple antibodies. There was concern for hemolytic process given patient's low haptoglobin, but patient had normal LDH and total bilirubin. Her hematologist, Dr. [**Last Name (STitle) **] was contact[**Name (NI) **] and clarified that given her cold agglutinin disease, her haptoglobin would be chronically low, and LDH and bilirubin should be followed for evidence of hemolysis. Her cold agglutinin disease also requires that her [**Name (NI) **] be warmed through a warmer prior to transfusion. # CHRONIC DIASTOLIC CHF, with acute exacerbation: # Acute renal failure: Patient's volume status was difficult to keep even initially. Initial talc pleurodesis not completely effective in setting of mild overload. Her home diuretics were initially because she was unable to take POs and keep herself hydrated, so she became very dry, requiring gentle IVFs. She subsequently developed volume overload, with mild acute renal failure. She was diuresed initially with IV lasix, and was then resumed on her home Lasix 60 mg po q day. Her acute renal failure resolved with diuresis. She appeared euvolemic at the time of discharge. # HYPERNATREMIA: Patient developed hypernatremia in setting of poor PO intake given odynophagia. She was given gentle maintenance rate of D5W to correct her free water deficit and her hypernatremia resolved. # CHRONIC UTI: Patient has chronic UTIs, normally on methanamine, which she was unable to take most of hospitalization, as she was unable to tolerate POs. It was restarted at the time of discharge. Medications on Admission: ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 1-2 puffs(s) by mouth every four (4) to six (6) hours as needed for cough/wheezing CYANOCOBALAMIN (VITAMIN B-12) - 1,000 mcg/mL Solution - inject monthly first dose was [**11-25**] FENOFIBRATE NANOCRYSTALLIZED [TRICOR] - 145 mg Tablet - 1 Tablet(s) by mouth QDay FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol - 1 inhalation(s) by mouth QDay Rinse mouth after use FUROSEMIDE - (Prescribed by Other Provider) - 40 mg Tablet - 1.5 Tablet(s) by mouth daily HYDROCORTISONE - 2.5 % Cream - apply to rash as needed do not use for more than 2 weeks LABETALOL - 100 mg Tablet - twice a day LEVOTHYROXINE - (Dose adjustment - no new Rx) - 75 mcg Tablet by mouth daily LOSARTAN - 50 mg Tablet - 1 Tablet(s) by mouth daily METHENAMINE HIPPURATE - (Prescribed by Other Provider: [**Name Initial (NameIs) **]) - 1 gram Tablet - 1 Tablet(s) by mouth twice a day NIFEDIPINE - 90 mg Tablet Extended Rel 24 hr - 1 Tablet(s) by mouth daily SIMVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth once a day ACETAMINOPHEN - 500 mg Tablet - 2 Tablet(s) by mouth every 6 hours as needed for rib pain ASPIRIN - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth QDay CALCIUM CARBONATE-VIT D3-MIN - (On Hold from [**2141-11-20**] to unknown for hypercalcemia) - 600 mg-400 unit Tablet - 1 Tablet(s) by mouth QDay CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D-3] - 1,000 unit Tablet, Chewable - 1 Capsule(s) by mouth QDay INCONTINENCE PAD, LINER, DISP [BLADDER CONTROL PAD LONG] - Pad - Use as needed up to six times per day SENNOSIDES [SENNA] - 8.6 mg Capsule - 1 Capsule(s) by mouth twice a day as needed for constipation SODIUM CHLORIDE - 0.65 % Aerosol, Spray - 1 spray IN twice a day Discharge Medications: 1. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 2. cyanocobalamin (vitamin B-12) 1,000 mcg/mL Solution Sig: One (1) mL Injection once a month. 3. fenofibrate nanocrystallized 145 mg Tablet Sig: One (1) Tablet PO once a day. 4. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1) spray each nostril Nasal twice a day. 5. Flovent HFA 110 mcg/actuation Aerosol Sig: One (1) puff Inhalation once a day. 6. furosemide 40 mg Tablet Sig: 1.5 Tablets PO once a day. 7. labetalol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. methenamine hippurate 1 gram Tablet Sig: One (1) Tablet PO twice a day: per other provider. 11. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO every eight (8) hours as needed for pain. 13. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 14. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 15. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed for constipation. 16. 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:*0* 17. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) Powder in Packet PO DAILY (Daily) as needed for constipation: may purchase over the counter as Miralax. Discharge Disposition: Home With Service Facility: suburban home care Discharge Diagnosis: Primary Diagnosis: Bilateral Exudative Pleural Effusions # Esophageal ulcer/bleeding # Acute renal failure # Acute on chronic diastolic heart failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [**Known lastname 7864**], You were admitted to the hospital because you have fluid collections in your lungs on both sides, and the Interventional Pulmonary doctors wanted to help stop one of those collections (pleural effusions) from coming back by putting talc powder in the space just outside your lungs. Unfortunately, nobody knows why you have these pleural effusions. You are going home with a catheter to drain this fluid, and you will have visiting nurses to help with this fluid drainage. While you were here, you started to have severe pain with swallowing and were not able to eat anymore. You then started to spit up a lot of [**Known lastname **]. Upper endoscopies (EGD) were performed, which showed an ulcer in your esophagus. You are being treate with medication to decrease the amount of acid in your stomach to treat this. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Please be sure to keep all of your follow up appointments as listed below: Department: [**Hospital3 249**] When: THURSDAY [**2142-4-19**] at 4:10 PM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7869**], MD [**Telephone/Fax (1) 2010**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

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icd9pcs

[ [ [] ] ]

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443, 2221

22935, 23069

23105, 23249

2243, 2577

2593, 3008

24,676

114,834

9720

Discharge summary

report

Admission Date: [**2151-8-20**] Discharge Date: [**2151-9-12**] Date of Birth: [**2070-5-18**] Sex: F Service: MEDICINE Allergies: Prochlorperazine / Metoclopramide / Cephalosporins / Penicillins Attending:[**First Name3 (LF) 2160**] Chief Complaint: Sepsis Major Surgical or Invasive Procedure: IR guided replacement of blocked J-tube History of Present Illness: 87 yo NH resident with h/o cervical ca and XRT, vescicovaginal/rectovesicle/rectovaginal fistulas, s/p bilateral percutaneous nephrostomy, and recurrent UTIs presents with fevers, rigors, fatigue, and decreased UOP. She presented to the hospital when her family noticed that she was not feeling well, acting lethargic, and producing less urine from her bilateral nephrostomy. The patient did not complain of chest pain, SOB, cough, or GI symptoms. These symptoms have been relatively new, as she had felt well in the week prior to admission. Her activity level is limited by her functional status, and has not traveled as a result. Her daughter also denies obvious sick contacts. . Of note, the patient has been admitted multiple to times for dislodged nephrostomy tubes, as well as recurrent UTIs. Her most recent UTI consisted of ESBL Klebsiella resulting in sepsis, central line placement, and treated with Meropenem and Flagyl x 2wks for question of C. diff infection. Previous UTIs have included VRE/MRSA bacteria, treated with linezolid and vancomycin. . In the ED, 97.0, 82, 102/50, 16, 97 % RA. She was noted to have rigors, and her BP decreased to 70's/40's. She was also tachycardic to the 110's. She was given IVF and sent to the MICU for close observation. While in the ED, the patient and her family refused central line placement. Pt recieved 5 L NS. . Admitted to [**Hospital Unit Name 153**] for sepsis. Past Medical History: 1. Cervical Cancer 30 yrs ago, treated with XRT. Known vesicovaginal fistula, with recently discovered rectovaginal fistula, and rectovesical fistula. Per d/c summary, she is a poor surgical candidate for repair of this, but could consider a diverting colostomy done endoscopically, however patient did not want any further invasive procedures. Status post bilateral nephrostomy tubes which per notes were last placed [**2151-4-8**]. 2. Type 2 DM 3. Hypothyroidism 4. History of VRE, MRSA UTIs 5. Bipolar d/o 6. Anemia of chronic disease, baseline around 28. 7. delirium. 8. UTI's with Klebsiella, VRE/MRSA, s/p meropenem, vancomycin, and linezolid therapy. 9. Pressure sores- stage IV decubitus ulcer Social History: Living at [**Hospital3 2558**] currently. Daughter [**Name (NI) **] is HCP. Family History: Non-contributory Physical Exam: VITALS: 76/33, 79, 16, 100% 5L NC (upon admission to [**Hospital Unit Name 153**]) GEN: Lying in bed, pale appearing, sleeping. HEENT: PERRL, anicteric sclera, dry MM, conjunctival pallor Neck: supple, no JVD appreciated Lung: Poor inspiratory effort, decreased BS on left Heart: Distant sounds, RRR, no m/r/g Abd: Soft, NT/ND Ext: warm, perfused, 1+ DP pulses, R PICC, bilat heels dressed Back: buttock dressing dry, intact Skin: pale apprearing, no ecchymosis or rashes noted Neuro: no focal deficits appreciated Pertinent Results: [**2151-8-20**] 12:27AM BLOOD Lactate-6.5* [**2151-8-30**] 04:00AM BLOOD calTIBC-88* VitB12-854 Folate-12.4 Ferritn-867* TRF-68* [**2151-8-19**] 08:38PM BLOOD Glucose-245* UreaN-19 Creat-0.6 Na-133 K-4.3 Cl-100 HCO3-25 AnGap-12 [**2151-8-20**] 05:40AM BLOOD WBC-17.2* RBC-2.47* Hgb-6.1* Hct-21.1* MCV-85 MCH-24.7* MCHC-29.0* RDW-18.2* Plt Ct-704* [**2151-9-4**] 05:45AM BLOOD WBC-5.6 RBC-3.00* Hgb-8.0* Hct-25.5* MCV-85 MCH-26.7* MCHC-31.5 RDW-19.6* Plt Ct-429 . [**2151-8-30**] CATHETER TIP-IV WOUND CULTURE-FINAL INPATIENT: No growth [**2151-8-23**] BLOOD CULTURE AEROBIC BOTTLE-FINAL {[**Female First Name (un) **] PARAPSILOSIS}; ANAEROBIC BOTTLE-FINAL INPATIENT [**2151-8-20**] URINE URINE CULTURE-FINAL {MORGANELLA MORGANII, 2ND ISOLATE}; ANAEROBIC CULTURE-FINAL INPATIENT [**2151-8-20**] BLOOD CULTURE AEROBIC BOTTLE-FINAL {KLEBSIELLA PNEUMONIAE, PROTEUS MIRABILIS}; ANAEROBIC BOTTLE-FINAL {KLEBSIELLA PNEUMONIAE, KLEBSIELLA PNEUMONIAE} EMERGENCY [**Hospital1 **] [**2151-8-20**] BLOOD CULTURE AEROBIC BOTTLE-FINAL {STAPHYLOCOCCUS, COAGULASE NEGATIVE, STAPHYLOCOCCUS, COAGULASE NEGATIVE}; ANAEROBIC BOTTLE-FINAL {KLEBSIELLA PNEUMONIAE} EMERGENCY [**Hospital1 **] . CTA Chest/Abdomen INDICATION: 81-year-old female with cervical cancer status post CRT with rectovesicovaginal fistulas, bilateral nephrostomy tubes and sacral decubitus ulcer. . TECHNIQUE: MDCT acquired axial images of the pelvis were obtained without IV contrast. IV contrast enhanced images of the chest were obtained per PE protocol with preliminary non-contrast enhanced images of the chest. Multiplanar reformations were obtained. . CT PELVIS WITHOUT IV CONTRAST: Stool and oral contrast are seen within what appears to be the vagina. The rectum contains moderate wall thickening with small amount of perirectal stranding. The inferior small and large bowel are otherwise unremarkable. There is a small amount of free fluid within the pelvis, with multiple surgical sutures along the pelvic sidewalls. Surrounding subcutaneous tissues contain diffuse soft tissue stranding consistent with third spacing. . The patient is status post right hip replacement. There is a soft tissue defect extending to the lower sacrum/coccyx with surrounding soft tissue density with no evidence of lytic changes or sclerotic changes to suggest osteomyelitis. . CTA CHEST: There is no evidence of filling defects within the pulmonary arterial vasculature. No evidence of pulmonary embolism. The aorta is of normal caliber throughout its visualized thoracic course with no evidence of dissection. There are coronary artery and aortic calcifications present. There are no pathologically enlarged nodes within the mediastinum, hila, or axilla. There is bilateral atelectasis with no focal areas of consolidation. . BONE WINDOWS: No suspicious lytic or sclerotic bony lesions. Unchanged bilateral sacroiliac sclerotic changes. . IMPRESSION: . 1. Stool and oral contrast seen anterior to the rectum consistent with rectovaginal fistula. The urinary bladder is not clearly visualized. 2. Rectal wall thickening. Etiologies for this appearance include infection, inflammatory change and malignancy. 3. Sacral decubitus ulcer with no evidence of osteomyelitis. 4. No evidence of pulmonary embolism or aortic dissection . [**8-30**] Echo: Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated. The aortic valve leaflets are moderately thickened. No masses or vegetations are seen on the aortic valve. There is mild to moderate aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. Transmitral Doppler and tissue velocity imaging are consistent with Grade I (mild) left ventricular diastolic dysfunction. The tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. . CXR [**9-1**]: There is a new left PICC terminating in the expected location of the left brachiocephalic vein. There is interval removal of the right PICC. There is a persistent left-sided pleural effusion, with probable left lower lobe atelectasis. No evidence of pneumothorax. The right lung is clear. No pleural effusion is appreciated on this frontal view of the chest on the right. There are aortic calcifications. There are bilateral nephrostomy tubes in place, seen within the abdomen. SUPINE PORTABLE RADIOGRAPH OF THE CHEST: A left-sided PICC line is seen with the tip in the left brachiocephalic vein. Differences in opacity of the lungs are most likely due to layering of the previously seen pleural effusions on this supine radiograph. Hazy opacity in the right upper lung is likely atelectasis. The heart size is stable. Again noted are bilateral nephrostomy pigtail catheters. Note is made of air-filled stomach and several air-filled bowel loops in mid abdomen. IMPRESSION: 1. Tip of left-sided PICC line in left brachiocephalic vein. 2. Bilateral layering pleural effusions with mild right upper lobe atelectasis. PORTABLE ABDOMEN Reason: r/o obstruction [**Hospital 93**] MEDICAL CONDITION: 81 year old woman with MMP, including multiple intrapelvic fistulas, now with increasing abdominal distension and lower GI bleeding. Hypoactive BS on exam. Please eval for obstruction. REASON FOR THIS EXAMINATION: r/o obstruction INDICATION: Recent abdominal distention, lower GI bleeding, please rule out obstruction. COMPARISON: CT scan [**2151-9-8**]. FINDINGS: Multiple distended small bowel loops are present, measuring up to 4.5 cm. The stomach is distended with air. The large bowel is collapsed. There is a foreign body in the right lower quadrant, confirmed by later CT available at the time of dictation. Bilateral nephrostomy tubes are present as well as right proximal femoral hardware. IMPRESSION: Small-bowel obstruction. Dr. [**Last Name (STitle) **] was aware of these findings at the time of dictation. CT ABDOMEN W/O CONTRAST [**2151-9-8**] 5:15 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Reason: r/o SBO [**Hospital 93**] MEDICAL CONDITION: 81 year old woman with MMP including multiple intrapelvic fistulas and recurrent UTIs, tx to [**Hospital Unit Name 153**] for hypotension. Developing abd distension, [**Month (only) **] BS, abd XR worrisome for SBO. REASON FOR THIS EXAMINATION: r/o SBO CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 81-year-old female with multiple medical problems and intrapelvic fistulas now with hypotension and abdominal distention. COMPARISON: [**2151-8-20**]. TECHNIQUE: MDCT axial images of the abdomen and pelvis were obtained without IV contrast. Multiplanar reformatted images were also performed. CT ABDOMEN WITHOUT IV CONTRAST: There are small bilateral pleural effusions, left greater than right with associated atelectasis. There is a small pericardial effusion. Given the limitations of evaluation without IV contrast, the liver, gallbladder, spleen, and adrenal glands are unremarkable. There is a small amount of perihepatic fluid. A hyperdensity within the pancreatic duct, likely represents refluxed contrast. Bilateral percutaneous nephrostomy tubes are again seen. A catheter is seen within the stomach. There is massive gastric dilatation as well as massive dilation of the loops of small bowel. There are scattered air fluid levels. Contrast reaches the level of the proximal small bowel. Marked wall thickening is seen at this level and vascular compromise cannot be excluded. A G-tube plug is seen in the terminal ileum. The loops of small bowel distal to this plug are collapsed. This likely represents the site of obstruction. A small amount of fluid is seen surrounding the small bowel loops at this location. Contrast within the ascending colon likely represents retained contrast from the previous examination. CT PELVIS WITHOUT IV CONTRAST: There is a moderate amount of fluid within the pelvis. Stool is likely seen within the bladder consistent with the patient's known rectovaginal fistula. A fixation pin is seen within the proximal femur. A soft tissue defect in the lower outer sacrum/coccyx is seen with no evidence of cortical destruction to suggest osteomyelitis. BONE WINDOWS: Again demonstrate bilateral sacroiliac sclerotic changes. Multiplanar reformatted images confirmed the above findings. IMPRESSION: 1. Mechanical small-bowel obstruction with transition point in the terminal ileum likely secondary to G-tube plug. A small amount of fluid surrounds the small bowel loops at the point of obstruction. Wall thickening of the proximal small bowel is concerning for vascular compromise. 2. Bilateral small pleural effusions. 3. Small pericardial effusion. 4. Sacral decubitus ulcer. 5. Findings consistent with known rectovaginal fistula. The findings were discussed with Dr. [**Last Name (STitle) **] at 9:20 p.m. on [**2151-9-8**]. WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2151-9-11**] 04:34AM 10.8# 3.43* 9.1* 32.5* 95# 26.6* 28.1* 19.1* 608* [**2151-9-10**] 06:05AM 6.5 3.22* 8.8* 28.3* 88 27.2 31.0 18.9* 410 [**2151-9-9**] 06:22AM 7.6 2.94* 8.0* 25.3* 86 27.2 31.7 19.0* 348 [**2151-9-8**] 04:34AM 5.5 3.32* 8.8* 29.1* 88 26.4* 30.1* 18.9* 402 [**2151-9-7**] 09:06PM 29.0* Fibrino FDP D-Dimer [**2151-9-7**] 06:00AM 0-10 [**2151-9-7**] 06:00AM [**Telephone/Fax (1) 32812**]* [**2151-9-7**] 01:47AM 234 951* Glucose UreaN Creat Na K Cl HCO3 AnGap [**2151-9-11**] 04:34AM 172* 12 0.7 134 4.3 104 27 7* [**2151-9-10**] 06:05AM 103 10 0.5 139 3.9 110* 25 8 [**2151-9-9**] 09:55PM 113* 11 0.6 138 3.9 108 27 7* [**2151-9-9**] 06:22AM 92 12 0.6 141 3.2* 109* 29 6* [**2151-9-8**] 04:34AM 188* 13 0.5 140 3.4 107 30 6* Brief Hospital Course: Hospital Course: 1. Polymicrobial Bacteremia/Sepsis due to Coagulase Negative Staphlococcus, ESBL-Klebsiella, Proteus Mirabilis, Candidia Parapsilosis: the patient was initially hospitalized and stablized in the ICU, and started on broad spectrum antibiotics. Blood cultures grew the organisms as listed above. She had two Echos which did not reveal any evidence of vegetations. Given her fungemia, the patient had an eye exam by Opthamology which did not reveal any evidence of endopthalmitis. Her original PICC line (R sided) was changed over a wire to a double-lumen PICC, but after new fungemia, this was removed and a new L sided PICC line was placed. Following antibiotics were continued- IV Vancomycin, Meropenem, Fluconazole, and Metronidazole (as C diff ppx) -initial planned for stopping on [**2151-9-14**]. Also per ID, she was not a candidate for long term suppressive therapy; the etiology of her polymicrobial sepsis was most likely the numerous intra-abdominal fistulas that provide a conduit for blood stream infections. . 2. Urinary Tract Infection secondary to Morganella Morganii: as above, this organism was sensitive to Meropenem. 3. Aspiration s/p failed speech and swallow evaluation: the patient was noted to cough frequently while fed. Several speech and swallow evaluations confirmed that the patient was aspirating, and the speech/swallow specialists recommended keeping the patient strict NPO with J tube feeds. The patient was started on tube feeding during her hospitalization as she was noted to be extremely malnourished (albumin < 2). This issue of feeding for comfort was brought up with the daughters, given her limitied life expectancy, but during the family meeting one daughter was so interested in her decubitus ulcer that this issue could not be resolved. However, eventually the J-tube was clogged and [**Company 19015**] and bicarb did not unclog the tube. She subsequently underwent IR guided replacment of her J-tube. . 4. Multifocal Atrial Tachycardia, resolved after repletion of her K/Mg and treatment with IV Beta Blocker. . 5. Bilateral Pleural Effusions/LE edema: likely secondary to volume overload and third spacing. Once on abx, she did not have any fevers or leucocytosis to suggest complicated parapneumonic effusions or empyema. Etiology of effusions and LE edema likely secondary to IVF given during sepsis-resuscitation and very low albumin (1.7). As mentioned, no evidence of CHF on Echos. 6. Anemia of Chronic Disease: as noted by high Ferritin/low TIBC. HCT remained stable. . 7. Stage IV decubitus Ulcer: this was treated aggressively during her hospitalization with frequent dressing changes/debridement. She was turned frequently and aggresive wound care was maintained. . 8. Blocked J-tube s/p IR guidied replacement: As above, the patient's J-tube was clogged, and therefore she underwent IR guided replacement of her J-tube. Eventually in view of the bowel obstruction (see below) - [**Company 32813**] was started in the ICU (second transfer) at the request of daughter - [**Name (NI) 1060**]. . 9. Vesicovaginal, Rectovaginal, Rectovesicular Fistulas: pt deemed not to be surgical candidate per discussion with patients PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 335**] [**Last Name (NamePattern1) 5351**]. 10. Hypotension: The patient was retransferred to the ICU for hypotension resulting from a vaginal bleed. Pressors were not started as per family preferance (see below). The BP responded transiently to boluses of IV fluids. 11. Bowel obstruction: 3-4 days prior to the patient's death - when she was in the ICU for hypotension - It was noted that the patient's abdomen was distended, sluggish bowel sounds and also constipation was noted. Flat plate and CT abdomen showed small bowel obstruction with possible ichemia of bowel . Surgery was consulted and their recommendation was that the patient was a very poor surgical candidate. The family also did not want operative intervention at this time. The results of conservative management for ischemic bowel and obstruction was made clear to the patient's family as well as the fact that she will likely progress in terms of the bowel ostruction and ischemia and will have a very poor prognosis. Their questions were answered. . 12. End of Life issues: Several family meetings were held between the hospitalists, Dr. [**Last Name (STitle) 5351**], and her two daughters. One daughter seemed almost fixed on her decubitis ulcer and steered the conversation away from any and all end-of-life issues such as feeding for comfort; what to do when the patient develops sepsis again, etc. On [**2151-9-10**], in the ICU, the patient had a bowel movement. However, the patient continued to remain hypotensive (SBP 70's). BP responded to small boluses of IV fluids. Family did not want central lines or pressors. On [**2151-9-10**] - After a long family conference with the ICU physicians - the family came to a consensus that there would be no escalation of care, including central lines and pressors. Morphine drip was started to make the patient comfortable and pt transferred to the medical floor. Overnight, on the floor the morphine drip was stopped because of decrease in resp rate to [**6-24**]/min. The patient was noted to be in no pain or discomfort, was not moaning. On [**2151-9-11**] - the patient was not responding to verbal or pain commands and agonal respirations were noted. Both daughters - [**Name (NI) **] (- HCP) and [**Doctor Last Name **] were at the bedside. The hospitalist had a long discussion with them - In view of very poor prognosis, there was a discussion regarding pursuing 'comfort care only'. However, the family wanted to discuss further about this among themselves but did say that they wanted to stop the antibiotics, give morphine only if patient was noted to be in discomfort and asked that no further fluid boluses be given for the low BP and no throat suction for secretions. They also did not want scopolamine patch or levsin sublingual to dry out the oral and throat secretions. They still wanted their mother to get the [**Name (NI) 32813**]. There was a conflict of opinion noted between the two sisters [**Name2 (NI) **] who was the HCP and [**Name (NI) 1060**]) during this decision making process. All their questions and concerns were appropriately answered. Assistance of palliative care team was obtained over the telephone and social worker was consulted to offer help to the family. At about 5-15am on [**2151-9-12**] - the patient was pronounced dead by the oncall doctor, Dr [**Last Name (STitle) 9570**]. Family requested an autopsy. Clinical details were provided to the pathologist performing the autopsy. Medications on Admission: Zyprexa, synthroid, gabapentin, oxycodone, iron, prilosec, MVI, megace Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 2. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 U U Injection TID (3 times a day). Disp:*qs U* Refills:*2* 4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 5. Fluconazole in Normal Saline 200 mg/100 mL Piggyback Sig: Two Hundred (200) mg Intravenous once a day: Note: course to end on [**9-14**]. Disp:*qs qs* Refills:*2* 6. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. Disp:*qs Tablet(s)* Refills:*0* 7. Meropenem 500 mg Recon Soln Sig: Five Hundred (500) mg Intravenous Q6H (every 6 hours): Note: course to end on [**9-14**]. Disp:*[**Numeric Identifier **] mg* Refills:*2* 8. Oxycodone 5 mg/5 mL Solution Sig: Five (5) mg PO Q6H (every 6 hours) as needed. Disp:*qs mg* Refills:*0* 9. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty (30) mg PO DAILY (Daily). Disp:*qs mg* Refills:*2* 10. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed. Disp:*qs Capsule(s)* Refills:*0* 11. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig: Five Hundred (500) mg Intravenous Q8H (every 8 hours): Note: course to end on [**9-14**]. Disp:*qs mg* Refills:*2* 12. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1) Appl Topical PRN (as needed). Disp:*qs qs* Refills:*2* 13. Lidocaine HCl 5 % Ointment Sig: One (1) Appl Topical PRN (as needed). Disp:*qs qs* Refills:*2* 14. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for rash. Disp:*qs qs* Refills:*0* 15. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gm Intravenous Q 24H (Every 24 Hours): Note: course to end on [**9-14**]. Disp:*30 gm* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Primary Diagnoses: Death: 1. Polymicrobial Bacteremia/Sepsis: Coagulase Negative Staphlococcus, ESBL-Klebsiella, Proteus Mirabilis, Candidia Parapsilosis 2. Urinary Tract Infection secondary to Morganella Morganii 3. Aspiration s/p failed speech and swallow evaluation 4. Multifocal Atrial Tachycardia, resolved 5. Bilateral Pleural Effusions, likely secondary to volume overload and third spacing 6. Anemia of Chronic Disease 7. Stage IV decubitus Ulcer 8. Blocked J-tube s/p IR guidied replacement 9. Vesicovaginal, Rectovaginal, Rectovesicular Fistulas: pt deemed not to be surgical candidate 10. Small bowel obstruction/ischemia Secondary Diagnoses: 1. h/o Cervical Cancer s/p XRT 2. Hypothyroidism 3. Bipolar Disorder Discharge Condition: Patient died in hospital Discharge Instructions: Patient died in hospital Followup Instructions: Patient died in hospital

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icd9cm

[ [ [] ] ]

[ "00.17", "97.02", "99.04", "00.14", "86.28", "38.93", "96.6" ]

icd9pcs

[ [ [] ] ]

22170, 22240

13289, 13289

332, 374

23027, 23053

3232, 8626

23126, 23153

2663, 2681

20148, 22147

9640, 9856

22261, 22911

20053, 20125

13307, 20027

23077, 23103

2696, 3213

22932, 23006

286, 294

9885, 13266

402, 1824

1846, 2552

2568, 2647

24,552

124,040

4370+4371

Discharge summary

report+report

Admission Date: [**2152-12-4**] Discharge Date: [**2152-12-15**] Date of Birth: [**2079-2-22**] Sex: F Service: CA/[**Last Name (un) **] HISTORY OF PRESENT ILLNESS: [**First Name8 (NamePattern2) **] [**Known lastname 18829**] is a 73 -year-old Russian speaking female with coronary artery disease and multiple risk factors, including diabetes, hypercholesterolemia, and hypertension who presented to the hospital on [**12-4**] with chest pain. Her pain was relieved with sublingual nitroglycerin and an electrocardiogram showed ST segment changes in V4, V5, and V6, compared to her previous electrocardiogram. She denied any other associated symptoms such as nausea, vomiting, diarrhea, shortness of breath, or diaphoresis. She was admitted to the hospital for a cardiac work up, given her high risk and positive signs on history and electrocardiogram. PAST MEDICAL HISTORY: 1. Coronary artery disease status post non-Q-wave myocardial infarction in [**2152-2-2**]. 2. Cardiac catheterization in [**2152-2-2**], showing three vessel disease. 3. Gastroesophageal reflux disease. 4. History of fecal incontinence. 5. Hypertension. 6. Diabetes. 7. Hypercholesterolemia. SOCIAL HISTORY: No smoking, no alcohol. PHYSICAL EXAMINATION: Vital signs: temperature of 96.4 F; pulse sinus of 80; blood pressure 160/100; O2 saturation 97% on two liters; fingerstick 150; weight 83 kg. In general, a pleasant elderly woman in no acute distress. Head, eyes, ears, nose, and throat examination: extraocular movements are intact, right surgical pupil. Neck examination: supple, no jugular venous distention, no lymphadenopathy. Chest examination: clear to auscultation bilaterally. Cardiovascular examination: regular rate and rhythm. Abdominal examination: soft, nontender. Rectal examination: brown stool, guaiac negative. Groin examination: positive femoral pulses. Neurologic examination: cranial nerves II through XII intact, sensation and motor grossly intact. LABORATORY DATA: White count of 7.3, hematocrit 39, platelets 216,000. Electrolytes: sodium 142, potassium 4.8, chloride 106, bicarbonate 25, BUN 20, creatinine 1.4, glucose of 270. Cardiac catheterization: 1) three vessel coronary artery disease, 2) normal systolic ventricular function, 3) ejection fraction of 60%. HOSPITAL COURSE: [**First Name8 (NamePattern2) **] [**Known lastname 18829**], given her symptomatic chest pain and previous coronary artery disease on cardiac catheterization, was referred for a coronary bypass. After the risks and benefits were explained to her and her family, she opted to proceed with the procedure. She received a coronary artery bypass graft on [**2152-12-8**]. She received four grafts during this operation. Her grafts were the following: 1) left internal mammary artery to left anterior descending, 2) saphenous vein graft to first obtuse marginal artery and second obtuse marginal artery, 4) saphenous vein graft to posterior descending artery. After the operation, [**First Name8 (NamePattern2) **] [**Known lastname 18829**] was transferred to the Cardiac Intensive Care Unit for postoperative care. She was weaned off the ventilator and eventually transferred to the floor on postoperative day five. Her postoperative course was significant for a urinary tract infection which was treated with Bactrim, and agitation which resolved with further consultation with family for this Russian speaking woman. The remainder of her course was significant only for a slow progress towards physical therapy. On discharge, she is being referred for rehabilitation. FOLLOW UP: She will go to rehabilitation with follow up with her primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4026**] and cardiac surgeon, Dr. [**Last Name (STitle) 14714**]. DISCHARGE MEDICATIONS: 1. Lisinopril 40 mg po q day. 2. Aspirin 81 mg po q day. 3. Zantac 150 mg po bid. 4. Lopressor 100 mg po bid. 5. Lipitor 10 mg po q day. 6. Metformin 1.0 gm [**Hospital1 **]. 7. Hydrochlorothiazide 25 mg po q day. 8. Insulin 35 units q AM - please adjust as needed. 9. Lasix 20 mg po q day times seven days. 10. Potassium chloride 20 mg po q day times seven days. 11. Imdur 60 mg q day - please note that this medication will now start as her preoperative medication. DISCHARGE CONDITION: Good. DISCHARGE STATUS: To rehabilitation. DIAGNOSES: Coronary artery bypass graft. [**First Name11 (Name Pattern1) 1569**] [**Last Name (NamePattern4) 18830**], M.D. [**MD Number(1) 18831**] Dictated By:[**Name8 (MD) 180**] MEDQUIST36 D: [**2152-12-15**] 08:20 T: [**2152-12-15**] 08:25 JOB#: [**Job Number 18832**] Admission Date: [**2152-12-4**] Discharge Date: [**2152-12-15**] Date of Birth: [**2079-2-22**] Sex: F Service: Cardiothoracic HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 18829**] is a 73-year-old Russian-speaking female with known 3-vessel coronary artery disease and multiple risk factors including diabetes, cholesterol, and hypertension who presented to the emergency room with chest pain on [**2152-12-4**]. Chest pain was relived with sublingual nitroglycerin and was found to be associated with new ST depressions approximately 1-mm in V4, V5, and V6 leads. Given her condition, she was admitted to the cardiac service. PAST MEDICAL HISTORY: 1. Coronary artery disease, status post non-Q-wave myocardial infarction in [**2152-2-2**]. 2. Cardiac catheterization in [**2152-2-2**] showing 3-vessel disease. 3. Gastroesophageal reflux disease. 4. Fecal incontinence. 5. Hypertension. 6. Diabetes mellitus. 7. Hypercholesterolemia. 8. Question retinal hemorrhage. PHYSICAL EXAMINATION: Temperature 96.4, pulse 80, blood pressure 160/100, respirations 20, satting 97% on 2 liters, sugar of 150, weight of 83 kg. In general, a pleasant, elderly female in no acute distress. HEENT examination revealed Pupils are equal, round and reactive to light and accommodation. Extraocular movements were intact. Neck examination was supple, no jugular venous distention, no lymphadenopathy. Chest examination was clear to auscultation bilaterally. No reproducible chest wall tenderness. Cardiovascular examination revealed a regular rate and rhythm, S1/S2. No murmurs, rubs or gallops. Abdominal examination revealed an obese, soft, nontender, and nondistended abdomen. Rectal examination revealed brown stool, guaiac negative. Groin with positive femoral pulses. No bruits. Extremity examination revealed dorsalis pedis 1+ bilaterally. Neurologic examination revealed cranial nerves II through XII were intact. Sensation and motor function were grossly intact. LABORATORY: White count 7.3, hematocrit 39, platelets 216. Electrolytes were sodium 142, potassium 4.8, chloride 106, bicarbonate 25, BUN 20, creatinine 1.4. Note: dictation ended after 3.9 minutes. [**First Name11 (Name Pattern1) 1569**] [**Last Name (NamePattern4) 18830**], M.D. [**MD Number(1) 18831**] Dictated By:[**Name8 (MD) 180**] MEDQUIST36 D: [**2152-12-14**] 19:16 T: [**2152-12-14**] 20:01 JOB#: [**Job Number 18833**]

[ "V45.82", "250.00", "530.81", "401.9", "272.0", "427.89", "411.1", "412", "414.01" ]

icd9cm

[ [ [] ] ]

[ "37.22", "36.15", "88.56", "36.13", "88.53", "39.61" ]

icd9pcs

[ [ [] ] ]

4386, 4890

3886, 4364

2335, 3612

3624, 3863

5772, 7223

4919, 5400

1920, 2317

5422, 5749

1218, 1243

27,304

109,073

4404

Discharge summary

report

Admission Date: [**2132-10-27**] Discharge Date: [**2132-11-4**] Date of Birth: [**2056-7-16**] Sex: M Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 1505**] Chief Complaint: murmur Major Surgical or Invasive Procedure: [**2132-10-30**] Bentall Procedure (25mm St. [**Male First Name (un) 923**] Aortic Valve Graft) History of Present Illness: 76 y/o male who found to have a murmur on his routine physical exam. He then underwent an echo which revealed a dilated aorta and aortic insufficiency. He was then referred for surgery. Past Medical History: Deep Vein Thrombosis, Arthritis, Melanoma s/p excision, Hydrocele, Glaucoma, s/p Appendectomy, s/p Hernia repair Social History: Tobacco: 4 pipes/day ETOH [**11-20**] glasses of scotch/day Retired, lives at home with wife Family History: Father died of aortic aneurysm at 66. 3 cousins died of aortic anuerysms between 40-50. Physical Exam: HEENT: EOMI, PERRL, NCAT Neck: Supple, FROM, -JVD, bruits Pulm: CTAB -w/r/r Heart: RRR 3/6 murmur Abd Soft, NT/ND, +BS Ext: Warm, bilat varicosities, [**11-20**]+ edema Neuro: A&O x 3, MAE, non-focal Pertinent Results: [**2132-11-3**] 03:59PM BLOOD WBC-10.2 RBC-3.57* Hgb-11.5* Hct-33.5* MCV-94 MCH-32.3* MCHC-34.4 RDW-13.1 Plt Ct-276# [**2132-10-27**] 08:45PM BLOOD WBC-6.8 RBC-4.07* Hgb-13.7* Hct-38.9* MCV-96 MCH-33.6* MCHC-35.1* RDW-13.1 Plt Ct-235 [**2132-11-4**] 06:40AM BLOOD PT-19.9* PTT-65.7* INR(PT)-1.9* [**2132-11-2**] 06:34PM BLOOD PT-19.8* PTT-36.0* INR(PT)-1.8* [**2132-11-2**] 07:55AM BLOOD PT-18.3* INR(PT)-1.7* [**2132-11-1**] 08:25AM BLOOD PT-17.4* INR(PT)-1.6* [**2132-10-30**] 01:15PM BLOOD PT-14.5* PTT-43.9* INR(PT)-1.3* [**2132-10-27**] 08:45PM BLOOD PT-14.2* PTT-29.2 INR(PT)-1.2* [**2132-11-3**] 01:02PM BLOOD Glucose-134* UreaN-14 Creat-0.8 Na-132* K-4.2 Cl-96 HCO3-26 AnGap-14 [**2132-10-27**] 08:45PM BLOOD Glucose-132* UreaN-10 Creat-0.9 Na-138 K-4.2 Cl-103 HCO3-26 AnGap-13 [**2132-10-27**] 08:45PM BLOOD ALT-16 AST-23 AlkPhos-67 Amylase-40 TotBili-0.6 [**2132-10-27**] 08:45PM BLOOD Lipase-34 [**2132-11-3**] 01:02PM BLOOD Mg-2.0 RADIOLOGY Preliminary Report CHEST (PA & LAT) [**2132-11-3**] 2:17 PM CHEST (PA & LAT) Reason: evaluate effusion [**Hospital 93**] MEDICAL CONDITION: 76 year old man s/p bentall REASON FOR THIS EXAMINATION: evaluate effusion INDICATION: Status post Bentall. Assess effusion. COMPARISON: [**2132-11-1**]. PA AND LATERAL CHEST: Sternal wires and the valve prosthesis are unchanged from the prior exam. There is similar cardiomegaly and tortuosity of the aorta. There are small bilateral pleural effusions. No pneumonia, failure, or pneumothorax. IMPRESSION: No short interval change in the appearance of the chest, with small bilateral pleural effusions. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4346**] DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**] [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 18940**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 18941**] (Complete) Done [**2132-10-30**] at 10:49:03 AM PRELIMINARY Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] R. Division of Cardiothoracic [**Doctor First Name **] [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2056-7-16**] Age (years): 76 M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Aortic valve disease. Left ventricular function. Valvular heart disease. ICD-9 Codes: 440.0 Test Information Date/Time: [**2132-10-30**] at 10:49 Interpret MD: [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6507**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2007AW02-: Machine: Echocardiographic Measurements Results Measurements Normal Range Aorta - Sinus Level: *4.5 cm <= 3.6 cm Aorta - Ascending: *6.5 cm <= 3.4 cm Findings LEFT ATRIUM: Moderate LA enlargement. No spontaneous echo contrast or thrombus in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is seen in the RA. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness and cavity size. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Moderately dilated aortic sinus. Markedly dilated ascending aorta. Mildly dilated descending aorta. Simple atheroma in descending aorta. AORTIC VALVE: Three aortic valve leaflets. Moderately thickened aortic valve leaflets. No AS. Moderate to severe (3+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderately thickened mitral valve leaflets. Mild mitral annular calcification. Physiologic MR (within normal limits). TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. Suboptimal image quality - poor echo windows. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions PRE-BYPASS: The left atrium is moderately dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated at the sinus level. The ascending aorta is markedly dilated The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is no aortic valve stenosis. Moderate to severe (3+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. The mitral valve leaflets are moderately thickened. Physiologic mitral regurgitation is seen (within normal limits). There is no pericardial effusion. POST CPB: 1. Preserved [**Hospital1 **]-ventricular systolic function 2. Mechanical prosthesis in aortic position. Weall seated and stable. 3. Trace AI 4. Tube graft in ascending aortic position. No other change Interpretation assigned to [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD, Interpreting physician Cardiology Report ECG Study Date of [**2132-10-30**] 2:34:56 PM Baseline artifact. Sinus rhythm. Non-diagnostic Q waves in leads II, III and aVF with probable ST-T wave abnormalities. However, artifact precludes clear visualization of the ST segments. Early R wave progression. Precordial T wave inversions. There is a single atrial premature beat. Since the previous tracing of [**2132-10-28**] the atrial premature beat is new and is probably paced. Inferior ST-T wave abnormalities may have appeared as well as the inferior Q waves. Clinical correlation is suggested. Read by: [**Last Name (LF) **],[**First Name3 (LF) 900**] A. Intervals Axes Rate PR QRS QT/QTc P QRS T 76 0 88 398/426 0 7 17 Brief Hospital Course: Mr. [**Known lastname **] was admitted pre-operatively for further cardiac work-up and to initiate Heparin therapy (d/t pt. previously being on Coumadin). On [**10-30**] he underwent a cardiac cath which ruled out any coronary artery disease, but did reveal AI and a dilated aorta. On [**10-30**] he was brought to the operating room where he underwent a Bentall procedure. Please see op note for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. On post-op day one he was started on beta blockers and diuretics and gently diuresed towards his pre-op weight. Later on this day his chest tubes were removed and he was transferred to the SDU for further care. Coumadin was initiated and Heparin was used as a bridge until patient was therapeutic. Epicardial pacing wires were removed per protocol. Physical therapy worked with him on strength and mobility. He was ready for discharge to rehab on POD 5. Plan for follow up at rehab for coumadin dosing, he has received 4mg [**2041-10-31**], 5mg [**11-3**], 7.5mg [**11-4**]. first draw wednesday [**11-5**] at rehab. Medications on Admission: Xalantan gtts, Coumadin (stopped 1 wk before admission), Prednisone (stopped 2 wks before admission), Timolol gtts, Alphagan gtts Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 4. Timolol Maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily). 5. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Warfarin 1 mg Tablet Sig: goal INR 2.5-3.0 Tablets PO once a day: please dose based on INR - draws mon/wed/fri goal INR 2.5-3.0 mech AVR . 8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed. Tablet(s) 9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day. Tablet(s) 10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. 11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days. 12. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day. 13. Multivitamins Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 14. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Ascending Aortic Aneurysm, Aortic Insufficiency s/p Bentall Procedure PMH: Deep Vein Thrombosis, Arthritis, Melanoma s/p excision, Hydrocele, Glaucoma, s/p Appendectomy, s/p Hernia repair Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 4044**]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Gently pat the wound dry. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 1 month. 7) Call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Dr. [**Last Name (STitle) **] in 4 weeks Dr. [**Last Name (STitle) **] after discharge from rehab Labs: PT/INR mon/wed/fri for dosing - goal 2.5-3.0 for mechanical aortic valve Completed by:[**2132-11-4**]

[ "716.90", "593.2", "V10.82", "511.9", "365.9", "441.2", "305.1", "562.10", "289.81", "424.1", "V58.61", "V12.51", "305.01" ]

icd9cm

[ [ [] ] ]

[ "35.22", "88.42", "37.22", "88.53", "38.45", "38.93", "88.72", "39.61", "88.56", "39.59" ]

icd9pcs

[ [ [] ] ]

10438, 10508

7775, 8995

295, 392

10739, 10745

1193, 2260

11508, 11716

869, 958

9175, 10415

2297, 2325

10529, 10718

9021, 9152

10769, 11485

5716, 6712

973, 1174

249, 257

2354, 5667

420, 607

629, 743

759, 853

6722, 7752

16,150

182,731

6369

Discharge summary

report

Admission Date: [**2148-4-17**] Discharge Date: [**2148-4-19**] Date of Birth: [**2085-10-10**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 1850**] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: intubated History of Present Illness: 62 year old F with h/o breast ca, metastatic to liver and bone, recently started on systemic therapy with weekly Navelbine, last tx was 2 wks ago. Pt recently admitted to [**Hospital1 18**] [**2148-4-8**] for perforated bowel with spontaneous closure. She was discharged home 4 days ago. On the day of admission, her family noticed that the patient was confused. . She was taken to [**Hospital3 **], where she was found to have Na 113, K 6.5 without ECG changes. She received Kayexalate, insulin and D50 and ~1L NS. Her Na prior to transfer was 117. ROS: The patient notes being fatigued and weak but otherwise "okay. She denies recent F/C/N/V/abdominal pain. She denies constipation/diarrhea. She reports SOB at baseline and uses 2L oxygen by Nasal cannula at home. She is thirsty and drinks fluids but has no appetite for solids. Her abd girth has not increased since D/C from [**Hospital1 18**]. Dark urine, but no other GU symptoms. Past Medical History: 1. Inflammatory breast carcinoma on the left side (ER positive, PR positive, HER-2/neu negative) diagnosed in [**7-21**], treated with neoadjuvant therapy of adriamycin and taxotere for 3 cycles, which was interrupted by admissions for pneumonia caused by [**Female First Name (un) **] and possibly [**Doctor First Name **]. Then received Xeloda and taxotere for 3 cycles and then had to Left MRM followed by chest wall XRT. Therefater she was on an aromatase inhibitor. In [**Month (only) 958**] [**2148**], found to have extensive mets to the liver and left pleural effusion. She was started on navelbine (last dose [**2148-4-5**]), along with a left thoracentesis. Abd CT shows innumerable mets in her liver. 2. Elevated lipids. 3. Hypertension. 4. Left sciatica. 5. Mild stress incontinence. 6. Diastolic dysfunction 7. Bowel Perforation- Social History: [**Known firstname **] lives alone on the [**Hospital3 **]; has several grown children who live nearby; her husband died of a brain tumor several years ago. Family History: Negative for breast, ovarian, or pancreatic cancer. Physical Exam: T=95.4 BP=120/68 HR=84 RR=22 O2sat=94% on 2L . GEN: ill appearing HEENT: PERRL, EOMI, icteric sclerae, clear OP, MMM CV: rrr, nl s1/s2 PULMO: lungs decreased breath sounds at bases ABD: distended, mild diffuse TTP, OB negative, diminished BS EXT: 2+ pitting edema b/l NEURO: axox3, cn2-12 intact SKIN: post radiation changes, weeping blisters on feet . MICU: PE: T 93.0 (oral) BP 87/57 HR 88 97 % AC 300 X 20 FiO2 100% GEN: intubated, sedated but arousable HEENT: PERRL, sclerae icteric, NGT in place with bloody material CV: rrr, nl s1 s2 LUNG: + wheeze anteriorly ABD: + Distension, NT, hypoactive BS EXT: +3 pitting edema to thighs B/L, weeping blisters on feet in gauze C/D/I. Pertinent Results: [**2148-4-18**] 05:19PM BLOOD Hct-37.0 [**2148-4-18**] 07:54PM BLOOD WBC-13.8*# RBC-3.14* Hgb-10.4* Hct-31.4* MCV-100* MCH-33.0* MCHC-33.1 RDW-17.7* Plt Ct-193 [**2148-4-19**] 04:27PM BLOOD Hct-29.7* [**2148-4-19**] 03:57AM BLOOD Neuts-93* Bands-0 Lymphs-0 Monos-4 Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-2* NRBC-0 [**2148-4-18**] 01:30AM BLOOD PT-14.2* PTT-43.6* INR(PT)-1.3 [**2148-4-19**] 04:27PM BLOOD PT-17.8* PTT-55.6* INR(PT)-2.0 [**2148-4-19**] 07:39AM BLOOD Fibrino-301 D-Dimer-3892* [**2148-4-19**] 08:48AM BLOOD FDP-10-40 [**2148-4-19**] 07:39AM BLOOD Glucose-170* UreaN-39* Creat-1.1 Na-122* K-4.8 Cl-94* HCO3-22 AnGap-11 [**2148-4-19**] 04:27PM BLOOD UreaN-37* Creat-1.1 Na-124* K-4.1 [**2148-4-18**] 01:30AM BLOOD ALT-140* AST-440* LD(LDH)-654* AlkPhos-1000* Amylase-60 TotBili-13.2* DirBili-7.2* IndBili-6.0 [**2148-4-19**] 03:57AM BLOOD ALT-161* AST-530* LD(LDH)-717* CK(CPK)-154* AlkPhos-917* TotBili-14.2* [**2148-4-18**] 01:30AM BLOOD proBNP-1363* [**2148-4-18**] 01:30AM BLOOD Albumin-2.5* Calcium-7.8* Phos-3.0 Mg-2.4 UricAcd-4.9 [**2148-4-19**] 07:39AM BLOOD Calcium-8.1* Phos-3.9 Mg-2.1 [**2148-4-18**] 01:30AM BLOOD Cortsol-53.4* [**2148-4-18**] 01:30AM BLOOD TSH-0.58 [**2148-4-18**] 07:11AM BLOOD Type-ART pO2-68* pCO2-41 pH-7.35 calHCO3-24 Base XS--2 [**2148-4-19**] 09:59AM BLOOD Type-ART Temp-36.4 Rates-/28 Tidal V-330 PEEP-10 FiO2-70 pO2-90 pCO2-27* pH-7.45 calHCO3-19* Base XS--2 -ASSIST/CON Intubat-INTUBATED Comment-AXILLARY T . ABD XR: Small-bowel obstruction. . CXR: Apparent interval increase in the previously demonstrated bilateral pleural effusions with bibasilar opacities consistent with collapse/consolidation. . ABD U/S: 1. Diffuse hepatic metastases. 2 Moderate volume of ascites. 3. Patent portal vein. . Brief Hospital Course: 1) UGIB: Pt developed an upper GI bleed. NG Lavage cleared. She was volume resuscitated, initially received 2 units of FFP, transfusion threshold of HCT < 30, placed on a PPI [**Hospital1 **], octreotide drip. . 2) Hypotension: Hypovolemia [**2-21**] GI bleed and sepis (hypothermic, elevated WBC). CVP now 19. fluid/blood resuscitation, placed on Levophed to MAP > 60, continued Levo, Flagyl for empiric coverage for aspiration/bowel flora. . 3) SBO: deemed a poor surgical candidate. Conservative treatment. NGT suction, IVFs. . 4) Respiratory failure: intubated for airway support as well as after probable aspiration pneumonia. Levo/Flagyl to cover aspiration. . 5) Hyponatremia: likely [**2-21**] decreased effective circulating volume. Improved with hypertonic saline initially and then normal saline resuscitation. . 6) Elevated LFTS: Has been high since [**Month (only) 958**] when new Liver metastatses discovered. Albumin 2.4. Received 2 bags FFP on [**4-18**]. . 7) End of life: Pt was made DNR/DNI initially, then CMO on [**2148-4-19**] and extubated. Pt expired with family present at [**2168**], an autopsy was denied. Discharge Disposition: Expired Discharge Diagnosis: Pt deceased Discharge Condition: Pt deceased Discharge Instructions: Pt deceased Followup Instructions: Pt deceased [**First Name8 (NamePattern2) 1176**] [**Name8 (MD) 1177**] MD [**MD Number(2) 1851**]

[ "V10.3", "198.5", "507.0", "560.9", "518.81", "995.92", "276.1", "197.2", "578.0", "V15.3", "197.7", "276.7", "038.9" ]

icd9cm

[ [ [] ] ]

[ "00.17", "96.04", "96.34", "96.71", "99.07", "99.04" ]

icd9pcs

[ [ [] ] ]

6066, 6075

4896, 6043

304, 315

6130, 6143

3120, 4873

6203, 6333

2340, 2394

6096, 6109

6167, 6180

2409, 3101

243, 266

343, 1283

1305, 2149

2165, 2324

69,243

155,212

53565

Discharge summary

report

Admission Date: [**2140-7-13**] Discharge Date: [**2140-7-20**] Date of Birth: [**2055-10-30**] Sex: M Service: MEDICINE Allergies: iodine dye Attending:[**First Name3 (LF) 425**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Tracheal intubation History of Present Illness: HPI: Mr. [**Known lastname 110088**] is 84M with history of CAD s/p 5V CABG ([**2124**]), 3V redo CABG in [**2134**] with porcine AVR, ischemic CM (EF 45%), HTN, HLD, R AKA amputation presents with dyspnea X 2-3 days to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospital. As per report, the patient has been getting more dyspneic with exertion, with his lasix recently increased by his cardiologist. Over the last three days, the patient reports having increasing edema, orthopnea, and DOE with ambulation from bed to bathroon. Denies any CP, no syncope, palpitations, or PRN. Does endorse throat pain, ?anginal equivalent. At [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] hospital he was in acute heart failure, with O2 saturations of 94% on 6L, trop 0.35. CXR notable for b/l effusions, pulmonary congestionwas given lasix. While there the patient received ASA 162 mg, Lasix 40 mg, rocephine 1 GM, and was started on heparin drip. Of note, in response to diuresis was noted to have systolic pressures dip into the 90s, at which point he was transferred to [**Hospital1 18**]. Of note patient had admission in [**4-14**] and diagnosed with meningioma and intracerebral aneurysms. In the ED, vitals were: 97.9 ??????F (36.6 ??????C), Pulse: 76, RR: 20, BP: 90/60, Rhythm: Sinus Rhythm, O2Sat: 96, O2Flow: 4L , Pain: 0 The [**Name (NI) **] pt given ASA 325, Rocephin 1 gm for CXR from outside hospital showing possible PNA?, and Heparin 4200 unit bolus and Gtt @ 12U/kg/hr. ED cardiologist saw him here and noted hypotension to the 80s although the patient was mentating and had good urine output. An echocardiogram was done in the ED (by the cardiology fellow) which showed reduced EF from [**4-14**] and septal WMA consistent with possible missed anterior MI. In ED patient became hypotensive SBPs 70s and given 750 CC IVF bolus after no response dopamine was started. Later pt's 02 sat dropped to 80s, ?evolving EKG changes, non rebreather was tried which didnt work then pt was intubated. pt SBP dipped into the 60s levofed was started in addition to dopamine Past Medical History: -HTN -HLD -CAD: s/p CABG x2 ([**2134**] - 3 vessel bypass w/ aortic valve replacement with porcine valve, [**2124**] - 5 vessel bypass) -Right AKA [**2-4**] gangrene 3 years ago -Left lower extremity bypass graft [**2-4**] peripheral vascular disease -Prostate Cancer - diagnosed in [**2088**], total prostatectomy, no chemotherapy or radiation -Remote left eye surgery, patient unable to recall what was done Social History: Patient lives with wife in a three floor building with his daughter and grandchildren living in the building. He recently moved into his daughter's house in [**Month (only) 1096**]. The patient worked as an electrician. Retired 22 years ago. Smoked 1ppd in 20s and 30s. Stopped 40 years ago. No alcohol abuse in past. Had not drank for many years. No elicit drug use. Family History: Brother - died in 50s from CHF Father - died in 70s from Prostate cancer Mother - died in 80s after hip fracture Denies history of neurologic disease such as seizures, brain tumors, or MS. Physical Exam: General: Intubated unresponsive. HEENT: NCAT, no scleral icterus noted, MMM, no lesions noted in oropharynx. Neck: No carotid bruits heard. Pulmonary: intubated Cardiac: third heart sound heard on exam, tachy Abdomen: soft, normoactive bowel sounds, no masses or organomegaly noted. Extremities: pulse appreciated in left foot by doppler, right leg AKA Ext warm Skin: No rashes or lesions noted. Neurologic: Mental Status: intubated Pertinent Results: [**2140-7-13**] 07:45PM PT-11.6 PTT-51.9* INR(PT)-1.1 [**2140-7-13**] 07:45PM PLT COUNT-152 [**2140-7-13**] 07:45PM WBC-15.0* RBC-3.41* HGB-10.0* HCT-30.2*# MCV-89 MCH-29.2 MCHC-33.0 RDW-18.5* [**2140-7-13**] 07:45PM WBC-15.0* RBC-3.41* HGB-10.0* HCT-30.2*# MCV-89 MCH-29.2 MCHC-33.0 RDW-18.5* [**2140-7-13**] 07:45PM CALCIUM-8.2* PHOSPHATE-3.6 MAGNESIUM-2.2 [**2140-7-13**] 07:45PM cTropnT-0.59* [**2140-7-13**] 07:45PM estGFR-Using this [**2140-7-13**] 07:45PM GLUCOSE-110* UREA N-34* CREAT-1.2 SODIUM-128* POTASSIUM-3.3 CHLORIDE-95* TOTAL CO2-26 ANION GAP-10 [**2140-7-13**] 09:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2140-7-13**] 09:50PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.004 Brief Hospital Course: Assessment and Plan Assessment: Mr. [**Known lastname 110088**] is 84M with history of CAD s/p CABG x2, AVR in [**2134**], ischemic CM (EF 45% in [**4-14**]) p/w worsening dyspnea, worse EF 20% found to be in cardiogenic and septic shock, has strep bovis positive blood cultures concerning for prosthetic valve endocarditis. ACUTE ISSUES #Shock: Multifactorial: The initial presentation included a broad differential of cardiogenic shock, septic shock, and adrenal insuffiency. Cardiogenic shock in the setting of recent anterior MI causing hypokinesis of anterior wall and cardiomyopathy and poor outflow from the heart. Septic in setting of positive blood culutures growingout strep bovis. Source of infection could be prostetic aortic valve endocarditis, initially coming from gut vs mouth. He was initially intubated after flash pulmonary edema ensued in the ED s/p fluid bolus for hypotension and then put on levophed and dopamine for pressor support while concominantly adding a lasix gtt for diuresis of pulmonary edema. Stress dose steroids were also initiated as the patient was chronically on decadron for menigiomas. A central line was placed for adequate pressor administration. The patient's blood pressures and urine output were adequate and the dopamine and levophed were titrated off. He then self-extubated without complications. Shortly after, troponin and CK-MB were noted to be drastically elevated at 7.58 and 99. However, because of goals of care (family did not want major surgery and interventions), no cardiac catheterization was undertaken. And although there was evidence of septic shock on initial presentation as he met SIRS criteria and we had [**4-6**] BCx positive for Strep Gallalyticus, he clinically did not appear septic as there were no pressor requirements and no IVF was given. The patient was initiated with ceftriaxone to treat his bacteremia and the steriods were tapered down to his home dose. The central line was removed and a PICC line was placed for possibility of needing home IV antibiotics. ID was consulted and patient can go home on PO amox 1 g [**Hospital1 **] indefinitely because he is goign home on hospice. Before discharge, the PICC line was removed as no IV abx will be given at home. Radiology called right before discharge and noted a possible infiltrate on latest CXR. Patient was discharged on Levaquin (10 day regimen) for treatment of possible community acquired pneumonia. #End of Life Care: Pt's family wanted pt to be DNR DNI after pt was extubated. Pt's family wanted home hospice so we got palliative care involved. He will be discharged on all oral medications to treat his presumptive bacteremia/endocarditis and pneumonia. Hospice will initiate his home O2 requirement #Episodes of resp distress: The patient had multiple episodes of shortness of breath and anxiety after extubation. Pt has tachy, HTN and incr RR and lower sats in the 80s when these occurred. It was felt to be episodes of flash pulmonary edema which responded to morphine, nitro dri, lasix. It is unclear why pt continues to have these episodes. Possibly ACS related. Likely a combination of anxiety, tachycardia/HTN causing increase in afterload, and ongoing ischemia which ultimately led to flash pulmonary edema. Along with addition of Metoprolol 50 mg [**Hospital1 **], we added captopril to decrease his flash pulmonary edema. We gave lasix PRN and morphine PRN for episodes of resp distress. To help with his anxiety and delerium we started him on zyprexa. # Rhythm: Pt had episodes where he had PVCs and also had episodes of atrial tachy and pt was started on amiodarone. Plan for amiodarone: 200 TID (day 1 was [**7-18**]) for 3 wks then 200 daily starting on [**2140-8-8**]. # Coronaries: Patient presenting with acute cardiac decompensation in setting of ischemic/septic embolic cardiomyopathy. He likely had a missed anterior MI vs septic embolic event with worsening EF new septal akinesis-dyskinesis. Family did not want any interventions did not want cath lab # [**Last Name (un) **]: Likely from CHF with intravascular low volume. His Cr improved around discharge. #Hyperglycemia Pt was put on Insulin sliding scale CHRONIC ISSUES: # meningiomas: At first we gave stress dose steroids in setting of shock then we he was better we continued home decadron 3mg. #MCA aneurysms: During hospital stay we focused on the bigger issues: cardiogenic shock, septic shock. Pt was placed onhep drip for a couple of hours at the beginning of hospital stay bc of concern of possible MI. This was discontinued a couple of hours later as pt got worse and went into cardiogenic shock. #Anemia: HCT was around his baseline. TRANSITIONAL ISSUES -Amiodarone: Amiodarone 200 mg TID for 3 weeks (day 1: [**7-18**]) , 200 [**Hospital1 **] (start on [**8-9**] for 2 weeks) then 200 mg daily after (start on [**8-24**]) -f/u presumed endocarditis -f/u MCA aneurysms Medications on Admission: amlodipine 5 mg atorvastatin 10 mg docusate 100 mg daily ferrous sulfate 325 mg daily lorazepam 0.5 mg q6h PRN losartan 50 mg daily magnesium oxide 400 mg daily metoprolol 50 mg TID mirtazapine 30 mg qhs MVI daily ranitidine 150 mg [**Hospital1 **] Lasix 40 mg daily Decadron 3 mg daily ASA 81 mg Discharge Medications: 1. Amiodarone 200 mg PO TID RX *amiodarone 200 mg 1 tablet(s) by mouth three times a day Disp #*60 Tablet Refills:*0 RX *amiodarone 200 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 2. Amoxicillin 1000 mg PO Q12H RX *amoxicillin 500 mg 2 capsule(s) by mouth every 12 hours Disp #*30 Tablet Refills:*3 3. Aspirin 81 mg PO DAILY RX *Adult Low Dose Aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. Dexamethasone 3 mg PO DAILY RX *DexPak 1.5 mg (51 tabs) 2 tablets(s) by mouth daily Disp #*30 Tablet Refills:*0 5. Furosemide 80 mg PO DAILY Please start [**7-21**] RX *furosemide 80 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 6. Levofloxacin 750 mg PO Q48H Duration: 10 Days RX *Levaquin 750 mg 1 tablet(s) by mouth every 48 hours Disp #*5 Tablet Refills:*0 7. Lisinopril 5 mg PO DAILY RX *lisinopril 5 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 8. Metoprolol Succinate XL 150 mg PO DAILY Hold if BP <90 and HR <60 RX *metoprolol succinate 100 mg 1.5 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 9. Mirtazapine 30 mg PO HS RX *mirtazapine 30 mg 1 tablet(s) by mouth once at night Disp #*30 Tablet Refills:*0 10. Morphine Sulfate (Concentrated Oral Soln) 5-10 mg PO Q2H:PRN anxiety, SOB, air hunger Sub-lingual RX *morphine concentrate 100 mg/5 mL (20 mg/mL) 0.25-.5 mL by mouth every 2 hours Disp #*6 Bottle Refills:*0 11. OLANZapine (Disintegrating Tablet) 2.5 mg PO QHS RX *olanzapine 2.5 mg 1 tablet(s) by mouth at night Disp #*30 Tablet Refills:*0 12. OLANZapine (Disintegrating Tablet) 2.5 mg PO ONCE A DAY PRN anxiety RX *olanzapine 2.5 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 13. home oxygen dx: CHF rx: please take 2-5L NC titrate to comfort 14. Ranitidine 150 mg PO BID Discharge Disposition: Home With Service Facility: [**Hospital 2188**] Discharge Diagnosis: Primary: decompensated CHF, endocarditis Secondary: coronary artery disease,pneumonia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: It was a pleasure taknig care of you here at [**Hospital1 18**]. You came to the hospital because you had shortness of breath. We did special imaging and saw that your heart wasnt squeezing well. You needed a breathing tube for a day and then you were able to breathe on your own. While you were here we found a bacteria growing in your blood and we treated you with IV antibiotics called ceftriaxone. It is most likely that the bacteria in your blood is from an infection in your heart called endocarditis. While you were here you also became agitated and upset at times and then became short of breath. We think you will start to feel more calm when you are home. We took a photo of your lungs the day befor eyou left and it showed you may have a new pneumonia. We are going to treat you for it with oral antibiotics because you are going home on hospice. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. We made the following changes to your antibiotics: please START amoxacillin 1 g [**Hospital1 **] will likely be on indefinitely. This is for your infection of the heart please START amiodarone 200 three times a day which you will take for 3 wks then 200 daily starting on [**2140-8-8**] This is for your heart rate which can become fast at times Please start ZYPREXA please START levofloxacin 750 mg every other day for 10 days Followup Instructions: We have schedule cardiology and infectious disease appointments for you. You can cancel these appointments if you do not think they are necessary and if you find it is difficult to transport out of the house. Department: NEUROLOGY When: MONDAY [**2140-8-29**] at 1:30 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12567**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1844**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: RADIOLOGY When: MONDAY [**2140-8-29**] at 11:55 AM With: RADIOLOGY MRI [**Telephone/Fax (1) 590**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 861**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: RADIOLOGY When: MONDAY [**2140-8-29**] at 11:15 AM With: RADIOLOGY MRI [**Telephone/Fax (1) 590**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 861**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage We are working on a follow up appt with Dr. [**Last Name (STitle) **] in the week. You will be called at home with the appointment. If you have not heard or have questions, please call [**Telephone/Fax (1) 62**]. Department: INFECTIOUS DISEASE When: THURSDAY [**2140-8-25**] at 10:00 AM With: [**Name6 (MD) **] [**Name8 (MD) 32437**], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage We are working on a follow up appt with Dr. [**Last Name (STitle) **] in the week. You will be called at home with the appointment. If you have not heard or have questions, please call [**Telephone/Fax (1) 62**]. Department: INFECTIOUS DISEASE When: THURSDAY [**2140-8-25**] at 10:00 AM With: [**Name6 (MD) **] [**Name8 (MD) 32437**], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

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Discharge summary

report

Admission Date: [**2178-8-31**] Discharge Date: [**2178-9-6**] Date of Birth: [**2111-7-10**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 943**] Chief Complaint: Chest pain. Major Surgical or Invasive Procedure: Pericardial drain placement [**2178-8-31**]. History of Present Illness: 67yoM with hx of HCC s/p liver [**Month/Day/Year **] in [**2174**] now relisted, s/p ichemic cholangiopathy with bilateral biliary stent placements, and recent [**Hospital1 18**] admission for similiar symptoms, re-presents today with persistent chest pain. During his prior admission, dates ([**2178-8-23**]) through ([**2178-8-25**]), the patients chest was worked up and was ruled out for MI, PE and Aortic Disection. During the admission the patient had his left percutaneous biliary catheter exchanged, treated for suspected cholangitis with Cipro/Flagyl however his chest pain persisted. His Total Bili, which was elevated to 7 from a baseline of 1.5 to 3, improved following the drain exchange. An echo during the admission saw a small pericardial effusion, which was not there during a TTE in ([**5-24**]). The patient was given PO tylenol that decreased the severity of the pain, however the pain was still persistenting on his discharge. . Today the patient presents with continued chest pain. He describes it as band like in nature across the front of his chest with radiation across the top of the back and to his proximal left arm. The pain is constant and severe, limiting him from falling asleep. He states it is worse with movement and upon deep inspiration. It is worse with leaning forward. No alleviating symptoms. The patient was recently discontinued off his Naloxone, which he was taking for persistent pruritis. . ROS is negative for fevers, chills, sweats, visual changes, loss of consciousness. However the patient has reported two loose dark brown-black stools per day. No BRBPR. One episode of "spitting up", no coffee ground emesis. No weightloss. The patient was admitted directly from his Gastroenterology physicians clinic. Past Medical History: - Status post liver [**Month/Year (2) **] [**4-/2174**] - Cirrohosis due to NASH - History of HCC - Diffuse biliary strictures due to ichemic cholangiopathy with subsequent bilateral percutaneous biliary drains, with multiple exchanges since placement - Type 2 diabetes - Hypertension - Parathyroid adenoma status post parathyroidectomy [**8-/2175**] - Chronic renal failure, baseline creatinine 1.3-1.4 Social History: Rare EtoH. Quit smoking [**2168**]. Retired. Previous director of Health Services for Prison Service. Married with three children. Family History: Father - [**Name (NI) **] CA Mother- CVAs Brother - DM, HTN No family history for liver disease or colon CA. Physical Exam: VS: 93.6 111/61 57 18 97% Gen: Very mild distress, Middle-aged male, Generally Well appearing HEENT: PERRL, EOMI Neck: Supple, No LAD CV: S1S2, distant HS, No MRG Resp: CTAB, ?reproduction of identical CP Abd: Soft, NT, ND BS+. No biliary drainage Ext: No C/C/E Neuro: Motor Grossly intact in 4 extremities Pertinent Results: Labwork on admission: [**2178-8-31**] 09:00AM WBC-12.4*# RBC-3.29* HGB-10.8* HCT-31.0* MCV-94 MCH-32.8* MCHC-34.8 RDW-13.3 [**2178-8-31**] 09:00AM PLT COUNT-196 [**2178-8-31**] 09:00AM UREA N-50* CREAT-2.1* SODIUM-118* POTASSIUM-4.8 CHLORIDE-91* TOTAL CO2-16* ANION GAP-16 [**2178-8-31**] 09:00AM GLUCOSE-120* [**2178-8-31**] 09:00AM PT-14.8* INR(PT)-1.3* [**2178-8-31**] 09:00AM CALCIUM-8.8 PHOSPHATE-4.9*# MAGNESIUM-2.3 [**2178-8-31**] 09:00AM ALT(SGPT)-67* AST(SGOT)-66* ALK PHOS-497* TOT BILI-4.0* [**2178-8-31**] 09:00AM tacroFK-6.2 [**2178-8-31**] 10:55AM CK-MB-NotDone cTropnT-<0.01 . ECG Study Date of [**2178-8-31**] Sinus rhythm. Prolonged A-V conduction. Ventricular ectopy. Borderline low voltage in the limb leads. Slightly prolonged Q-T interval. Compared to the previous tracing of [**2178-8-25**] diffuse ST segment elevations have improved. Ventricular ectopy is not as frequent. Voltage in the limb leads, and to some degree the precordial leads, has decreased. . TTE (Complete) Done [**2178-8-31**] The left atrium is mildly dilated. The right atrial pressure is indeterminate. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is borderline pulmonary artery systolic hypertension. There is a moderate sized circumferential pericardial effusion with sustained right atrial collapse, consistent with low filling pressures or early tamponade. Compared with the prior study (images reviewed) of [**2178-8-25**], the pericardial effusion is larger and increased pericardial pressure is now suggested. Serial evaluation and clinical correlation is suggested. . DUPLEX DOPP ABD/PEL Study Date of [**2178-8-31**] IMPRESSION: 1. Large regional/geographic hypoechoic area involving the central portion of the liver, not in a vascular distribution. Findings are nonspecific, however, concerning for possible ischemia or cholangitis. Further evaluation with contrast-enhanced CT or MR is recommended. This was discussed with Dr. [**First Name8 (NamePattern2) 1169**] [**Last Name (NamePattern1) **] on [**2178-8-31**]. 2. Bilateral pleural effusions and small pericardial effusion. . CHEST (PA & LAT) Study Date of [**2178-8-31**] IMPRESSION: Worsening left lower lobe atelectasis. No acute cardiopulmonary process or displaced rib fractures. . C.CATH Study Date of [**2178-9-1**] FINAL DIAGNOSIS: 1. Pericardial tamponade with improvement in hemodynamics after removal of 610 cc of bloody fluid. 2. Moderate systemic arterial hypertension, post pericardiocentesis. . Portable TTE (Focused views) Done [**2178-9-2**] The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). There is no ventricular septal defect. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade. . CT ABD W&W/O C Study Date of [**2178-9-4**] IMPRESSION: 1. Small-to-moderate pericardial effusion. Bilateral large pleural effusions with bibasilar atelectasis. 2. Non-obstructive left renal calculus. 3. Focal hyperemia in the left hepatic lobe as described above; this could represent early inflammatory hyperemia or focal pericholangitis or reactive changes secondary to trauma from recent percutaneous catheter exchange. No microabscesses, focal hepatic lesions, or masses were identified. There is mild intrahepatic biliary ductal dilation, unchanged. . CHEST (PA & LAT) Study Date of [**2178-9-4**] IMPRESSION: 1) Slight decrease in pericardial effusion. 2) Slight increase in right pleural effusion but unchanged small left pleural effusion. . Labwork on discharge: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2178-9-6**] 05:00AM 6.1 2.64* 8.6* 25.2* 95 32.5* 34.0 13.7 204 RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2178-9-6**] 05:00AM 127* 29* 1.5* 131* 3.9 96 24 15 ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili [**2178-9-6**] 05:00AM 68* 60* 673* 3.1* Brief Hospital Course: 67 year-old man with history of hepatocellular carcinoma status post liver [**Year (4 digits) **] in [**2174**] now relisted presenting with chest pain and found to have tamponade/pericarditis. . 1. Tamponade/pericarditis: The patient presented with tamponade physiology and was sent to the cardiac cath laboratory [**2178-9-1**] for drain placement, with 700 cc serosanguinous drainage. The patient was initially monitored in the CCU. The drain was removed [**2178-9-2**] and repeat TTE showed only a trivial effusion. The etiology of the effusion remains unclear. Differential diagnosis includes cirrhosis, infection, malignant. Bacterial cultures are negative at the time of discharge. Viral cultures and serologies for EBV, CMV, VZV, adenovirus, and [**Location (un) **] virus are pending at the time of discharge and should be followed-up as an outpatient. This was unlikely to represent TB with [**Doctor First Name **] minimally elevated and PPD negative. Cytology was negative for malignant cells. An autoimmune etiology is unlikely given his degree of immunosuppression. The patient was initially treated with NSAIDs, which were discontinued due to chronic renal failure, and he was subsequently treated with a prednisone burst with good effect. He was treated with prednisone 20 mg daily x 2 days and 10 mg x 2 days during admission, and discharged with 10 mg x 4 days until further evaluation by Dr. [**Last Name (STitle) 497**] at his follow-up appointment. He was scheduled for follow-up with Dr. [**Last Name (STitle) 171**] in cardiology. . 2. Hyperechoic liver lesion: There was a hyperechoic liver lesion noted on ultrasound as above. CT abdomen was performed for further evaluation, and the lesion was most likely an area of hyperemia or inflammation, and was not thought to represent a recurrence of hepatoma. . 3. Atrial flutter/fibrillation: The patient had atrial flutter with variable block during the time of transfer to the CCU with tamponade. He reverted back to sinus rhythm, but then returned to atrial flutter during admission. He was rate-controlled with metoprolol. It is unlikely that this represented cardiac ischemia and cardiac enzymes were negative at the time, however, he has numerous risk factors and should be considered for outpatient cardiac stress test for further evaluation. His CHADS2 score is 2, and he should be considered for anticoagulation as an outpatient. Anticoagulation was not addressed during admission due to pericarditis and risk of hemorrhagic effusion. He was scheduled for follow-up with Dr. [**Last Name (STitle) 171**] in cardiology. . 4. Acute on chronic renal failure: Baseline creatinine 1.6, with creatinine 2.1 on admission. Hydrochlorothiazide and valsartan were held. The patient's creatinine improved with gentle fluids. . 5. Bilateral pleural effusions: He was noted to have small bilateral pleural effusions on chest x-ray. The patient denied shortness of breath or other symptoms. The effusions may be related to liver disease. Further evaluation and management was deferred to the outpatient setting. . 6. Hyponatremia: Improved on discharge. The patient is hypervolemic and his hyponatremia is likely from cirrhosis. Diuretic use was likely contributing, and his hydrochlorothiazide was held during admission. He was placed on free water restriction of 1.2 liters per day. . 7. Status post liver [**Last Name (STitle) **]: He is now relisted due to donor-graft-associated cholangiography. The patient was continued on tacrolimus and mycophenolate, with adjustment of the tacrolimus level during admission. He was continued on rifampin and bactrim prophylaxis. He was continued on ursodiol for cholangiopathy. . 8. Hypertension: The patient was normotensive during admission. His valsartan and triamterene-hydrochlorothiazide were held for acute renal failure as above. His valsartan was restarted on discharge, but triamterene-hydrochlorothiazide was not. He was continued on felodipine and metoprolol. . 9. Type 2 diabetes: No active issues. The patient was continued on with lantus with sliding scale insulin. . 10. Hyperlipidemia: No active issues. The patient was continued on statin, zetia. Medications on Admission: Rifampin 300 mg PO Q12H Sertraline 100 mg PO QPM Ezetimibe 10 mg PO QPM Simvastatin 10 mg PO DAILY Ferrous Gluconate 325 mg PO DAILY Sulfameth/Trimethoprim SS 1 TAB PO DAILY Insulin SC Tacrolimus 14 mg PO Q12H Metoprolol Tartrate 50 mg PO TID Terazosin 5 mg PO HS Multivitamins 1 TAB PO DAILY Triamterene-Hydrochlorothiazide 2 CAP PO DAILY Mycophenolate Mofetil 1000 mg PO BID Ursodiol 900 mg PO BID Omeprazole 20 mg PO DAILY Valsartan 320 mg PO DAILY Potassium Chloride 20 mEq PO DAILY Felodipine 10 mg SR PO DAILY Discharge Medications: 1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. Rifampin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 4. Sertraline 100 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 5. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 9. Ursodiol 300 mg Capsule Sig: Three (3) Capsule PO BID (2 times a day). 10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 11. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 12. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Insulin Glargine 100 unit/mL Solution Sig: Thirty (30) units Subcutaneous at bedtime. 14. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain for 5 days. Disp:*30 Tablet(s)* Refills:*0* 15. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 4 days. Disp:*4 Tablet(s)* Refills:*0* 16. Tacrolimus 1 mg Capsule Sig: Ten (10) Capsule PO 6am and 6pm: Adjust as indicated. 17. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): 320mg dose. (Diovan). 18. Felodipine 10 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 19. Humalog 100 unit/mL Cartridge Sig: per sliding scale Subcutaneous [**First Name8 (NamePattern2) **] [**Last Name (un) **] Recs. 20. Potassium Chloride 10 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary: - Tamponade - Pericarditis - Hypoechoic liver lesion - Atrial flutter - Acute on chronic renal failure . Secondary: - Status post liver [**Last Name (un) **] [**4-/2174**] - Cirrohosis due to NASH - History of HCC - Diffuse biliary strictures due to ichemic cholangiopathy with subsequent bilateral percutaneous biliary drains, with multiple exchanges since placement - Type 2 diabetes - Hypertension - Parathyroid adenoma status post parathyroidectomy [**8-/2175**] - Chronic renal failure, baseline creatinine 1.3-1.4 Discharge Condition: Afebrile, vital signs stable. Chest-pain free. Discharge Instructions: You were admitted to the hospital with fluid and inflammation in the sac surrounding your heart, called tamponade and pericarditis. Your pain improved after drainage of the fluid and treatment with steroids and oxycodone. We remain unsure as to the cause of your symptoms, but it likely represented an infection, with some studies pending. . You had an area of concern noted on liver ultrasound. You had an abdominal CT that showed this area was unlikely to be a cancer and was more likely an area of inflammation. . While in the hospital, you developed an irregular heart rhythm called atrial flutter or fibrillation. You should discuss future use of coumadin, a blood thinner, and your personal risk of stroke with your primary care physician and cardiologist. . You had a bump in your kidney tests on admission. This improved with discontinuation of Triamterene-Hydrochlorothiazide. These medications have been on hold. You should discuss with Dr. [**Last Name (STitle) 497**] resuming this medication. . Please contact a physician or report to an emergency department if you experience fevers, chills, chest pain, shortness of breath, abdominal pain, nausea, vomiting, diarrhea, or any other concerning symptoms. . Please take your medications as prescribed. - You should continue Prednisone 10 mg daily for 4 more days--until your appointment as with Dr. [**Last Name (STitle) 497**]. - You can take Oxycodone every four hours as needed for pain; this medication is sedating and you should use caution when driving or operating heavy machinery. - Your Tacrolimus dose was adjusted to 10 mg daily. Dr. [**Last Name (STitle) 497**] will contact you regarding dosage adjustment. - Your Triamterene-Hydrochlorothiazide was discontinued. - No other changes were made to your medications. . Please keep your follow-up appointments as below. Followup Instructions: Previously scheduled appointments: Follow-up with your primary care doctor: Provider: [**Name10 (NameIs) **] [**Name Initial (NameIs) **] [**Name12 (NameIs) **], M.D. Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2178-9-18**] 10:00 Provider: [**Name10 (NameIs) 1037**] [**Name8 (MD) 5647**], MD Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2178-11-5**] 3:15 Provider: [**Name10 (NameIs) 454**],ONE [**Name10 (NameIs) 454**] Date/Time:[**2178-11-18**] 7:00 . Please see Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**] as scheduled this week, call his office at ([**Telephone/Fax (1) 1582**] with questions about the time. . Please call Dr.[**Name (NI) 5103**] office to schedule an appointment for follow-up within the next 10days.

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icd9cm

[ [ [] ] ]

[ "88.55", "37.21", "37.0" ]

icd9pcs

[ [ [] ] ]

14468, 14474

7831, 12035

325, 371

15047, 15097

3203, 3211

16993, 17756

2749, 2860

12602, 14445

14495, 15026

12061, 12579

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2875, 3184

7437, 7808

274, 287

399, 2156

3225, 5920

2178, 2584

2600, 2733

16,760

171,605

17236

Discharge summary

report

Admission Date: [**2200-7-30**] Discharge Date: [**2200-8-16**] Date of Birth: [**2127-5-13**] Sex: F Service: Vascular Surgery CHIEF COMPLAINT: Symptomatic pseudoaneurysm of previous proximal anastomosis of abdominal aortic aneurysm tube graft. HISTORY OF PRESENT ILLNESS: The patient is a 73-year-old nondiabetic white female with chronic obstructive pulmonary disease, hypertension, and hypercholesterolemia who had undergone a repair of ruptured infrarenal abdominal aortic aneurysm 10 years ago at an outside hospital. Following the repair, the patient developed a proximal anastomotic pseudoaneurysm. At that time, the patient refused treatment. Over the previous week, the patient complained of extreme fatigue. Over the last three to four days, she complained of abdominal pain and was seen in the [**Hospital 1474**] Hospital Emergency Room on [**2200-7-30**]. An abdominal computed tomography scan indicated a leaking abdominal aortic aneurysm as well as an atrophic left kidney. Her hematocrit was 25.2. The patient was Med-flighted to the [**Hospital1 190**] Emergency Room for further evaluation. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hypercholesterolemia. 3. Chronic obstructive pulmonary disease. PAST SURGICAL HISTORY: Repair of infrarenal ruptured abdominal aortic aneurysm with supraceliac cross clamp 10 years ago at an outside hospital. FAMILY HISTORY: Family history was noncontributory. SOCIAL HISTORY: The patient lives alone. She has family living nearby. She quit smoking cigarettes in [**2196**] after two packs per day for the previous 50 years. She does not drink alcohol. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Albuterol inhaler. 2. Metoprolol. 3. Lescol-XL. 4. Flexeril. 5. Percocet. PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed her temperature was 98.4, her heart rate was 100, her blood pressure was 180/108, and her oxygen saturation was 100% on 3 liters oxygen via nasal cannula. In general, a calm elderly white female in no acute distress. Head, eyes, ears, nose, and throat examination revealed pupils were equal, round, and reactive to light. Chest examination revealed the lungs were clear bilaterally. Heart was regular in rate and rhythm without murmur. The abdomen was soft. No pulsatile mass. Moderate tenderness over the left upper quadrant and left flank. Extremity examination revealed the feet were equally warm. Right dorsalis pedis and posterior tibialis pulses were palpable. Left dorsalis pedis and posterior tibialis pulses were dopplerable. Neurologic examination was nonfocal. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories from the outside hospital prior to admission revealed her white blood cell count was 7.5, her hematocrit was 25.2, and her platelets were 454,000. PERTINENT RADIOLOGY/IMAGING: Electrocardiogram revealed a normal sinus rhythm with Q waves in V4 through V6. A computed tomography of the abdomen with intravenous contrast revealed a large pseudoaneurysm at the proximal anastomosis of the prior tube graft repair of the abdominal aortic aneurysm with a large retroperitoneal hemorrhage at the renal artery level. CONCISE SUMMARY OF HOSPITAL COURSE: The patient was started on a Nipride drip in the Emergency Department for her hypertension of 180/108. Her goal systolic blood pressure was 100 to 110. She was seen and examined in the Emergency Department by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and taken to the operating room for emergent repair of the pseudoaneurysm at the proximal anastomosis of a previously placed infrarenal aortic tube graft. A supraceliac aortic cross clamp was necessary. The patient received multiple units of packed red blood cells and fresh frozen plasma intraoperatively. Following surgery, the patient had warm feet with palpable pedal pulses on the right and a palpable posterior tibialis pulse on the left. The patient was transferred to the Surgical Intensive Care Unit postoperatively. She remained intubated and sedated. On postoperative day two, the patient was noted to have pancreatitis with an amylase of 555 and a lipase of 472. These peaked respectively at 581 and 891. The patient was aggressively hydrated, and after several days her amylase and lipase returned to baseline. On postoperative day three, the patient's heart rate was noted to be in the 40s, and no blood pressure was obtainable. Cardiopulmonary resuscitation was started, and epinephrine and atropine were given. The patient developed atrial fibrillation and was prepared for cardioversion after amiodarone was started. However, cardioversion was not necessary because she spontaneously reverted to a normal sinus rhythm. A chest x-ray showed congestive heart failure. Cardiology was consulted. An echocardiogram at the bedside showed an ejection fraction of 40% to 45%. Continued amiodarone infusion was recommended at least until the patient was extubated. The patient diuresed well with small intravenous doses of Lasix. Pressors were discouraged secondary to the patient's single functioning right kidney. The patient was transfused several units of packed red blood cells over the next two days to keep her hematocrit greater than 30. Her cardiac enzymes and troponin T were negative. The patient remained intubated until [**2200-8-8**]. Multiple previous attempts at extubation brought on respiratory distress. After extubation, the patient's pulmonary toilet was maximized. She was encouraged to use incentive spirometry. Albuterol nebulizer treatments were helpful. Nutrition via total parenteral nutrition was started on [**2200-8-4**] because of the patient's extensive intubation and failure to be weaned off the ventilator. The nasogastric tube was finally removed on [**2200-8-9**]. The patient remained nothing by mouth until she had a bowel movement on [**2200-8-10**] following a rectal suppository. She was then allowed a few sips. However, the patient became distended, nauseated, and vomited small quantities. An abdominal ultrasound on [**2200-8-12**] showed multiple small gallstones with mild gallbladder edema. No intrahepatic ductal dilatation, and moderate abdominal ascites. The patient tried clear liquids again with minimal success. A computed tomography of the abdomen with contrast done on [**2200-8-14**] showed mild pancreatitis with three small fluid collections inferior to the pancreas, with the largest measuring 3.5 cm. There was a left subphrenic fluid collection. A small intimal flap was seen in the abdominal aorta. The flow within the aortic pseudoaneurysm had been excluded. There was concern that these fluid collections could represent a pancreatic pseudocyst. The General Surgery team was consulted. They evaluated the patient and planned to compare her abdominal computed tomography done at the outside hospital. The patient continued to take clear liquids but refused a regular diet in spite of having reasonable bowel sounds. Stool samples for Clostridium difficile cultures were sent. In the meantime, Flagyl 500 mg by mouth three times per day times two weeks was started empirically. The initial two samples were negative for Clostridium difficile. Physical Therapy was consulted to see the patient on [**2200-8-12**]. The patient declined to participate because she was too fatigued. Physical Therapy saw the patient again two days later and recommended a [**Hospital 3058**] rehabilitation stay. However, the patient refused a [**Hospital 3058**] rehabilitation and insisted she be discharged to home. Therefore, Physical Therapy recommended several more sessions until they cleared her for safety at home. The patient developed some thrush and was started on Nystatin swish-and-swallow on [**2200-8-15**]. Her methicillin-resistant Staphylococcus aureus screens done in the Surgical Intensive Care Unit were negative. The patient refused further workup by the General Surgery team and insisted on leaving the hospital on [**2200-8-16**] in spite of being told that she was not medically stable and still had several medical issues that were resolving. Nevertheless, the patient refused to stay and signed a statement stating she was leaving against medical advice. The patient was told to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in several days, and she was also given a prescription to complete her 2-week course of oral Flagyl. Prior to the patient's departure from the hospital, her abdominal incision was clean, dry, and intact. She had equally warm feet with palpable posterior tibialis pulses bilaterally. MEDICATIONS ON DISCHARGE: 1. Albuterol inhaler. 2. Metoprolol. 3. Lescol-XL. 4. Flexeril. 5. Percocet. 6. Flagyl 500 mg by mouth three times per day (times two weeks). DISCHARGE STATUS: The patient was discharged to home with home Physical Therapy which the patient refused. DISCHARGE DISPOSITION: The patient left against medical advice. PRIMARY DISCHARGE DIAGNOSES: 1. Leaking pseudoaneurysm of previous tube graft repair of abdominal aortic aneurysm. 2. Emergent repair of pseudoaneurysm of previous tube graft repair of abdominal aortic aneurysm on [**2200-7-30**]. SECONDARY DISCHARGE DIAGNOSES: 1. Pancreatitis. 2. Atrial fibrillation. 3. Congestive heart failure. 4. Cardiac arrest. 5. Respiratory failure with extended intubation. 6. Postoperative malnutrition. 7. Blood loss anemia. 8. Atrophic left kidney seen on abdominal computed tomography. 9. Departure from hospital against medical advice. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. 2914 Dictated By:[**Last Name (NamePattern1) 3954**] MEDQUIST36 D: [**2200-9-23**] 00:42 T: [**2200-9-23**] 07:21 JOB#: [**Job Number 48305**]

[ "441.3", "427.5", "518.81", "997.4", "285.1", "577.0", "427.31", "496", "996.74" ]

icd9cm

[ [ [] ] ]

[ "38.44", "99.15", "99.60" ]

icd9pcs

[ [ [] ] ]

9017, 9067

1417, 1454

9324, 9895

8734, 8993

1715, 3223

1276, 1399

3252, 8708

167, 269

298, 1141

1163, 1251

1471, 1689

6,726

181,829

22874

Discharge summary

report

Admission Date: [**2139-3-13**] Discharge Date: [**2139-4-6**] Date of Birth: [**2062-9-21**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 371**] Chief Complaint: s/p fall Subdural hematoma C-spine fracture Major Surgical or Invasive Procedure: s/p Craniotomy, Sundural hematoma evacuation s/p C6 fracture fixation-fusion s/p tracheostomy s/p PEG s/p IVC filter placement s/p pleurocentesis s/p lumbar puncture History of Present Illness: Patient is 76 year old male with a history of alcohol abuse and COPD presented to OSH s/p fall from the chair (said to be mechanical, while trying to put his pants on), with loss of consciousness. Family stated that patient had history of falls before, and in the week prior to presentation he had multiple falls and was complaining of headaches. On presentation patient was alert and oriented, complaining about headache and neck pain, after initial work up that revealed SDH and c-spine fracture, patient was transferred to [**Hospital1 18**] for further care. On arrival, patient seem aggitated, complaining of a headache and neck pain, denied chest pain, SOB, abdominal pain, extremity pain Past Medical History: atrial flutter atrial fibrillation s/p CVA COPD and home O2 EtOH abuse s/p L CEA s/p THR Social History: lives at home with his wife heavy alcohol use in the past heavy smoker in the past Family History: non-contributory Physical Exam: on arrival PERLA EOMI, pupils [**4-1**] bilaterally, TM clear billaterally, no lacerations noted Regular rate and rythm Bilateral ronchi and some [**Doctor Last Name 34965**], no crepitus, no tenderness Soft/non-tender/non-distended, Rectal: good tone, guac negative FAST-negative warm well perfused, 1+ edema bilaterally AOx3 MS5/5 bilaterally sensation grossly intact spine: TLS spine-no tenderness, no step offs Pertinent Results: [**2139-3-13**] 11:43PM TYPE-ART PO2-123* PCO2-39 PH-7.43 TOTAL CO2-27 BASE XS-2 [**2139-3-13**] 11:43PM K+-3.7 [**2139-3-13**] 11:43PM freeCa-1.04* [**2139-3-13**] 11:33PM CK(CPK)-135 [**2139-3-13**] 11:33PM CK-MB-3 cTropnT-0.08* [**2139-3-13**] 05:32PM TYPE-ART PH-7.43 [**2139-3-13**] 05:32PM GLUCOSE-179* LACTATE-1.5 K+-4.2 [**2139-3-13**] 10:32AM GLUCOSE-167* UREA N-14 CREAT-0.8 SODIUM-145 POTASSIUM-3.5 CHLORIDE-109* TOTAL CO2-29 ANION GAP-11 [**2139-3-13**] 10:32AM WBC-9.5 RBC-4.18* HGB-13.0* HCT-38.0* MCV-91 MCH-31.2 MCHC-34.3 RDW-14.2 [**2139-3-13**] 01:20AM PT-17.5* PTT-28.9 INR(PT)-1.9 CT C-spine [**2139-3-13**]: Bilateral fracture of the transverse processes of C6, possibly comminuted on the right. Severe disruption of the anterior longitudinal ligament with fracture extending through, and marked widening of the intervertebral disk space, particularly anteriorly, with disruption of the calcifications of the anterior longitudinal ligament and lordotic angulation of the cervical spine at this level. There appears to be deformation of the thecal sac. These results were communicated immediately to Dr. [**Last Name (STitle) **] [**Name (STitle) 59135**] of trauma at the time of image aquisition and interpretation. Ct head [**2139-3-13**]: Large right subdural hematoma, containing multiple densities, including a fluid-fluid level and an area of high-density hemorrhage anteriorly, consistent with acute on subacute subdural hemorrhage. Marked mass effect, with right to left subfalcine herniation, unca; herniation, and leftward displacement of the brainstem. No fractures identified. These results were called immediately to Dr. [**Last Name (STitle) **] of the trauma service. MR [**Name13 (STitle) 2853**] [**2139-3-14**]: 1. Widening of the disc space anteriorly at the C6-7 level, indicative of acute injury in a patient with fused cervical spine from DISH. 2. Small amount of fluid collection posterior to the C6 vertebral body in the epidural region, indicates a small epidura hematoma or effusion. In absence of significant marrow edema to the vertebral bodies, the presence of these epidural hematomas/fluid collections, is suggestive of acute trauma. No evidence of intrinsic spinal cord signal abnormalities. Other changes as above. Brief Hospital Course: Neurological: patient was diagnosed with a large right subdural hematoma acute on chronic and midline shift and ? early herniation. Neurosurgical service was notified and recommended hematoma evacuation after coags are corrected. In the mean time, after long discussion with the family, patient's wife and daughter wanted to hold off on all agressive treatments and intubation while they are making the decision on further management. At the mean time patient was admitted to Trauma ICU, he started to recieve vitamin K and FFP to correct his coagulopathy. His mental status was followed closely with serial exam. @)5:30 patient and his family made a decision to proceed fully with all treatments and he was booked for the operating room. @0700 patient mental status started to deteriorate, he was intubated and taken emergently to the operating room to hematoma evacuation, which was done successfully. Please see operating note for details. In the following weeks patient had a few follow up CT scan which showed not acute changes. he was eventually weaned off all sedation. Now: moving lower extremities spontaneously, moving RUE, withdrawing LUE to pain. opening eyes spontaneously, minimal tracking, does not follow commands. he has been stable in this condition, making very slow progress with movements. ## Cardiovascular: Patient had multiple cardiac risk factors, postoperativly developed worsening congestive heart failure, which was treated with minimizing IVF and lasix diuresis. Patient had an echocardiogram which showed an EF<40%, worsening of RV function and septal defect, as compare to pre-admission studies, most likely indication MI prior to admission. While in the hospital patient had no acute EKG changes (pre or post operatively), he initially had a troponin leak, but never qualified for frank MI. Post operatively patient had dysrhythmia's, including non sustained ventricular tachycardia, PAC, PVC, his electrolytes were normalized. Cardiology and EP services were consulted. Their evaluation revealed most likely a cardiac event in the past, and recommendation included continuing b-blockade, starting ACE inhibitor and aldactone for cardioprotection and further CAD work up in the future. Also started on amiodarone. Anticoagulation when possible (4 weeks after initial even by neurosurgery) ## Respiratory: patient has significant COPD history with home O2, he also and CHF in the initial parts of his hospitalization, which resolved with diuresis. Once intubated however, we had hard time weaning patient off the vent. Most likely as combination of both decreased mental status and significant respiratory diseas. For that reason tracheostomy was performed. After that procedure, patient weannig has expedited. no evidence of pneumonia. As part of the work up of his fever and disrythmia, patient had CTA of the chest which revealed no PE and bilateral pleural effusion, L>R. Pleural tap was performed on the left side, with 900cc of clear staw fluid, culture negative to date. Now: weaning of the vent, tolerating longer and longer periods of trach mask. no evidence of infection, no evidence of CHF ## GI: through out this admission patient had no GI symptoms, he tolerated TF well, and PEG was placed once it was clear that he will be ventilator dependant for a while. No concerns no issues ## Renal: Through out the admission patient renal function remained stable, tolerated lasix diuresis. no concerns no issues ## FEN: after patient operative management was completed, he was started on tube feedings through initially NGT and then PEG. patient tolerating tube feedings well and is currently on goal nutrition. Through his hospital admission, patient had intermittent hypokalemia, hypomagnesimia, hypophosphatemia which was corrected accordingly ## Endo: with history of diabetes mellitus type 2, patient remained on insulin drip through most of his icu stay (able to keep his blood glucose in 100-150 range) and is currently transitioning to insulin fixed doses and sliding scale. His TSH was checked and was found to be within normal limits. ## MSK: initial work up reveled significant degenerative changes thoughout patient spine and C6 fracture anteriorly and well as through transverse foramena. he was taken to the operating room by orthopedic service and c5-7 fusion was performed. Patient is to remain in c-collar untill seen by ortho service in the follow up ## ID: Throughout his admission patient continued to spike fevers up to 103. he has been pan cultured multiple times, with only positive culture is that of sputum culture for seratia (pan sensitive, treated with levofloxacin). his other cultures included blood, urine, sputum, CVL tip, CSF, pleural fluid and are all negative to date. Now: we are presuming that patient fever spike are related to his head injury, he will finish 10 day course of levofloxacin for seratia in the sputum and vancomycin will be stopped once last CVL tip culture come back negative ## Social: patient is full code. his wife and daughter was heavily involved in patient care. Medications on Admission: 1. labetolol 2. effexor 3. lasix 4. coumadin 5. albuterol Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 2. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 4. Acetaminophen 160 mg/5 mL Elixir Sig: One (1) PO Q4-6H (every 4 to 6 hours) as needed. 5. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 7. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN (as needed). 11. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**2-1**] Sprays Nasal QID (4 times a day) as needed. 12. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Four (4) Capsule, Sustained Release PO PRN (as needed) as needed for K < 4. 14. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 15. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Enoxaparin Sodium 40 mg/0.4mL Syringe Sig: One (1) Subcutaneous DAILY (Daily). 17. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet Sig: One (1) Packet PO X1 PRN as needed for phos < 3. 18. Quetiapine Fumarate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 19. Potassium Chloride 20 mEq Packet Sig: Two (2) PO BID (2 times a day). 20. Insulin Regular Human 300 unit/3 mL Syringe Sig: One (1) Subcutaneous sliding scale. 21. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day): 400 tid x 5 days, then 400 [**Hospital1 **] x 7 days, then 400 qd x 7 days, then 200 qd ongoing. 22. Magnesium Sulfate 50 % Solution Sig: One (1) Injection PRN (as needed) as needed for mg<2.0. 23. Furosemide 10 mg/mL Solution Sig: 40mg Injection [**Hospital1 **] (2 times a day). 24. Lorazepam 2 mg/mL Syringe Sig: One (1) Injection Q4H (every 4 hours) as needed. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: s/p fall subdural hematoma s/p craniotomy, subdural hematoma evacuation C6 fracture, s/p c5-7 fusion respiratory failure s/p tracheostomy failure to thrive s/p gastrostomy tube placement DM2 tachyarrhythmia ventricular tachycardia atrial tachycardia atrial flutter depression hypokalemia hypomagnesemia hypophosphatemia fever of unknown origin CHF COPD EtOH abuse Discharge Condition: stable Discharge Instructions: wean of ventilator as tolerated continue Tubefeedings wound check daily out of bed to chair with PT d/c hard collar [**4-3**], soft collar after that Followup Instructions: please follow up in Trauma clinic in 2 weeks Follow up with ortho [**Hospital **] clinic in 2 weeks Follow up with vascular service after c-collar is removed for IVC filter removal Once improve, follow up with cardiology for further CAD work up Completed by:[**2139-4-6**]

[ "496", "518.81", "852.20", "805.06", "286.9", "805.07", "427.1", "461.8", "250.00", "428.0", "E884.2", "427.31" ]

icd9cm

[ [ [] ] ]

[ "81.62", "96.6", "99.04", "38.93", "38.7", "01.39", "99.61", "81.02", "03.31", "96.04", "43.11", "34.91", "31.1", "88.72", "84.51", "96.71", "99.07" ]

icd9pcs

[ [ [] ] ]

11696, 11775

4259, 9320

356, 523

12182, 12190

1943, 4236

12388, 12663

1475, 1493

9428, 11673

11796, 12161

9346, 9405

12214, 12365

1508, 1924

273, 318

551, 1247

1269, 1359

1375, 1459

1,631

104,107

8845

Discharge summary

report

Admission Date: [**2194-12-7**] Discharge Date: [**2194-12-23**] Date of Birth: [**2118-3-21**] Sex: M Service: CARDIOTHORACIC Allergies: Amiodarone Analogues Attending:[**First Name3 (LF) 1505**] Chief Complaint: severe aortic stenosis, coronary artery disease Major Surgical or Invasive Procedure: liver biopsy CABG x1 (LIMA->LAD), AVR (19mm CE magna) [**12-18**] History of Present Illness: Mr. [**Known lastname 30842**] is a 76-year-old male, with known severe critical aortic stenosis that has been followed and now reached a level of 0.5 cm2 by echocardiography, who [**Known lastname 1834**] cardiac catheterization that confirmed the presence of critical aortic stenosis and showed an 80-90% proximal left anterior descending stenosis, with a 70% stenosis of a small ramus branch. He is presenting for valve and coronary surgery. The ejection fraction is preserved. Past Medical History: idiopathic thrombocytopenic purpura hepatitis C x8-10years coronary artery disease aortic stenosis hypertension hyperlipidemia atrial fibrillation pulmonary fibrosis secondary to amiodarone squamous cell CA of the RLE PSH: TURP [**2171**] hernia repair [**2171**] Social History: quit smoking 13 years ago rare use of alcohol Family History: Father: diabetes, died at age 55yo from unknown causes Mother: died in 70s Physical Exam: T 98.6 HR 73 BP 129/72 RR 18 97%RA NAD RRR, incis: c/d/i CTAB s/nt/nd, +BS no c/c/e Pertinent Results: [**12-8**] Carotids FINDINGS: Duplex evaluation was performed of both carotid arteries. Minimal plaque was identified. On the right, peak systolic velocities are 62, 66, 66 in the ICA, CCA, ECA respectively. The ICA to CCA ratio is 0.9. This is consistent with no stenosis. On the left, peak systolic velocities are 59, 54, 73 in the ICA, CCA, ECA respectively. The ICA to CCA ratio is 1.1. This is consistent with no stenosis. There is antegrade flow in both vertebral arteries. [**12-10**] abdominal u/s: FINDINGS: The liver is normal in echotexture without focal lesions. Gallbladder contains several layering stones without signs of cholecystitis. Common bile duct is normal in diameter measuring 0.4 cm. The pancreas is unremarkable. The aorta is normal in diameter. The right kidney measures 10.1 cm in length. There is a caliceal diverticulum in the upper pole containing calcium with an additional 0.6 x 4.2 x 1.0 cm simple cyst. The spleen is normal in size measuring 10.2 cm. [**2194-12-12**] Liver needle biopsy: 1) Mild portal chronic, predominantly mononuclear cell, inflammation. 2) Focal, mild steatosis. 3) Trichrome stain: Focal mild portal fibrosis. 4) Iron stain: No stainable iron. [**2194-12-7**] 03:40PM BLOOD WBC-6.9 RBC-4.50* Hgb-14.6 Hct-43.3 MCV-96 MCH-32.4* MCHC-33.8 RDW-12.5 Plt Ct-74* [**2194-12-18**] 11:05AM BLOOD WBC-12.5* RBC-2.43*# Hgb-8.3*# Hct-24.3*# MCV-100* MCH-34.2* MCHC-34.2 RDW-12.8 Plt Ct-63* [**2194-12-18**] 05:06PM BLOOD WBC-15.0* RBC-3.51*# Hgb-11.4*# Hct-32.5*# MCV-92# MCH-32.4* MCHC-35.1* RDW-15.1 Plt Ct-148*# [**2194-12-23**] 07:05AM BLOOD WBC-14.1* RBC-4.28* Hgb-13.8* Hct-39.9* MCV-93 MCH-32.1* MCHC-34.5 RDW-15.1 Plt Ct-54* [**2194-12-21**] 05:30AM BLOOD PT-14.4* INR(PT)-1.4 [**2194-12-22**] 07:30AM BLOOD PT-14.1* INR(PT)-1.4 [**2194-12-10**] 07:25AM BLOOD HCV Ab-POSITIVE Brief Hospital Course: Mr. [**Known lastname 30842**] was admitted to the Cardiac Surgery service under the care of Dr. [**Last Name (STitle) **]. Given his low platelet counts (74) at [**Hospital1 **] and at [**Hospital1 18**], a hematology consult was obtained for further evaluation. His thrombocytopenia had been previously documented and worked up by Dr. [**Last Name (STitle) 30843**]. An abdominal ultrasound showed no signs of splenomegaly and his heparin-dependent antibody assay was negative. In addition, the Hepatology team was asked to evaluate Mr. [**Known lastname 30842**] for his thrombocytopenia in the presence of HCV. On [**12-12**], Mr. [**Known lastname 30842**] [**Last Name (Titles) 1834**] an ultrasound-guided liver biopsy. The results were mild portal chronic, predominantly mononuclear cell, inflammation; and focal, mild steatosis. Mr. [**Known lastname 30842**] was cleared for surgery by the Hematology and Hepatology teams. His chronic thrombocytopenia was attributed to either ITP or HCV. He received platelet transfusions pre-operatively. On [**12-18**], he [**Month/Year (2) 1834**] his CABG x1 and AVR without complications. Please see Dr.[**Name (NI) 5572**] Operative Note for further detail. Post-operatively, he did well. He was extubated, his chest tubes removed, and transferred to the floor by POD #2. His platelet and hematocrit levels were closely followed. By the time of discharge on POD #5, his epicardial wires were removed, he was evaluated by physical therapy, had good pain control, and was tolerating a regular diet, although complained of poor appetite. His Coumadin was restarted on [**12-20**] for his atrial fibrillation. Medications on Admission: Coumadin 2.5mg PO daily Atacand 32mg PO daily Lopressor 100mg PO BID Insulin NPH 22 [**Hospital1 **] Glucotrol 5' Digoxin 0.125' Lipitor 20' Celexa 20' Protonix 40' Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: titrate for INR between 1.5-2.5. 7. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 9. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed. 10. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days: for [**Date range (1) 24295**]. 11. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 7 days: to start [**Date range (1) 30844**]. 12. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Humulin N 100 unit/mL Suspension Sig: Eleven (11) units Subcutaneous twice a day. 15. Humalog 100 unit/mL Cartridge Sig: One (1) Units Subcutaneous four times a day as needed for hyperglycemia: insulin sliding scale. Discharge Disposition: Extended Care Facility: [**Hospital1 **] - [**Location (un) 47**] Discharge Diagnosis: idiopathic thrombocytopenic purpura coronary artery disease aortic stenosis diabetes hyperlipidemia atrial fibrillation hepatitis C Discharge Condition: Good Discharge Instructions: If you have any chest pain, difficulty breathing, persistent nausea/vomiting, redness/oozing from your incision site, seek medical attention immediately. Followup Instructions: Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 6256**] Follow-up appointment should be in 2 weeks Provider: [**Last Name (Prefixes) 413**],[**First Name3 (LF) 412**] [**Telephone/Fax (1) 170**] Follow-up appointment should be in 1 month Completed by:[**2194-12-23**]

[ "250.00", "515", "287.31", "414.01", "401.9", "427.31", "424.1", "E942.0", "070.70" ]

icd9cm

[ [ [] ] ]

[ "50.11", "39.61", "99.05", "36.15", "99.07", "35.21" ]

icd9pcs

[ [ [] ] ]

6640, 6708

3352, 5026

336, 404

6884, 6891

1476, 3329

7093, 7427

1281, 1357

5241, 6617

6729, 6863

5052, 5218

6915, 7070

1372, 1457

249, 298

432, 914

936, 1202

1218, 1265

20,643

110,392

4824

Discharge summary

report

Admission Date: [**2103-10-13**] Discharge Date: [**2103-10-16**] Date of Birth: [**2039-3-10**] Sex: M Service: MEDICINE Allergies: Levofloxacin Attending:[**First Name3 (LF) 3326**] Chief Complaint: CC: SOB Major Surgical or Invasive Procedure: No major surgical or invasive procedures. History of Present Illness: HPI: 64 yo male with Hx of CAD s/p NSTEMI, severe COPD with multiple intubations on chronic steroids, who p/w onset of SOB over several hours. One day prior to admission, pt reports that he had been sitting in bed and noted the gradual progression of SOB over several hours. Denies sudden onset SOB, CP, pleuritic pain, orthopnea, pnd, inc le edema. States that it feels like a COPD flare. +occ cough, unchanged from chronic pattern. +yellow sputum, unchanged in frequency or character. Took ipratroprium/albuterol nebs x10, without improvement and decided to come to the ED. . In ED, 108, 140/90, 23, 88% ra. Durintg time in room, bp dropped to 97/69, rec'd 1.5L NS w/ subsequent improvement in BP. Rec'd cipro 250 mg. Also rec'd solumdrol 125, and underwent bipap while in ED. Past Medical History: PMH: 1. COPD on 4 L O2 at home and s/p multiple admissions and intubations for flares-FEV1 .47(19%) FEV1/FVC 36% on 4L home 02, and BiPap QHS. 2. Hypertension 3. Hyperlipidemia 4. CAD s/p NSTEMI ([**2101**]) [**4-10**] with cath normal 5. Chronic low back pain L1-2 laminectomy from accident at work 6. Steroid induced hyperglycemia 7. Left shoulder pain for several months 8. Cataract 9. GERD 10. Chronic indwelling urethral catheter. Social History: Married with six children. Lives at home in [**Location (un) 16174**] with wife. Retired [**Company 19015**] mechanic. Exposed to a lot of spray paint. Former smoker. Quit 25 years ago. 20 pack year history. Occassional EtOH Quit marijuana 3 years ago. Denies IV drug use. Activity limited due to prior spine and current shoulder problems. Family History: Mother with asthma and [**Name (NI) 2481**] Father with [**Name2 (NI) 499**] cancer Physical Exam: PE: 97.1, bp 123/43, 92, 18, 99% 4L NC Well appearing male, not utilizing acc mm, breathing comfortably in NAD. PERRL. OP clr, MMM 6cm JVP Regular S1,S2. No m/r/g. LCA b/l. +inc expiratory time. +bs. soft. nt. nd. no le edema. Pertinent Results: EKG: 85bpm, nl axis, nl interval, non-specific IVCD, unchanged. . CXR [**2103-10-13**] AP UPRIGHT PORTABLE CHEST X-RAY: The study is limited secondary to patient's positioning. The right costophrenic angle is not seen. The cardiac silhouette is normal in size. The aorta is tortuous. There is stable overinflation of bilateral lung fields, with flattening of the cardiac silhouette, and bilateral hemidiaphragms. Hyperlucency bilaterally and symmetrically is consistent with diffuse emphysema. The imaged lung fields are otherwise clear, with slight stable scarring at the left lung base. There is no pneumothorax, and the pulmonary vasculature is normal. IMPRESSION: 1. No acute cardiopulmonary process. 2. Underlying diffuse bilateral emphysema. . [**2103-10-15**] 5:09 pm URINE **FINAL REPORT [**2103-10-16**]** URINE CULTURE (Final [**2103-10-16**]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH FECAL CONTAMINATION. . [**2103-10-13**] 1:05 pm URINE Site: CATHETER **FINAL REPORT [**2103-10-14**]** URINE CULTURE (Final [**2103-10-14**]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH FECAL CONTAMINATION. . [**2103-10-13**] BLOOD CX: NEGATIVE . [**2103-10-13**] 02:35PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.016, BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-MOD; RBC-[**11-25**]* WBC->50 BACTERIA-MANY YEAST-NONE EPI-0-2 TRANS EPI-0-2 [**2103-10-13**] GLUCOSE-114* UREA N-16 CREAT-0.8 SODIUM-141 POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-29 ANION GAP-15, CALCIUM-9.0 PHOSPHATE-4.5 MAGNESIUM-1.7, WBC-14.0* RBC-4.52* HGB-12.2* HCT-37.8* MCV-84 MCH-27.1 MCHC-32.3 RDW-15.4, NEUTS-67.9 LYMPHS-24.3 MONOS-4.3 EOS-3.2 BASOS-0.4, PLT COUNT-333 Brief Hospital Course: A/P: 64 yo male with HTN, severe COPD with FEV1 20%, on home oxygen 4L and chronic steroids, with multiple prior intubations, admitted with COPD flare and hypotension. . 1) Shortness of breath: The patient's presentation was consistent with a COPD flare. There was no new infiltrate on Chest X-ray, and there was no change in the consistency/amount/frequency of his sputum production. Pulmonary embolism is highly unlikely. It was felt there was no indication for antibiotics. We continued his steroids at prednisone 60mg po qd, and discharged the patient on a taper over 10 days. We continued albuterol and ipratropium bromide nebulizer treatments, scheduled. The pt was started on fluticasone and salmeterol inhalers, and he will use these as an outpatient. He did not have to go on Bipap. At discharge, he was able to walk around the ICU five times. He reports this is his baseline. He will follow up with Dr. [**Last Name (STitle) 575**], his pulmonologist in the next 2 weeks. . 2) [**Name (NI) **] The pt had one episode of SBP in the 90s in the ED. He was asymptomatic. We considered a normal variation in BP, and could not r/o mild volume depletion given insensible losses vs adrenal insufficiency as pt is on steroid taper. We recommend cortstim on the pt as an outpatient. We continued steroids for COPD flare. Our goal was for MAP<60 and UOP<30cc/hour, supported with fluid boluses if need be, however he did not require this. He was with stable VS throughout his [**Hospital Unit Name 153**] stay. No more episodes of hypotension. He was placed on his high blood pressure medications while in the [**Hospital Unit Name 153**]. . 3) [**Name (NI) 20182**] The pt's urine cultures came back positive for >3 colony types, consistent with fecal contamination. Urology felt that this was likely colonization, given he has a chronic indwelling catheter. The catheter was changed on [**2103-10-15**], and urology recommended Macrodantin for 3 day course given the cath change. The pt is to follow up with Dr.[**Name (NI) 20183**] at [**Hospital1 112**] for potential transurethral needle ablation of the prostate for benign prostatic hyperplasia. . 4) [**Name (NI) 3674**] Pt has history of anemia in past, unclear when his last colonoscopy was. Will have pt follow up with PCP as outpatient to schedule colonoscopy. Stools were guiaic negative. . 5) Coronary Artery Disease- No current evidence of angina. We continued his ACE inhibitor/[**Name (NI) **]/statin. . 6) Code status- FULL. Medications on Admission: Meds: 1.Aspirin 325 mg qd 2.Atorvastatin Calcium 10 mg qd 3.Calcium Carbonate 500 mg qd 4.Cholecalciferol (Vitamin D3) 400 unit qd 5.Senna 8.8 mg/5 mL [**Hospital1 **] 6.Sertraline 50 mg qd 7.Albuterol Sulfate 0.083 % Neb q4hours 8.Ipratropium Bromide Nebq4hours 9.Multivitamin qd 10.Lisinopril 5 mg qd 11.Prednisone 30mg qd on taper(down from 40mg on [**7-25**]) 12.Percocet Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Date Range **]:*30 Tablet(s)* Refills:*2* 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Date Range **]:*30 Tablet(s)* Refills:*4* 3. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Date Range **]:*30 Tablet(s)* Refills:*3* 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed: Please see your primary care physician for refills of this medication. . [**Date Range **]:*30 Tablet(s)* Refills:*0* 5. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation Q12H (every 12 hours). [**Date Range **]:*1 Disk with Device(s)* Refills:*2* 6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Date Range **]:*30 Tablet(s)* Refills:*2* 7. Cepacol 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed). [**Date Range **]:*30 Lozenge(s)* Refills:*0* 8. Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q24H (every 24 hours). [**Date Range **]:*30 Tablet Sustained Release(s)* Refills:*2* 9. Nitrofurantoin Macrocrystal 50 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) for 2 days: To Complete a 3 day course. . [**Date Range **]:*8 Capsule(s)* Refills:*0* 10. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Date Range **]:*30 Tablet(s)* Refills:*2* 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). [**Date Range **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 12. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer Inhalation every six (6) hours. [**Date Range **]:*120 nebulizer* Refills:*2* 13. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer treatment Inhalation Q6H (every 6 hours). [**Date Range **]:*120 nebulizer treatment* Refills:*2* 14. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). [**Hospital1 **]:*qs MDI* Refills:*2* 15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): for constipation. [**Hospital1 **]:*60 Capsule(s)* Refills:*2* 16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed: for constipation. [**Hospital1 **]:*60 Tablet(s)* Refills:*2* 17. Prednisone 10 mg Tablet Sig: see instructions Tablet PO once a day for 7 days: Take 4 tab po qd for 1 day, then 3 tab po qd for 2 days, then 2 tab po qd for 2 days, then 1 tab po qd for 2 days. . [**Hospital1 **]:*16 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 20184**] medical services Discharge Diagnosis: 1. Chronic Obstructive Pulmonary Disease flare/exacerbation 2. Chronic indwelling urethral catheter 3. Benign Prostatic Hypertrophy 4. Hypertension 5. Hyperlipidemia 6. Coronary artery disease 7. Chronic lumbago 8. Gastroesophageal Reflux Disease Discharge Condition: Stable Discharge Instructions: If you experience worsening shortness of breath, coughing and sputum production increased in quantity or quality, please report to the emergency room immediately. If you notice that you are requiring more inhalers or oxygen than normal, please come to the ER. Please follow up with your physicians (see information below). Please take all of your medications. Followup Instructions: 1. Provider: [**First Name8 (NamePattern2) 1569**] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 612**]. Date/Time: You will be called by [**Name8 (MD) 20185**], RN from Dr. [**Name (NI) 20186**] office regarding a time in the next two weeks for you to come in. 2. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10134**], MD Phone:[**Telephone/Fax (1) 7976**] Date/Time:[**2103-11-6**] 9:30 AM. 3. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 5003**] Date/Time:[**2103-11-26**] 11:30 4. Please follow up with Dr.[**Name (NI) 20183**] at [**Hospital6 13185**], Urology, for evaluation for your transurethral needle ablation of the prostate. 5. Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2104-4-7**] 11:00 Completed by:[**2103-10-17**]

[ "458.9", "719.41", "414.01", "V58.65", "401.9", "724.2", "600.01", "491.21", "412", "596.0", "272.4" ]

icd9cm

[ [ [] ] ]

[ "57.94", "93.90" ]

icd9pcs

[ [ [] ] ]

9729, 9797

4193, 6709

284, 328

10096, 10105

2334, 4170

10514, 11489

1986, 2071

7136, 9706

9818, 10075

6735, 7113

10129, 10491

2086, 2315

236, 246

356, 1146

1168, 1607

1623, 1970

31,467

154,682

54515

Discharge summary

report

Admission Date: [**2106-11-15**] Discharge Date: [**2106-11-17**] Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 618**] Chief Complaint: acute onset right hemiplegia and aphasia Major Surgical or Invasive Procedure: TEE History of Present Illness: 84yo M h/o Afib off coumadin who was in his usual state of health this morning, on the toilet, when he was witnessed to have the acute onset of inability to speak and right hemiplegia. He apparently woke in good health and walked to the restroom; when there was no response, he was found by his daughter with decreased responsiveness to tactile stimuli and R hemiplegia. He was last known well at 7:10am. He was taken to [**Last Name (un) 4068**], where head CT showed dense L MCA and hypodensities in the left inferior frontal lobe and left corona radiata. He was given IV tPA at 9:58am at a dose of 8.6mg bolus and total infusion of 77.4mg and transferred here for consideration of IA tPA and further evaluation and treatment. Pre-treatment NIHSS by report was 27, which improved to 22 after tPA was given. His family was en route and unavailable. Past Medical History: HTN Afib, off coumadin Hypothyroidism h/o EtOH abuse peripheral neuropathy Depression Osteoarthritis Gout h/o TIA PSH: s/p cholecystectomy Social History: lives with his daughter. Former [**Name2 (NI) **] epidemiologist. Former smoker. h/o EtOH abuse Family History: NA Physical Exam: VS 97.9 78 168/94 10 100% on 6L NC Gen eyes closed, NAD HEENT NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck Supple, no carotid bruits appreciated. No nuchal rigidity Lungs CTA bilaterally CV irreg, nl S1S2, no M/R/G noted Abd soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted Ext No C/C/E b/l Skin no rashes or lesions noted NEURO MS [**Name13 (STitle) **] response to verbal stimuli; to sternal rub he moans and opens his eyes. No verbal output. Follows a command to squeeze his left hand but not to open his eyes, stick out his tongue, or show two fingers. CN PERRL 2 to 1.5mm. Funduscopic exam revealed no papilledema, exudates, or hemorrhages. EOMI to oculocephalic maneuver. Corneal reflex and nasal tickle present bilaterally. R lower facial droop. Gag reflex intact. MOTOR Normal bulk and tone. Withdraws to noxious stimuli purposefully in the left arm, which also has some antigravity purposefull movement to adjust his nasal canula. He withdraws both legs to noxious stimuli purposefully. In the right arm, he has extensor posturing to noxious stimuli. No adventitious movements noted. No asterixis noted. No myoclonus noted. SENSORY Grimaces to noxious stimuli in all four extremities. REFLEXES [**Hospital1 **] Tri [**Last Name (un) 1035**] Pat Ach L 2 2 2 0 0 R 2 2 2 0 0 Plantar response was extensor bilaterally. Gait: unable, due to decreased level of consciousness CODE STROKE SCALE: Neurologic (NIHSS): 28 1a. LOC: stuporous (2) 1b. LOC questions: does not state age or month (2) 1c. LOC commands: did not close eyes but gripped with (nonparetic) hand (1) 2. Best gaze: No gaze palsy (0) 3. Visual: complete hemianopsia (2) 4. Facial Palsy: R facial palsy (2) 5a. Left arm: some effort v gravity (2) 5b. Right arm: no movement (4) 6a. Left leg: no effort v gravity (3) 6b. Right leg: no effort v gravity (3) 7. Limb ataxia: unable to assess 8. Sensory: no sensory loss bilaterally (0) 9. Language: mute (3) 10. Dysarthria: unintelligible or worse (2) 11. Extinction/inattention: unable to assess Pertinent Results: [**2106-11-16**] 02:11AM BLOOD WBC-13.1* RBC-4.17* Hgb-13.3* Hct-38.8* MCV-93 MCH-31.9 MCHC-34.3 RDW-14.2 Plt Ct-308 [**2106-11-16**] 02:11AM BLOOD PT-14.6* PTT-24.8 INR(PT)-1.3* [**2106-11-16**] 02:11AM BLOOD Glucose-139* UreaN-19 Creat-1.3* Na-140 K-3.8 Cl-103 HCO3-21* AnGap-20 [**2106-11-16**] 02:11AM BLOOD ALT-16 AST-31 LD(LDH)-191 CK(CPK)-141 AlkPhos-100 Amylase-25 TotBili-0.6 [**2106-11-16**] 02:11AM BLOOD Lipase-21 [**2106-11-15**] 08:18PM BLOOD CK-MB-4 cTropnT-<0.01 [**2106-11-16**] 02:11AM BLOOD CK-MB-4 cTropnT-<0.01 [**2106-11-16**] 10:17AM BLOOD CK-MB-5 cTropnT-<0.01 [**2106-11-16**] 02:11AM BLOOD Albumin-4.1 Calcium-8.9 Phos-2.9 Mg-1.8 Cholest-206* [**2106-11-16**] 02:11AM BLOOD %HbA1c-5.5 [**2106-11-16**] 02:11AM BLOOD Triglyc-89 HDL-56 CHOL/HD-3.7 LDLcalc-132* [**2106-11-16**] 02:11AM BLOOD TSH-0.95 [**2106-11-16**] 02:11AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG CT, CTA and perfusion [**2106-11-15**]: Ischemia throughout the left ACA and MCA territories, with apparent irreversible infarction in the a small region of the left frontal lobe and a portion of the distribution of the left superior division of the left MCA. There are occlusions of the left MCA in the distal M1 aegment and the A2 segment of the ACA. CT [**2106-11-16**]: 1. New large left basal ganglia bleed with midline shift. 2. New bilateral intraventricular hemorrhages. 3. New right subarachnoid bleed. Brief Hospital Course: Mr. [**Known lastname 111539**] had received IV tPA at the OSH prior to transfer as he was in the 3 hours window. On arrival to [**Hospital1 18**] CTA and CTP films were done. Upon reviewing these images, the size of the infarction was felt too large to consider IA tPA, given the risk of hemorrhage. He was therefore admitted to the ICU for closer monitoring. There his SBP was kept less than 185 and his diastolic less than 105. He was also maintained normothermic and normoglycemic. A FLP and A1c were checked as well. He was not given any antiplatelet or anticoagulants. He was ruled out for an MI with 3 sets of CE and monitored on tele. Within the first 24 hours of his admission, a repeat HCT was performed which showed a new large L basal ganglia bleed with midline shift as well as new bilateral intraventricular hemorrhages and a new right subarachnoid bleed. These findings were discussed with his family and they decided to make him CMO. He was then transferred to a private room on the floor and treated with morphine as needed. He died the following day with his family at the bedside. Medications on Admission: NA Discharge Medications: NA Discharge Disposition: Expired Discharge Diagnosis: Stroke with hemorrhagic transformation Discharge Condition: Expired Discharge Instructions: NA Followup Instructions: NA [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]

[ "427.31", "434.91", "244.9", "274.9", "303.01", "355.8", "401.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6265, 6274

5081, 6185

306, 311

6356, 6365

3618, 5058

6416, 6513

1486, 1490

6238, 6242

6295, 6335

6211, 6215

6389, 6393

1505, 3599

225, 268

339, 1193

1215, 1357

1373, 1470

71,988

137,277

13067

Discharge summary

report

Admission Date: [**2125-3-10**] Discharge Date: [**2125-3-17**] Date of Birth: [**2064-2-25**] Sex: F Service: NEUROLOGY Allergies: Quinolones / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / Oxycodone / morphine / butorphanol / Cephalosporins / Cortisone / pentazocine / Propantheline Attending:[**First Name3 (LF) 5831**] Chief Complaint: Called by Emergency Department to evaluate for status epilepticus Major Surgical or Invasive Procedure: intubation and extubation History of Present Illness: Dr. [**Known lastname 39951**] is unresponsive (and subsequently intubated) and unable to provide any history. History obtained from review of transfer notes and speaking with her brother. Dr. [**Known lastname 39951**] is a 61 year-old woman with PMH significant for myasthenia [**Last Name (un) 2902**] (per her brother diagnosed about 6 years ago; currently receiving IVIG infusions), seizure d/o (history of seizures unknown per family; currently on Trileptal 450 mg [**Hospital1 **] and Vimpat 100 mg [**Hospital1 **]), and cervical cancer s/p hysterectomy who presented to OSH earlier today with lethargy and altered mental status and was transferred to [**Hospital1 18**] with urinary sepsis and seizures. At baseline, she is alert and oriented. This morning, she was noted to be lethargic and was only oriented x 1. She was taken to OSH, where she was found to be febrile to 101.2 and had a positive UA, for which she was treated with Zosyn. While at OSH, she underwent NCHCT, which did not show any acute process. She then was noted to have GTC seizure, which was noted as lasting 15-20 seconds. She received Ativan 1 mg for this, with reported resolution of convulsive activity, but she had subsequent twitching, for which she received another Ativan 1 mg. She was then transferred to [**Hospital1 18**]. According to EMS, during entire transport, she was nonverbal and nonresponsive. Her eyes were noted to be deviated to the right and she was having intermittent twitching of her shoulders and legs. Upon arrival to [**Hospital1 18**] ED, she was intubated due to concern for status epilepticus. Past Medical History: -myasthenia [**Last Name (un) 2902**] -HTN -Seizure d/o - possibly pseudoseizures? -?mitochondrial disorder -hypothyroidism Social History: Per family, she lives with her mother. Otherwise, unable to obtain from patient. Family History: Unable to obtain from patient Physical Exam: At admission: Vitals: T: 101.2 P: 132 R: 20 BP: 180/86 SaO2: 99% (NRB--> subsequently intubated) General: unresponsive, intubated [**Last Name (un) 39952**] after arrival to ED HEENT: NC/AT, dry mucus membranes, ET tube in place shortly after arrival to ED Neck: Supple Chest: scar over left chest (port-a-cath) Pulmonary: anterior lung fields cta b/l Cardiac: tachycardic, S1S2 Abdomen: soft, +BS Extremities: warm, well perfused Neurologic: eyes initially open and deviated to right. Nonverbal. No commands. Right pupil 4 mm and sluggishly reactive to light. Left pupil 3 mm and sluggishly reactive. Unable to Doll her out of rightward gaze. Weak corneals b/l. She had persistent twitching of both eyes. Face otherwise appeared symmetric. Occasional twitching of shoulders. Intermittent spontaneous movement of LUE prior to intubation. No other spontaneous movement noted. She withdraws all extremities to noxious stimuli. Intermittent twitching of L>R LE. Unable to elicit any reflexes. There is clonus at ankles. Extensor plantar response b/l. At transfer out of NeuroICU: Now awake, alert. [**Doctor Last Name **] fluent. Comprehension intact. Tearful and anxious. Giveway weakness, maybe 4+ in neck flexors, otherwise full strength throughout. (Pt reports receiving home PT currently). No fatigue-ability on upward gaze nor deltoid pumps. This exam remained stable throughout the admission. Pertinent Results: [**2125-3-10**] 10:00PM BLOOD WBC-11.4* RBC-3.96* Hgb-12.5 Hct-40.6 MCV-103* MCH-31.7 MCHC-30.9* RDW-14.2 Plt Ct-307 [**2125-3-10**] 10:00PM BLOOD Neuts-74.3* Lymphs-18.3 Monos-6.8 Eos-0.3 Baso-0.3 [**2125-3-10**] 10:00PM BLOOD PT-11.2 PTT-24.7* INR(PT)-1.0 [**2125-3-10**] 10:00PM BLOOD Plt Ct-307 [**2125-3-10**] 10:00PM BLOOD Glucose-130* UreaN-17 Creat-0.8 Na-146* K-3.8 Cl-106 HCO3-25 AnGap-19 [**2125-3-10**] 10:00PM BLOOD ALT-14 AST-35 AlkPhos-41 TotBili-0.4 [**2125-3-10**] 10:00PM BLOOD cTropnT-0.05* [**2125-3-11**] 03:00AM BLOOD CK-MB-5 cTropnT-0.06* [**2125-3-11**] 12:23PM BLOOD cTropnT-0.03* [**2125-3-10**] 10:00PM BLOOD Albumin-4.0 [**2125-3-11**] 03:00AM BLOOD Calcium-7.2* Phos-2.9 Mg-1.6 [**2125-3-10**] 10:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-5* Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2125-3-10**] 10:07PM BLOOD Lactate-1.5 [**2125-3-10**] 10:00PM URINE RBC-2 WBC-41* Bacteri-FEW Yeast-NONE Epi-1 [**2125-3-10**] 10:00PM URINE Blood-SM Nitrite-NEG Protein-100 Glucose-NEG Ketone-40 Bilirub-SM Urobiln-NEG pH-6.0 Leuks-MOD [**2125-3-10**] 10:00PM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.026 [**2125-3-10**] 10:00PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG [**2125-3-10**] 11:19PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-87* Polys-19 Bands-3 Lymphs-71 Monos-6 [**2125-3-10**] 11:19PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-1423* Polys-43 Lymphs-53 Monos-4 [**2125-3-10**] 11:19PM CEREBROSPINAL FLUID (CSF) TotProt-34 Glucose-86 [**2125-3-10**] 11:23PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS PCR-PND [**2125-3-10**] 11:19 pm CSF;SPINAL FLUID #3. GRAM STAIN (Final [**2125-3-11**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Preliminary): NO GROWTH. [**2125-3-10**] 10:00 pm URINE **FINAL REPORT [**2125-3-12**]** URINE CULTURE (Final [**2125-3-12**]): NO GROWTH. [**2125-3-13**] 8:45 am STOOL CONSISTENCY: SOFT Source: Stool. **FINAL REPORT [**2125-3-13**]** C. difficile DNA amplification assay (Final [**2125-3-13**]): Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). [**2125-3-10**] 10:00 pm BLOOD CULTURE Blood Culture, Routine (Pending): ECG: Baseline artifact. Sinus tachycardia versus supraventricular tachycardia. Repeat tracing is suggested. No previous tracing available for comparison. Intervals Axes Rate PR QRS QT/QTc P QRS T 162 0 98 290/468 0 -10 162 CXR - 1 view: IMPRESSION: 1. Limited study demonstrates endotracheal tube in mid trachea. No acute cardiopulmonary process noted. 2. Left internal jugular line is noted with the tip likely in the right atrium. EEG [**2125-3-11**]: IMPRESSION: This telemetry captured no pushbutton activations. The record showed a slow moderate voltage background, large and unchanged throughout. There was also the superimposition of faster beta activity. Usually they signed off medication effect. There was some generalized slowing. There were no electrographic seizures or clearly epileptiform features. EEG [**2125-3-12**]: IMPRESSION: This telemetry captured no pushbutton activations. The record showed normal waking and sleep patterns. There were a few sharp features on the left but no overtly epileptiform abnormalities. There were no electrographic seizures. EEG [**2125-3-13**]: IMPRESSION: This telemetry captured no pushbutton activations. The background remained a bit slow although there were normal posterior frequencies in wakefulness. There was occasional generalized slowing and even less frequent slowing in the right temporal region. There were no clearly epileptiform features or any electrographic seizures. EEG [**2125-3-14**]: IMPRESSION: This is a normal continuous EEG monitoring study. There were no pushbutton activations. No epileptiform discharges or electrographic seizures were recorded. Excessive beta activity was noted most likely related to medication effect. DISCHARGE LABS: [**2125-3-16**] 07:00AM BLOOD WBC-8.1 RBC-3.65* Hgb-11.6* Hct-37.8 MCV-104* MCH-31.8 MCHC-30.8* RDW-14.1 Plt Ct-265 [**2125-3-16**] 01:06PM BLOOD Glucose-121* UreaN-3* Creat-0.4 Na-142 K-3.4 Cl-107 HCO3-28 AnGap-10 [**2125-3-16**] 01:06PM BLOOD Calcium-8.0* Brief Hospital Course: Dr. [**Known lastname 39951**] is a 61 year-old woman with PMH significant for myasthenia [**Last Name (un) 2902**] (per her brother diagnosed about 6 years ago; currently receiving IVIG infusions) and seizure d/o (history of seizures unknown per family; currently on Trileptal 450 mg [**Hospital1 **] and Vimpat 100 mg [**Hospital1 **]) who was transferred from OSH with urinary infection and seizures. Upon arrival, it was believed that she was in nonconvulsive status as she never returned to baseline after her GTC at OSH and had eyes deviated to the right with intermittent twitching of her eyes and extremities. On initial exam, she was nonverbal and unresponsive, with the eyes deviated to the right and unable to Doll out of this position. On later exam in ED, eyes were in midline. She continued to have intermittent twitching of her eyes, shoulder and L>R lower extremity. She was intubated in the ED for status epilepticus and loaded with Keppra 1 gram. Patient initially thought to have UTI and treated with Zosyn, however UCx showed no growth. Pt is s/p intubation [**2125-3-12**] and on [**3-13**] was tearful, complaining of depression and anxiety, but was able to be transferred to the neurology service. She has had a course c/b anxiety and depression requiring benxodiazepines. . # Neuro: Pt's EEGs while here showed no seizures. She was started on keppra with good effect and we continued her home vimpat and trileptal. We continued her home mycophenolate and mestinon for her myasthenia, however, we did not see any clinical signs of myasthenia. We want the pt to come to our EMG lab in the near future for repeat diagnostic testing for this. When she initially came in, we put her on vanc and ceftriaxone and acyclovir until her CSF cultures were negative x48hrs and her HSV PCR returned negative and they were then all stopped. We initially held pt's home zanaflex and vicodin, but these were then reintroduced with good effect for her back pain. . #Psych: Pt endorsed auditory (cat meowing) hallucinations and increased depression/anxiety while in the ICU. Reports hx of depression in past that required imipramine treatment. She had no further episodes of auditory hallucinations on the floor and was able to admit that she knew that her cat wasn't in the hospital. We consulted psychiatry and they recommended holding her home trilafon, but we were then able to restart her home trazodone and duloxetine. On later recommendations they suggested ativan 0.5mg [**Hospital1 **] PRN anxiety which we started. They also recommended low dose ritalin, but we felt that this would not be a good idea at this time given her many medical issues. . # CVS: Pt had an episode of chest pain and SOB on [**3-14**] in the setting of severe anxiety. Her EKG was unchanged and her troponin was 0.02 (which was lower than when she came in at 0.06). Her SOB improved with ativan. We contact[**Name (NI) **] her PCP to ask if she could be taken off verapamil, which she takes for migraines, as this can worsen myasthenia. He was ok with this. In addition, we started pt on low dose lisinopril given intermittent HTN and her mildly elevated troponin. . # Pulm: pt extubated [**3-12**] 8am, with no further pulmonary issues other than an episode of SOB as above that resolved with ativan. . # ENDO: we continued pt's home dose synthroid while here. . # ID: received zosyn for UTI at admission but when UCx showed no growth, this was stopped. . # Code Status: DNR/DNI PENDING RESULTS: Blood Culture [**2125-3-10**] TRANSITIONAL CARE ISSUES: Patient will need her electrolytes checked QOD to ensure that she doesn't have further episodes of hypokalemia and hypocalcemia. In addition, given pt's mildly elevated troponin she will need an outpatient cardiac stress test. Her PCP has already been informed and has agreed to set this up. Medications on Admission: (per recent d/c summary from OSH): -Hydralazine 50 mg tid -Coreg 6.5 mg [**Hospital1 **] -Cymbalta 20 mg daily -Trazodone 100 mg qhs -Folic Acid 5 mg [**Hospital1 **] -Verapamil SR 240 mg daily -Lomotil 2.5 mg qid prn diarrhea -Mestinon 120 mg tid -Mylanta 30mL q4h prn indigestion -Norvasc 10 mg daily -Calcium with D -Os-Cal [**Hospital1 **] -Protonix 40 mg [**Hospital1 **] -Synthroid 88 mcg daily -Timolol 0.5% opht solution 1 drop each eye qPM -Trilafon 8 mg [**Hospital1 **] -Trileptal 450 mg [**Hospital1 **] -Hydrocodone/APAP 5/500 2 tabs q6h prn pain -Vimpat 100 mg [**Hospital1 **] -Zanaflex 8 mg qid Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution Sig: 5,000 units Injection TID (3 times a day). 2. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. folic acid 1 mg Tablet Sig: Five (5) Tablet PO BID (2 times a day). 6. pyridostigmine bromide 60 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 7. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. oxcarbazepine 150 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 10. levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 11. lacosamide 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 12. hydralazine 25 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 13. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 14. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID PRN () as needed for anxiety. 16. tizanidine 2 mg Tablet Sig: Four (4) Tablet PO every six (6) hours as needed for back muscle pain: Hold for sedation. 17. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 18. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 19. trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 20. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever/pain: Do not exceed 4 grams of tylenol in 24 hours. 21. hydrocodone-acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for back pain: Do not exceed 4 grams of tylenol in 24 hours. 22. Heparin Flush (10 units/ml) 5 mL IV PRN line flush Indwelling Port (e.g. Portacath), heparin dependent: Flush with 10 mL Normal Saline followed by Heparin as above daily and PRN per lumen. 23. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port Indwelling Port (e.g. Portacath), heparin dependent: When de-accessing port, flush with 10 mL Normal Saline followed by Heparin as above per lumen. 24. Lomotil 2.5-0.025 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for diarrhea. 25. Mylanta 200-200-20 mg/5 mL Suspension Sig: Thirty (30) mL PO every four (4) hours as needed for indigestion. 26. Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet Sig: One (1) Tablet PO once a day. 27. Os-Cal 500 + D 500mg (1,250mg) -600 unit Tablet Sig: One (1) Tablet PO once a day. 28. timolol 0.5 % Drops Sig: One (1) drop Ophthalmic at bedtime: 1 drop in each eye. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Seizures 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 Dr. [**Known lastname 39951**], You were seen in the hospital because of seizures and weakness. We initially thought that you might have been having a myasthenia [**Last Name (un) 2902**] flare, however your strength rapidly improved without intervention once your seizures were under control. We made the following changes to your medications: 1) We STARTED you on SUBCUTANEOUS HEPARIN. You only have to take this while you are rehab. 2) We STARTED you on KEPPRA 1500mg twice a day. 3) We STARTED you on LISINOPRIL 10mg once a day. 4) We STARTED you on ATIVAN 0.5mg twice a day as needed for anxiety 5) We STARTED you on DOCUSATE 100mg twice a day. 6) We STARTED you on SENNA 8.6mg twice a day as needed for constipation. 7) We STARTED you on TYLENOL as needed for pain or fever. You are taking Vicodin already, which has tylenol in it. Therefore you have to be sure that you don't exceed 4 grams of tylenol total in 24 hours when taking both medications. 8) We STOPPED you VERAPAMIL as this can worsen your myasthenia. 9) We STOPPED your TRILAFON. Please continue to take your other medications as previously prescribed. If you experience any of the below listed Danger Signs, please contact your doctor or go to the nearest Emergency Room. It was a pleasure taking care of you on this hospitalization. Please observe the following seizure safety guidelines: SEIZURE SAFETY ________________________________________________________________ The following tips will help you to make your home and surroundings as safe as possible during or following a seizure. Some people with epilepsy will not need to make any of these changes. Use this list to balance your safety with the way you want to live your life. Make sure that everyone in your family and in your home knows: - what to expect when you have a seizure - correct seizure first aid - first aid for choking - when it is (and isn't) necessary to call for emergency help Avoid things that are known to increase the risk of a seizure: - forgetting to take medications - not getting enough sleep - drinking a lot of alcohol - using illegal drugs In the kitchen: - As much as possible, cook and use electrical appliances only when someone else is in the house. - Use a microwave if possible. - Use the back burners of the stove. Turn handles of pans toward the back of the stove. - Avoid carrying hot pans; serve hot food and liquids directly from the stove onto plates. - Use pre-cut foods or use a blender or food processor to limit the need for sharp knives. - Wear rubber gloves when handling knives or washing dishes or glasses in the sink. - Use plastic cups, dishes, and containers rather than breakable glass. In the living room: - Avoid open fires. - Avoid trailing wires and clutter on the floor. - Lay a soft, easy-to-clean carpet. - Put safety glass in windows and doors. - Pad sharp corners of tables and other furniture, and buy furniture with rounded corners. - Avoid smoking or lighting fires when you're by yourself. - Try to avoid climbing up on chairs or ladders, especially when alone. - If you wander during seizures, make sure that outside doors are securely locked and put safety gates at the top of steep stairs. In the bedroom: - Choose a wide, low bed. - Avoid top bunks. - Place a soft carpet on the floor. In the bathroom: - Unless you live on your own, tell a family member or [**Name2 (NI) 8317**] before you take a bath or shower. - Hang the bathroom door so it opens outward, so it can be opened if you have a seizure and fall against it. - Don't lock the bathroom door. Hang an "Occupied" sign on the outside handle instead. - Set the water temperature low so you won't be hurt if you have a seizure while the water is running. - Showers are generally safer than baths. Consider using a hand- held shower nozzle. - If taking a bath, keep the water shallow and make sure you turn off the tap before getting in. - Put non-skid strips in the tub. - Avoid using electrical appliances in the bathroom or near water. - Use shatterproof glass for mirrors. At work: - Consider telling your co-workers that you have epilepsy and the correct first aid for seizures. - Climb only as high as you can fall without injuring yourself. - When working around machinery, make sure that safety features are in place, and consider wearing protective clothing. - Try to keep consistent work hours so you don't have to go a long time without sleep. - Try to limit your exposure to flashing lights if this can trigger your seizures. Out and about: - Carry only as many medications with you as you will need, and 2 spare doses. - Wear a medical alert bracelet to let emergency workers and others know that you have epilepsy. - Stand well back from the road when waiting for the bus and away from the platform edge when taking the subway. - If you wander during a seizure, take a friend along. - Don't let fear of a seizure keep you at home. Sports: - Use common sense to decide which sports are reasonable. - Exercise on soft surfaces. - Wear a life vest when you are close to water. - Avoid swimming alone. Make sure someone with you can swim well enough to help you if you need it. - Wear head protection when playing contact sports or when there is a risk of falling. - When riding a bicycle or rollerblading, wear a helmet, knee pads, and elbow pads. Avoid high traffic areas; ride or skate on side roads or bike paths. Driving: - You may not drive in [**State 350**] unless you have been seizure- free for at least 6 months. - Always wear a seatbelt. Parenting: - Childproof your home as much as possible. - If you are nursing a baby, sit on the floor or bed with your back supported so the baby will not fall far if you should lose consciousness. - Feed the baby while he or she is seated in an infant seat. - Dress, change, and sponge bathe the baby on the floor. - Move the baby around in a stroller or small crib. - Keep a young baby in a playpen when you are alone, and a toddler in an indoor play yard, or childproof one room and use safety gates at the doors. - When out of the house, use a bungee-type cord or restraint harness so your child cannot wander away if you have a seizure that affects your awareness. - Explain your seizures to your child when he or she is old enough to understand. Followup Instructions: Patient will need an outpatient cardiac stress test. Her PCP has been informed. Department: NEUROLOGY When: THURSDAY [**2125-4-19**] at 10:00 AM With: DRS. [**Name5 (PTitle) **] & [**Doctor Last Name 37664**] [**Telephone/Fax (1) 2846**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

[ "33.24", "03.31", "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

15573, 15645

8248, 11776

482, 509

15698, 15698

3883, 5632

22205, 22591

2414, 2446

12759, 15550

15666, 15677

12123, 12736

15881, 16203

7966, 8225

2461, 3864

6237, 7949

16232, 22182

377, 444

11802, 12097

537, 2151

15713, 15857

2173, 2299

2315, 2398

5664, 6202

8,067

191,160

1538

Discharge summary

report

Admission Date: [**2163-4-30**] Discharge Date: [**2163-5-7**] Service: NSU ADMITTING DIAGNOSIS: Large left acute subdural hematoma. HISTORY OF PRESENT ILLNESS: Patient is an 86-year-old female of paroxysmal Afib, anticoagulated on Coumadin presented to [**Hospital1 69**] from [**Hospital3 **] with large left acute subdural hematoma status post fall. Per report, patient was "not feeling well" last night, which was [**2163-4-29**]. Was found on the floor and had a witnessed fall. Son states the patient had an arrhythmia. Unclear etiology. Patient thought to be worked up with a Holter monitor. Received 2 units of FFP at [**Hospital6 1597**]. Also 500 of Dilantin. C. Spine fracture, DJD, INR is 1.7. At [**Hospital1 **], INR was 1.5, received factor VII. Underwent left craniotomy. PAST MEDICAL HISTORY: Hypertension, Afib, venous insufficiency. MEDICATIONS: Coumadin 2.5 daily, HCTZ 12.5 daily, quinapril 40 b.i.d., [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 10 mEq daily, and atenolol 100 mg daily. PHYSICAL EXAM: Patient is afebrile, vital signs stable on Nipride. Patient is intubated. Pupils are minimally reactive. Lungs are clear to auscultation. Abdomen is soft, no tenderness. HOSPITAL COURSE: Patient is admitted to ICU. Patient was given Kefzol for drain that was placed by neurosurgery for evacuation of hematoma with drain placement. On postop day 1, intubated, positive corneas, moves legs spontaneously, left upper extremity localizes, right upper extremity plegia. Postop head CT showed residual acute subdural hematoma. No underlying contusions. Blood pressure was to be kept less than 140, greater than 100. was given 25 b.i.d. Surgery was consulted because of abdominal pain and felt that patient had pancreatitis of unknown etiology. Patient had been hypernatremic, hyperchlorademic. Throughout her stay, she had very limited neuro exam. Social work saw patient and met with family. On postop day 4, intubated, sedated, opens eyes spontaneously, moves left upper extremity, moves right side spontaneously. Withdraws lower extremities bilaterally. Still continues to have platelets relatively low. That particular day she was 64,000. Family had mentioned to the team that patient did not want to be in this situation, and it was being initiated within the family of possible comfort measures only. On [**5-5**], more discussion with the family about CMO. Patient was doing about the same. Never progressed neurologically. On [**5-6**], continued to be afebrile, vital signs stable, intubated, moving left upper extremity, withdraws left lower extremity. On [**2163-5-7**], afebrile, vital signs stable. I's an O's are good. Platelets are 228, and today he opens eyes to stimulation, slight internal rotation and flexion. So the family decided to put the patient on comfort measures only and after that was done, patient had passed away shortly after that. It was family's decision that they did not want a biopsy on this patient. FINAL DIAGNOSIS: Left large subacute hematoma. [**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], [**MD Number(1) 1360**] Dictated By:[**Last Name (NamePattern1) 4835**] MEDQUIST36 D: [**2163-5-8**] 00:04:45 T: [**2163-5-8**] 06:40:14 Job#: [**Job Number 9010**]

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icd9cm

[ [ [] ] ]

[ "99.69", "38.91", "01.31", "99.29", "96.72", "38.93", "99.05", "99.07" ]

icd9pcs

[ [ [] ] ]

1262, 3013

3031, 3312

1073, 1244

176, 804

110, 147

827, 1057

19,059

193,479

48185

Discharge summary

report

Admission Date: [**2124-3-17**] Discharge Date: [**2124-3-22**] Date of Birth: [**2065-11-22**] Sex: F Service: MEDICINE Allergies: Penicillins / Clindamycin / Celery / Bee Sting Kit Attending:[**First Name3 (LF) 783**] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a 58 year-old female with a history of morbid obesity s/p gastric bypass, pulmonary hypertension, and asthma who presents with few days of increasing dyspnea t home (home O2 3 L NC). Developed productive cough yesterday. Went to see PCP and was found to have low SaO2 of 85. PCp sent pt to the ED for evaluation. . On arrival to the ED, she was found to have an O2 sat of 68% on 2.5 Lbut her VS were otherwise stable (T 98.6, HR 85, RR 30 BP 138/66). She was mentating appropriately, A&O x 3, and stated that her SOB was at its baseline. She was thought to have an asthma exacerbation, for which she was given nebs, steroids; NO abx. An EKG was performed and by report demonstrated new TWi in III,avF (new); this EKG is uanavilable. CEs were sent, though she denied CP, and the first set was negative. She was later placed on a 50% ventimask and had an O2 sat of 96% at that time. A CXR was also performed and was negative for any acute process and no evidence of hyperinflation. . Of note, during her prior hospitalization, she was found to have a room air sat in the 70s% and 75% on 2L. . ROS: No CP, vomiting, diarrhea, weakness, fevers. + cough with white sputum. + usual sharp epigastric abd pain (resolved). Past Medical History: - morbid obesity s/p hernia repair [**6-1**] and gastric bypass surgery - OSA on nocturnal BIPAP (18/15) and 2-3L home O2 - obesity hypoventilation syndrome - pulmonary HTN thought from OSA and obesity hypoventilation - right heart failure - h/o iron deficiency anemia - asthma: last PFTs in [**4-5**] with marked obstructive defect and FEV1 of 38%. Also had [**Month (only) **] FVC suggestive of restrictive defect - Hypertension - Osteoarthritis of bilateral knees Social History: The patient lives with her two sons. [**Name (NI) **] [**Name2 (NI) 269**] for home support, though family is concerned that this is not enough. Not currently working. She denies any tob/etoh/illicit drug use. Family History: non-contributory Physical Exam: VS: T 98.3F, 114/50 76 20 94% 3L Gen: Comfortable, obese, speaking in full sentences HEENT: PERRL, anicteric Neck: Supple, no JVD appreciated. Lungs: Diminshed bilaterally, scattered fine crackles at bases, wheezes superiorly Cor: s1s2 RRR, distant Abd: Obese, soft, NT/ND; multiple well-healed scars, mobile, non-reducible mass at epigastrium 6x6 cm. Ext: non-pitting edema bilaterally symmetric, increased from baseline per patient. Neuro: A&O x 3, normal speech. Pertinent Results: Labs on admission: [**2124-3-17**] 02:30PM WBC-8.8 RBC-4.86 HGB-11.9* HCT-42.1 MCV-87 MCH-24.6* MCHC-28.4* RDW-20.5* [**2124-3-17**] 02:30PM NEUTS-78.0* LYMPHS-15.8* MONOS-3.3 EOS-2.5 BASOS-0.3 [**2124-3-17**] 02:30PM CALCIUM-7.9* PHOSPHATE-2.9 MAGNESIUM-1.6 [**2124-3-17**] 02:30PM CK-MB-NotDone cTropnT-<0.01 proBNP-[**Numeric Identifier **]* [**2124-3-17**] 02:30PM GLUCOSE-108* UREA N-21* CREAT-1.3* SODIUM-143 POTASSIUM-5.1 CHLORIDE-94* TOTAL CO2-42* ANION GAP-12 . CXR [**2124-3-17**]: Unchanged cardiomegaly with evidence of pulmonary arterial hypertension and vascular congestion. No overt evidence of pulmonary edema. No evidence of pneumonia. . CXR [**2124-3-18**] - IMPRESSION: Unchanged evidence of cardiomegaly and enlargement of the pulmonary arteries, suggesting pulmonary hypertension. No evidence of acute pulmonary edema . . [**2-22**] ECHO: The left atrium is normal in size. The estimated right atrial pressure is 10-20mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Left ventricular systolic function is hyperdynamic (EF 70-80%). There is no ventricular septal defect. The right ventricular free wall is hypertrophied. The right ventricular cavity is markedly dilated with depressed free wall contractility. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is severe pulmonary artery systolic hypertension. The pulmonic valve leaflets are thickened. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. The main pulmonary artery is dilated. The branch pulmonary arteries are dilated. There is no pericardial effusion. IMPRESSION: advanced cor pulmonale . Labs on discharge: . [**2124-3-19**] 04:01AM BLOOD Type-ART pO2-88 pCO2-84* pH-7.36 calTCO2-49* Base XS-17 [**2124-3-22**] 07:05AM BLOOD WBC-8.2 RBC-4.72 Hgb-11.8* Hct-40.5 MCV-86 MCH-24.9* MCHC-29.0* RDW-21.0* Plt Ct-194 [**2124-3-22**] 07:05AM BLOOD Glucose-124* UreaN-20 Creat-1.1 Na-142 K-4.8 Cl-93* HCO3-49* AnGap-5* [**2124-3-22**] 07:05AM BLOOD Calcium-8.4 Phos-3.4 Mg-1.9 [**2124-3-19**] 03:40AM BLOOD Hapto-61 [**2124-3-22**] 01:41AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010 [**2124-3-22**] 01:41AM URINE Blood-LG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-MOD [**2124-3-22**] 01:41AM URINE RBC->50 WBC-21-50* Bacteri-MOD Yeast-NONE Epi-0-2 Brief Hospital Course: 58F with sever pulm hyptersion, asthma, and CHF, p/w hypoxia to PCP's office. . # Hypoxia: Pt has known baseline poor pulmonary function, with history of hypoxia and is on home O2, 2.5L at rest, 3L while ambulating. There is no correlation with pulse oximetry at these settings. She had a recent admission for asthma exacerbation and finished her predinsone taper 2 days ago. Her volume overload was felt to be due to decreased dose of torsemide during last admission and increased Na load with tomato soups. On initial exam she had minimal wheezing, but ~10 lb weight gain and fine crcakles bilaterally. Based on crackles and elevated BNP there was concern for volume overload. By admission to MICU, she was weaned to 2 L NC + 50% Venti. Her torsemide was increased to 40 mg [**Hospital1 **] and patient was -1L in ICU. She was continued on alternating NC and BiPAP on home settings. She was continued on home inhalers. . Patient was transferred to the floor and her exam was consistent with volume overload. She was started on IV lasix and diuresed ~ 5.4L during the next 3 days. Her diuresis was limited by relative, 90-100mmHg, asymptomatic hypotension. Patient never had shortness of breath or chest tightness during this admission. She was continued on her sidenafil for cor pulmonale. Her O2 saturations improved to 90-92% on 3L NC, with abmulatory saturations of 90-92% requiring 4L on flat ground and 4-6L NC for ambulation up a flight of stairs to maintain O2 sat > 92%. Her discharge weight was 269 lbs. Patient was discharged home in this stable condition, with recommendation of 3L NC at rest and 3-4L NC with ambulation. She was referred for outpatient pulmonary rehabilitation. She was discharged on Torsemide 40mg [**Hospital1 **]. . # Hay fever. Patient had persistent symptoms of nasal congestion, post nasal drip and clear sputum with occaisional cough. She stated that she has had a long time standing diagnosis of hayfever though did not appear to be documented in OMR. She was started Loratadine 10mg daily. . # EKG changes: By report new TWI in inferior leads. No complaints of chest pain or pressure. Patient had clean coronaries on catheterization in [**2120**]. An official interpretation of ECG showed RAD, RV Hypertrophy and diffuse ST/T changes without interim change from [**2124-2-21**]. Patient was continued on ASA. . # Abdominal pain: The patient had no abd pain on admission and was tolerating a diet without a problem. This issue has been extensively evaluated on previous admission, she had recent abdominal CT at [**Hospital1 18**] with no acute issues found. Patient was tolerating her diet. She was restricted to 1.5L of fluid per day. . # Renal insufficiency: Baseline creat difficult to assess, was 1.0 on last discharge and is 1.4 currently. During last admission was 1.5-1.7. Pt was volume overloaded. As patient diuresed 3L, her Cr improved to 1.1. It is likely that her euvolemic Cr is slightly elevated as pt w/ Hx of HTN and RVHF. . # OSA: Patient was continue on BiPAP at home settings. . # PPX: SC heparin given to prevent DVT (watch PLTs closely); . # Code status: Full code (she did not desire intubation: requests discussion to be held with her mom & sister if that is needed) . Patient was discharged in hemodynamically stable conditon, with improved oxygen requirement. Medications on Admission: 1. Codeine-Guaifenesin 10-100 mg/5 mL Syrup 5-10 MLs PO Q6H prn cough 2. Benzonatate 100 mg PO TID 3. Ferrous Sulfate 325 mg po qd 4. Sildenafil 25 mg po tid 5. Aspirin 81 mg po qd 6. Fluticasone 110 mcg/Actuation Aerosol One Puff [**Hospital1 **] 7. Lidoderm 5 %(700 mg/patch) Adhesive Patch 8. Albuterol 90 mcg/Actuation Aerosol 2 puffs q4h prn SOB 9. Home O2 10. Ketoconazole 2 % Cream Topical twice a day; apply to face. 11. Metronidazole 0.75 % Cream Topical twice a day; apply to face. 12. Torsemide 40 mg po qd Discharge Medications: 1. Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. Disp:*1 bottle* Refills:*0* 4. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) for 10 days. Disp:*30 Capsule(s)* Refills:*0* 5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Sildenafil 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 8. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*2 containers* Refills:*2* 9. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. Disp:*2 inhalers* Refills:*2* 10. Ketoconazole 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day): apply to face twice daily. Disp:*1 container* Refills:*2* 11. Metronidazole 0.75 % Cream Sig: One (1) Topical once a day for 10 days: apply to face. Disp:*1 tube* Refills:*1* 12. Torsemide 20 mg Tablet Sig: Two (2) Tablet PO twice a day: Take one tablet at 8am and 4pm. Disp:*120 Tablet(s)* Refills:*2* 13. 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* 14. Outpatient Pulmonary Rehab Please obtain Pulmonary Rehabilitation Services upon your discharge. Please call [**Telephone/Fax (1) 2484**] to make an appointment. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] [**Location (un) 269**] Discharge Diagnosis: Primary: CHF (diastolic) exacerbation Secondary: Cor Pulmonale, Obstructive Sleep Apnea, Asthma, Morbid Obesity. Discharge Condition: Stable, with improved oxygenation, free of abdominal pain. Discharge Instructions: You were admitted to [**Hospital1 18**] due to low oxygen levels and weight gain. These were felt to be due to to heart failure exacerbation. The exacerbation was felt to be due to a recent cold you have had and increased intake of canned soups. Please do not eat canned foods if possible since they have high level of sodium. You required a temporary ICU stay, where you were given extra doses of diuretics. Your oxygen levels improved. You received additional doses of diuretics while in the hospital. With this treatment your oxygen levels improved. You shed 5.5L of fluid and your discharge weight was 269 lbs. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1.5L per day. You were discharged hgome without shortness of breath, without abodminal pain, ability to walk up the stairs. You will require an increased level of oxygen at home: 3L at rest and 4-5L while ambulating. You will also require to follow up with your PCP regarding [**Name Initial (PRE) **] urine culture. Changes to your medications include: - Increased Torsemide back to 40mg twice daily - Started Loratadine 10mg daily for allergy symptoms - Increased oxygen supplementation as above. Should you experience shortness of breath, chest pain, cough, fevers, chills, nausea, vomiting, increased weight, or any other symptom concerning to you, please call your primary care doctor or go to the emergency room. Followup Instructions: Please follow up with the following appointments: . MD: Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3029**] Specialty: pcp Date and time: [**2124-3-28**] at 11am Location: [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Bldg, [**Location (un) 895**] North Suite Phone number: [**Telephone/Fax (1) 250**] Special instructions if applicable: Appointment #2 MD: Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Specialty: Pulmonary Date and time: [**2124-3-27**] at 10:45am Location: [**Hospital Ward Name 23**] Bldg, [**Location (un) **] Phone number: [**Telephone/Fax (1) 612**] [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**] Completed by:[**2124-3-24**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

11416, 11493

5631, 8981

331, 337

11650, 11711

2852, 2857

13225, 14028

2332, 2350

9551, 11393

11514, 11629

9007, 9528

11735, 13202

2365, 2833

272, 293

4914, 5608

365, 1598

2871, 4895

1620, 2089

2105, 2316

7,241

127,440

24296

Discharge summary

report

Admission Date: [**2178-5-1**] Discharge Date: [**2178-5-8**] Date of Birth: [**2139-9-13**] Sex: M Service: MEDICINE Allergies: Betadine Viscous Gauze / Lisinopril / Valsartan / Diovan / banana / walnuts / avacado Attending:[**Doctor First Name 3298**] Chief Complaint: Fever Major Surgical or Invasive Procedure: tunneled hemodialysis line placement hemodialysis History of Present Illness: Mr. [**Known lastname **] is a 38 year old man with a hx of ESRD awaiting initiation of HD, HTN, and chronic dCHF, recurrent infections/bacteremia, who presents with fever 102.5, headache and generalized body aches x 1 day. He complains enlarged right groin lymph nodes as well as multiple blisters to his bilateral legs and reports that he has scratched on which has now opened. He does also report [**2-1**] loose bowel movements earlier today, last episode in afternoon, non-bloody. On review of systems, he denies any urinary symptoms, cough, shortness of breath, chest pain, abdominal pain, weight loss. He does report appetite loss for past 1 day. Of note, he was admitted to [**Hospital1 18**] [**Date range (3) 61600**] for sepsis secondary to lower extremity cellulitis in the setting of scratching his legs and causing skin abrasions. His hospital course was complicated by very brief MICU transfer for concern of septic shock. He has developed tender bilateral inguinal lymphadenopathy. Blood cultures had remained negative. He was initially treated with vancomycin and cefepime, then transitioned to clindamycin upon discharge. In the ED, initial vitals are as follows: 100.2 95 185/94 20 100%RA. Exam notable for small lymph nodes in his right inguinal region. Skin does not look erythematous around blisters, not warm to touch. No murmur was noted on exam. Labs notable for WBC 11.4 with 91%PMNs, BUN/Cr 86/5.2, negative UA, lactate 1.7. CXR showed no acute process. Blood cultures were drawn x2. The pt received a dose of vancomycin 1mg IV and cefepime 1gm IV in the ED. He also received tylenol PO and 1L NS. Vitals prior to transfer 101.5, 88, 18, 184,89, 100%ra. Currently, patient feels tired. He still feels a little generally weak. Lives alone but reports a gentleman nearby coughing a lot nearby him at the shelter. ROS: Denies night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, constipation, melena, hematochezia, dysuria, hematuria. Past Medical History: - chronic type B aortic dissection dignosed 3 years ago - poorly controlled HTN - ESRD pending initiations of dialysis - Acute disseminated encephalomyelitis (brain biopsy)-8years ago - group B streptococcal bactremia in [**2171**] - Phlebitis with MSSA bacteremia in [**2177-12-31**] - eczema - childhood asthma - allergic rhinitis - rotator cuff injury - G6PD deficiency Social History: currently unemployed, previously employed as a bartender. does not have housing, lives with friends or goes to shelter. (per OMR below) - tobacco: smokes [**12-1**] ppdx 12 years - ETOH: [**1-2**] drinks/ week - Denies illicit drugs Family History: Mother w/ CAD in her forties as well as DM and HTN; mother passed in [**2-/2177**] due to infectious complications of hip arthrosis. Maternal grandfather with DM and maternal grandmother w/ HTN. Aunt w/ breast cancer in her late 40's. Physical Exam: Admission: Vitals - 100.0 198/106 95 20 99%RA GENERAL: alert, oriented, sleepy but alert when awakened and pleasant. well-built african american man in no acute distress HEENT: mildly dry mucus membranes, muddy sclerae, pink conjunctivae CARDIAC: reg rhythm, normal rate, end-systolic murmur throughout (likely from fistula) LUNG: clear to auscultation bilaterally ABDOMEN: soft, nontender, nondistended EXT: 3+ bilateral edema, symmetric LYMPH: + significant R inguinal lymphadenopathy (improved from prior, per patient) DERM: thickened plaques scattered over lower extremities, particularly on calves and dorsum of toes and heels/ankles consistent with eczema; has a few areas with breaks in skin, but erythema not visible with dark skin color and does not appear infectious, no discharge PSYCH: Listens and responds to questions appropriately, pleasant Discharge: VS 97.3-98.5, 111-156/69-99, 73-76, 98-100%RA GEN Alert, oriented, no acute distress HEENT NCAT EOMI sclera anicteric, OP clear. NECK supple, no JVD, no LAD PULM Good aeration, CTAB no wheezes, rales, ronchi CV RRR normal S1/S2, no mrg Right tunnelled line c/d/i, some tenderness to palpation. ABD soft NT ND normoactive bowel sounds, no r/g EXT WWP 2+ pulses palpable bilaterally, bilateral lower extremities with 1+ woody edema and less warm to palpation L>R. Bilateral groin lymphnodes present NEURO CNs2-12 intact, motor function grossly normal Pertinent Results: ADMISSION LABS: [**2178-5-1**] 12:30AM BLOOD WBC-11.4*# RBC-3.17* Hgb-9.6* Hct-29.4* MCV-93 MCH-30.3 MCHC-32.6 RDW-14.6 Plt Ct-152 [**2178-5-1**] 01:35PM BLOOD WBC-9.2 RBC-3.26* Hgb-9.7* Hct-30.3* MCV-93 MCH-29.9 MCHC-32.2 RDW-14.8 Plt Ct-145* [**2178-5-1**] 12:30AM BLOOD Neuts-91.9* Lymphs-4.7* Monos-2.5 Eos-0.5 Baso-0.3 [**2178-5-2**] 07:01AM BLOOD Neuts-70.9* Lymphs-15.3* Monos-8.5 Eos-4.6* Baso-0.9 [**2178-5-1**] 12:30AM BLOOD PT-12.1 PTT-32.4 INR(PT)-1.1 [**2178-5-1**] 12:30AM BLOOD Glucose-106* UreaN-86* Creat-5.2* Na-134 K-4.3 Cl-103 HCO3-16* AnGap-19 [**2178-5-1**] 01:35PM BLOOD ALT-17 AST-30 LD(LDH)-276* AlkPhos-53 TotBili-0.6 [**2178-5-1**] 01:35PM BLOOD Calcium-8.6 Phos-4.0 Mg-1.7 [**2178-5-1**] 12:41AM BLOOD Lactate-1.7 DISCHARGE LABS: [**2178-5-8**] 07:10AM BLOOD WBC-6.9 RBC-3.34* Hgb-9.8* Hct-31.1* MCV-93 MCH-29.4 MCHC-31.7 RDW-14.1 Plt Ct-258 [**2178-5-8**] 07:10AM BLOOD Glucose-87 UreaN-84* Creat-7.0* Na-137 K-4.8 Cl-100 HCO3-25 AnGap-17 [**2178-5-8**] 07:10AM BLOOD Calcium-9.0 Phos-5.7* Mg-2.4 OTHER PERTINENT LABS: [**2178-5-1**] 01:35PM BLOOD ALT-17 AST-30 LD(LDH)-276* AlkPhos-53 TotBili-0.6 [**2178-5-6**] 07:35AM BLOOD calTIBC-300 Ferritn-296 TRF-231 [**2178-5-6**] 07:35AM BLOOD PTH-642* [**2178-5-5**] 12:06PM BLOOD 25VitD-7* [**2178-5-4**] 07:20AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE [**2178-5-4**] 07:20AM BLOOD HCV Ab-NEGATIVE URINALYSIS: [**2178-5-1**] 12:15AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.007 [**2178-5-1**] 12:15AM URINE Blood-SM Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2178-5-1**] 12:15AM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-0 [**2178-5-1**] Blood cultures negative x2 [**2178-5-1**] 12:15 am URINE Site: NOT SPECIFIED CHEM # 68849L [**5-1**] 12:5AM. **FINAL REPORT [**2178-5-2**]** URINE CULTURE (Final [**2178-5-2**]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ECG [**2178-5-1**] 9:18:36 AM Sinus rhythm. Left atrial abnormality. Left ventricular hypertrophy. Lateral ST-T wave changes as recorded on [**2178-3-26**], without diagnostic interim change. The P-R interval has normalized. CHEST (PA & LAT) Study Date of [**2178-5-1**] 12:36 AM CHEST, PA AND LATERAL: The lungs are clear. Mild cardiomegaly is unchanged. The aorta is tortuous and unfolded. There are no pleural effusions or pneumothorax. Multilevel degenerative changes in the thoracic spine. IMPRESSION: Chronic mild cardiomegaly. VENOUS DUP EXT UNI (MAP/DVT) RIGHT Study Date of [**2178-5-4**] 2:38 PM IMPRESSION: 1. Failing right cephalic-radial AVF due to thrombosis of the cephalic vein at the antecubital fossa. 2. Widely patent basilic vein, see digitized image on PACS for formal sequential measurements. 3. Widely patent brachial and radial arteries with no evidence of calcification or wall thickening. TUNNELED W/O PORT Study Date of [**2178-5-5**] 8:17 AM IMPRESSION: Successful placement of 23 cm tip-to-cuff 15.5 French tunneled hemodialysis catheter via a right internal jugular approach. The tip is in the right atrium, and the catheter is ready for use. Brief Hospital Course: Mr. [**Known lastname **] is a 38M with hx of ESRD (uncontrolled HTN, chronic type B dissection), depression, presenting with fever to 102.5F likely from lower extremity cellulitis, initiated on HD this admission. ACTIVE ISSUES: # ESRD: now on HD. ESRD likely secondary to chronic poorly controlled hypertension and involvement of aortic dissection with blood supply to one kidney. Fistula had been placed [**2178-2-24**] but never matured to a large enough size. Due to uremia (malaise, pruritus), and HTN, patient initiated dialysis [**2178-5-5**] following tunnelled line placement. He is being discharged to [**Hospital1 **] to continue his HD (M/W/F schedule). Long-term plans include placement of another fistula (he has an upcoming Transplant Surgery appointment to discuss these plans). After being discharged from [**Hospital1 **], he has a bed at [**Location (un) **] [**Location (un) **] for M/W/F dialysis to be followed by his Nephrologist, Dr. [**Last Name (STitle) 7473**]. # s/p fall: with zygomatic arch fracture. He had a syncopal episode and fall following his second session of dialysis on [**2178-5-6**]: he fell, struck his head, and had some arm shaking. This was clearly positional and occurred immediately following HD with fluid removal. Low clinical suspicion for seizure given his presentation (no tonic-clonic jerking, no incontinence or tongue biting). He was aware soon after the episode though slightly altered after receiving lorazepam. The episode was thought to be from convulsive syncope due to orthostasis or vasovagal factors as at presentation SBP's all >180 and with HD these fell to the 130's and this is likely a bit low for the patient. Unfortunately no BP checked immediately after episode. He was observed in the MICU overnight after the episode, and had no recurrence. He was ambulating without issues. Imaging demonstrated zygomatic arch fracture, will be followed up by Plastic Surgery as an outpatient. He is on a brief course of Augmentin per Plastics reccs for prophylaxis of sinusitis given facial fracture. # Fever: resolved. Possibly from lower extremity cellulitis and breach in skin integrity given similarity in presentation to last month and remarkable warmth on legs. But otherwise, could just have represented a viral illness. Empirically treated with Vancomycin from admission until [**5-3**] when he was switched to Cephalexin (course was completed on [**5-7**]). He had no more fevers throughout the hospitalization. # Chronic dCHF: now more euvolemic. He had significant lower extremity edema bilaterally which has been difficult to control over the last month. His nephrologist, Dr. [**Last Name (STitle) 4883**], has allowed him to take whatever dose of torsemide works for him to get fluid off, so he has been taking torsemide 60mg [**Hospital1 **] for a few weeks. This is the dose he was continued on. With HD, he was euvolemic at the time of discharge with only mild LE edema. # HTN: stable. Very difficult to control hypertension at baseline, requiring large doses of labetalol in addition to amlodipine and Hydralazine. During his stay, his BP was labile but much better controlled on HD. After his episode of syncope (see above) his BP was lower (SBP 100) so his regimen was downtitrated. His Labetalol dose was decreased (note that due to dissection he should remain on Labetalol), his Amlodipine was decreased, and his Hydralazine was discontinued. INACTIVE ISSUES: # Type B Aortic Dissection: stable. Chronic aortic dissection, stable by MRI in 2/[**2177**]. He is on Labetalol. # Borderline eosinophilia: resolved. Absolute count 386 <- 496 <- 330 <- 57. ? due to vancomycin versus hydralizine. Much less likely other etiologies. The eosinophilia resolved. # Itching legs: resolving slowly. Likely [**1-1**] uremia and eczema. Better with HD, Sarna, and Hydroxyzine. # Depression: stable. Continued citalopram 40mg PO qd. # Tobacco Use: he knows the risks of smoking. He was offered a nicotine patch and encouraged to quit. TRANSITIONAL ISSUES: - Social issues: patient is homeless currently - HD schedule: M/W/F - Long-term HD plans: Placement of fistula on left per transplant team (to be discussed at upcoming Transplant Surgery appointment) - Dispo: to [**Hospital1 **] for HD and ongoing fistula placement plans. After discharged from there, he has been accepted at [**Location (un) **] Brookine Medications on Admission: 1. sevelamer carbonate 1600 mg PO TID W/MEALS 2. labetalol 800mg PO BID 3. amlodipine 10mg daily 4. petrolatum Ointment QID 5. torsemide 20 mg tabs -- has been taking 3 tabs (60mg) [**Hospital1 **] x 3-4 weeks 6. citalopram 40 mg daily Discharge Medications: 1. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 2. petrolatum Ointment Sig: One (1) Topical twice a day as needed for dry skin. 3. torsemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*0* 4. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day. 5. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for dry skin. 6. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 7. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. amoxicillin-pot clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. 9. amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day. 10. labetalol 200 mg Tablet Sig: Two (2) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [**Hospital6 2222**] - [**Location (un) 538**] Discharge Diagnosis: PRIMARY: cellulitis end-stage renal disease fractured zygomatic arch SECONDARY: Hypertension chronic type B aortic dissection childhood asthma G6PD deficiency Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname **], It was our pleasure to care for you at [**Hospital1 18**]. You were admitted for fevers and lightheadedness which was possibly due to a viral illness or a skin infection of your legs. We started you on antibiotics to help control the infection. During this admission, the decision was made to initiate you on hemodialysis. You underwent the sessions without complication. Your HD schedule is M/W/F. On [**5-6**] you stood up after an HD session and you fell, fracturing your zygomatic arch. Per Plastic Surgery recommendations, we started you on antibiotics and will have you follow up as an outpatient. Now you are safe to be discharged to the [**Hospital1 **] with plans for outpatient dialysis as well as fistula placement. We made the following changes to your medications: Please DECREASE Amlodipine Please DECREASE Labetalol Please START Augmentin for 7 days, through [**5-13**] Please START hydroxyzine for itching Please START Sarna lotion for itching Please START a nicotine patch to help you quit smoking. It is important that you please stop smoking Followup Instructions: PRIMARY CARE Department: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 2010**] When: THURSDAY [**2178-5-14**] at 10:30 AM With: Dr [**First Name4 (NamePattern1) 1060**] [**Last Name (NamePattern1) 1520**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage NOTE: This appointment is with a hospital-based doctor as part of your transition from the hospital back to your primary care provider. [**Name10 (NameIs) 616**] this visit, you will see your new primary care doctor (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]) in follow up. PLASTIC SURGERY When: FRIDAY [**2178-5-15**] at 1:30 PM With: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern1) 6751**], MD [**Telephone/Fax (1) 6742**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage TRANSPLANT SURGERY When: MONDAY [**2178-5-18**] at 10:45 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 14955**], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage When you are discharged from [**Hospital1 **], you will receive your hemodialysis at [**Location (un) **] [**Location (un) **] Dialysis Center. You will be followed by your nephrologist, Dr [**Last Name (STitle) 4883**]. [**Location (un) **] [**Location (un) **] Dialysis Center [**Location 8262**], [**Numeric Identifier 1415**] Phone: [**Telephone/Fax (1) 5972**] Schedule: Mon, Wed & Fri at 5:00pm

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icd9cm

[ [ [] ] ]

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icd9pcs

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26,877

176,595

53223

Discharge summary

report

Admission Date: [**2159-3-18**] Discharge Date: [**2159-3-22**] Date of Birth: [**2112-1-18**] Sex: F Service: MEDICINE Allergies: Keflex / Dilantin Attending:[**First Name3 (LF) 689**] Chief Complaint: weakness, poor po intake, urinary freq Major Surgical or Invasive Procedure: Right internal jugular central venous line History of Present Illness: Admitted to the ICU [**2-24**] to hypotension (responsive to IVF) in the setting of a UTI. The patient was brought to [**Hospital1 18**] for weakness x several days, poor po intake and an episode of confusion at 3am on the morning PTA. In the ED: initial VS: T 102, BP 102/64, HR 57, RR 24, 02 sat 100%RA She was noted to have a + UA and was given 500mg levoflox. Her ECG showed some TWI (II, III, aVF), therefore a ROMI protocol was started. She was given ASA and tylenol. While in the ED the pt. became hypotensive (from 110's to 70's) which was fluid responsive(2L). She did not req. pressors. Her lactate was 1.6. . ROS: no fevers, +cough x 1 month, poor appetite x several days, denies SOB or CP. Denies diarrhea. Admits to urinary freq and LBP. Past Medical History: 1. R MCA bifurcation aneurysm s/p clipping in [**2151**], c/b perioperative stroke with residual L side weakness and dysarthria, seizures 2. Depression 3. Seizure d/o s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] 4. HTN 5. Hyperchol Social History: (per omr): lives w/ mom in [**Name (NI) 86**], sedentary tobacco: smokes [**1-24**] ppd EtOH/DOA: denies Family History: Significant for brain hemorrhage in maternal uncle. Physical Exam: VS: Temp: 96.9 BP: 122/77 HR: 60 CVP: 7 RR: 23 O2sat 94RA GEN: Laying in bed, alert and oriented, dysarthric HEENT: Dry MM, left eye fully reactive, right eye minimally reactive, EOMI, RIJ in place RESP: slight expiratory wheezes CV: RRR no murmurs ABD: NT, ND, normoactive BS Back: CVA tenderness L>R EXT: non-edematous LE. Post-stroke residual weakness and contractures of Left hand and left LE. Righ upper and lower ext 5/5 strength. Pertinent Results: =================== ADMISSION LABS ================== WBC-9.9 Hct-50.2* MCV-92 MCH-32.0 MCHC-34.7 RDW-13.2 Plt Ct-222 Neuts-88.7* Bands-0 Lymphs-8.0* Monos-2.9 Eos-0.2 Baso-0.3 PT-13.4 PTT-32.9 INR(PT)-1.1 Glucose-130* UreaN-11 Creat-0.7 Na-135 K-3.9 Cl-100 HCO3-22 AnGap-17 BLOOD CK(CPK)-135 ================= RADIOLOGY ================= CT BRAIN ([**2159-3-18**]) 1. Status post right aneurysm clip placement via right craniectomy. 2. Stable old large right MCA territory infarct and smaller old left parietal infarct. CHEST X-RAY ([**2159-3-18**]) No acute cardiopulmonary process detected. ================== MICROBIOLOGY ================== URINE CULTURE (Final [**2159-3-20**]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. OF TWO COLONIAL MORPHOLOGIES. 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 MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S ================== DISCHARGE LABS ================== WBC-4.9 Hct-45.0 MCV-93 MCH-32.0 MCHC-34.4 RDW-13.0 Plt Ct-176 Glucose-88 UreaN-10 Creat-0.7 Na-134 K-4.4 Cl-100 HCO3-26 AnGap-12 Mg-2.1 Brief Hospital Course: 47 yo F w/ pmh s/p aneurysm clipping c/b stroke, admitted with AMS, influenza and UTI, much improved. # Hypotension: transiently to SBP of 70's upon admission. Patient was responsive to fluid resusitaction and this likely represented SIRS [**2-24**] influenza and UTI. Patient was treated with Ciprofloxacin 250mg [**Hospital1 **] and will need to continue treatment for 5 more days. Influenza was symptomatically treated and patient is no longer under droplet precautions. Patient will need to follow up with primary care physician [**Last Name (NamePattern4) **] [**1-24**] weeks. . # AMS: At admission, note of altered mental status was made. This likely represents toxic metabolic response in the setting of decreased reserve from history of prior Right MCA infarct. Head CT negative for acute process. MRI/MRA had been scheduled as an ouptatient but we were not able to obtain it as the exact type and model of clip utilized was not known. We were unable to obtain outside records in a time for test to be performed during this admission and will need to be re-scheduled as an outpatient once this information is obtained. She has follow up scheduled with outpatient neurologist. # ECG changes: While patient was hypotensive in the ED, TWI and slight ST depressions were noted on ECG. Cardiac enzymes were negative x 3 and patient remained asymptomatic during admission. No events on telemetry. No further testing indicated at this time. #UTI: Patient with pyuria on admission, urine culture with growth of pan-sensitive e. coli. As above, patient to complete remaining 5 days of antibiotic course. #SEIZURE Disorder: No changes during this admission, patient kept on tegretol # contractures: We continued dantrolene. # hypercholesterolemia: We continue simvastatin at outpatient dose # Hypertension: Although anti-hypertensives were held during hypotension, patient tolerated re-starting of all meds at home dose before discharge. No changes to outpatient medical regimen were made during this admisison. # depression: We continued fluoxetine #FEN: regular cardiac diet. replete lytes. #PPx: subq heparin, bowel reg #CODE: full (confirmed with mother/hcp) Medications on Admission: Tegretol 300mg [**Hospital1 **] clonidine 0.1mg [**Hospital1 **] dantrolene 25mg [**Hospital1 **] lisinopril 10mg qdaily bisoprolol/hctz 10/6.25mg qdaily fluoxetine 30mg qdaily simvastatin 20mg qdaily Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Carbamazepine 100 mg Tablet, Chewable Sig: Three (3) Tablet, Chewable PO BID (2 times a day). 4. Dantrolene 25 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Fluoxetine 10 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily). 6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 8. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) treatment Inhalation every six (6) hours as needed for shortness of breath or wheezing for 7 days. 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) treatment Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing for 7 days. 10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days. 11. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Bisoprolol-Hydrochlorothiazide 10-6.25 mg Tablet Sig: One (1) Tablet PO once a day. 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Influenza Type B infection Urinary track infection Discharge Condition: Hemodynamically stable, improved. Discharge Instructions: You were admitted with low blood pressure and altered mental status. During your hospitalization, we found you had a urinary track infection as well as the flu. Because you have been progressively declining in your ability to walk, you will benefit from inpatient rehabiliation. Please take all medications as prescribed and keep all doctors [**Name5 (PTitle) 4314**]. If you experience any chest pain, nausea, vomiting, diarrhea, or any other concerning symptoms, please seek medical attention. Followup Instructions: Please follow up with your primary care physician, [**Name10 (NameIs) **] [**First Name (STitle) **] [**Name (STitle) 1395**], Thursdday, [**3-29**] 1:45pm Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2159-6-4**] 1:30

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

7441, 7511

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316, 361

7606, 7642

2081, 3736

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1556, 1609

6186, 7418

7532, 7585

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1624, 2062

238, 278

389, 1142

1164, 1417

1433, 1540

72,073

110,136

53579

Discharge summary

report

Admission Date: [**2161-12-22**] Discharge Date: [**2161-12-31**] Date of Birth: [**2119-9-15**] Sex: F Service: SURGERY Allergies: Vasotec / Metformin / Lactose Attending:[**First Name3 (LF) 1390**] Chief Complaint: MVC Major Surgical or Invasive Procedure: [**2161-12-23**] - L1 through L3 spinal fusion, closed reduction nasal fracture, primary closure of right alar base laceration History of Present Illness: 42 yo F s/p MVC, unrestrained driver. Veered off road into [**Doctor Last Name 6641**]. +LOC, +airbag deployment. Unclear cause of crash; pt thinks she may have fallen asleep. Seen at OSH, found to have unstable L2 burst fracture, as well as L1 and L3 transverse process fractures. Imaging of CT torso, head, cspine otherwise negative on preliminary read. Transferred to [**Hospital1 18**] for further management. Pt also noted to have significant left facial swelling; transferred to TSICU for airway monitoring. INJURIES: - L2 unstable burst fracture - L1 bilateral transverse process fractures - L3 right transverse process fracture - mildly displaced nasal bone fracture Past Medical History: PMH: - DM2 - HTN - obesity - MRSA - chronic pain PSH: - lap RnY gastric bypass ([**Doctor Last Name **] [**2159**]) c/b intraperitoneal bleed requiring emergent exlap ([**Doctor Last Name **] [**2159**]) - lap cholecystectomy [**2152**] Social History: Patient lives at home with her parents, husband, and two children. Patient is a house wife, and her husband is a waitor at a chinese restaurant. Patient denies tobacco, alcohol or drug use. Family History: Family history of diabetes: father, paternal grandmother and grandfather. Maternal grandmother with [**Name2 (NI) 499**] cancer. Physical Exam: 96.4, 87, 108/60, 20, 98 % on room air alert and oriented, no acute distress facial edema, improved scleral hemorrhages bilaterally, periorbital ecchymoses bilaterally, EOMI, PERRL bruising along anterior neck, full ROM CTA B/L RRR soft, obese abdomen, nondistended, mild tenderness in epigastrium Pertinent Results: [**2161-12-22**] 07:55PM WBC-10.1# RBC-4.27 HGB-12.6 HCT-37.3 MCV-88 MCH-29.6 MCHC-33.8 RDW-12.7 [**12-22**] CT torso (2nd read): L2 burst fracture with moderate bony retropulsion into the spinal canal with small perivertebral hematoma. Transverse process fractures of L1, L2 and L3. Otherwise no acute injury in the chest, abdomen, or pelvis. [**12-22**] CT head (2nd read): No acute intracranial hemorrhage [**12-22**] CT cspine (2nd read): No acute fracture or malalignment of the cervical spine [**12-22**] CT face: Mildly displaced right nasal bone fracture. Significant soft tissue swelling and hematoma over the left face [**12-22**] CXR: no acute process [**12-22**] MRI L spine: Burst fracture of L2 with tear of the anterior and posterior longitudinal ligaments, but no obvious involvement of the interspinous ligaments. Significant retropulsion of fracture fragments into the spinal canal with posterior displacement and compression of the cauda equina. The conus terminates at the L1 level. [**12-24**] CXR: Tip of endotracheal tube is above the level of the clavicles, terminating about 7 cm above the carina. This could be advanced several centimeters for standard positioning. New nasogastric tube is coiled within the proximal stomach. Cardiomediastinal contours are within normal limits, and lungs are clear. No pleural effusion or pneumothorax. [**2161-12-25**] CT Torso: There is mild bilateral atelectasis. The airways are patent to the subsegmental level. There are no pulmonary nodules. No pulmonary effusion or pneumothorax. A central venous catheter is seen with the tip in the superior vena cava. The heart, pericardium, and great vessels are normal. No axillary or mediastinal lymphadenopathy is seen. The esophagus is normal and there is no hiatal hernia. Lack of contrast enhancement limits the examination of the intraabdominal viscera. Within the limitation, the liver, spleen, adrenals, pancreas, and kidneys are unremarkable. There is a small exophytic, hypodense lesion in the superior pole of the right kidney, that is too small to characterize. The patient is post-cholecystectomy and post Roux-en-Y gastric bypass. The gastrojejunal and jejunojejunal anastomoses are intact. The [**Month/Day/Year 499**] is within normal limits. The intraabdominal vasculature is unremarkable. There is no free fluid or free air. There is no abdominal wall hernia. There is no mesenteric or retroperitoneal lymphadenopathy. No evidence of intraabdominal bleed. The bladder is normal, there is a Foley catheter seen in the bladder. The terminal ureters, rectum, uterus, and adnexa are unremarkable. There is no free fluid in the pelvis. There is no pelvic wall or inguinal lymphadenopathy. The patient is post L1-L3 fusion. Some small foci of air are seen in the posterior subcutaneous tissues consistent with postoperative changes. There is a defect in the left iliac crest from prior bone graft donor site. No hematomas are seen. Brief Hospital Course: Ms. [**Known lastname **] was admitted to the TSICU for intensive care and management following her MVC. On [**2161-12-23**] she went to the operating room with orthopedic surgery for L1-L3 spinal fusion and closed reduction of nasal bone fracture by plastic surgery. Post-operatively she was febrile to 103.2 and cultures were sent. She was extubated the following day but pain control posed a challenge so the chronic pain team was consulted. Lopressor was administered given tachycardia and hypertension but she subsequently was hypotensive to the 70's, which partially responded to a 1L bolus and neo was started. Her hematocrit trended down and she was transfused 2u pRBCs for hct 19. She subsequently stabilized off pressors and was transferred to the floor. Pain control continued to be an issue on the floor. Her regimen was altered multiple times including the use of lidocaine patch, gabapentin, standing tylenol, long acting PO narcotics, and short acting PO narcotics. Ms. [**Known lastname **] was fitted for a TLSO brace and received that on [**12-28**]. She began working with PT and OT who recommended a course of inpatient rehab, feeling that she is a fall risk, needing more time to adjust to the brace, and that she will benefit from an aggressive PT/OT program to assist her in regaining her strength and prior activity level. She did have a mild TBI screen and OT felt that she had normal processing and would not require a cognitive [**Month/Year (2) **] follow up after discharge. The patient remained very resistant to being discharged to a rehabilitation facility and preferred to stay in the hospital and work with PT/OT until they cleared her for home with services. She did work with PT daily and both her family were educated in the use of the TLSO brace and in coordinating ADLs with the use of the brace, rolling walker, and commode. On [**12-31**], Ms. [**Known lastname **] was discharged to home with home PT and follow up appointments with her primary care provider, [**Name10 (NameIs) **] chronic pain physician, [**Name10 (NameIs) **] plastic surgeon, her orthopedic spine surgeon, and her bariatric surgeon and nutritionist. She is also being asked to make a routine ophthalmology appointment to have a dilated fundoscopic exam in the near future. She was discharged with prescriptions for a 10 day supply of her pain medication regimen in order to provide her with enough medication until her follow up visit with her chronic pain physician [**Last Name (NamePattern4) **] [**2162-1-7**]. She was given prescriptions for all of the pain medications other than the liquid oxycodone. It was difficult to find a local pharmacy that carried a supply of oxycodone in the liquid form. This prescription was filled by [**Hospital1 18**] pharmacy and the patient was given a 7 day supply of the medication at the time of discharge. Medications on Admission: - dilaudid 8mg liquid q3-4 - Lantus 20-40 units intermittently - Vitamin B-12' - Cozaar 150' Discharge Medications: 1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. docusate sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. gabapentin 300 mg Capsule [**Hospital1 **]: One (1) Capsule PO TID (3 times a day). Disp:*30 Capsule(s)* Refills:*0* 5. acetaminophen 500 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q8 (). Disp:*60 Tablet(s)* Refills:*0* 6. morphine 45 mg Cap, ER Multiphase 24 hr [**Hospital1 **]: One (1) Cap, ER Multiphase 24 hr PO Q8H (every 8 hours). Disp:*30 Cap, ER Multiphase 24 hr(s)* Refills:*0* 7. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). Disp:*10 Adhesive Patch, Medicated(s)* Refills:*0* 8. famotidine 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Cozaar 50 mg Tablet [**Hospital1 **]: Three (3) Tablet PO once a day. Disp:*90 Tablet(s)* Refills:*2* 10. multivitamin Tablet [**Hospital1 **]: Two (2) Tablet PO once a day. Disp:*60 Tablet(s)* Refills:*2* 11. thiamine HCl 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 12. Calcium Citrate + 315-200 mg-unit Tablet [**Hospital1 **]: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 13. oxycodone 5 mg/5 mL Solution [**Hospital1 **]: [**11-14**] mL PO q3. Disp:*900 mL* Refills:*0* 14. Lantus 100 unit/mL Solution [**Month/Year (2) **]: Twenty (20) units Subcutaneous at bedtime. Discharge Disposition: Home With Service Facility: [**Location (un) 2203**] VNA Discharge Diagnosis: Polytrauma L2 unstable burst fracture L1 bilateral transverse process fractures L3 right transverse process fracture mildly displaced nasal bone fracture Discharge Condition: You must wear the TLSO brace at all times when you are out of bed and walking around. Discharge Instructions: You have been treated for multiple injuries that you endured as a result of a car accident. You had multiple specialty teams participating in your care and it is very important that you follow up with each of them. We have made appointments for you listed below. If you need to change the date or time for these appointments, please contact their offices. You will need to see your primary care provider, [**Name10 (NameIs) **] chronic pain physician, [**Name10 (NameIs) **] spine surgeon, and the plastic surgeon. Your bariatric surgeon would also like to follow up with you. We also advise you to make a routine appointment to be evaluated by an ophthalmologist to have a dilated eye examination. You will be working with home physical therapists as well and it is important that you keep your brace on at all times when you are out of bed and follow their recommendations closely as they work with you moving forward. You should not drive while taking narcotic pain medications. It is very important that you follow this restriction. You cannot safely drive on your current medication regimen. You should take the bowel regimen prescribed to you to prevent constipation while taking your current pain medication regimen. You should take the vitamins prescribed to you as directed by your bariatric surgeon. You should plan to take 20 units of lantus each night, every night. Check your sugars at home. Follow up with your primary care doctor about your diabetes regimen. It is important that you take your medicine everyday, it is long-acting, and helps to keep your sugars under control throughout the day. Followup Instructions: [**2162-6-15**] 11:15a [**Last Name (LF) **],[**First Name3 (LF) **] H (LIVER CTR.) LM [**Hospital Unit Name **], [**Location (un) **] LIVER CENTER (SB) [**2162-2-17**] 10:30a [**Location (un) **],GASTRIC SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] BARIATRIC SURGERY [**2162-2-17**] 10:15a [**Doctor Last Name **],GASTRIC SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] GASTRIC BYPASS PRIVATE (NHB) [**2162-1-12**] 01:00p MANDYAM,VASUDEV C. (Primary Care) SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] [**Hospital 191**] MEDICAL UNIT (SB) [**2162-1-12**] 09:40a [**Last Name (LF) 4983**],[**First Name8 (NamePattern2) 1141**] [**Last Name (NamePattern1) 95**] (Ortho-Spine) SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] SPINE CENTER (SB) [**2162-1-7**] 08:40a [**Doctor Last Name 8380**] FLUORO 6 (Chronic Pain) ONE [**Location (un) **] PLACE ([**Location (un) **], MA), [**Location (un) **] PAIN MANAGEMENT CENTER (SB) [**2162-1-4**] 02:00p [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]-CC3 [**Doctor First Name 147**] SPEC (Plastic Surgery) SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] SURGICAL SPECIALTIES CC-3 (NHB) Completed by:[**2161-12-31**]

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icd9cm

[ [ [] ] ]

[ "21.81", "81.62", "21.71", "77.79", "81.07", "03.53" ]

icd9pcs

[ [ [] ] ]

9864, 9923

5072, 7941

295, 423

10121, 10209

2086, 5049

11873, 13171

1620, 1752

8085, 9841

9944, 10100

7967, 8062

10233, 11850

1767, 2067

252, 257

451, 1132

1154, 1394

1410, 1604

18,673

131,897

26382

Discharge summary

report

Admission Date: [**2130-6-25**] Discharge Date: [**2130-7-4**] Date of Birth: [**2058-10-26**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1974**] Chief Complaint: s/p fall, lethargy Major Surgical or Invasive Procedure: None. History of Present Illness: 71 yo Farsi speaking female with history of CAD s/p CABG x 4, COPD on home bipap + oxygen, DM2, CHF, VT s/p AICD [**1-2**], schizophrenia, multiple falls in the past (most recent in [**4-5**]), presents after an unwitnessed fall on [**6-25**] AM on way to bathroom. Her had initially noticed that she seemed more sleepy than normal. When the daughter returned to check on her that evening, she found her mother down in the bathroom. She has been more sleepy since yesterday afternoon. The patient (with assistance from the daughter for translation) says that she felt dizzy before she fell. She hit her head on the door at the time of the fall, she denies other trauma. She did complain of LLQ abdominal pain which has resolved. She was unconscious briefly but awoke on the bathroom floor. She was incontinent of bowel and bladder on her way to the bathroom. Denies chest pain, shortness of breath, nausea, vomiting, fever, or chills, dysuria, diarrhea, or changes in her bowel movements. No recent changes in meds or diet. No sick contacts. She uses the bipap regularly although the daughter states that sometimes the medications she is taking make her sleepy so she misses it. . Vitals in the ED were temp 99.1, HR 95, BP 125/43, sats initially 70s% on RA-> 98% on NRB. In the ED she was noted to be somnolent and in moderate respiratory distress distress. An ABG in the ED was 7.30/75/199, her baseline CO2 is usually in the 60s. Lab notable for Na 152, nl BUN/creat 0.8, stable hct 32. U/A was negative, bld cx sent and remained negative. She was complaining of LLQ abdominal tenderness so an abdominal CT was performed which was unremarkable. She also had some right wrist tenderness, an x-ray showed no fracture. She was treated with BIPAP in the ED and transferred to the [**Hospital Unit Name 153**]. . Of note she was admitted [**Date range (3) 65254**] for a similar episode. On that admission she had fallen on her way to the bathroom after removing her BIPAP and Oxygen. On that admission she was felt to have worsening of her COPD due to CHF and a URI. Past Medical History: 1. CAD: s/p 4-vessel CABG [**2119**] 2. CHF: ECHO [**1-3**] w/ 1+ MR, minimal AS, EF 40% w/ regional wall motion abnormalities 3. DM Type 2 4. HTN 5. COPD: on home O2 3.5L/m, BIPAP (settings 14/8) with multiple past admissions w/ pCO2 in the 70-80 range 6. Schizophrenia: initially symptomatic w/ paranoia and hallucinations, well controlled w/ meds 7. L3 fracture: [**2127**] 8. Symptomatic VT: s/p ICD in [**1-2**] Social History: lives alone in [**Hospital3 **] apartment; has home health aide daily; meals are prepared by the pt's daughter; walks independently but sometimes uses walker; uses home O2 at all times and BiPAP at night; smoked 60 pack-years but quit in [**2123**]; no alcohol, IVDU, or cocaine use. Family History: 1. CAD: mother died of MI at unknown age Physical Exam: VS: Temp 98.3, Pulse 66, BP 119/42, RR 21, 97% on BIPAP 2L O2 14/10 Gen: alert, oriented, cooperative, Farsi speaking female HEENT: MMM, OP clear, PERRL, BIPAP mask in place Neck: no lymphadenopathy, no JVD Lungs: clear to auscultation bilaterally CV: RRR, nl S1S2 3/6 SEM at LLSB Abd: soft, non-tender, non-distended positive BS Ext: no edema Neuro: limited by bipap and language barier but grossly intact Pertinent Results: [**2130-6-25**] 07:20PM WBC-9.0 RBC-3.65* HGB-11.4* HCT-32.9* MCV-90 MCH-31.3 MCHC-34.8 RDW-14.6 [**2130-6-25**] 07:20PM NEUTS-86.7* BANDS-0 LYMPHS-8.5* MONOS-3.6 EOS-0.9 BASOS-0.2 [**2130-6-25**] 07:20PM PLT SMR-NORMAL PLT COUNT-174 [**2130-6-25**] 07:20PM DIGOXIN-0.5* [**2130-6-25**] 07:20PM VALPROATE-20* [**2130-6-25**] 07:20PM CK-MB-15* MB INDX-1.1 cTropnT-<0.01 proBNP-1049* [**2130-6-25**] 07:20PM CK(CPK)-1420* [**2130-6-25**] 07:20PM GLUCOSE-181* UREA N-24* CREAT-0.8 SODIUM-152* POTASSIUM-3.6 CHLORIDE-111* TOTAL CO2-34* ANION GAP-11 [**2130-6-25**] 07:43PM LACTATE-0.7 [**2130-6-25**] 07:24PM PO2-199* PCO2-75* PH-7.30* TOTAL CO2-38* BASE XS-8 . . CT ABD/PELVIS: 1. No evidence of acute traumatic injury. 2. Unchanged nonspecific liver and renal lesions and right infrahilar lymphadenopathy. . . CXR: Single AP radiograph of the chest performed on [**2130-6-25**] at 19:30 hours is compared with the prior radiograph of [**2129-4-19**]. No significant adverse interval change is noted. There is cardiomegaly. There is a transvenous pacemaker unchanged in position. There is minimal subsegmental atelectasis at the left base. There is no evidence of acute consolidation or frank failure on the current examination. . . TTE: The left atrium is markedly dilated. The right atrium is moderately dilated. The estimated right atrial pressure is 5-10 mmHg. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. There is mild aortic valve stenosis (area 1.2-1.9cm2). No 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 an anterior space which most likely represents a fat pad. Compared with the prior study (images reviewed) of [**2129-1-10**], overall left ventricular systolic function now appears improved. Previously described anteroseptal and apical wall motion abnormalities are probably still present, but current study is technically suboptimal for full evaluation of regional wall motion. The severity of aortic stenosis has increased. . . Brief Hospital Course: 1) Hypercarbic respiratory failure: Pt was admitted with elevated CO2 and her hypercarbia was likely the cause of her lethargy and fall. The etiology of her hypercarbic respiratory failure was likely due oversedation from multiple psychiatric medications on top of overlying COPD and lack of use of BiPAP. She was restarted on Bipap and her medication regimen was cut down. Her topamax and restoril were stopped and depakote dose was reduced. She was continued on abilify, risperdal, and zoloft. Her resp status was improved with this. She was continued on frequent nebulizers. There was no evidence of pneumonia or other acute pulmonary process. She should continue on BiPAP at nite and for about 2 hours in the afternoon or any time she naps. . 2) UTI: Pt had a Foley catheter in since admission and on day of discharge she c/o dysuria and urine appeared cloudy. She was started on cefpodoxime empirically for UTI pending U/A and culture. Should get 2 week course for complicated UTI. Catheter removed. After discharge, urine culture grew < 100K enterococcus [**Last Name (un) 36**] to ampicillin. . 3) Schizophrenia: Medications adjusted as above. . 4) HA: Pt c/o HA throughout admission. She had 2 head CT's given fall (one on admission and one on discharge) without evidence of ICH. She states she gets HA at home too and this felt similar. Respond to tylenol. . 5) CAD/CHF: No active issues. Continued on ASA, beta blocker, atorvastatin, digoxin, lasix. Appeared euvolemic throughout. . 6) DM2: Initially, on SSI, then restarted home dose of glyburide. Medications on Admission: 1. Lasix 60mg daily 2. Digoxin 25 mcg daily 3. Glyburide 5mg daily 4. Toprol 25mg daily 5. Aspirin 81 mg daily 6. Levothyroxine 125 mcg daily 7. Medroxyprogestrone 10mg daily 8. Lipitor 10mg daily 9. Zoloft 75mg daily 10. Abilify 20md daily 11. Risperdal 2mg qHS 12. Depakote 250 mg daily 13. Prenatal vitamin 14. Phoslo with meals - doesn't take regularly 15. DuoNeb 4X day 16. Flovent 4puffs [**Hospital1 **] 17. Flonase 50 mcg [**Hospital1 **] 18. Restoril 7.5mg qHS 19. Nitroglycerin 20. Topomax 100mg qHS Discharge Medications: 1. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 2. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Medroxyprogesterone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO at bedtime. 9. Sertraline 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 10. Aripiprazole 10 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 11. Risperidone 2 mg Tablet Sig: One (1) Tablet PO at bedtime. 12. Divalproex 125 mg Capsule, Sprinkle Sig: One (1) Capsule, Sprinkle PO DAILY (Daily). 13. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 14. DuoNeb 2.5-0.5 mg/3 mL Solution Sig: One (1) inhalation Inhalation four times a day. 15. Fluticasone 110 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation [**Hospital1 **] (2 times a day). 16. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: One (1) Spray Nasal [**Hospital1 **] (2 times a day). 17. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. 18. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 20. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 21. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 22. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-31**] Drops Ophthalmic PRN (as needed). 23. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 2 weeks: for UTI, day 1=[**7-4**]. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 86**] Discharge Diagnosis: PRIMARY: Hypercarbic respiratory failure secondary to COPD exacerbation s/p fall UTI, complicated . SECONDARY: CAD s/p CABG Diastolic CHF Diabetes type 2 Schizophrenia Headache, NOS Discharge Condition: Good--respiratory status stable, oxygenation at baseline. Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet. Take medications as prescribed. Please seek medical attention for fevers, increasing shortness of breath, chest pain, constipation, or any other symptoms that concern you. Followup Instructions: Please call Dr. [**Last Name (STitle) 4922**] to set up a follow up appointment after discharge from rehab.

[ "414.00", "276.0", "327.23", "V45.81", "293.0", "564.00", "280.9", "599.0", "295.90", "789.04", "428.0", "428.30", "493.22", "041.04", "V45.02", "244.9", "250.00", "518.84" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10177, 10248

6139, 7715

334, 342

10474, 10534

3681, 6116

10857, 10968

3196, 3238

8276, 10154

10269, 10453

7741, 8253

10558, 10834

3253, 3662

276, 296

370, 2438

2460, 2879

2895, 3180

19,470

102,383

52013

Discharge summary

report

Admission Date: [**2199-8-1**] Discharge Date: [**2199-8-6**] Date of Birth: [**2150-7-11**] Sex: F Service: CARDIOTHORACIC Allergies: Latex / Morphine Attending:[**First Name3 (LF) 922**] Chief Complaint: angina with exertion Major Surgical or Invasive Procedure: cabg x 2 with IABP [**2199-8-2**] (LIMA to LAD, SVG to OM) History of Present Illness: 49 yo female with 4 months of increasing chest discomfort with exertion. Cath at [**Hospital 1474**] Hospital revealed 70-90% LM, RCA with mild irregularities and nl LAD and CX. EF was 18% by ETT on [**7-25**]. IABP placed post-cath at OSH. Referred for CABG with Dr. [**Last Name (STitle) 914**]. Past Medical History: pancreatitis elev. chol. NIDDM depression/anxiety ETOH Non-Hodgkin's lymphoma with XRT retinal artery stenoses COPD/asthma hypothyroid shoulder injury post-MVA s/p splenectomy/partial pancreatectomy Social History: lives with mother works as a lunch lady smokes 1 ppd for 20 years 3-4 beers/week Family History: father died of MI at 47 brother with PTCA at 50 Physical Exam: HR 82 158/98 RR 20 100% sat on 2L 5'7" 145 # NAD, conversant, A and O X3 PERRL , EOMI, MMM OP benign neck supple, no LA, carotids with radiated IABP CTAB RRR S1 S2 no murmur abd soft, NT, + BS extrems warm, no edema 2+ bil. carotids/ radials 2+ left fem/DP, right with IABP Pertinent Results: [**2199-8-5**] 06:35AM BLOOD WBC-11.4* RBC-3.84* Hgb-10.7* Hct-31.8* MCV-83 MCH-27.7 MCHC-33.5 RDW-17.5* Plt Ct-303 [**2199-8-5**] 06:35AM BLOOD Plt Ct-303 [**2199-8-5**] 06:35AM BLOOD PT-12.2 PTT-28.2 INR(PT)-1.0 [**2199-8-5**] 06:35AM BLOOD Glucose-114* UreaN-14 Creat-0.8 Na-132* K-4.7 Cl-98 HCO3-22 AnGap-17 [**2199-8-1**] 08:26PM BLOOD ALT-18 AST-17 LD(LDH)-131 AlkPhos-50 TotBili-0.2 [**2199-8-1**] 08:26PM BLOOD Albumin-4.2 [**2199-8-1**] 08:26PM BLOOD %HbA1c-6.6* [Hgb]-DONE [A1c]-DONE [**2199-8-4**] 03:40PM BLOOD TSH-11* Brief Hospital Course: Admitted from OSH post - cath with IABP on [**8-1**] on IV heparin and NTG. Hct decreased to 26.5 and vascular surgery consult done to evaluate for retroperitoneal bleed. This was negative by CT scan.Underwent cabg x2 (please see operative report for details of procedure) on [**8-2**] and transferred to the CSRU in stable condition on a phenylephrine drip. IABP pulled later that day after weaning. Extubated overnight and transferred to the floor on POD #1 to begin increasing her activity level. Psych consult obtained for better management of anxiety and agitation and meds were adjusted. Chest tubes removed without incident. Pacing wires removed without incident on POD #3. She has remained hemodynamically stable, and ready for discharge home today. Medications on Admission: lipitor 10 mg daily lamictal 200 mg daily methocarbamol 750 mg daily prevacid 30 mg [**Hospital1 **] levothyroxine 88 mcg daily trazodone 300 mg daily metformin 850 mg daily citalopram 40 mg daily albuterol 2 puffs 4 times daily flovent 2 puffs [**Hospital1 **] serevent 2 puffs [**Hospital1 **] singulair 10 mg daily xanax 0.5 mg TID NTG prn Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:*60 Capsule(s)* Refills:*0* 3. Atorvastatin 10 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. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 9. Lamotrigine 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 12. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7 days. Disp:*28 Capsule, Sustained Release(s)* Refills:*0* 13. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 14. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 15. Metformin 850 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 16. Citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 17. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. Disp:*30 Tablet(s)* Refills:*0* 18. Lopressor 50 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: CAD elev. cholesterol COPD pancreatitis non-Hodgkin's lymphoma DM-2 HTN depression ETOH abuse Discharge Condition: good Discharge Instructions: no lotions, creams or powders on any incision may shower and pat dry no driving for one month no lifting greater than 10 pounds for 10 weeks call for fever greater than 100, redness or drainage Followup Instructions: see Dr. [**Last Name (STitle) 29478**] in [**11-26**] weeks see Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**12-28**] weeks See Dr. [**Last Name (STitle) 914**] in 4 weeks [**Telephone/Fax (1) 170**] Completed by:[**2199-8-6**]

[ "411.1", "414.01", "V17.3", "V10.79", "300.4", "493.20", "250.00", "272.0" ]

icd9cm

[ [ [] ] ]

[ "39.61", "97.44", "36.15", "36.11" ]

icd9pcs

[ [ [] ] ]

5225, 5280

1943, 2703

301, 362

5418, 5425

1388, 1920

5667, 5929

1025, 1074

3097, 5202

5301, 5397

2729, 3074

5449, 5644

1089, 1369

241, 263

390, 689

711, 911

927, 1009

71,577

122,980

4332

Discharge summary

report

Admission Date: [**2162-11-21**] Discharge Date: [**2162-12-2**] Date of Birth: [**2092-2-2**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1990**] Chief Complaint: Transfer from OSH with Acute on Chronic Renal Insufficiency, Obstructing right uric acid stone, Hypoxia Major Surgical or Invasive Procedure: Intubation Right Internal Jugular Central Line Right Ureteral Stent History of Present Illness: 70 yo male with three vessel CABG ([**2147**] following anterior wall MI and cardiac arrest) and ICD implantation, CHF (EF: 25% sp MI, 40% on [**11-19**]), DM, CRI, uric acid stones. . Patient presented to Wakefeild/[**Location (un) **] on [**2162-11-18**] under the urology service for treatment of kidney stones for which he had been diagnosed earlier in the week. Pt initially complained of right-sided lower abdominal pain and flank tenderness. Patient was sent home from Dr.[**Name (NI) 18722**] (urology) office and passed two stones the Sunday prior to presentation. By the following Tuesday the patient represented to Dr. [**Last Name (STitle) **] given severe right lower abdominal/groin pain. On presentation patient's kidney function was noticed to be increased from his baseline creatinine of 1.8 to 2.4. He was admitted for pain control and further management of renal calculi/renal insufficiency. CT abdomen was performed on [**2162-11-18**] which showed right ureter 7mm stone with mild to moderate distention. Planned for ESWL vs. Stent placement. However patient became hypoxic and these interventions were delayed. Patient was given IVF and pain controlled. Renal was contulted and thought that worsening renal function was secondary obstruction and ATN in the setting of NSAID use. . Patient was receiving dilaudid for pain control and became somnolent on [**2162-11-18**] and had a syncopal event. Patient was given narcan and ICD evaluated without event appreciated. On [**11-19**] patient became increasingly hypoxic and required transfer to the ICU for BiPAP intermittently. Also started on lasix gtt with good response. EKG without evidence of ischemia. CXR with cardiomegaly and vascular engorgement concerning for CHF exacerbation. CAT scan of chest on [**2162-11-19**] revealed diffuse patchy airspace aopacities of nonspecific etiology. . Pt also with low grade temperaures 99-100 WBC count up to [**Numeric Identifier 7923**]. Patient started on ceftriaxone given concern for infection. Urine cultures were no growth. Transferred to [**Hospital1 18**] ICU for further evaluation of hypoxia, intervention for renal calculi. Vitals prior to transfer: Temp 98.6, 72, 19, 122/54, 93% on 6 liters. . In the intensive care unit, patient continues to note mild right lower quadrant pain and nausea. Past Medical History: -- Diabetes mellitus -- High cholesterol -- Transient ischemic attack a year ago -- Left prosthetic eye. -- Cardiac history includes coronary artery disease status post coronary artery bypass [**2147**] sp pacemaker placement. Social History: He lives with is wife of 52 and children. He smokes eighty packs per year, but stopped in [**2148**]. Retired. Family History: Non-Contributory Physical Exam: Admission: VS: Temp: 97.8 BP:150/58 HR:70 RR: 25 O2sat 100 GEN: Labored breathing, speaks in full sentences HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules RESP: Bilateral wheezes, no rales, diminished BS right base CV: RR, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e SKIN: no rashes/no jaundice/no splinters NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. No pass-pointing on finger to nose. 2+DTR's-patellar and biceps . On Discharge: GEN: Alert, oriented, speaking in full sentences HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules RESP: CTA-B CV: RR, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: improved left upper extremity edema SKIN: no rashes/no jaundice/no splinters, black eschar on left big toe NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. No pass-pointing on finger to nose. 2+DTR's-patellar and biceps Pertinent Results: Labs: [**2162-11-21**] 04:29PM BLOOD WBC-9.8 RBC-3.22* Hgb-9.8*# Hct-29.5* MCV-92 MCH-30.6 MCHC-33.4 RDW-14.0 Plt Ct-166 [**2162-11-21**] 04:29PM BLOOD Neuts-88.1* Lymphs-6.6* Monos-4.3 Eos-0.9 Baso-0.1 [**2162-11-21**] 04:29PM BLOOD PT-14.1* PTT-26.2 INR(PT)-1.2* [**2162-11-21**] 04:29PM BLOOD Glucose-65* UreaN-61* Creat-3.5*# Na-135 K-3.9 Cl-96 HCO3-28 AnGap-15 [**2162-11-21**] 04:29PM BLOOD ALT-27 AST-26 AlkPhos-86 TotBili-0.8 [**2162-11-21**] 04:29PM BLOOD Albumin-3.5 Calcium-8.3* Phos-7.0*# Mg-2.1 [**2162-11-21**] 04:29PM BLOOD Digoxin-1.7 [**2162-11-21**] 06:09PM BLOOD Type-ART Temp-37.6 pO2-123* pCO2-59* pH-7.32* calTCO2-32* Base XS-2 Intubat-NOT INTUBA [**2162-11-21**] 06:09PM BLOOD Lactate-0.6 . Microbiology: Urine/Blood/BAL Cultures: No Growth, final . Studies: . CT Chest Abdomen COMPARISON: Outside hospital CT abdomen [**2162-11-20**]. TECHNIQUE: MDCT helical images were acquired through the chest, abdomen and pelvis without intravenous contrast. IV contrast was deferred given the patient's elevated creatinine of 3.7. Sagittal and coronal reformats were generated and reviewed. FINDINGS: CT OF THE CHEST: An endotracheal tube ends approximately 5 cm above the carina. A left chest wall pacemaker is present with two leads terminating in the right ventricle. The nasogastric tube ends in the body of the stomach. There are multifocal nodular opacities seen in the right and left upper lobes, which may represent an acute infectious process. These are improved since the prior study. Bilateral small pleural effusions are present, with associated compressive atelectasis of both lower lobes, right greater than left. No significant axillary lymphadenopathy is detected. Multiple prominent mediastinal lymph nodes are seen in the right paratracheal region, prevascular and para-aortic region measuring up to a maximum of 12 mm. CT OF THE ABDOMEN WITHOUT INTRAVENOUS CONTRAST: Within the limitations of a non-contrast study, the liver, the gallbladder, the spleen, adrenal glands are unremarkable. There is mild right hydronephrosis, which is not significantly changed since the prior study. A right ureteric stent is in stable position, terminating in the bladder. Assessment of stent patency cannot be performed in this study. The left kidney is stable in appearance, with tiny non-obstructive calculi in the lower pole. The stomach, small and large bowel are unremarkable. There is no intra-abdominal free fluid or air. Multiple small lymph nodes are seen in the retroperitoneum, measuring up to a maximum of 7 mm in short axis, and are not enlarged to CT limits of significant adenopathy. CT OF THE PELVIS WITHOUT INTRAVENOUS CONTRAST: The urinary bladder is empty with a Foley catheter in place. The distal end of right ureteric stent is in the bladder. There is no left hydroureteronephrosis. A rectal tube is in place. The sigmoid colon is unremarkable except for mild diverticulosis, without evidence of acute diverticulitis. No significant pelvic lymphadenopathy or free fluid is detected. OSSEOUS STRUCTURES AND SOFT TISSUES: No bone lesions suspicious for infection or malignancy are detected. Mild multilevel degenerative changes of the thoracolumbar spine are present. The patient is status post CABG with multiple intact sternotomy wires. IMPRESSION: 1. Bilateral moderate pleural effusions, with associated compressive atelectasis of the lung bases. Multifocal nodular opacities in both upper lobes, likely infectious in etiology. These have slightly improved since the earlier CT of [**2162-11-19**]. Multiple prominent mediastinal lymph nodes, likely reactive. 2. Mild right hydronephrosis, stable in appearance since the prior study. A right ureteric double-J stent is in place. Previously seen proximal right ureteric stone is not definitely visualized in the current study. 3. Multiple non-obstructive left renal calculi. 4. Reactive retroperitoneal lymphadenopathy, stable. CXR ([**11-21**]): Developing multifocal pneumonia . Renal US ([**11-22**]): Mild right renal hydronephrosis as was seen on the abdomen CT of [**2162-11-17**]. A non-obstructing stone is seen at the lower pole of the right kidney, and two small non-obstructing stones are seen at the lower pole of the left kidney. No hydronephrosis is seen in the left kidney. . ECHO ([**11-23**]): The left atrium is elongated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed with anteroseptal and septal apical hypokinesis (LVEF= 50-55 %). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is a mild resting left ventricular outflow tract obstruction. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. 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. The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the report of the prior study (images unavailable for review) of [**2155-1-9**], regional wall motion abnormalities are somewhat similar but overall left ventricular systolic function has improved Brief Hospital Course: 70 yo male with three vessel CABG ([**2147**] following anterior wall MI and cardiac arrest) and ICD implantation, CHF (EF: 25% sp MI, 50% on [**11-23**]), DM, CRI, uric acid stones. Who was found to have right ua stone. During OSH course became volume overloaded requiring lasix gtt and bipap. . 1. Hypoxia: Initially at OSH thought to be CHF given occurance in the setting of IVF for nephrolithiasis. Known CHF with EF 40% at OSH. On admission to [**Hospital1 18**], pt appeared to have pneumonia on CT that had presumably developed in the hospital setting, so he was started on vanc, ceftriaxone and azithro; this regimen was changed to vancomycin and zosyn on [**11-21**], with a plan for an 8 day course as no organisms were ever cultured from sputum, mini BAL sample, blood. Pt was initially managed on non-invasive ventilation, but on [**11-22**] the pt was intubated due to worsening hypoxia, and paradoxical breathing. Patient received TTE on [**11-23**] with 50-55% EF. Pt was extubated on [**11-28**] in the afternoon and tolerated 40% face tent with oxygen saturations in the low 90%. Regarding vascular congestion, patient initially actively diuresised with Lasix; on the floor patient allowed to autodiuresis with good UOP. On the floor supplemental oxygen weaned with improved respiratory status. At time of discharge patient saturating >98% on 2L. . 2. Acute on Chronic Renal Insufficiency: Patient creatinine trended up from a baseline of 1.8 to 3.4 at the outside hospital. Renal consult at the OSH felt this change was likely secondary to both obstruction with renal calculi and ATN. After transfer to [**Hospital1 18**] stent was placed in the right ureter with continued worsening of creatine. [**Hospital1 18**] nephrology examined the patient's urine sediment and found muddy brown casts confirming the diagnosis of ATN. Initially the patient was diuresed with IV lasix and diuril before urine output increased in the setting of post ATN diuresis. On the floor creatinine continued to improve, was 1.5 on discharge. Diovan was held during admission. Should be restarted as an outpatient. . 3. Uric Acid Renal Calculi: Patient with history of uric acid stones and CT scan at outside hosptial with mild/moderate hydronephrosis on the right. At [**Hospital1 18**] urology placed ureteral stent. Urine culture without evidence of infection. Will plan to follow-up with [**Hospital1 **] Urology in coming weeks for stent exchange and likely lithetripsy. . 4.Normocytic Anemia: Slow drop in HCT at OSH. Hematocrit stable at [**Hospital1 18**]. Stools Guaiac negative. Pt does continued to have evidence of hematuria throughout stay. Will need to be monitored as outpatient. did get one unit of PRBCs while here with appropriate hct bump. Hct stable around 30 on discharge for several days. . 5. Diabetes Mellitus: Patient with episodes of hypoglycemia at OSH on home lantus 80 units QHS and HISS. At [**Hospital1 18**] lantus was decreased to 40 units daily. On [**11-26**] patient reguired insulin gtt for blood sugars in 400s. Finally patient was transitioned back to lantus 80 units daily. On the floor lantus held in setting of hypoglycemia. Changed lantus back to 40u qHS prior to discharge because of morning lows. Will need to follow-up with PCP. [**Name10 (NameIs) **] adjust at rehab as needed. . 6. CAD/Congestive Heart Failure: [**Company 1543**] GEM III VR in place. Toprol XL changed to Metoprolol Tartrate 12.5 TID while in ICU. Diovan and digoxin held given change in renal function. Can be started as outpatient. Metoprolol titrated to 25 mg [**Hospital1 **] on discharge. . 7. Deconditioning: patient will need extensive PT for ICU deconditioning and will need some pulmonary rehabilitation post intubation and pneumonia. Medications on Admission: Medications at home: -- Diovan 40-mg/day -- Toprol 37.5-mg/day -- Digoxin 0.125-mg/day -- Aspirin 81-mg [**Hospital1 **] -- Fish oil daily -- Celexa 40-mg/day -- Lantus 80 units/day -- NovoLog sliding scale -- Tylenol #3. . Meds on transfer: -- Norvasc 10 mg PO Daily -- ASA 81mg Daily -- Ceftriaxone 1 Gram IV Daily -- Vitamin D 1000 Units PO Daily -- Celexa 40mg Daily -- Lanoxin 0.25mg Every other Day -- Pepcid 20mg QHS -- Lantus 80 units in the evenings -- Metoprolol XL 50mg PO Daily -- Flomax 24mg PO QHS -- Dilaudid 0.5mg IV every 3 hours PRN pain -- Zofran 4mg Every 6 hours as needed for nausea -- Novolog sliding scale -- Flovent 110 mcg 2 puffs inhaled twice daily -- Duonebs 3 mlg every 4 hours PRN shortness of breath -- Lasix gtt Discharge Medications: 1. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for fungal rash. 4. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**3-16**] Puffs Inhalation Q6H (every 6 hours) as needed for wheezes. 5. Lantus 100 unit/mL Solution Sig: Forty (40) u Subcutaneous at bedtime. 6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. heparin Sig: 5000 (5000) units Subcutaneous three times a day. 8. Humalog 100 unit/mL Solution Sig: ASDIR by sliding scale units Subcutaneous four times a day: see attached sliding scale. 9. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation every six (6) hours as needed for shortness of breath or wheezing: can use if inhaler is not working. 10. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia: only if needed; has used prior to admission. Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: Primary: Kidney stones Pneumonia Congestive Heart Failure . Secondary Hypertension Discharge Condition: Mental status: clear and coherent Ambulates with assistance Discharge Instructions: Dr. [**Last Name (STitle) **] [**Known lastname **] it was a pleasure taking care of you. You were admitted to [**Hospital1 18**] for continued management of your kidney stone, kidney failure as well as difficulty breathing. . You initially presented to the outside hospital for persistent abdominal pain secondary to kidney stones. These stones were thought responsible for decreased kidney function. While at [**Hospital1 **], the urology team saw you and placed a stent to relief your obstruction. You will need to follow-up with the urologists in 2 weeks for evaluation and further treatment of your stones. . Regarding your breathing difficulties, it was thought secondary to a pneumonia as well as excess fluid in your lungs. Your pneumonia was treated with antibiotics and resolved prior to discharge. You were actively diuresised to faciliate removal of excess water. At time of discharge your breathing had markedly improved. . Regarding your ICD, the battery was scheduled to be changed on [**11-26**] however due it was decided to postpone placement until you were stronger. You will need to follow-up with your cardiologist as an outpatient. . CHANGES TO YOUR MEDICATIONS: - HOLD your DIOVAN and DIGOXIN until you see your PCP. [**Name Initial (NameIs) **] DECREASE your LANTUS qhs to 40units, continue humalog sliding scale To treat your shortness of breath: - CONTINUE using inhalers and/or nebulizers as needed in next 1-2 weeks to aid in breathing. - CONTINUE FLUTICASONE one puff twice daily Followup Instructions: Please follow-up with Urology in [**1-13**] weeks for stent removal. Department: Urology Name: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9125**] When: Thursday [**2162-12-23**] at 9:30 AM Location: UROLOGY PRACTICE ASSOCIATES (Inside [**Location (un) 1036**]) Address: [**Street Address(2) 18723**], [**Location (un) **],[**Numeric Identifier 18724**] Phone: [**Telephone/Fax (1) 18725**] Notes: Please bring all your medical cards to this appointment. . Please follow up with cardiology for battery replacement after your rehabilitation stay Completed by:[**2162-12-3**]

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icd9cm

[ [ [] ] ]

[ "56.0", "38.97", "38.91", "87.74", "59.8", "33.29", "57.32", "96.72" ]

icd9pcs

[ [ [] ] ]

15676, 15748

10014, 13779

408, 477

15875, 15875

4537, 9991

17494, 18092

3225, 3243

14574, 15653

15769, 15854

13805, 13805

15961, 17117

13826, 14029

3258, 3907

3921, 4518

17146, 17471

265, 370

505, 2829

15890, 15937

2851, 3079

3095, 3209

14047, 14551

51,895

161,110

35486

Discharge summary

report

Admission Date: [**2183-8-16**] Discharge Date: [**2183-8-19**] Date of Birth: [**2149-7-3**] Sex: F Service: MEDICINE Allergies: azithromycin Attending:[**First Name3 (LF) 1990**] Chief Complaint: shortness of breath and dysphagia Major Surgical or Invasive Procedure: none History of Present Illness: 34 Yo female w/ no PMH now presenting with DYSPHAGIA. Sore throat began 3 days ago, and worsened with severe pain, unable to tolerate any po, and increasing difficulty breathing especially in the past day. Presented to PCP 2 days ago, given amoxicillin without effect, rapid strep and mono were negative. Patient presented to OSH, was seen by ENT and deemed to have supraglottitis with mild edema, given morphine, decadron, and ceftriaxone, and transferred to our facility in case she needed an airway. Has not been able to eat/drink for the last 2 days, but denies fever, chills, nausea, vomiting, diarrhea, constipation, headache, abdominal pain, chest pain. All of childhood vaccinations are up to date. No respiratory exposures. Denies any recent oral sex. Only allergy to azithromycin. . In the ED her vital signs: T 96.6; HR 97; BP 133/63; RR 16; O2 97%. Labs Leukocytosis 18.4 w/ 92% PMN, otherwise unremarkable. ENT was consulted and supraglottic swelling per direct visualization, recommended unasyn, humidified air, decadron 10mg q8 x3 doses; (one dose already given at OSH, 2nd dose given in ED). CT scan: inflammatory process involving the supraglottic larynx and epiglottis with mucosal edema resulting in airway compromise. no fluid collection or abscess. She was transferred to ICU for monitoring of airway closure. NO recent travel history - . On arrival to the MICU, patient's VS: afebrile HR:94 BP: 116/69 RR:25 100% RA Past Medical History: s/p tonsillectomy as child disk herniation Social History: Former military, currently works as consultant for VA. Denies smoking, drinking, illicit drug use. Family History: grandmother with [**Name2 (NI) 500**] cancer, unknown type. Physical Exam: Admission Exam: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding GU: no foley 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. Pertinent Results: Admission Labs: [**2183-8-16**] 04:08AM BLOOD WBC-18.4* RBC-4.15* Hgb-11.6* Hct-36.1 MCV-87 MCH-27.9 MCHC-32.1 RDW-13.1 Plt Ct-338 [**2183-8-16**] 04:08AM BLOOD Neuts-92.3* Lymphs-7.0* Monos-0.5* Eos-0 Baso-0.1 [**2183-8-16**] 04:08AM BLOOD PT-12.6* PTT-26.6 INR(PT)-1.2* [**2183-8-16**] 04:08AM BLOOD Glucose-138* UreaN-10 Creat-0.7 Na-139 K-4.3 Cl-105 HCO3-25 AnGap-13 [**2183-8-16**] 04:18AM BLOOD Lactate-1.1 OSH CT neck: (per read) inflammatory process involving the supraglottic larynx and epiglottis with mucosal edema resulting in airway compromise. no fluid collection or abscess Brief Hospital Course: 34 year old previously healthy female who presented to OSH with 3 days throat pain and dysphagia, found to have supra-epiglotitis, transferred d/t concern for worsening air-way obstruction. Active issues: # supraglottic swelling/inflammation: pt. improved with antibiotics and steroids (both IV). ENT was involved in her care and directly visualized the involved supraglottic structures and made recommendations throughout her stay. Ultimately, the steroid was stopped, and pt. transitioned to oral abx and discharged to home with instructions to follow up with ENT and her primary MD. Medications on Admission: None. Discharge Medications: 1. Amoxicillin-Clavulanic Acid 875 mg PO Q12H Duration: 7 Days RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet by mouth twice a day Disp #*14 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: supraglotitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to [**Hospital1 18**] with complaints of difficulty swallowing and throat pain. You were found to have a severe throat infection. To treat this you were place in steriods and antibiotics. You eventually improved and were able to tolerate food and pills by mouth. You will be sent home on antibiotics (see prescription). . Medication changes: Followup Instructions: Please follow up with: 1) PCP 2) ENT - call for appt. within the next 7-10 days: [**Telephone/Fax (1) 41**].

[ "464.50", "V45.86", "278.00", "478.6" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

4164, 4170

3326, 3517

306, 312

4227, 4227

2711, 2711

4766, 4878

1985, 2047

3972, 4141

4191, 4206

3942, 3949

4377, 4721

2062, 2692

4743, 4743

233, 268

3532, 3916

340, 1785

2727, 3303

4242, 4353

1807, 1852

1868, 1969

29,829

143,568

1585

Discharge summary

report

Admission Date: [**2145-4-22**] Discharge Date: [**2145-5-25**] Service: MEDICINE Allergies: Apple / Lisinopril Attending:[**First Name3 (LF) 3984**] Chief Complaint: bilateral SDH Major Surgical or Invasive Procedure: s/p bilateral burr holes for SDH evacuation History of Present Illness: 85yo RHM on coumadin for A-fib, sustained fall on [**2-/2066**] where he hit his head. He was taken to [**Location (un) **] ED where head CT revealed bilat cystic hygromas. He was scheduled for an MRI which was performed two weeks ago and referred to Neurologist (Dr. [**Last Name (STitle) **]/?[**Hospital3 68**]) who is scheduled to see him this Friday. However, Pt fell again ~[**4-11**] and hit the side of his head and has had increasingly hesitant speech and some difficulty ambulating, therefore was referred for an outpatient NCHCT this afternoon. Pt was called back to the ED once the films were read and subsequently transferred to [**Hospital1 18**] for further eval. Past Medical History: -atrial fib, on coumadin. -HTN -mild CHF, stress test negative -diabetes; diet controlled -tremor since childhood Social History: Previously worked for [**Company 2318**] ([**Location (un) **] Line). 1 drink per day. Neg tob. Lives independently. Family History: non-contributory Physical Exam: (on transfer to medicine) . VS: Tmax 101.4 Tc 99.8 BP 124/80 HR 110 (100-114) RR 26 02 100% 2L Gen: NAD. Sleeping, difficult to arouse, awakens to somnolent, answers few questions, then HEENT: Bilateral surgical scars, with scab, mild edema Sclera anicteric. PERRL, Dry MM Neck: JVP appro 10-12 cm CV: irreg irreg, tachycardic, No m/r/g. Chest: Resp were unlabored, no accessory muscle use. not cooperative with exam, Right sided crackles Abd: Mildly distended, non-tender Ext: No c/c. Right knee with bruise, very trace edema r>L Skin: No stasis dermatitis, ulcers, scars. Pertinent Results: CBC: [**2145-4-21**] WBC-8.0 RBC-3.93* Hgb-12.6* Hct-36.2* MCV-92 MCH-32.1* MCHC-34.9 RDW-12.9 Plt Ct-291 Neuts-80.4* Lymphs-13.2* Monos-4.5 Eos-1.9 Baso-0.2 . CHEM: [**2145-4-21**] Glucose-99 UreaN-30* Creat-1.4* Na-140 K-3.6 Cl-99 HCO3-28 AnGap-17 . LFTs: [**2145-4-22**] ALT-10 AST-17 LD(LDH)-174 CK(CPK)-55 AlkPhos-56 TotBili-0.6 . COAGS: [**2145-4-21**] PT-24.5* PTT-31.6 INR(PT)-2.4* [**2145-4-22**] PT-14.1* INR(PT)-1.2* [**2145-4-24**] PT-13.4 PTT-31.3 INR(PT)-1.1 . CE:s [**2145-4-21**] 10:25PM BLOOD cTropnT-<0.01 [**2145-4-22**] 06:52AM BLOOD cTropnT-<0.01 [**2145-4-23**] CK-MB-NotDone cTropnT-0.02* . URINE: [**2145-4-24**] Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.012 Blood-LGE Nitrite-NEG Protein-TR Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG . [**4-24**] BCx: NGTD x 2 [**4-24**] Urine: no growth . [**4-21**] CT HEAD IMPRESSION: 1. Acute on chronic bilateral subdural hematomas, no priors available for comparison to assess for change. Considerable mass effect with evidence of early downward transtentorial herniation. . CT C-SPINE IMPRESSION: 1. No fracture or malalignment. Degenerative chages described above. 2. Calcified right thyroid nodule. Recommend clinical correlation. . [**4-23**] CT HEAD IMPRESSION: Status post evacuation of bilateral subdural hematomas which are now slightly smaller in size. No new areas of hemorrhage identified. Slight improvement in effacement of the suprasellar cistern. Slight shift of the septum pellucidum to the left and partial effacement of the left lateral ventricle unchanged. . [**4-24**] CXR Increasing left basilar opacification is present adjacent to a markedly elevated left hemidiaphragm. This may be related to worsening atelectasis or an area of developing pneumonia. Asymmetric density at left costophrenic junction is probably due to degenerative changes accentuated by patient rotation, but attention to this area on a repeat non-rotated radiograph would be helpful. Cardiomediastinal contours appear stable allowing for rotation. Right lung remains clear. Questionable small left pleural effusion is noted. . [**4-25**] CT HEAD IMPRESSION: Slight increase in size of the left-sided subdural hematoma, and stable appearance of the right-sided subdural hematoma, both of which appear heterogeneous. Decrease in the amount of pneumocephalus compared to the most recent prior study. More effacement involving the suprasellar cistern compared to the [**4-23**] study, although relatively stable compared to the [**4-22**] study. . CHEST (PA & LAT) FINDINGS: In comparison with the study of [**4-24**], there is again a striking elevation of the left hemidiaphragmatic contour with some atelectatic changes above this. The remainder of the lungs is essentially clear. Little change in the appearance of the cardiomediastinal silhouette. IMPRESSION: Little change. Brief Hospital Course: The patient was admitted to the neurosurgery service with bilateral SDHs on [**2145-4-22**]. He had been on coumadin for A-Fib prior to being admitted. The coumadin was stopped and he was given FFP and vitamin K to reverse his INR. He went to the OR for bilateral burr holes on [**2145-4-23**]. The surgery went well with no complications. A cardiology consult was obtained prior to taking the patient to surgery. He was deemed a low-moderate risk for surgery. They recommended holding his lasix for 2 days. It was restarted on [**2145-4-25**]. The patient also had negative cardiac enzymes. . On [**2145-4-24**] the patient was febrile and a CXR revealed pneumonia. The patient may have aspirated while eating. He was started on cipro and flagyl. Neurologically the patient was stable. He had a repeat head CT on [**2145-4-25**] which was stable with no new hemmorhage. Medicine was consulted for help managing the pneumonia and CHF. The patient was ultimately transferred to the medical service later that day. . While on the medicine service the patient was continued on a 10 day course of cipro/flagyl and remained afebrile throughout. Urine and blood cultures were negative. He was kept NPO and on aspiration precautions while his mental status improved. During this time of understandable poor po intake his sodium rose to 150 and he was treated with D5W. Lasix was held. His electrolytes abnormalities were aggressively corrected and his mental status improved. On [**4-28**] speech and swallow evaluated the patient and deemed him safe to eat a pureed diet. On [**4-29**] he was eating well with acceptable po intake. Electrolytes were much improved and lasix was restarted in [**Hospital1 **] dosing instead of his previous daily dosing due to the diuretic braking effect experienced with daily lasix dosing. . His atrial fibrillation was difficult to control and required progressive increase of his beta blocker. His blood pressure tolerated this uptitration well. He remained off of warfarin for 7 days per post-op neurosurgical protocol. Warfarin was restarted on [**2145-4-30**] at his previous dose of 2.5 mg qPM. . His foley catheter was d/c'ed on [**4-27**] and the patient voided without problem (although he was incontinent) until [**4-29**], when he was noted not have voided during the overnight shift. He was bladder scanned which reveal 1 liter of retained urine. He was straight cathed with good effect and was subsequently able to urinate. On [**2145-4-30**] he developed abdominal pain, a foley catheter was inserted with >1.5 L. He will be discharged with a foley catheter. . On [**4-29**] he developed diarrhea and a new WBC count. A C Diff assay was sent and was negative x3. He has abdominal pain on [**5-1**]. KUB was consistent with ileus, and once foley was inserted and >1.5L removed, patient had 5 sponteneous bowel movements, formed. Abdominal pain improved. KUB also improved. . During his stay on the medicine service he received DVT ppx with sQ heparin and havd GI ppx with a bowel regimen and a crushable PPI. He developed a-fib with RVR, hypotension and hct drop and was transferred to the MICU, Rate control with nodal blockade had been difficult given hypotension. CHADS2 score is 4 (CHF, HTN, Age, DM), suggesting a high risk of thromboembolic disease and pt had been anti-coagulated as outpt. This had been discontinued d/t subdural hematomas. Pt had been started on heparin gtt, with plan for possible cardioversion in several weeks. However, a hematocrit drop occurred which was concerning and warfarin was dicontinued. He was evaluated by EP who recommended treatment of his underlying medical conditions as well as rate control with metoprolol and digoxin. Also-he is not an anticoagulation candidate. His rate was well controlled on metoprolol and digoxin. . Urinary Retention/Hematuria: Patient has known BPH and is on doxazosin. Developed retention d/t likely clot while in the ICU. His Doxazosin was held as could be contributing to hypotension. His hematocrit was due to a bladder wall hematoma secondary to foley trauma. It cleared with CBI and he has had no further clots. He developed Fevers/leukocystosis that was felt to be likely GU in origin given multiple instrumentation. However, increased cough/secreations raised the possiblity of aspiration when pulled dobhoff out himself, Vanc/zosyn was started empirically and continued for a total course of 14 days. He will continue to take these abx one week after discharge. . C.diff: presumed but 3 negatives here, toxin B pending. will complete 14 days PO vanc. stays on precaution until tox B back. . His mental status continued to wax and wane, delta MS-felt to be likely toxic-metabolic in setting of fever and infection with aspects of ICU deleriuma and lack of sleep. Nonfocal neuro exam, though evolving sdh was considered Head CT-area of hyperdensity in frontal area, does not explain change in mental status. Digoxin level was normal and pt remained stable. . Medications on Admission: doxazosin 1mg qam, 2mg qpm diovan [**11-20**] qam amiodarone 200mg qam ([**Last Name (LF) **], [**First Name3 (LF) **], t, th); 100mg qam MWF omeprazole 20mg qd Kcl 20mg qd coumadin 2.5mg qpm lasix 40mg qd centrum silver qd tylenol 650 tid tums 2 tabs [**Hospital1 **] fibercon Discharge Medications: 1. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2 times a day) as needed for constipation. 2. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily) as needed for constipation. 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 4. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 5. Calcium Carbonate 500 mg Tablet, Chewable [**Hospital1 **]: Two (2) Tablet, Chewable PO BID (2 times a day). 6. Hexavitamin Tablet [**Hospital1 **]: One (1) Cap PO DAILY (Daily). 7. K-Dur 20 mEq Tab Sust.Rel. Particle/Crystal [**Hospital1 **]: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. 8. Zosyn 4.5 gram Recon Soln [**Hospital1 **]: 4.5 Intravenous every eight (8) hours for 7 days. 9. Vancomycin 1,000 mg Recon Soln [**Hospital1 **]: One (1) gram Intravenous every twelve (12) hours for 7 days. 10. Insulin Regular Human 100 unit/mL Cartridge [**Hospital1 **]: as directed by sliding scale Injection qachs. 11. Calcium Carbonate 500 mg Tablet, Chewable [**Hospital1 **]: Two (2) Tablet, Chewable PO BID (2 times a day). 12. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 13. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: 1.5 Tablets PO QID (4 times a day). 14. Digoxin 250 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 15. Furosemide 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 16. Lidocaine HCl 2 % Gel [**Last Name (STitle) **]: One (1) Appl Mucous membrane PRN (as needed). 17. Acetaminophen 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H (every 6 hours) as needed. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Primary: bilateral subdural hematomas aspiration pneumonia bladder wall hematoma atrial fibrillation with rapid ventricular response . Secondary: # atrial fib rate controlled # HTN # mild [**Last Name (LF) 9215**], [**First Name3 (LF) **] 50-55% # diabetes; "diet controlled" now on insulin # tremor since childhood Discharge Condition: stable, improved Discharge Instructions: You were admitted to the hospital after a fall and changes in your mental status and ability to walk. You were found to have significant bleeds around both sides of your brain. Our neurosurgeons performed a surgery to treat this problem. [**Name (NI) **] in the hospital you developed a pneumonia for which you were treated with antibiotics. You will be going to rehab to work on regaining your strength and walking ability. . The following changes have been made to your medication regimen: 1) You will no longer be taking your warfarin 2) We have discontinued your amiodarone 3) We have changed your metoprolol to 37.5mg qid 4) We have modified yout lasix dosing to 40mg once daily . Please take all medicines as prescribed. Please keep all followup appointments. If you experience any worsening confusion, weakness, or other symptoms that concern you, please call your doctor or go to the ED. Followup Instructions: Primary Care: Please make an appointment to see your PCP: [**Name10 (NameIs) 9216**],[**Name11 (NameIs) 9217**] [**Name Initial (NameIs) **] [**Telephone/Fax (1) 9218**] in the next 2-3 weeks. . Cardiology: Please make a followup appointment with your cardiologist Dr. [**Last Name (STitle) 5217**] in the next 2-3 weeks, [**Telephone/Fax (1) 9219**]. . Neurosurgery: [**Name6 (MD) **] [**Last Name (NamePattern4) 9151**], MD Phone:[**Telephone/Fax (1) 1669**] [**6-15**], 2:30pm CAT SCAN Phone:[**Telephone/Fax (1) 327**] [**6-9**] at 10:00am, [**Hospital Unit Name **] [**Location (un) 470**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**] Completed by:[**2145-5-31**]

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icd9cm

[ [ [] ] ]

[ "99.04", "01.31", "99.07", "81.91", "96.07", "38.91", "38.93" ]

icd9pcs

[ [ [] ] ]

12003, 12082

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240, 285

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313, 998

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23,197

121,009

3649

Discharge summary

report

Admission Date: [**2150-2-4**] Discharge Date: [**2150-2-7**] Date of Birth: [**2090-5-16**] Sex: F Service: [**Company 191**] HISTORY OF PRESENT ILLNESS: (Per admitting intern, Dr. [**Last Name (STitle) **]. Mrs. [**Known lastname 5936**] is a 59-year-old woman with a history of diabetes mellitus type 1, CAD, hypertension, and history of syncope, who presented on [**2150-2-4**] with bradycardia and hypotension status post brief syncopal episode. The patient was in her usual state of health until the morning of [**2150-2-4**] when she returned from a shopping trip and subsequently developed weakness, dizziness, decreased visual focus; she felt faint and then lost consciousness. The patient's husband was present and caught her, so she sustained no trauma to her head or anywhere else. The patient had taken her Zestril and Nifedipine that morning. The patient's husband called EMS after she syncopized; EMS found the patient to be reportedly hypotensive (systolic blood pressure in the 60's) and bradycardic. In the Emergency Room the patient received three amps of calcium gluconate, D50 with insulin, Narcan, Glucagon and 6 liters of IV fluid without improvement. Thus, the patient was admitted to the [**Hospital Ward Name 332**] ICU where she was given pressor support with Dopamine. PAST MEDICAL HISTORY: 1) Diabetes mellitus type 1 times 30+ years; complicated by neuropathy, retinopathy, and gastroparesis. The patient has been on an insulin pump times 2 years. Her [**Last Name (un) **] attending is Dr. [**Last Name (STitle) 16560**]. 2) Coronary artery disease; status post MI in [**2137**]. Coronary catheterization in [**2138**] revealed clear coronaries. Exercise mibi in [**2148-6-1**] revealed no perfusion defects. Echocardiogram [**2150-2-4**] revealed left ventricular ejection fraction greater than 55%, with 2+ MR and mild LVH. 3) Hiatal hernia, GERD. 4) Status post TAH BSO. 5) History of esophagitis. 6) Bilateral cataracts, status post surgery. 7) History of syncope. 8) Hypertension. 9) Anxiety. 10) Question of medical non compliance. ALLERGIES: No known drug allergies. MEDICATIONS: Valium 10 mg q a.m., Adalat 30 mg q day, Bactroban ointment, Premarin 625 mcg per day, Fluoxetine 40 mg q day, Glucagon prn for low glucose, Humalog via insulin pump, Ibuprofen prn, Lisinopril 20 mg q day, Metoprolol 25 mg [**Hospital1 **], Neurontin 800 mg qid, Ranitidine, NPH 24 units subcu q a.m. and 12 units subcu q p.m. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Patient has approximate 10 pack year history of smoking. She admits drinking approximately three alcoholic beverages per week. There is question of possible excessive alcohol use in the patient's past. She denies history of IV drug use. The patient lives with her husband. PHYSICAL EXAMINATION: On presentation (per admitting intern, Dr. [**Last Name (STitle) **], vitals, temperature 96.1, heart rate 56, blood pressure 60/40, respirations 14, satting 100% on room air. In general, normal appearing, tanned female in no acute distress. HEENT: Surgical pupils, extraocular movements intact. Neck supple, no JVD or thyromegaly. Cardiac, regular rate and rhythm without murmurs, rubs or gallops. Normal S1 and S2. Pulmonary, clear to auscultation bilaterally. Abdomen, nontender, non distended, soft, positive hypoactive bowel sounds. NG lavage negative in the Emergency Room. Extremities, no edema, non palpable pedal pulses, cool extremities. Rectal exam, guaiac negative in the Emergency Room. Neuro exam, alert and awake. LABORATORY DATA: On presentation, CBC revealed white count of 8.4, hematocrit 28.2, platelet count 176,000. Chem 7 revealed sodium 143, potassium 3.4, chloride 113, CO2 19, BUN 33, creatinine 1.4, glucose 93, calcium 6.2, magnesium 1.5, phosphorus 3.1. Coag studies revealed INR 1.1, PT 12.8, PTT 30.2. ABG on admission revealed PH 7.25, PCO2 47 and PO2 90. Lactate level was 2.6. EKG revealed normal sinus rhythm, rate of 60/minute, normal axis and intervals, left ventricular hypertrophy, no significant change from prior study of [**2149-12-17**]. Urine tox screen was positive for Amphetamines, otherwise urine tox screen was negative. Urinalysis revealed 100 protein and 100 glucose; no white blood cells, no bacteria. Urine culture was sent. CT angiogram of the chest was obtained and was negative for pulmonary embolus. Also during the hospitalization, the patient's LFTs were checked. ALT was 49, AST 72, LD 216, alkaline phosphatase 95, total bilirubin 0.3. HOSPITAL COURSE: As noted above, the patient was admitted to the ICU for further evaluation and treatment of her bradycardia and hypotension. She was treated initially with Dopamine pressor support, which was eventually weaned as the patient's blood pressure improved. Additionally, the [**Last Name (un) **] endocrine service was consulted regarding control of the patient's blood sugar. The patient was maintained initially on an insulin drip and then switched to her outpatient insulin pump on [**2150-2-1**]. In terms of other endocrine issues, a TSH level was checked and found to be elevated at 6.7, thus patient was started on Synthroid. There was some suspicion for the possibility of adrenal insufficiency; thus ACTH level was checked and is pending at the time of discharge. However, cortisol level was found to be 18. Thus, this finding reduced the suspicion of adrenal insufficiency. The patient did quite well during her brief stay in the Intensive Care Unit. Her blood pressure medications were discontinued and subsequently her bradycardia and hypotension abated. The exact etiology of the patient's above noted symptoms remains unclear, however, the consensus among those carrying for her was that in all likelihood her difficulties had arisen as a result of her anti-hypertensive medications. No clear cardiac etiology could be sited for the patient's symptoms. She was ruled out for myocardial infarction by serial CKs. Additionally, as noted above, an echocardiogram did not reveal any clear etiologies for her syncope, bradycardia or hypotension. The patient was transferred to the [**Company 191**] service, medical floor, on [**2150-2-6**]. While on the floor her above noted care was continued (patient remained on her insulin pump and was kept off of her antihypertensive medications). The patient as noted to have grown enterococcus species in her urine (greater than 100,000 organisms per ml.). Thus, the patient was started on Levofloxacin to treat a urinary tract infection. The patient remained afebrile, with vital signs stable and excellent control of her fingerstick blood sugar levels during her time on the medicine floor. CONDITION ON DISCHARGE: Vital signs stable, afebrile, anxious to be discharged home. Good glucose control. DISCHARGE DIAGNOSIS: 1. Syncope of unclear etiology, accompanied by hypotension and bradycardia. 2. Diabetes mellitus type 1, on insulin pump. 3. Coronary artery disease. 4. Hiatal hernia/GERD. 5. Hypertension. 6. Anxiety. DISCHARGE MEDICATIONS: The patient was discharged home on her above noted outpatient medication regimen, with the following exceptions: The patient was specifically instructed to quit taking her anti-hypertensive medications for the time being; she is to continue taking Aspirin, however. The patient was given a prescription for Levofloxacin 500 mg po q day, to treat the above noted UTI. The patient was also given a prescription for a blood pressure cuff monitor, so that she may monitor her blood pressure at home; she is to keep a log of these results and follow-up with her primary care physician regarding her findings. Also, patient should be maintained on Synthroid 50 mcg q day. FOLLOW-UP: The patient is to follow-up with her primary care physician in the next week. [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 4200**], M.D. [**MD Number(1) 4201**] Dictated By:[**Last Name (NamePattern1) 1550**] MEDQUIST36 D: [**2150-2-7**] 13:38 T: [**2150-2-7**] 18:17 JOB#: [**Job Number 16561**]

[ "780.2", "414.01", "357.2", "412", "285.9", "458.9", "250.61", "599.0", "427.89" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7100, 8141

6867, 7076

4577, 6736

2842, 4559

173, 1322

1345, 2526

2543, 2819

6761, 6846

31,977

132,534

47361

Discharge summary

report

Admission Date: [**2180-1-25**] Discharge Date: [**2180-1-30**] Date of Birth: [**2128-8-29**] Sex: F Service: CARDIOTHORACIC Allergies: Latex Attending:[**First Name3 (LF) 922**] Chief Complaint: cad Major Surgical or Invasive Procedure: CABG x 4 History of Present Illness: pt with known CAD. Here for CABG Past Medical History: DM2 "Mild" COPD OA of the right hip Social History: Pt is a nurse at a nursing home. Smokes [**12-15**] ppd x 24 years. No EtOH. No drugs. Married with 6 children Family History: PGM: died at 50 of MI, DM2. M: HTN, DM2. B: HTN. . Physical Exam: a/o nad grosslt intact cta rrr obese distal pulses Pertinent Results: [**2180-1-29**] 06:28AM BLOOD WBC-11.1* RBC-3.77* Hgb-10.1* Hct-32.0* MCV-85 MCH-26.9* MCHC-31.6 RDW-13.4 Plt Ct-122* [**2180-1-29**] 06:28AM BLOOD Plt Ct-122* [**2180-1-29**] 06:28AM BLOOD Glucose-139* UreaN-13 Creat-0.6 Na-135 K-4.4 Cl-104 HCO3-22 AnGap-13 [**2180-1-28**] 04:45AM BLOOD Calcium-7.6* Phos-2.8 Mg-2.1 [**2180-1-27**] 02:04AM BLOOD Glucose-129* Lactate-2.1* Na-133* K-4.6 Cl-106 [**2180-1-28**] 12:17 PM CHEST (PORTABLE AP) SINGLE VIEW, CHEST: There has been interval removal of the left chest tube without evidence of pneumothorax. Right PICC line is seen to extend deep into the right atrium. Withdrawal by approximately 6-8 cm is recommended. The right upper lobe opacification appears unchanged. There may be small bilateral pleural effusions, unchanged. Mild volume overload also appears unchanged. IMPRESSION: Interval removal of left chest tube without pneumothorax. Right basilic PICC extending into the right atrium. Withdrawal by 6-8 cm is recommended. Unchanged right upper lobe opacification Brief Hospital Course: pt admitted / [**Hospital 100246**] hospital course CABG x 4, no complications. Transfered to the CVICU. weaned pressure support / extubated CT out day # 1 xray no pnuemo transfered to the floor Foley out day 2 / pt ambulation PW out day 3 cleared for home dc day 4 pt BB/diuresed Medications on Admission: ASA 325', Byetta 5', humalog SS, imdur 120', lantus 8 hs, norvasc 2.5', synthroid 50', toprol xl 25', vicodin prn, ntg Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 2. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. Disp:*30 Suppository(s)* Refills:*0* 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 6. 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* 7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 7 days. Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 11. insulin Sliding Scale & Fixed Dose Fingerstick QACHS Insulin SC Fixed Dose Orders Bedtime Glargine 60 Units Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Humalog Glucose Insulin Dose 0-60 mg/dL 4 oz. Juice 4 oz. 61-109 mg/dL 0 Units 0 Units 0 Units 0 Units 110-140 mg/dL 15 Units 15 Units 15 Units 0 Units 141-199 mg/dL 18 Units 20 Units 18 Units 0 Units 200-239 mg/dL 21 Units 23 Units 21 Units 10 Units 240-280 mg/dL 24 Units 26 Units 24 Units 12 Units > 280 mg/dL Notify M.D. 12. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: CAD Discharge Condition: good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 1504**]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 1 month. 7) Call with any questions or concerns. Followup Instructions: Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 177**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 170**] Follow-up appointment should be in 1 month Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Telephone/Fax (1) 14328**] Follow-up appointment should be in 2 weeks Completed by:[**2180-1-30**]

[ "496", "250.02", "414.01", "411.1", "458.29", "412", "305.1", "244.9" ]

icd9cm

[ [ [] ] ]

[ "36.13", "38.93", "36.15", "39.61" ]

icd9pcs

[ [ [] ] ]

4175, 4230

1750, 2043

275, 286

4278, 4285

692, 1727

4999, 5324

553, 606

2212, 4152

4251, 4257

2069, 2189

4309, 4976

621, 673

232, 237

314, 348

370, 408

424, 537

32,505

198,103

33192

Discharge summary

report

Admission Date: [**2154-9-23**] Discharge Date: [**2154-9-28**] Date of Birth: [**2071-11-11**] Sex: F Service: CARDIOTHORACIC Allergies: Codeine Attending:[**First Name3 (LF) 165**] Chief Complaint: Chest Pressure Major Surgical or Invasive Procedure: [**2154-9-27**] - Coronary artery bypass graft x 2 - saphenous vein grafts to left anterior descending artery and obtuse marginal artery. Intra-aortic balloon pump insertion in the right femoral artery. History of Present Illness: Pt is a 82y/o F with PMH of CAD s/p two MIs in [**2125**], cardiac cath in [**1-/2154**], and stroke presenting with L-sided chest and axillary tightness, diaphoresis and right leg cramping for 1.5 hours. Chest tightness was non-radiating, located mid-sternal and left axillary. No nausea. + h/o similar L axillary tightness and right leg cramping in the past. Symptoms, including the right leg cramping, relieved with 1 sl ntg from EMS. . Pt has history of presentation to ED in [**2-5**] with acute onset jaw and ear pain and was found to have LBBB with minor ant. ST elevations and was taken emergently to the cath lab. At this time cath showed moderate disease in the distal left main and mid RCA with mild disease in the LAD and LCX. The left main had a discrete 40% distal stenosis and the RCA had a diffuse 30% mid stenosis. No interventions. . In the ED, initial vitals were T:98.1 HR: 65 BP: 164/40 RR: 20 O2Sat: 98%. 1st set of CE negative. CXR demonstrated mild pulmonary edema. D-dimer elevated at 1277 so CTA was performed which showed no PE, dissection or PNA. Patient received aspirin and was admitted for further evaluation and management. . Pt denies any complaints this AM. No chest pain/pressure/tightness. Denies jaw pain. States that she feels quite healthy overall. . On cardiac review of systems pt states that she never sleeps flat, always sleeps on her side with two pillows thus cannot tell whether she has orthopnea. Denies PND, palpitations, syncope or presyncope. Past Medical History: # CAD - hx of MI x 2 (Shore [**Hospital 107**] Hospital in NJ), Cardiac cath in [**1-/2154**] (moderate disease in the distal left main and mid RCA with mild disease in the LAD and LCX. The left main had a discrete 40% distal stenosis and the RCA had a diffuse 30% mid stenosis. No interventions.) # Stroke in [**2125**] or [**2126**], pt denies any residual deficits. # COPD # Hypertension # Hyperlipidemia # Hx of breast cancer s/p resection > 40 years ago Social History: Pt lives in [**Hospital3 **] and gets help with medications. She has past smoking hx 15 year ago (smoked for 50 years - 1ppd), past EtOH use with up to 4-5 drinks on a weekend. Family History: Family history of premature coronary disease in her sister <60 yo Breast cancer in sister, mother, grandmother. Physical Exam: VS - 156/58 67 16 100% on 2.5L (now breathing comfortably on RA) Gen: WDWN female in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with no apparent JVD. CV: PMI located in 5th intercostal space, midclavicular line. Regular rate, infrequent ectopic beats. Normal S1, S2. No m/r/g. No thrills, lifts. Chest: Increased AP diameter. Resp is unlabored. Mild crackles in bilateral bases. Abd: Soft, NTND. No HSM or tenderness. Normoactive bowel sounds Ext: 1+ pitting pedal edema Skin: No stasis dermatitis, ulcers, scars, or xanthomas. . Pulses: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ Pertinent Results: [**2154-9-23**] 02:40AM WBC-7.0 RBC-4.60 HGB-13.1 HCT-38.9 MCV-85 MCH-28.4 MCHC-33.6 RDW-14.2 PLT COUNT-242 [**2154-9-23**] 02:40AM NEUTS-75.3* LYMPHS-18.1 MONOS-5.1 EOS-1.1 BASOS-0.3 [**2154-9-23**] 02:40AM GLUCOSE-95 UREA N-22* CREAT-1.3* SODIUM-140 POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-29 CALCIUM-9.4 PHOSPHATE-3.2 MAGNESIUM-2.0 [**2154-9-23**] 03:30AM PT-12.4 PTT-26.0 INR(PT)-1.0 [**2154-9-23**] 03:30AM D-DIMER-1277* [**2154-9-23**] 02:40AM CK(CPK)-313* CK-MB-6 cTropnT-0.04* [**2154-9-23**] 10:25AM CK(CPK)-285* CK-MB-6 cTropnT-0.04* [**2154-9-23**] 06:53PM CK(CPK)-286* CK-MB-6 cTropnT-0.04* . Chemical stress/perfusion test (Persantine-MIBI) [**2154-9-24**] . Stress: INTERPRETATION: 82 yo woman (h/o MI x 2; cardiac catheterization revealing moderate LM and RCA disease and mild LAD and LCx disease without intervention) was referred to evaluate an atypical chest discomfort. The patient was administered 0.142 mg/kg/min of persantine over 4 minutes. No chest, back, neck or arm discomforts were reported by the patient during the procedure. In the presence of baseline ECG abnls, no additional ST segment changes were noted during the procedure. The rhythm was sinus with no ectopy noted. The hemodynamic response to the persantine infusion was appropriate. Three min post-MIBI, the patient received 125 mg aminophylline IV. IMPRESSION: No anginal symptoms or ECG changes from baseline. Nuclear report sent separately. . Perfusion imaging: INTERPRETATION: The image quality is adequate. Left ventricular cavity size is moderately dilated. Rest and stress perfusion images reveal a large area of moderate to severe and fixed perfusion defect involving the inferior and inferseptal walls and a large area of moderate to severe and fixed perfusion defect in the proximal and mid anterior and ateroseptal walls. Gated images reveal global hypokinesis more pronounced in the inferior wall and septum. The calculated left ventricular ejection fraction is 34%. IMPRESSION: 1. Large area of moderate to severe and fixed perfusion defect involving the inferior and inferseptal walls 2. Large area of moderate to severe and fixed perfusion defect in the proximal and mid anterior and anteroseptal walls. 3. Dilated LV with septal and inferior wall hypokinesis; LVEF 34%. . Cardiac catherization [**2154-9-25**] COMMENTS: 1. Selective coronary angiography of this right dominant system revealed 2-vessel coronary artery disease involving the Left main. The LMCA tapered distally to a 60% stenosis, which by IVUS had a cross sectional area of 4.9 mm2. The LAD had a 60% stenosis at the origin with heavy calcification. The LCX was a non-dominant vessel and had heavy calcification proximally. The RCA was a dominant vessel with a 40% stenosis in the mid segment. 2. Resting hemodynamics demonstrated elevated left sided filling pressures, with a LVEDP of 20 mm Hg. 3. Left ventriculography revealed hypokinesis of the anterior, apical and inferior walls, with a depressed ejection fraction of 45-50%. There was no transaortic gradient on pullback of the catheter from the left ventricle to the aorta. . Carotid U/S [**2154-9-26**] IMPRESSION: Less than 40% stenosis of the internal carotid arteries bilaterally. . Echo [**2154-9-27**] PRE CPB Mild spontaneous echo contrast is seen in the body of the left atrium. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is moderate regional left ventricular systolic dysfunction with severe hypokinesis of the septal, inferoseptal, and inferior walls. The anterior, anterlateral, and lateral walls display low normal function. Overall left ventricular systolic function is moderately depressed (LVEF= 30 %). The right ventricle displays focal hypokinesis of the apical free wall. The wall of the left atrium is thickened throughout - ? Infiltrative process. There is severe and fairly diffuse calcification of most of the thoracic aorta. There are complex (>4mm) atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Mild (1+) mitral regurgitation is seen. There is a small pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results in the operating room at the time of the study. . POST CPB The patient is receiving infusions of epinephrine, norepinephrine and milrinione. The left ventricle now displays akinesis of all segments other than the anterior wall which displays moderate hypokinesis. The overall left ventricular ejection fraction is about 10 to 15%. The right ventricle shows apical akinesis with moderate hypokinesis of the basal right ventricle. A balloon pump is seen in the descending thoracic aorta with its tip about 2 cm below the distal arch. The mitral regurgitation is reduced - now trace. The aortic insufficiency remains moderate. . [**2154-9-27**] CXR FINDINGS: Endotracheal tube is in satisfactory position. Right IJ Swan-Ganz catheter is noted. There is an intraaortic balloon pump in satisfactory position. Bilateral chest tubes are noted. There is no appreciable pneumothorax. Cardiac silhouette is not enlarged when compared with preoperative film, and maybe slightly smaller. There is no definite consolidation or effusion. Brief Hospital Course: Ms. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2154-9-23**] for further management of her chest tightness. She ruled out for a myocardial infarction by enzymes. As she complained of shortness of breath and leg pain, a CTA was performed which showed no pulmonary embolism. An ultrasound of her right leg was negative for a deep vein thrombosis. Heparin was started for deep vein thrombosis prophylaxis while in the hospital. The CT scan did reveal and incidental finding of an air-fluid level in esophagus. A proton pump inhibitor was continued and follow-up was recommended to for evaluation for possible esophageal dysmotility. Ms. [**Known lastname **] [**Last Name (Titles) 1834**] a Persantine-MIBI stress test which showed large areas of mod to severe perfusion defects in inferior, anterior and septal walls. The LV was dilated with septal and inferior wall hypokinesis; LVEF was 34%. Given the evidence of large defects and her significant cardiac history, a cardiac catheterization was performed. This revealed left main and significant two vessel disease. Given the severity of her coronary disease as well as the significant aortic calcification, the cardiac surgical service was consulted. Ms. [**Known lastname **] was worked-up in the usual preoperative manner. A carotid duplex ultrasound showed no significant carotid artery disease. Given her extensive coronary and aortic calcification, it was planned that she would undergo an thoracoscopic [**Female First Name (un) 899**] harvest followed by off pump single vessel coronary artery bypass grafting through a key hole incision. Then prior to discharge, she would undergo stenting of her circumflex artery. On [**2154-9-27**], Ms. [**Known lastname **] was taken to the operating room where she [**Known lastname 1834**] coronary artery bypass grafting to two vessels. An attempt was made to do an off pump Endo-CABG however hemodynamically she was unable to tolerate this and thus [**Known lastname 1834**] a sternotomy with traditional two vessel bypass. A biopsy was obtained from her left ventricle given the atypical (possible amyloid)appearance of her heart. Please see operative note for details. An intra aortic balloon pump was placed to help her wean from bypass. Due to profound swelling, her chest was left open and she was brought to the intensive care unit in critical condition. Overnight she became increasingly acidotic and arrested in the morning. She was resuscitated per ACLS protocol and maintained a blood pressure for 20 minutes. Again she arrested and given her very poor prognosis, her family elected to not proceed with care. She expired at 8:02 AM on [**2154-9-28**]. Medications on Admission: Per records faxed from [**Last Name (un) 4367**] [**Hospital3 400**] Fluticasone-Salmeterol 250-50 mcg/Dose [**Hospital1 **] Ramipril 5 mg DAILY Aricept 5 mg Daily Aspirin 81 mg daily Fluticasone 50 mcg/Actuation Spray 2 Nasal DAILY Furosemide 60 mg DAILY Isosorbide Mononitrate 90 mg PO daily Metoprolol Succinate 25 mg Daily Omeprazole 20 mg daily Clopidogrel 75 mg DAILY Potassium Chloride 10 mEq daily Atrovent MDI [**Hospital1 **] and Q6hrs PRN Ezetimibe 10 mg Tablet Daily Tylenol 500 mg [**Hospital1 **] PRN Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: CAD Discharge Condition: Deceased Discharge Instructions: None Followup Instructions: None [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2154-10-4**]

[ "427.41", "440.0", "496", "426.3", "530.81", "428.22", "272.4", "V15.82", "996.72", "414.01", "458.29", "412", "427.5", "277.39", "998.11", "424.1", "997.1", "426.10", "V10.3", "425.7", "428.0", "V45.71", "438.9", "403.90", "585.9", "276.2" ]

icd9cm

[ [ [] ] ]

[ "99.05", "39.61", "39.64", "89.68", "37.25", "99.04", "99.62", "96.71", "36.12", "34.01", "88.53", "38.91", "37.22", "88.56", "34.04", "99.07", "89.64", "00.24", "37.61" ]

icd9pcs

[ [ [] ] ]

12496, 12505

9212, 11901

289, 494

12553, 12563

3594, 9189

12616, 12742

2710, 2824

12467, 12473

12526, 12532

11927, 12444

12587, 12593

2839, 3575

235, 251

522, 2016

2038, 2499

2515, 2694

1,949

196,537

29748+57656+57657

Discharge summary

report+addendum+addendum

Admission Date: [**2128-3-30**] Discharge Date: [**2128-4-7**] Date of Birth: [**2064-1-23**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 398**] Chief Complaint: Right lower extremity pain and swelling Major Surgical or Invasive Procedure: 1. Incision and drainage of right calf hematoma with placement of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1661**]-[**Location (un) 1662**] drain ([**4-1**]) 2. Diagnostic venogram ([**4-1**]) 3. Placement of Gunther Tulip vena cava filter ([**4-1**]) History of Present Illness: 65 yo woman w/ h/o COPD, respiratory failure s/p trach [**1-20**] after failure to wean post-op at [**Hospital1 2177**] after ruptured diverticula s/p surgical repair, as well as being recently admitted to [**Hospital1 18**] MICU [**Date range (1) 71218**] for asystolic cardiac arrest at rehab on [**2128-3-20**] after d/c'd there from [**Hospital1 2177**], who presents today from [**Hospital 671**] [**Hospital 4094**] Hospital w/ worsening right leg pain and swelling. This was first noted by the RN yesterday morning. The patient's right leg was noted to be more swollen and ecchymotic today so she was sent in for evaluation. Per report, patient is usually in bed and has been bed bound since arrival to rehab on [**2128-3-25**] from her last admission at [**Hospital1 18**]. Per patient, her leg pain has been worsening for weeks. Denies numbness or tingling. She is able to move her foot, but states that this is very painful. . On arrival to ED, patient afeb, tachy to 112, satting 100% on AC 450x16/5/0.3. Plain films of knee and tib/fib did not reveal fracture. LENI negative for DVT; however, a 12cm hematoma seen. Vascular surgery drained hematoma in ED. Also noted to have WBC of 19, stable from her last admission, but then up to 30 prior to leaving ED. Currently, receiving Vanc/Gent since last admission to cover for possible VAP after acinetobacter [**Hospital1 **] found in sputum. In addition, bicarb 42 (2 days ago at rehab was 41); ABG unsuccessful in ED. RT informed ED staff of bad cuff [**Last Name (LF) 3564**], [**First Name3 (LF) **] cuff pressures were increased to the 40's. Also reports of patient disconnecting vent tubing multiple times while in ED. [**Name8 (MD) **] RN staff were concerned that this may be purposeful. Although pt has h/o depression, she denies SI. While in ED, patient received Xanax 0.25mg x1, seroquel 50mg x1, ativan (total 2.5mg), and morphine 1mg x1. . Patient admitted to the MICU for observation after drainage of her hematoma. Currently, patient answering some questions, denies pain. Past Medical History: - h/o cardiac arrest: asystolic ([**2128-3-20**]) - Respiratory failure, chronically ventilated after failure to wean following surgery at [**Hospital1 2177**] - Small subsegmental PE: tx'd w/ lovenox bridged to coumadin (held [**3-29**]) - h/o Pneumothorax: s/p chest tube [**Date range (1) 65044**] - h/o perforated sigmoid colon s/p resection and colostomy - h/o bacteremia [**3-19**] line infection and diverticulitis - h/o probable VAP ([**3-24**]): Sputum cx w/ acinetobacter [**First Name9 (NamePattern2) **] [**Last Name (un) 36**] to Gentamicin and MSSA; but since patient MRSA+ she was treated w/ vancomycin and gent - COPD (steroid dependent) - B12 deficiency - fractured right ankle [**2126**] - MRSA in nares - anxiety - depression - HTN - atrial fibrillation . Of note, recent hospitalization at [**Hospital1 2177**], she presented with fall and weakness, found to be in a fib with AVR, converted to sinus rhythm. Apparently intubated for respiratory failure in setting EtOH withdrawal and DT's. While intubated, had fever to 103.8, elevated WBC and + blood cultures. abd CT with free air and to OR for ex-lap with sigmoid colectomy, [**Doctor Last Name 3379**] procedure. post-op she could not be weaned off the vent and underwent trach and PEG tube on [**2128-2-5**]. she was discharged to [**Hospital3 **] on vanco due to her + blood cultures and MRSA history. Social History: Currently resides at rehab ([**Hospital 671**] [**Hospital 4094**] Hospital). Family History: non-contributory Physical Exam: VS: T: 100.5; HR: 139; BP: 120/99; RR 26-34; O2 % 97% VENT: A/C 400x20 (25) / 5 / 0.3 (PIP 18) GEN: elderly woman, lying in bed, trach in place, moving all extremities and body w/ twitching/squirming movements; NAD HEENT: PERRL bilat, EOMI bilat, anicteric, dryMM, OP clear NECK: JVP not elevated CV: tachy, normal s1s2, no murmurs, no S3/S4 CHEST: CTA bilat anteriorly. Poor air movement. no crackles/wheezes. ABD: +midline scar mostly healed w/ area of opening packed w/ xeroform; colostomy LLQ; NABS; soft, ND, NT, no masses EXT: +ace wrap around RLE; 2+ pedal edema on right; right foot slightly warmer than left. NEURO: unable to answer all questions (cannot assess orientation), CN 2-12 intact bilat, sensory/motor exam intact bilat Pertinent Results: [**2128-3-30**] 11:00AM BLOOD WBC-18.8* RBC-2.39* Hgb-7.7* Hct-23.2* MCV-97 MCH-32.3* MCHC-33.2 RDW-15.7* Plt Ct-279 [**2128-3-30**] 11:00AM BLOOD Neuts-80.5* Lymphs-16.6* Monos-2.1 Eos-0.6 Baso-0.2 [**2128-3-30**] 08:50PM BLOOD Hypochr-2+ Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-1+ Stipple-1+ [**2128-3-30**] 11:00AM BLOOD PT-12.1 PTT-33.0 INR(PT)-1.0 [**2128-3-30**] 11:00AM BLOOD Plt Ct-279 [**2128-3-30**] 11:00AM BLOOD Glucose-130* UreaN-15 Creat-0.8 Na-139 K-4.9 Cl-91* HCO3-42* AnGap-11 [**2128-3-30**] 11:00AM BLOOD CK(CPK)-24* [**2128-3-30**] 11:32PM BLOOD ALT-16 AST-19 AlkPhos-128* Amylase-93 TotBili-0.4 [**2128-3-30**] 11:00AM BLOOD Calcium-8.7 Phos-4.2# Mg-2.2 [**2128-3-30**] 11:06PM BLOOD Type-[**Last Name (un) **] pO2-27* pCO2-80* pH-7.37 calTCO2-48* Base XS-15 . CXR: no CHF or infiltrate, trach tube appears in good position . R TIB/FIB PLAIN FILMS: neg for fx . R KNEE PLAIN FILMS: neg for fx . R LENI: 1. No DVT. 2. 12 cm collection in the posteromedial right calf, likely a hematoma . Bilateral LENI: 1. No DVT in the left lower extremity. 2. Evolution of right calf hematoma, which is now slightly smaller in size . PERIPHERAL SMEAR/FLOW CYTOMETRY: immature cell forms; Flow cytometry on peripheral blood showed half lymphocytes are abnormal/lymphoma cells; final heme/path report pending. Brief Hospital Course: MICU COURSE: . #) RIGHT LOWER EXTREMITY HEMATOMA: 12cm hematoma found on LENI on admission. This was thought likely to be related to anticoagulation received for PE which was started on recent hospital admission. s/p drainage by surgery in ED (>200cc drained). No evidence of compartment syndrome per surgery. Hematocrit dropped during admission, requiring a total of 7units PRBC transfusions throughout entire admission. On [**2128-4-1**], patient went to OR with vascular surgery s/p evacuation of hematoma and placement of JP drain. Last transfusion was night of [**2128-4-2**]. Anticoagulation was continued to be held at the time discharge. Bilateral LENI's negative for DVT. Removable IVC filter was placed in OR by vascular surgery on [**2128-4-1**]. . #) FEVER/LEUKOCYTOSIS: The patient was found to have a significant leukocytosis during her last admission (WBC 16 at the time of d/c). Her WBC count on this admission was initially 18.8 w/ 80N, 16L. On review of prior labs here, her WBC count seemed to be chronically elevated in past. She also had a low grade temp early in her admission. Her UA and CXR were negative. Blood cultures also negative. She was continued on Gentamicin and vancomycin started on her last admission for her known VAP of acinetobacter and MSSA (although has h/o MRSA). Sputum this admission grew acinetobacter again sensitive to gentamicin, as well as MRSA. Antibiotics were discontinued after a 14 day course. . In addition, the hematopathologist reported that her peripheral blood smear showed immature forms and performed flow cytometry on her blood. Per preliminary report, flow cytometry on her peripheral blood showed approximately half of her lymphocytes were abnormal/lymphoma cells. Heme/path commented that this appeared to be consistent with a B-cell lymphoproliferative disorder; however, further subclassification is pending at this time. The patient and family were informed of these results. After further discussion with the family, they wish to make sure the patient is "comfortable," and do not wish to pursue aggressive treatments given her poor overall prognosis. However, patient disagreed with this, and wants everything done. Patient will be transferred back to rehab and may have heme/onc evaluation after final path report returns. Patient's outpatient physician was updated regarding this new diagnosis, and is aware that diagnosis is not finalized at this time. . #) HISTORY OF PE: PE was diagnosed on [**2128-3-20**]. Her CTA showed an incomplete right lower lobe subsegmental PE. She was started on lovenox during her last admission with a bridge to coumadin. Her anticoagulation was held on this admission given her RLE bleeding. Bilateral LENIs negative for DVT. As mentioned above, an IVC filter was placed for further prophylaxis. . #) A FIB: Patient has a history of A fib. She appeared to be in sinus during this admission. She is now off anticoagulation as above due to active bleeding. . #) FEN: She was continued on tube feeds during this admission. This will need to be . #) CODE STATUS: FULL CODE; after diagnosis of heme malignancy, patient's family considered making patient DNR/DNI/CMO; however, patient refused this status and stated that she wanted to live "every minute possible" and disagreed with DNR/DNI status. Patient confirmed that she wanted to be FULL CODE. This was relayed to the family, and they agreed that she should be able to make that decision for herself. Therefore, the patient is FULL CODE. . #) COMMUNICATION: - Son [**Doctor Last Name **] - primary contact) [**Telephone/Fax (1) 71219**] - Brother [**Doctor Last Name 449**] [**Telephone/Fax (1) 71220**] . #) DISPO: Patient was transferred back to rehab. . Medications on Admission: Gentamicin 80mg IV Q12H (last dose given [**3-30**] @2am) Vancomycin 1gm IV Q12H (last dose given [**3-30**] @9am) Coumadin 5mg NG QHS (held [**3-29**]) Lovenox 80mg SC BID (last dose 2/12; held [**3-30**]) Albuterol INH Q4Hprn Combivent 4puffs INH Q4Hprn Zantac 150mg NG [**Hospital1 **] Flovent 110mcg 2puffsd [**Hospital1 **] Tylenol 650mg NG Q6H Colace liquid 100mg NG [**Hospital1 **] Prozac liquid 20mg NG Daily Seroquel 50mg NG TID Seroquel 100mg NG QHS Xanax 0.25mg NG TID Xalatan 1 gtt HS Acular 0.5% 1gtt QID Pred Forte 1% 1gtt [**Hospital1 **] Atrovent INH 4puffs Q4Hprn Prednisone liquid 5mg NG daily Discharge Disposition: Extended Care Facility: [**Hospital3 672**] Hospital Discharge Diagnosis: 1) Right Lower extremity hematoma 2) Blood loss anemia 3) Pulmonary embolism 4) Leukocytosis Discharge Condition: Stable Discharge Instructions: Please continue medications as prescribed after discharge. Follow up with your PCP after transfer to rehab. Followup Instructions: Please follow up with your primary care doctor after returning to rehab. Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 11983**] Admission Date: [**2128-3-30**] Discharge Date: [**2128-4-7**] Date of Birth: [**2064-1-23**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 6727**] Addendum: 1. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4-6H (every 4 to 6 hours) as needed. 2. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4H (every 4 hours) as needed. 3. Ranitidine HCl 15 mg/mL Syrup Sig: One [**Age over 90 2238**]y (150) mg PO BID (2 times a day). 4. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 5. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 6. Insulin Regular Human 100 unit/mL Solution Sig: As directed as directed Injection ASDIR (AS DIRECTED): Insulin Sliding Scale. 7. Fluoxetine 20 mg/5 mL Solution Sig: Twenty (20) mg PO DAILY (Daily). 8. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 10. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 11. Fluticasone 110 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation [**Hospital1 **] (2 times a day). 12. Alprazolam 0.25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 13. Flurbiprofen Sodium 0.03 % Drops Sig: One (1) Drop Ophthalmic QID (4 times a day). 14. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five (5) ML PO Q6H (every 6 hours) as needed for cough. 15. Morphine Sulfate 1 mg IV Q2H:PRN pain 16. Lorazepam 1-2 mg IV Q4H:PRN Hold for SBP<100 17. Gentamicin in Normal Saline 100 mg/50 mL Piggyback Sig: One Hundred (100) mg Intravenous Q24H (every 24 hours) for 1 days: Last Dose [**2128-4-6**]. Discharge Disposition: Extended Care Facility: [**Hospital3 **] Hospital [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6728**] MD [**MD Number(1) 3662**] Completed by:[**2128-4-6**] Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 11983**] Admission Date: [**2128-3-30**] Discharge Date: [**2128-4-7**] Date of Birth: [**2064-1-23**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 6727**] Addendum: On [**2128-4-6**] prior to anticipated discharge, the patient had an episode of acute respiratory distress and hypoxia. This improved somewhat with suctioning and nebs. The patient underwent bronchoscopy, which revealed a large mucopurulent plug aspirated from the R mainstem bronchus. BAL was done (gram stain negative for organisms). Vancomycin and Gentamycin were restarted given acinetobacter and MRSA seen in sputum several days prior (course had been completed). Plan is for these antibiotics to be continued until BAL results return. Please call [**Hospital1 8**] on Friday [**4-9**] for BAL culture results. Today, patient is comfortable, respiratory status stable. . Please see updated medication list in this addendum and in discharge instructions. Pertinent Results: FLOW CYTOMETRY REPORT FLOW CYTOMETRY IMMUNOPHENOTYPING The following tests (antibodies) were performed: HLA-DR, FMC-7, Kappa, Lambda, and CD antigens 2, 5, 7, 19, 20, 23. RESULTS: Three color gating is performed (light scatter vs. CD45) to optimize lymphocyte yield. Abnormal/lymphoma cells comprise 49% of lymphoid gated events. B cells demonstrate a monoclonal lambda (dim) light chain restricted population. They co-express pan-B cell markers CD19, 20 along with CD5, CD23 (subset, dim) and FMC (subset). They do not express any other characteristic antigens including CD10. INTERPRETATION Findings are of involvement by CD5-positive B-cell lymphoproliferative disorder. The immunophenotypic differential diagnosis of a CD5-positive B-cell lymphoproliferative disorders includes a) An early, evolving Prolymphocytic leukemia. Note: review of her peripheral blood shows 12% mature appearing lymphocytes with 2% atypical lymphocytes with prolymphocytic features. b) A chronic lymphocytic leukemia with increased prolymphocytes (CLL/PLL). c) A Mantle cell lymphoma, peripheralized. Given the dim surface immunoglobulin expression and subset expression of CD23, this possibility is less likely, however, sample will be sent to cytogenetics for FISH analysis to look for t(11;14) to exclude this possibility. Discharge Medications: 1. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4-6H (every 4 to 6 hours) as needed. 2. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4H (every 4 hours) as needed. 3. Ranitidine HCl 15 mg/mL Syrup Sig: One [**Age over 90 2238**]y (150) mg PO BID (2 times a day). 4. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 5. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 6. Insulin Regular Human 100 unit/mL Solution Sig: As directed as directed Injection ASDIR (AS DIRECTED): Insulin Sliding Scale. 7. Fluoxetine 20 mg/5 mL Solution Sig: Twenty (20) mg PO DAILY (Daily). 8. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 10. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 11. Fluticasone 110 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation [**Hospital1 **] (2 times a day). 12. Alprazolam 0.25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 13. Flurbiprofen Sodium 0.03 % Drops Sig: One (1) Drop Ophthalmic QID (4 times a day). 14. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five (5) ML PO Q6H (every 6 hours) as needed for cough. 15. Morphine Sulfate 1 mg IV Q2H:PRN pain 16. Lorazepam 1-2 mg IV Q4H:PRN Hold for SBP<100 17. Gentamicin in Normal Saline 100 mg/50 mL Piggyback Sig: One Hundred (100) mg Intravenous Q24H (every 24 hours) for d/c when cultures negative days: to be continued until BAL confirmed negative - please call on [**4-9**] for micro results. 18. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 19. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily) as needed: for PICC line. 20. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram Intravenous Q 12H (Every 12 Hours) for until cultures negative days: to be continued until BAL cultures are confirmed negative - please call on [**4-9**] for results. Discharge Disposition: Extended Care Facility: [**Hospital3 **] Hospital Discharge Diagnosis: 1) Right Lower extremity hematoma 2) Blood loss anemia 3) Pulmonary embolism 4) Leukocytosis Discharge Condition: Stable Discharge Instructions: Please continue medications as prescribed after discharge. Follow up with your PCP after transfer to rehab. . Discharge medications include antibiotics vancomycin and gentamycin. Bronchoscopy with BAL was done on the day prior to discharge and is no growth to date. Please call [**Hospital1 8**] 48 hours after discharge (on Friday [**4-9**]) to get culture results. If negative, can discontinue antibiotics. You can call the ICU at [**Telephone/Fax (1) 11984**] or the lab at [**Telephone/Fax (1) 11985**] to get this information. . Heme-onc consultation should be considered (please see discharge summary addendum for pathology report indicating heme malignancy). Followup Instructions: Please follow up with your primary care doctor after returning to rehab. . Heme-onc consultation should also be considered. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6728**] MD [**MD Number(1) 3662**] Completed by:[**2128-4-7**]

[ "459.0", "401.9", "V46.11", "266.2", "E934.2", "427.31", "V58.61", "285.1", "728.89", "300.4", "238.79", "496", "V44.0" ]

icd9cm

[ [ [] ] ]

[ "38.7", "96.72", "33.24", "86.04" ]

icd9pcs

[ [ [] ] ]

17993, 18045

6396, 10138

353, 628

18182, 18191

14565, 15885

18909, 19191

4235, 4253

15908, 17970

18066, 18161

10164, 10779

18215, 18886

4268, 5009

274, 315

656, 2720

2742, 4124

4140, 4219

1,839

141,353

26501

Discharge summary

report

Admission Date: [**2118-12-23**] Discharge Date: [**2118-12-29**] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1267**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2118-12-24**] Three Vessel CABG(LIMA to LAD, vein grafts to OM and PDA) History of Present Illness: This is a 83 year old female with known history of coronary artery disease. She has suffered two prior MI in the past. She presented to [**Hospital3 35813**] Center on [**2118-12-20**] with atypical angina. Cardiac catheterization revealed severe three vessel coronary disease including left main, with an ejection fraction of 45%. Given the severity of her coronary artery disease, she was transferred to the [**Hospital1 18**] for cardiac surgical intervention. Past Medical History: Coronary artery disease, hypertension, peripheral vascular disease, elevated cholesterol, history of TIA's, sick sinus syndrome s/p pacemaker, obesity, osteoporosis, s/p right kidney surgery, chronic bronchitis Social History: Denies active tobacco. Admits to social ETOH. Lives alone at an [**Hospital3 **] facility. Family History: Significant for HTN. Denies premature CAD. Physical Exam: Vitals: T 97.5 BP 140/62, HR 60, RR 14, SAT 97% on room air General: elderly female in no acute distress HEENT: oropharynx benign, PERRL Neck: supple, no JVD, no carotid bruits Heart: regular rate, normal s1s2, 3/6 systolic murmur Lungs: clear bilaterally Abdomen: obese, soft, nontender, normoactive sounds, umbilical hernia noted Ext: warm, no edema, no varicosities Pulses: decreased distally Neuro: alert and oriented, CN 2-12 intact otherwise nonfocal Pertinent Results: [**2118-12-23**] 04:20PM URINE RBC-[**2-19**]* WBC-21-50* BACTERIA-FEW YEAST-NONE EPI-0 RENAL EPI-0-2 [**2118-12-23**] 04:20PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-5.0 LEUK-MOD [**2118-12-23**] 04:20PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.019 [**2118-12-23**] 04:38PM PLT COUNT-200 [**2118-12-23**] 04:38PM PT-12.7 PTT-25.2 INR(PT)-1.1 [**2118-12-23**] 04:38PM WBC-8.9 RBC-3.92* HGB-11.9* HCT-34.8* MCV-89 MCH-30.3 MCHC-34.1 RDW-13.7 [**2118-12-23**] 04:38PM %HbA1c-6.1* [Hgb]-DONE [A1c]-DONE [**2118-12-23**] 04:38PM ALBUMIN-3.7 CALCIUM-9.8 PHOSPHATE-3.3 MAGNESIUM-1.8 [**2118-12-23**] 04:38PM ALT(SGPT)-15 AST(SGOT)-16 ALK PHOS-97 AMYLASE-55 TOT BILI-0.3 [**2118-12-23**] 04:38PM GLUCOSE-109* UREA N-29* CREAT-1.3* SODIUM-140 POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-26 ANION GAP-13 [**2118-12-27**] 07:25AM BLOOD WBC-11.7* RBC-2.79* Hgb-8.3* Hct-24.8* MCV-89 MCH-29.7 MCHC-33.3 RDW-15.0 Plt Ct-158 [**2118-12-27**] 07:25AM BLOOD Glucose-108* UreaN-27* Creat-1.2* Na-137 K-4.0 Cl-104 HCO3-26 AnGap-11 [**2118-12-23**] Carotid Duplex Ultrasound Sinus rhythm. The P-R interval is 0.18. Left bundle-branch block. Compared to the previous tracing of [**2118-12-20**] atrial ectopy is no longer recorded. [**2118-12-27**] 07:25AM BLOOD WBC-11.7* RBC-2.79* Hgb-8.3* Hct-24.8* MCV-89 MCH-29.7 MCHC-33.3 RDW-15.0 Plt Ct-158 [**2118-12-27**] 07:25AM BLOOD Plt Ct-158 [**2118-12-28**] 07:55AM BLOOD Glucose-103 UreaN-28* Creat-1.2* K-4.1 Brief Hospital Course: Mrs. [**Known lastname 30380**] was admitted under the cardiac surgical service and underwent routine preoperative evaluation which included a carotid ultrasound. The carotid ultrasound showed only mild plaques in both internal carotid arteries, less than 40% bilaterally. Workup was otherwise unremarkable and she was cleared for surgery. She remained stable on medical therapy. On [**12-24**], Dr. [**Last Name (STitle) **] performed three vessel coronary artery bypass grafting. The operation was complicated by a mild coagulopathy thought to be related to her Plavix. Platelets were given with improved bleeding. Postoperative transesophageal echocardiogram showed an ejection fraction of approximately 40% with mild mitral regurgitation. For further details, see operative note. Following the operation, she was brought to the CSRU. Within 24 hours, she awoke neurologically intact and was extubated. She successfully weaned from inotropic support and maintained stable hemodynamics. Her CSRU course was uneventful and she transferred to the SDU on postoperative day two. She was gently diuresed towards her preoperative weight. The physical therapy service was consulted for assistance with her postoperative strength and mobility. [**Hospital **] Clinic consult was obtained for better glucose management. The EP service also interrogated her pacemaker and adjusted her atrial sensitivity. Mrs. [**Known lastname 30380**] was informed that her PPM was functioning well. She will follow up with her cardiologist regarding further management of her PPM. Her Blood Glucose levels improved with the addition of glipizide. On POD 5 Mrs. [**Known lastname 30380**] was transferred to a Rehabilitation facility for further strengthening and conditioning. Medications on Admission: IV Nitro, Pravachol 20 qd, Plavix 75 qd, Lopressor 25 [**Hospital1 **], Cozaar Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 months. 6. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 14 days. Disp:*28 Tablet(s)* Refills:*0* 10. Potassium Chloride 20 mEq Packet Sig: One (1) PO Q12H (every 12 hours) for 14 days. Disp:*28 packets* Refills:*0* 11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*40 Tablet(s)* Refills:*0* 12. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q4-6H (every 4 to 6 hours) as needed. Disp:*qs qs* Refills:*0* 13. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*15 Tablet(s)* Refills:*2* 14. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 15. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 16. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). Disp:*qs qs* Refills:*2* Discharge Disposition: Extended Care Facility: [**Doctor Last Name 65471**] Discharge Diagnosis: Coronary artery disease, hypertension, peripheral vascular disease, elevated cholesterol, history of TIA's, sick sinus syndrome s/p pacemaker, obesity, osteoporosis, s/p right kidney surgery Discharge Condition: Good Discharge Instructions: Patient may shower, no baths. No creams, lotions or ointments to incisions. No driving for at least one month. No lifting more than 10 lbs for at least 10 weeks from the date of surgery. Monitor wounds for signs of infection. Please call with any concerns or questions. Remove groin staples on [**2119-1-3**] Remove sternotomy staples [**2119-1-7**] Followup Instructions: Cardiac surgeon, Dr. [**Last Name (STitle) **] in [**3-22**] weeks. Local PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in [**1-20**] weeks. Local cardiologist in [**1-20**] weeks. Completed by:[**2118-12-29**]

[ "401.9", "424.0", "998.11", "278.00", "411.1", "412", "V45.01", "250.00", "733.00", "443.9", "272.0", "414.01", "427.81" ]

icd9cm

[ [ [] ] ]

[ "99.05", "36.15", "89.60", "36.12", "39.61" ]

icd9pcs

[ [ [] ] ]

6771, 6826

3296, 5058

281, 358

7060, 7067

1746, 3273

7466, 7697

1209, 1253

5187, 6748

6847, 7039

5084, 5164

7091, 7443

1268, 1727

231, 243

386, 851

873, 1085

1101, 1193

82,998

176,068

40215

Discharge summary

report

Admission Date: [**2152-11-24**] Discharge Date: [**2152-12-13**] Date of Birth: [**2076-9-19**] Sex: M Service: SURGERY Allergies: Acetaminophen / Aspirin Attending:[**First Name3 (LF) 2597**] Chief Complaint: venous stasis ulcer Major Surgical or Invasive Procedure: Bilateral lower extremity debridement s/p Split thickness skin graft with VAC placement [**2152-12-11**] History of Present Illness: 76 yoM with h/o HTN, HL, dementia/anxiety presents for b/l LE venous stasis ulcers of 3 years. Pt has had ulcers followed by wound clinic for 7 months with last visit 1 year ago and currently has had home VNA come on a daily basis for dressing changes (unna boots, wet to dry dressings, debridements, etc.) for the last 2 years. Pt states that the ulcers wax and wane in improvement and worsening but notes that the ulcers have been worsening considerably in appearance and pain in the last few months. Pt was last seen by Dr. [**Last Name (STitle) **] at his clinic on [**2152-11-20**] and it was decided that the pt would be admitted to the hospital for iv antibiotics and questionable OR debridement. Pt denies F/C/N/V as well as CP and SOB. Pt's PCP is [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD of [**Hospital3 **] Medical Associates Past Medical History: PAST MEDICAL HISTORY: - HTN - HL - dementia - anxiety PAST SURGICAL HISTORY: - AAA [**2144**] Social History: SOCIAL HISTORY: Pt lives at home with ex-wife. Does not use cane/walker for ambulatory assistance. Suffers occasional mechanical falls at home. Quit smoking [**2148**]; previous 2ppd/40 yrs Quit drinking alcohol [**2148**]; previously 1-6packperday/40 yrs Denies illicit drug use. Family History: FAMILY HISTORY: Diabetes Physical Exam: Vital Signs: Temp: 97.3 RR: 18 Pulse: 74 BP: 90/44 Neuro/Psych: Oriented x3, Affect Normal, NAD. Heart: Abnormal: Murmur. Lungs: Clear, Normal respiratory effort. Gastrointestinal: Non distended, No masses, Guarding or rebound. Pulse Exam (P=Palpation, D=Dopplerable, N=None) RUE Radial: P. LUE Radial: P. RLE Femoral: P. Popiteal: P. DP: P. PT: D. LLE Femoral: P. Popiteal: D. DP: P. PT: N. ULCERS VAC'D DONOR SITE WITH Xeroform over thigh donor site Pertinent Results: [**2152-11-24**] 5:55 pm SWAB Source: right lower leg. NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S). WOUND CULTURE (Final [**2152-11-30**]): ANAEROBIC CULTURE (Final [**2152-11-26**]): UNABLE TO R/O PATHOGENS DUE TO OVERGROWTH OF SWARMING PROTEUS SPP.. [**2152-11-29**] 1:00 pm SWAB RIGHT LEG LATRAL ULCER. GRAM STAIN (Final [**2152-11-29**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). WOUND CULTURE (Final [**2152-12-2**]): PROTEUS MIRABILIS. SPARSE GROWTH. PRESUMPTIVE IDENTIFICATION. PROTEUS MIRABILIS. SPARSE GROWTH. SECOND TYPE. PROTEUS MIRABILIS | PROTEUS MIRABILIS | | AMIKACIN-------------- <=2 S <=2 S AMPICILLIN------------ =>32 R =>32 R AMPICILLIN/SULBACTAM-- 8 S 8 S CEFAZOLIN------------- <=4 S 8 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CIPROFLOXACIN--------- =>4 R =>4 R GENTAMICIN------------ =>16 R =>16 R MEROPENEM-------------<=0.25 S <=0.25 S PIPERACILLIN/TAZO----- <=4 S <=4 S TOBRAMYCIN------------ =>16 R 8 I TRIMETHOPRIM/SULFA---- =>16 R =>16 R ANAEROBIC CULTURE (Final [**2152-12-3**]): NO ANAEROBES ISOLATED. Blood Culture, Routine (Final [**2152-12-6**]): NO GROWTH. [**2152-11-28**] 09:06PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.020 URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ECHO: The left atrium is markedly dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. Overall left ventricular systolic function is normal (LVEF 75%). The right ventricular free wall is hypertrophied. The right ventricular cavity is dilated with depressed free wall contractility. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are moderately thickened. The aortic valve is not well seen. There is at least moderate aortic valve stenosis. 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 impaired relaxation. The tricuspid valve leaflets are mildly thickened. Severe [4+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] There is a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade. PMIBI: IMPRESSION: 1. Normal myocardial perfusion. 2. Normal left ventricular cavity size and systolic function. 3. Right ventricular enlargement with evidence of pressure/volume overload. CTA: R/O PE IMPRESSION: 1. No pulmonary embolus. 2. No thoracic aorta dissection. 3. Pulmonary hypertension probably responsible for right heart enlargement. 4. No pulmonary edema. 5. Calcification of aortic valve leaflets. Atherosclerotic coronary calcifications. 6. No pericardial effusion. 7. Bilateral small pleural effusions and mild adjacent bibasilar atelectasis. 8. Mild bronchial wall thickening could be due to asthma. 9. Small amount of perihepatic free fluid. Brief Hospital Course: Mr. [**Known lastname 87601**] is a 76 yoM who was admitted to the hospital on [**11-24**] for empiric IV antibiotics and possible wound debridement. Preoperatively, the Geriatric service was consulted for management and recommendations of patient's baseline dementia. Patient was deemed cabable of consenting to procedures by Psychiatry. On [**11-29**], he was taken to the operating room for bilateral leg debridement. OR cultures grew MRSA sensitive to Vancomycin and proteus sensitive to Unasyn and his antibiotics coverage was narrowed. In the am of POD 1, the patient became tachycardic, hypoxic, and hypotensive. His blood pressure improved with fluid bolus and patient was transferred to the VICU for closer monitoring. A few hours later he became hypotensive and tachycardic again, requiring fluid rescuscitation. EKG showed ST depressions, a Cardiology consult was called, and patient was transferred to the CVICU. Echocardiogram showed a dilated, hypokinetic RV with EF 70%. He ruled out for PE. Troponins peaked at 0.11. Per Cardiology, no need for cardiac catheterization. He was transferred back to the floor on POD 2. On [**12-7**], antibiotics were switched to PO Bactrim and cefpodoxine. Plastic Surgery was consulted for skin graft. A preoperative echocardiogram and a persantine stress test were done as part of cardiac clearance to return to the OR again for skin grafting. He was cleared from a cardiac perspective and on [**12-11**] he returned to the operating room for further debridement and split thickness skin graft with VAC placement with Plastic Surgery(Dr.[**Last Name (STitle) **]) . Mr. [**Known lastname 87601**] had an uneventful postoperative course with good pain control. Foley was replaced on [**12-12**] for urinary retention. Flomax was started and foley was removed at midnight [**12-13**]. Pt voiding adequate amounts on discharge. VAC is to stay in place until arrangements are made by Plastic Surgery for pt to return for VAC change in the operating room (1 week). Medications on Admission: Aricept 5', Tamazepam 15prn, lasix 40', alprazolam 0.5TID, lisinopril 30', metaprolol 12.5", plavix 75', vicodin 7.5-750 [**1-1**] q6pain, colace" Discharge Medications: 1. donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 4. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 5. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 8. furosemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 10. miconazole nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 12. Bactrim DS 800-160 mg Tablet Sig: One (1) Tablet PO twice a day. 13. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 14. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous DAILY (Daily). 15. lisinopril 30 mg Tablet Sig: One (1) Tablet PO once a day. 16. alprazolam 0.5 mg Tablet Sig: One (1) Tablet PO three times a day: prn. Discharge Disposition: Extended Care Facility: [**Hospital 4542**] Rehabilitation and Nursing of [**Location (un) 38**] Discharge Diagnosis: Bilateral lower extremity venous stasis ulcers Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the vascular surgery service for management of your bilateral lower leg ulcers. You had debridement in the operating room. Your legs are wrapped with aquacel Ag and ace wraps. Please keep them wrapped and elevated as much as possible. Please contact us if you experience any fever greater than 101.5, increased leg swelling or redness, thick drainage from your wounds, or worsening of your ulcers. Please take your antibiotics and other medications as instructed. Open Wound: VAC DRESSING Patient's Discharge Instructions Introduction: This will provide helpful information in caring for your wound. If you have any questions or concerns please talk with your doctor or nurse. You have an open wound, as opposed to a closed (sutured or stapled) wound. The skin over the wound is left open so the deep tissues may heal before the skin is allowed to heal. Premature closure or healing of the skin can result in infection. Your wound was left open to allow new tissue growth within the wound itself. The wound is covered with a VAC dressing. VAC will be changed when patient returns for VAC removal. The VAC: _ helps keep the wound tissue clean _ absorbs drainage _ prevents premature healing of skin - promotes healing When to Call the Doctor: Watch for the following signs and symptoms and notify your doctor if these occur: Temperature over 101.5 F or chills Foul-smelling drainage or fluid from the wound Increased redness or swelling of the wound or skin around it Increasing tenderness or pain in or around the wound Followup Instructions: Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2152-12-18**] 11:00 Please call Dr [**Last Name (STitle) 88297**] office at [**Telephone/Fax (1) 88298**]. They will schedule an appointment for VAC removal. Please call the office daily for appt. Completed by:[**2152-12-13**]

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icd9cm

[ [ [] ] ]

[ "86.28", "86.22", "86.69" ]

icd9pcs

[ [ [] ] ]

9687, 9786

6186, 8199

305, 412

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136,354

48474

Discharge summary

report

Admission Date: [**2149-5-16**] Discharge Date: [**2149-5-18**] Date of Birth: [**2067-6-6**] Sex: F Service: MEDICINE Allergies: Amoxicillin / Atenolol / Bupropion Hcl Attending:[**First Name3 (LF) 3984**] Chief Complaint: tachypnea, elevated lactate Major Surgical or Invasive Procedure: None History of Present Illness: This is an 81 yo F with a hx of dementia, HTN, and a large RLL mass who presents with poor PO intake and a cough for the last three days. She resides at [**Hospital **] [**Hospital **] Nursing home and the above symptoms were noted by the staff. Labs drawn on [**5-15**] showed a BUN of 88 and a creatine of 4. She was started on IVF but stopped after 600cc after ? increased wetness of cough. Per the NH, prior to ED transfer her UOP was minimal. Her labs continued to worsen on [**5-16**] so she was sent to the ED for eval. . In ED, vitals were 97.8, 92, 136/85, 36, 95% 4L . A CXR was noted to have a RML/RLL infiltrate so she received vanc/cefepime/levofloxacin for HAP as well as nebs. No one was able to place a foley due to ? obstruction by pelvic mass but pelvic CT showed the problem was a collapsed bladder with no mass seen. She was given 2L of NS in the ED but had a persistently elevated lactate with no hypotension. She was also noted to be markedly tachypneic with RR in the 30s but without significant hypoxia, satting 95% on 2L. Given these two features, she was admitted to the ICU. . On presentation to the ICU, she notes that she feels "lowsy" and feels SOB. Denies chest pain, N/V/D. Notes some occasional r sided abdominal pain. Rest of ROS not obtainable due to patient's dementia and poor historian. Past Medical History: Alzheimers dementia hypertension NIDDM HYPERLIPIDEMIA GOUT ANXIETY ALLERGIC RHINITIS HYPOTHYROIDISM OSTEOARTHRITIS HIATAL HERNIA PAROTID ENLARGEMENT s/p bilat cataract [**Doctor First Name **]. h/o Acute renal failure [**2144**] due to sepsis / pneumonia, which resolved. Large RLL mass causing RLL collapse ? Diastolic CHF ? COPD Social History: Lives at [**Hospital **] [**Hospital **] Nursing Home with her husband. Unable to complete ADLs on her own, daughter involved in her care. No etoh, tobacco, illicits. Family History: Non contributory Physical Exam: On admission VS - 94.5, 92, 122/72, 35, 94% 3L NC GENERAL - chronically ill appearing female in NAD, comfortable, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - decreased BS at right base, slightly decreased airmovement diffusely, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - soft, ND, mild tenderness in R side of abdomen without rebound or guarding but only intermittently tender. EXTREMITIES - WWP, no c/c/, 2+ peripheral pulses (radials, DPs), 1+LE edema SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox1, CNs II-XII grossly intact, muscle strength [**6-10**] throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, gait defferred Pertinent Results: [**2149-5-16**] 05:50PM BLOOD WBC-12.4* RBC-3.05* Hgb-10.7* Hct-31.2* MCV-102* MCH-35.3* MCHC-34.4 RDW-17.3* Plt Ct-198 [**2149-5-18**] 04:05AM BLOOD WBC-18.7* RBC-2.97* Hgb-10.3* Hct-30.5* MCV-103* MCH-34.6* MCHC-33.6 RDW-17.7* Plt Ct-199 [**2149-5-16**] 05:50PM BLOOD Glucose-176* UreaN-109* Creat-5.7*# Na-131* K-5.7* Cl-87* HCO3-19* AnGap-31* [**2149-5-18**] 03:30PM BLOOD Glucose-73 UreaN-22* Creat-1.2* Na-138 K-4.2 Cl-102 HCO3-21* AnGap-19 [**2149-5-16**] 05:50PM BLOOD ALT-29 AST-44* LD(LDH)-236 CK(CPK)-119 AlkPhos-95 Amylase-252* TotBili-0.3 [**2149-5-18**] 09:30AM BLOOD ALT-47* AST-101* LD(LDH)-390* AlkPhos-45 TotBili-0.1 [**2149-5-16**] 05:50PM BLOOD Lipase-1082* [**2149-5-18**] 09:30AM BLOOD Lipase-1801* [**2149-5-16**] 05:50PM BLOOD CK-MB-5 proBNP-8641* [**2149-5-16**] 05:50PM BLOOD Lactate-5.5* [**2149-5-18**] 03:33PM BLOOD Lactate-4.2* Brief Hospital Course: This is an 81 yo F with dementia, hiatal hernia, RLL mass who presents with lethargy, decreased PO intake, SOB, and ARF. . #. PEA: The patient went into PEA and then aystole. She was DNR/DNI. . #.Respiratory failure/HAP: The patient had a known RLL mass, that was likely causing a post obstructive pneumonia. Given her large hiatal hernia she was at increased risk of aspiration and the infiltrate in her RLL and RML lung zones was larger suggestion recent aspiration. She was treated for a possible HAP. She was placed on vancomycin, cefepime, levoqin, and flagyl. After her first night in the ICU her levoquin was discontinued. She was also treated with nebs. She was ventilated her first evening in the ICU with non-invasive BiPAP for hypercarbia which was likely secondary to dilaudid. She also had evidence of volume overload and was on CVVH. The next morning in the ICU her respiratory status continued to decline with increasing oxygen requirement. The patient was DNR/DNI. She was continued on facemask oxygen. . #.Anuric renal failure: The patient had a collapsed bladder leading to anuria. Her renal dopplers were negative. A IJ HD catheter was placed and she was started on CVVH. The patient was noted to be hypocalemic and was started on continous calcium infusion. . #. RUQ pain: The patient had intermittent RUQ pain. A CT of the abdomen showed pancreatitis and cholelithiasis. She was kept NPO and was written for morphine PRN. . #. Acidosis: The patient had acidosis that was partly uremic and partly lactic. Her acidosis was likely secondary to her taking metformin in setting of renal failure. She was changed to an ISS and her acidosis was improving. . #. Elevated lactate/AG acidosis: Her AG acidosis was likely from relatively poor perfusion in the setting of hypovolemia due to poor PO intake. The concurrent use of metformin was likely contributing to her acidosis in the setting of renal failure. Uremia was likely also contributing to her acidosis. . #. Hyperkalemia: She had hyperkalemia likely from ARF. She had no EKG changes and was treated with kayexelate as well as CVVH. . .#. HTN: She was continued on her home verapamil. An arterial line was placed to better monitor her BP. . . #. Gout: Allopurinol was held in the setting of renal failure. . #. Hyperlipidemia: She was continued on her home simvastatin. . #. Hypothyroidism: She was continued on levothyroxine. . #. Dementia: She was continued on home aricept and namenda . . #. PPx - DVT ppx with SQ Heparin, bowel regimen, and PPI. . #. Code - DNR/DNI . # Comm: [**Name (NI) 3692**] [**Name (NI) **] daughter/HCP Phone: [**Telephone/Fax (1) 102055**] Medications on Admission: Lantus 5 units qhs Verapamil SR 240mg PO BID Metformin 500mg PO BID Glipizide 5mg PO BID Novolin SS Lasix 60mg PO BID Prednisone 2.5mg PO daily (for ? COPD) Atrovent 4x/day Albuterol neb 3x/day Ferrous Sulfate 325mg PO daily Namenda 5mg PO BID Aricept 10mg PO qhs Levothyroxine 75mcg PO daily calc/vit D Allopurinol 300mg PO daily MVI Tylenol PRN ASA 81mg PO daily Simvastatin 80mg PO daily omeprazole 40mg PO BID Fexofenadine 180mg PO daily Discharge Medications: Deceased Discharge Disposition: Expired Discharge Diagnosis: deceased Discharge Condition: deceased Discharge Instructions: deceased Followup Instructions: deceased [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**] Completed by:[**2149-6-3**]

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icd9cm

[ [ [] ] ]

[ "38.95", "39.95" ]

icd9pcs

[ [ [] ] ]

7233, 7242

4046, 6707

326, 332

7294, 7304

3164, 4023

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7328, 7338

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259, 288

360, 1686

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18,345

194,134

4609

Discharge summary

report

Admission Date: [**2111-9-24**] Discharge Date: [**2111-9-26**] Date of Birth: [**2068-10-17**] Sex: M Service: MEDICINE Allergies: Aspirin / Iodine; Iodine Containing / Norvasc Attending:[**First Name3 (LF) 134**] Chief Complaint: transferred from [**Hospital1 **] for cath tomorrow (presumably after aspirin desensitization tonight, though pt refuses) Major Surgical or Invasive Procedure: Cardiac cath with stenting of the LAD. History of Present Illness: 42yo with extensive cardiac history including multiple RCA interventions, s/p CABG in [**2104**] with radial artery to the RCA, s/p OM2 stent in [**3-22**], s/p VF arrest during LAD stenting at [**Hospital1 498**] in [**6-22**], s/p AICD placement [**8-23**], who was transferred from [**Hospital1 **] for diagnostic catheterization. He reported SSCP x 1mo which was associated with minimal exertion, diaphoresis, and chest heaviness. This occurred daily and lasted <5mins, resolved spontaneously or with sublingual nitrogen. He reported that his AICD has paced but has not defibrillated since [**7-1**]. His PCP sent him for a ETT with sestimibe, which was positive for sx, negative for ST changes, positive for new anteroapical ischemia. He was thus referred to [**Hospital1 **] for an elective catheterization today. Cath findings include 90% occlusion in the LAD above the prior stent, other stents patent, other vessels and radial graft without problems. [**Name (NI) **] has an allergy to [**Name (NI) **], and was premedicated with prednisone 60mg, benadryl 25mg, and zantac 150mg prior to cath today. He has not had any problems with [**Name2 (NI) **] when premedicated. He also has an ASA allergy, reports swelling of his throat and hives; he has not had any ASA x 12yrs. His last stent at [**Hospital1 18**] was treated with plavix and integrelin x 18h. He adamantly refuses ASA desensitization and was very agitated when ASA was mentioned, with SBP increasing to the 170s. He reports chest heaviness beginning when the RN began to ask him about ASA desensitization. At the OSH, VSS were stable with HR 70s, BP 120s-140s/70s-80s, SaO2 96%/RA. He was started on heparin gtt at 900units/hr starting at 155pm w/ a 4000unit bolus. Past Medical History: CAD s/p MIs in [**2103**], [**2107**], [**2108**] s/p CABG [**2104**] s/p stents to mid-LAD, OM2, RCA, LCx HTN hypercholesterolemia h/o facial palsy, idiopathic, occurs every couple years and resolves with steroids Social History: h/o tobacco use, just walked out on wife who is an alcoholic 3d ago, h/o noncompliance w/ meds secondary to financial situation Family History: Mother died MI age 51 paternal grandfather died MI age 50 Brother age MI age 49 Physical Exam: VS: T97.9, HR 81, ABP 133/76, RR 18, SaO2 96%/2L Genl: slightly agitated man lying in bed in NAD except when ASA mentioned HEENT: NCAT, PERRL, MMM, OP clear Neck: JVP 2cm above sternal notch, no carotid bruits CV: RRR, nl S1, S2, I/VI systolic murmur at LSB Pulm: CTA bilaterally Abd: decreased BS, soft, nontender, nondistended GU: femoral sheath in place, clean/dry/intact, no bruits, no hematoma, no tenderness Ext: warm and dry, DP and PT 2+, no edema Neuro: grossly nl, no facial droop Pertinent Results: EKG: NSR at 70bpm, nl axis, nl intervals, old q waves in II, III, avF, no ST changes, no TWI; no sig change from previous . ETT: appropriate exercise tolerance (8.6 METs), 94% of max HR, w/ appropriate BP response, occ PVCs in recovery, CP c/w angina, no ST chnages, septal and apical akinesis, LVEF 35%, nl LV size and thickness; distal anterior, anteroseptal, inferior, distal inferolateral, inferoapical, inferoseptal, distal anterolateral defects (old), new anteroapical ischemia. . C Cath [**2111-9-25**] COMMENTS: 1. Successful predilation using a Voyager 2.5 X 12 balloon, stenting using a Cypher 3.5 X 18 stent and post dilation using NC Ranger 3.5 X 15 and 4.0 X 15 balloons of the proximal LAD with lesion reduction from 95% to 0%. The final angiogram showed TIMI III flow with no dissection and no distal embolisation. 2. Dipyridamole commenced due to severe Aspirin allergy. Clopidogrel to continue indefinitely. FINAL DIAGNOSIS: 1. Successful stenting of the proximal LAD lesion. 2. Antiplatelet therapy with Clopidogrel and Dipyridamole (due to severe Aspirin allergy) Cath results ([**6-21**]): 1. Two vessel coronary artery disease. 2. Mild systolic ventricular dysfunction. 3. Stenting of the mid LAD. COMMENTS: 1. Selective coronary angiography of this right dominant system demonstrated two vessel coronary artery disease. The LMCA was without angiographic disease. The LAD was difusely disease with maximum stenosis of 70% in the mid segment and 60-70% distally. The LCX had diffuse lumenal irregularities with a widely patent stent in the LCX-OM. The RCA was totally occluded in the mid segment with good distal filling via the radial->RCA graft. 2. Resting hemodynamics demonstrated mildly elevated left sided filling pressures, LVEDP=17 mmHg, and normal right sided filling pressures. 3. Left ventriculography demonstrated depressed ejection fraction estimated at 45% with inferior hypokinesis. 4. Successful stenting of the mid LAD with a 2.5 x 18 mm Cypher (drug-eluting) stent. . Cath results ([**3-22**]): 1. Two vessel coronary artery disease. Patent radial artery graft to rPDA. 2. Successful direct stenting of the OM2. COMMENTS: 1. Coronary angiography revealed two vessel disease in this right dominant system. LMCA had no flow-limiting lesions. LAD had mild luminal irregularities throughout its course with two 60% lesions in the mid and distal segments. Small D2 had a 99% lesion. LCX was ectatic in the proximal segment, large OM2 branch had a 90% proximal lesion. RCA had several in-stent lesions proximally and was totally occluded in the mid segment. RA-PDA was patent. 2. Hemodynamics showed normal central aortic pressure. 3. LEft ventriculography was not performed. 4. Successful direct stenting of the OM2 was performed using a 2.5x13 mm [**Name (NI) **] Sonic [**Name2 (NI) 19576**], post-dilated using a 2.5 mm balloon. There was no residual stenosis, normal flow, and no apparent dissection. . Cath results ([**7-/2104**]): FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Successful PTCA and stenting of the RCA (see PTCA comments). COMMENTS: 1. Coronary angiography in this right dominant circulation revealed 2 vessel coronary artery disease. The left main artery showed diffuse 20% stenosis. The left circumflex and large OM1 had mild irregularities only. The LAD revelaed a discrete 60% mid stenosis, and the diagonals were small diffusely diseased vessels. The RCA was widely patent at the level of the previous stent proximally, with 20% diffuse in-stent restenosis. There were serial stenoses distal to the stent with 80%, 60%, and 80% stenoses with the most distal of these lesions occurring at the origin of an aneurysmal section of the distal RCA, before the PDA origin. 2. Successful PTCA and stenting of the RCA (see PTCA comments). . Cath results ([**2-/2104**]): FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Successful stenting of the proximal RCA (see PTCA Comments). COMMENTS: 1. Limited coronary angiography revealed an 80% restenotic lesion of the proximal RCA with diffuse ectasia in the vessel. There was extensive calcification and possibly a stented region in the proximal RCA just after the lesion as well. 2. Successful placement of a PS204 bililary stent in the proximal RCA expanded to 4.5 mm with 0% residual stenosis (see PTCA Comments). 3. Probable contrast allergy with hives. 4. Hematoma after reopro/heparin treated with compression and protamine. Brief Hospital Course: Assessment: 42yo man with extensive h/o cardiac dz, including CAD s/p single vessel CABG and multiple stents (RCA, Cx, LAD) after multiple MIs, s/p AICD placement, h/o vfib arrest w/ LAD stent, here for ASA desensitization and premedication for LAD stenting of lesion proximal to old LAD stent tomorrow. . Plan: . 1. [**Name (NI) 19577**] pt was admitted for therapeutic cath with Dr. [**Last Name (STitle) 1295**] to treat 90% LAD occlusion above prior LAD stent. The pt was found to have 95% proximal LAD lesion which was successfully treated with a cypher stent. The pt was given pre and post cath hydration as well as heparin and integrillin X18 hours prior to cath. He refused ASA desensitization and dipyridamole was commenced due to severe Aspirin allergy. Clopidogrel was also written post-cath. The pt experienced some chest heaviness post-cath which was successfullt treated with a nitro drip off which he was eventually weaned. Throughout his admission he was continued on metoprolol, lisinopril, plavix and statin. 2. h/o V fib - Pt has a h/o V fib for which an AICD had been placed. He was monitored on telemetry throughout his admission. 3. h/o systolic dysfunction - Throughout his admission the pt remained clinically not in CHF. His I/Os, sats, and sympotatology were monitored throughout the admission. . 4. GERD - The pt was placed on protonix and IV heparin. . 5 FEN: Pt on cardiac diet throughout admission. 6. Commmunication was with HCP: pt's wife [**Telephone/Fax (1) 19578**] 7. Code status: full Medications on Admission: Plavix 75mg qd Crestor 10mg qd Lisinopril 40mg qd Metoprolol 50mg [**Hospital1 **] Protonix 40mg qd fish oil 1000mg qd Discharge Disposition: Home Discharge Diagnosis: coronary artery disease Discharge Condition: good Discharge Instructions: Please follow-up with Cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**] and PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 17122**] [**Last Name (NamePattern1) 5448**] as below. Please contact your PCP or go to [**Name (NI) **] if you experience: --chest pain --shortness of breath Contact PCP or go to ED if pain at cath site does not resolve or if you note swelling in that area. Followup Instructions: Please contact Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**] and set-up appointment for 2-3 weeks from discharge. Please contact PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 17122**] [**Last Name (NamePattern1) 5448**] ([**Telephone/Fax (1) 19579**] and set-up appointment for one month from discharge

[ "414.01", "272.0", "530.81", "401.9", "412", "V45.81", "V45.02" ]

icd9cm

[ [ [] ] ]

[ "00.40", "99.20", "88.56", "00.45", "00.66", "37.22", "36.07" ]

icd9pcs

[ [ [] ] ]

9435, 9441

7736, 9265

428, 469

9509, 9516

3247, 4179

10004, 10359

2638, 2720

9462, 9488

9291, 9412

7110, 7713

9540, 9981

2735, 3228

267, 390

497, 2236

2258, 2475

2491, 2622

42,013

131,114

16256

Discharge summary

report

Admission Date: [**2169-11-7**] Discharge Date: [**2169-11-10**] Date of Birth: [**2092-9-12**] Sex: M Service: MEDICINE Allergies: Percocet Attending:[**First Name3 (LF) 358**] Chief Complaint: fever, abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: 77M s/p colectomy and liver resection presents with fever, hypotension and abdominal pain. The pt. initially presented in [**2164**] with bright red blood per rectum, abdominal pain, and weight loss, which led to an emergent colon resection in [**State 108**] for an obstructing mass with ulceration within the colon. This mass revealed moderately differentiated adenocarcinoma with clear margins and 5 nodes were sent and 0 of 5 lymph nodes involved. A staging CT scan at that time was negative for metastasis. He had a CEA of 1.3 back in [**2164**] and then underwent adjuvant 5-FU with leucovorin beginning in [**2164-5-8**] through [**2164-10-8**]. He completed 6 cycles of this chemotherapy. Mr. [**Known lastname 1007**] had a surveillance colonoscopy on [**2165-2-20**], which revealed more than 10 mixed non-bleeding polyps throughout his entire colon. These were found to be adenomas by pathology and he subsequently underwent subtotal colectomy on [**2165-7-23**]. He underwent surgery on [**2169-6-20**] and had an extended right hepatic lobectomy, cholecystectomy and extensive lysis of adhesions. The specimen within the liver revealed metastatic, moderately differentiated adenocarcinoma consistent with colon primary. Started chemotherapy [**10-16**] with Xeloda and Oxaliplatin. Patient has been feeling poorly for approx 1 week with, fevers, chills, aching. Called oncologist's office reporting 6 days of general malaise, arthralgias, myalgias, fever, and mild cough. He also has decreased appetite and diarrhea. He reports being "in bed for 6 days" but had not sought medical attention. On arrival to ED, T 102 R 93, 96% 2LNC BP 114/73, 2 Large Bore IV's placed. patient received NS 1000cc x6, Patient received Unasyn 3gm x 1, Vanc 1gm x 1, Zosyn 4.5mg IV x1. Underwent CT Abd. Had BM x1 described as diarrhea, tylenol 650mg PO. Surgery was consulted that stated that there was no acute surgical process. Upon arrival to the unit, the pt was resting comfortably. Complains of mild RUQ pain. Denies CP/SOB. Reports that his chemotherapy regimen was stopped one week ago for side effects of rash. Reports chronic diarrhea but no change from baseline. Past Medical History: # Colon Ca (s/p resection, chemo) # PUD # BPH # COPD # OSA # Dyslipidemia # Gout # Arthritis # Extended right Hepatic Lobectomy (4B,5,6,7,8), [**2169-6-20**] # Left colectomy [**4-/2164**], # Subtotal Colectomy & Ventral Hernia Repair [**7-/2165**], # Percutaneous cholycystectomy [**5-16**] ALL: Percocet - Itching PCP: [**First Name4 (NamePattern1) 2048**] [**Last Name (NamePattern1) 46364**] Social History: Pt is a retired police officer. Denies EtOH, illicits, IVDA. Continues to smoke a few cigarettes a day. Family History: Non-contributory Physical Exam: upon transfer to medical floor: Vitals: Tc 99.1 Tm 100.4 BP 100/56 (94/50-111/54) RR 18 O2sat 97% on 2LNC Gen: NAD lying comfortably and speaking full sentences Heent: MMM Resp: Clear to auscultation b/l Card: RRR no mrg Abd: RUQ>RLQ tenderness, distended, no peritoneal signs Extr: WWP Neuro: Alert and oriented. Pertinent Results: LABS ON ADMISSION: [**2169-11-7**] 11:46AM WBC-11.1*# RBC-3.96* HGB-12.2* HCT-34.6* MCV-88 MCH-30.7 MCHC-35.1* RDW-17.3* [**2169-11-7**] 11:46AM NEUTS-40* BANDS-9* LYMPHS-19 MONOS-29* EOS-0 BASOS-0 ATYPS-2* METAS-1* MYELOS-0 [**2169-11-7**] 11:46AM PLT COUNT-215# [**2169-11-7**] 11:46AM PT-15.7* PTT-27.3 INR(PT)-1.4* [**2169-11-7**] 11:46AM CK-MB-NotDone [**2169-11-7**] 11:46AM cTropnT-<0.01 [**2169-11-7**] 11:46AM ALT(SGPT)-19 AST(SGOT)-21 CK(CPK)-71 ALK PHOS-163* TOT BILI-2.0* [**2169-11-7**] 11:46AM LIPASE-16 [**2169-11-7**] 11:46AM ALBUMIN-3.5 CALCIUM-8.8 PHOSPHATE-3.4 [**2169-11-7**] 11:46AM GLUCOSE-133* UREA N-18 CREAT-1.8* SODIUM-132* POTASSIUM-3.9 CHLORIDE-98 TOTAL CO2-21* ANION GAP-17 [**2169-11-7**] 02:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [**2169-11-7**] 02:10PM URINE RBC-0 WBC-0 BACTERIA-RARE YEAST-NONE EPI-0 [**2169-11-7**] 02:10PM URINE HYALINE-[**4-12**]* [**2169-11-7**] 02:10PM URINE MUCOUS-FEW [**2169-11-7**] 07:33PM LACTATE-1.7 IMAGING: CXR: Lungs are clear without evidence of pneumonia or CHF. There is basilar atelectasis. There is no pneumothorax or pleural effusion. The cardiomediastinal silhouette is normal. The aorta is somewhat ectatic. There are surgical clips at the GE junction, likely due to previous fundoplication. There are calcified splenic granulomas and surgical clips in the left upper quadrant. The bones are unremarkable. Imp: No acute intrathoracic process. CT Abd/Pelvis without contrast [**11-7**]: Long segment of abnormally thickened right sided distal small bowel proximal to colonic pelvic anastomosis. Diff. dx includes ischemia, as well as infection/inflammatory CT abd/pelvis with po and IV contrast [**11-10**] - Mild decrease in the thickening of the small bowel loops in the right abdomen. Mucosal enhancement of these bowel loops excludes ongoing ischemia, but reperfusion injury can not be excluded. Infectious etiologies of the small bowel are more likely though. No perforation or abscess. Brief Hospital Course: 1) Fevers/abdominal pain: Presented with fevers and R sided abdominal pain. CT abd/pelvis without contrast revealed thickening of the small bowel prior to the anastamosis site as well as surrounding inflammatory changes. Surgery was consulted who felt that findings were unlikely secondary to anastomotic failure and that there were no acute surgical issues. He was given broad spectrum IV antibiotics, IVFs for SBPs in the 70-80s and admitted to the MICU. In the MICU, the pt was further fluid resuscitated and received approximately at total of 13 L of IVFs during his ED and MICU course. Anti-hypertensives were held and the patient never required pressors. He was placed on IV vancomycin, zosyn, and flagyl and stools cultures were sent which were significant for C diff neg X 1. He was transferred out of the ICU to the medical floor where he underwent a CT abd/pelvis with IV and po contrast (once ARF had resolved) per surgery recs which showed some resolution of the previously seen small bowel wall thickening prior to the anastomosis site with mucosal enhancement preserved, thus making the possibility of ischemic bowel less likely. An infectious or inflammatory process was most likely. Further stool cultures were negative for C diff neg X 2, and were also negative for Salmonella, shigella, E Coli O157:H7, Campylobacter, and O&P negative. A viral process was thought to be most likely, but as stool cxs were not entirely finalized at the time of discharge, he was discharged home on a 7 day course of po ciprofloxacin. In terms of the remaining fever work-up, urine and blood cultures were negative. 2) Hyponatremia: Na 132 from baseline of 140s, in setting of elevated Cr 1.8 from baseline 0.8. on admission. Hyponatremia thought to be due to hypovolemia and resolved with IVFs. 3) ARF: Cr 1.8 from baseline of 0.8 - 1.2 on admission. Etiology likely prerenal from dehydration vs. ATN from hypotension. Cr trended downward to 1.1 at the time of discharge with IVFs. The patient was given IVF with HCO3 and mucomyst prior to contrast administration for CT abd/pelvis . 4) Metastatic colon CA: Xeloda recently discontinued prior to admission due to rash. Further plan per the pt's primary oncology team. FEN: NPO for now, replete lytes PRN 5) Anemia: Hct 31 on admission and trended downward to 24 in the setting of 13L IVFs. There were no signs of GI bleeding and the patient remained HD stable. At the time of discharge, repeat Hct 29. Medications on Admission: [**Doctor First Name **] 180mg Ambien 5mg MVI Citracal + D Imodium A-D 2mg Lisinopril 10mg PO Daily Pravachol 40mg PO Daily Protonix 40mg PO Daily Tylenol 325mg PO Daily Tylenol-Codeine #3 300mg-30 Vitamin D 400mg Po Daily Xeloda 500mg PO Daily (Recently D/C'd) Discharge Medications: 1. Pravachol 40 mg Tablet Sig: One (1) Tablet PO once a day. 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Tylenol-Codeine #3 300-30 mg Tablet Sig: Two (2) Tablet PO at bedtime. 4. [**Doctor First Name **] 180 mg Tablet Sig: One (1) Tablet PO once a day. 5. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain: do not exceed greater than 4g tylenol/day. 6. Vitamin D 400 unit Tablet Sig: One (1) Tablet PO once a day. 7. Citracal + D 315-200 mg-unit Tablet Sig: Two (2) Tablet PO once a day. 8. Centrum Silver 500-250 mcg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 9. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 4 days. Disp:*8 Tablet(s)* Refills:*0* 11. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day. Disp:*30 Capsule, Sustained Release(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Sepsis Acute renal failure Abdominal pain Diarrhea Hyponatremia Secondary Diagnosis: Metastatic colon cancer COPD Hyperlipidemia Gout Arthritis BPH Discharge Condition: Stable. Blood pressures stable, diarrhea resolving, afebrile, ambulating independently without difficulty. Discharge Instructions: You wre admitted with flu-like symptoms including mild cough, fever/chills, malaise, muscle aches, abdominal pain, and diarrhea. You had two CT scans of your abdomen that showed possible inflammation or infection in your small bowel. You were seen by the surgeons who did not feel you had an acute surgical issue. A possible infection was treated with IV antibiotics, which was transitioned over to a pill called ciprofloxacin by the time of discharge. Please continue to eat and drink as much fluids as possible. You were dehydrated when you came in and had some kidney failure, which has resolved with IV fluids. The following changes were made to your medications: 1) You will need to take an antibiotic called ciprofloxacin for a total of 1 week. You have 4 days remaining. 2) We have started you on a daily potassium supplement due to your chronic diarrhea and loose stools. Please take 10 mEq of potassium chloride a day. Please follow-up with your PCP [**Name Initial (PRE) 176**] 1 week and have your potassium blood level checked. 3) We are continuing to hold lisinopril, a blood pressure medication, until your diarrhea is back to baseline as you came in with low blood pressures. Please speak to your PCP [**Last Name (NamePattern4) **] 1 week about possibly restarting this. 4) Please take all other medications as previously prescribed. Please call your doctor or return to the emergency room if you experince any of the following: fever > 101, lightheadedness, chills, increasing abdominal pain or diarrhea, bloody or dark, black colored stools, nausea, or vomiting. Followup Instructions: Please follow-up with your PCP [**Name Initial (PRE) 176**] 1 week. You will need to have your potassium and red blood cell level checked. You will also need to have your blood pressure checked and should ask your doctor about possibly restarting lisinopril. Please follow-up with your oncologist, Dr. [**Last Name (STitle) **], in regards to your treatment plan within 2 weeks. Please call ([**Telephone/Fax (1) 45687**] to make an appointment. Completed by:[**2169-11-11**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9379, 9385

5528, 7986

291, 298

9597, 9706

3439, 3444

11338, 11817

3066, 3084

8298, 9356

9406, 9406

8012, 8275

9730, 11315

3099, 3420

230, 253

326, 2508

9511, 9576

9425, 9490

3458, 5505

2530, 2929

2945, 3050

67,715

117,091

38220

Discharge summary

report

Admission Date: [**2116-5-12**] Discharge Date: [**2116-5-18**] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Increasing shortness of breath Major Surgical or Invasive Procedure: [**2116-5-13**] Aortic Valve Replacement(21mm St. [**Male First Name (un) 923**] Porcine) [**2116-5-12**] Cardiac Catheterization History of Present Illness: This is a [**Age over 90 **] year old female who presented with increasing shortness of breath with exertion. She has known severe aortic stenosis by echocardiogram. Prior to aortic valve replacement surgery, she was admitted for cardiac catheterization. Past Medical History: Aortic Stenosis Type II Diabetes Mellitus Depression History of Pneumonia [**2113**] s/p Cataract Surgery Social History: Lives: alone in CT - staying with daughter currently Occupation: retired teacher Tobacco: None ETOH: None Illicit Drugs: None Family History: No premature coronary artery disease Physical Exam: On Admission Pulse: 81 Resp: 16 O2 sat: 97 RA B/P Right: 161/75 Left: 157/69 Height: 5'2" Weight: 63.5 kg General: Elderly female in no acute distress Skin: Dry [x] areas under breast bilateral with minimal skin breakdown - history of problems, chest with moles [**Name (NI) 4459**]: [**Name (NI) 22031**] [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur 3/6 systolic Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] no palpable masses Extremities: Warm [x], right foot cooler than left Edema: trace Varicosities: multiple superficial bilat LE Neuro: Grossly intact, nonfocal exam Pulses: Femoral Right: cath site Left: +2 DP Right: +1 Left: +1 Radial Right: +2 Left: +2 Carotid Bruit Right: trans murmur Left: trans murmur Pertinent Results: [**2116-5-12**] WBC-7.2 RBC-3.85* Hgb-10.9* Hct-33.5* Plt Ct-243 [**2116-5-12**] PT-13.5* PTT-21.8* INR(PT)-1.2* [**2116-5-12**] Glucose-187* UreaN-16 Creat-1.0 Na-138 K-4.3 Cl-103 HCO3-26 [**2116-5-12**] ALT-10 AST-17 AlkPhos-82 Amylase-72 TotBili-0.4 [**2116-5-12**] %HbA1c-7.4* [**2116-5-12**] Cardiac Catheterization: 1. Selective coronary angiography in this right dominant system demonstrated no angiographically apparent coronary artery disease. The LMCA, LAD, LCx, and RCA were all free of angiographically apparent flow-limiting coronary artery disease. There was a fistula seen from the proximal LAD to the left pulmonary artery. 2. Limited resting hemodynamics revealed moderate arterial systolic hypertension (SBP 163mmHg). [**2116-5-13**] Intraop TEE: PRE-BYPASS: There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results before CPB. POST-BYPASS: Normal biventricular systolic function. LVEF 55%. Intact thoracic aorta. There is an aortic bioprosthesis located in the native aortic position, well seated and functioning well with a residual mean gradient of 12mm of Hg. There is no perivalvular leak. Mild TR. [**2116-5-17**] 04:25AM BLOOD WBC-10.9 RBC-3.52* Hgb-10.3* Hct-31.1* MCV-88 MCH-29.1 MCHC-33.0 RDW-15.0 Plt Ct-171 [**2116-5-18**] 09:44AM BLOOD PT-17.9* PTT-25.6 INR(PT)-1.6* [**2116-5-18**] 09:44AM BLOOD UreaN-29* Creat-1.5* Na-130* K-4.5 Cl-96 Brief Hospital Course: Mrs. [**Known lastname 85196**] was admitted and underwent routine preadmission testing which included a cardiac catheterization. Left heart catheterization revealed normal coronary arteries. The remainder of her preoperative workup was unremarkable and she was cleared for surgery. [**2116-5-13**] Dr. [**Last Name (STitle) **] performed aortic valve replacement surgery. See operative report for further details. After surgery, she was brought to the CVICU for invasive monitoring. Within 24 hours, she awoke neurologically intact and was extubated without incident. On postoperative day one, she was noted to have an asymptomatic 15 beat run of ventricular tachycardia. Electrolytes were repleted per protocol and beta blockade was resumed. All lines and drains were discontinued in a timely fashion. Beta-blocker/Statin/Aspirin was intitiated. POD#3 Ms.[**Known lastname 85196**] went into postoperative rapid atrial fibrillation. Anticoagulation was initiated with Coumadin. It was treated with Amiodarone, increased dosage of B-Blocker and she converted to NSR. POD#3 was transferred to the step down unit for further monitoring. Physical therapy consulted for evaluation of strength and mobility. She continued to progress and on POD# 5 she was cleared by Dr.[**Last Name (STitle) **] for discharge to [**Location (un) 1514**] [**Hospital **] rehabilitation. All follow up appointments were advised. Medications on Admission: Januvia 100 mg daily, Glipizide 10 mg daily, Metformin 500 mg [**Hospital1 **], Lipitor 10 mg daily Discharge Medications: 1. Aspirin 81 mg [**Hospital1 8426**], Delayed Release (E.C.) Sig: One (1) [**Hospital1 8426**], Delayed Release (E.C.) PO DAILY (Daily). 2. Ranitidine HCl 150 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO BID (2 times a day). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Metoprolol Tartrate 25 mg [**Hospital1 8426**] Sig: Three (3) [**Hospital1 8426**] PO TID (3 times a day). 5. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 10 days. 6. Lasix 40 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO once a day for 10 days. 7. Glipizide 5 mg [**Hospital1 8426**] Sig: Two (2) [**Hospital1 8426**] PO BID (2 times a day). 8. Metformin 500 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO BID (2 times a day). 9. Acetaminophen 325 mg [**Hospital1 8426**] Sig: Two (2) [**Hospital1 8426**] PO Q4H (every 4 hours) as needed for pain/temp. 10. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 11. Atorvastatin 10 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO DAILY (Daily). 12. Hydralazine 25 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO Q6H (every 6 hours). 13. Warfarin 1 mg [**Hospital1 8426**] Sig: [**Name8 (MD) **] MD [**First Name (Titles) 8426**] [**Last Name (Titles) **] Once Daily at 4 PM: INR goal 2-2.5 for AFib. 14. Warfarin 2 mg [**Last Name (Titles) 8426**] Sig: One (1) [**Last Name (Titles) 8426**] PO ONCE (Once) for 1 days. 15. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 16. Amiodarone 200 mg [**Last Name (Titles) 8426**] Sig: Two (2) [**Last Name (Titles) 8426**] PO BID (2 times a day): 400 mg twice daily x 7 days, then decrease to 200 mg twice daily x 7 days, then decrease to 200 mg once daily. 17. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). Discharge Disposition: Extended Care Facility: [**Hospital 1514**] Health Care Center - [**Location (un) 1514**] Discharge Diagnosis: Aortic Stenosis, s/p AVR Type II Diabetes Mellitus Depression Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: Dr. [**Last Name (STitle) **] #[**Telephone/Fax (1) 170**] appointment set up for [**6-18**] at 1:15pm Dr. [**First Name (STitle) 487**] or Dr. [**Last Name (STitle) 42367**] in [**12-14**] weeks, call for appt Dr. [**Last Name (STitle) **] in [**12-14**] weeks, call for appt Completed by:[**2116-5-18**]

[ "427.31", "997.1", "285.9", "458.9", "311", "E849.7", "414.19", "424.1", "250.00", "997.91", "427.1", "E878.4" ]

icd9cm

[ [ [] ] ]

[ "37.22", "39.61", "88.56", "35.21" ]

icd9pcs

[ [ [] ] ]

7452, 7544

3863, 5271

299, 431

7650, 7866

1940, 3840

8705, 9013

1005, 1043

5421, 7429

7565, 7629

5297, 5398

7890, 8682

1058, 1921

229, 261

459, 715

737, 845

861, 989

5,525

152,074

52636

Discharge summary

report

Admission Date: [**2109-9-20**] Discharge Date: [**2109-9-27**] Date of Birth: [**2050-4-3**] Sex: M Service: ADMITTING DIAGNOSIS: Infected [**Doctor Last Name 4726**]-Tex mesh. HISTORY OF PRESENT ILLNESS: Patient is a 59-year-old male status post kidney transplant on [**2109-8-5**] with postoperative cause complicated by wound dehiscence requiring replacement of an abdominal wall [**Doctor Last Name 4726**]-Tex mesh. The patient was subsequently discharged to rehabilitation facility, but was briefly readmitted to the Medical Center following an increase in his creatinine noted on [**2109-9-11**]. Patient was discharged home two days later following an improvement in his creatinine with hydration. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1661**]-[**Location (un) 1662**] drain draining the area around the [**Doctor Last Name 4726**]-Tex graft was discontinued just prior to the patient's discharge on [**2109-9-13**]. The patient returned to the Medical Center on [**2109-9-20**] for kidney biopsy when his creatinine levels were noted to be slightly increased once again. On arrival at the Medical Center, he was noted to have diffuse abdominal wall erythema. The decision was made to immediately return the patient to the operating room for the removal of a suspected abdominal wall [**Doctor Last Name 4726**]-Tex mesh. PAST MEDICAL HISTORY: End-stage renal disease (suspected viral etiology), hypotension, SBE in [**4-9**], gastroesophageal reflux disease. PAST SURGICAL HISTORY: Kidney transplant [**2109-8-6**], urethral dilatation, cataract surgery. ALLERGIES: None. MEDICATIONS AT HOME: Prednisone 5 q day, midodrine 7.5 mg tid, CellCept 1 gram [**Hospital1 **], fludrocortisone 0.1 mg q day, Reglan 10, Valcyte 450 q day, Neoral, Bactrim, Protonix, and ferrous sulfate. PHYSICAL EXAM: Vitals are 98.4, 80, 110/65, and 98% on room air. Lungs: Expiratory wheezes throughout. Cardiovascular: Regular, rate, and rhythm. Abdomen: Soft, obese, nondistended with blanching erythema throughout the anterior abdominal wall. The patient's surgical incision appeared well-healed. Rectal examination was guaiac negative and the patient had 2+ dorsalis pedis pulses. LABORATORIES: White blood cell count 6.0, hematocrit 27, platelets 242,000. Chem-7 was 138/4.9/106/17/71/4/133. HOSPITAL COURSE: Patient was taken to the operating room on [**2109-9-20**] where the [**Doctor Last Name 4726**]-Tex mesh was removed and replaced with a Dexon mesh. The patient was started on Vancomycin, Kefzol, and Flagyl intraoperatively. The mesh that was removed was sent to the Microbiology Lab for Gram stain and culture as well as some fluid found around the mesh. The patient was transferred to the SICU. The decision to keep the patient intubated was made because of his wheezy lung examination and the fact that he was a difficult intubation. The patient was ultimately extubated on postoperative day #2. Transferred to a General Surgical Floor and started on a regular diet. By postoperative day three, the patient's abdominal fluid culture returned with positive Corynebacterium only. This was suspected to be just normal skin flora. The patient's abdominal wall erythema had increased markedly since surgery. The patient remained afebrile and his renal function which on admission had a creatinine of 4 had decreased to 2.6 by postoperative day #3. The patient was still wheezy, although ventilating well. He did not complain of any shortness of breath. On postoperative day #4, the patient's abdominal wall incision was noted to be slightly separated at the superior pole. TID dressing changes with wound packing was initiated. The J-P output from the drain left at the site during surgery continued to put out a large amount of fluid (On postoperative day three, output out of the J-P drain was 1440 mL, on postoperative day four, it was greater than 950 mL, on postoperative day number five, it was greater than 1350 mL, on postoperative day number six it was 1150 mL, and postoperative day number seven was 975 mL). The J-P drain was kept on wall suction since with an open incision, the J-P bulb was not able to maintain suction on its own. By postoperative day number five, the patient's creatinine was down to baseline at 1.8. The patient remained afebrile and his incision looked clean with viable tissue and no surrounding erythema. The patient's white cell count had been noted to decrease from 5.9 on the day of admission to a low of 1.8 on postoperative day #5. The low white cell count was suspected to be secondary to the patient's Valcyte and CellCept. Decision was made to discontinue the Valcyte and to give the patient a dose of Neupogen. The patient's white cell count trend will need to be followed, but on postoperative day number six, it was up to 2.4. By postoperative day #7, the patient was deemed to be stable and ready for discharge to a rehabilitation facility for continued monitoring and wound dressing changes. The patient will be discharged on antibiotics by mouth and will need to followup with the [**Hospital 1326**] Clinic one week following discharge. Cultures from the patient's mesh and the fluid surrounding the mesh ultimately did not grow any pathogenic organisms. DISCHARGE MEDICATIONS: Neoral 150 mg po bid, fludrocortisone acetate 0.2 mg po q day, CellCept [**Pager number **] mg po bid, calcium carbonate 1 gram po tid between meals, prednisone 5 mg po q day, Protonix 40 mg po q day, Colace 100 mg po bid, Percocet 1-2 tablets po q4-6 hours prn, Bactrim single strength one tablet po q day, midodrine 7.5 mg po tid, and levofloxacin 500 mg po q day x14 days. CONDITION ON DISCHARGE: Stable. FOLLOWUP: Patient is to followup with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in the [**Hospital 1326**] Clinic seven days following discharge. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3598**], MD [**MD Number(1) 3599**] Dictated By:[**Name8 (MD) 997**] MEDQUIST36 D: [**2109-9-27**] 08:30 T: [**2109-9-27**] 08:38 JOB#: [**Job Number 61448**]

[ "584.9", "E878.2", "996.69", "998.59", "V42.0", "530.81", "288.0" ]

icd9cm

[ [ [] ] ]

[ "54.0", "54.72" ]

icd9pcs

[ [ [] ] ]

5325, 5702

2372, 5301

1661, 1846

1546, 1639

1862, 2354

229, 1382

152, 200

1405, 1522

5727, 6174

4,905

127,949

27340+57540

Discharge summary

report+addendum

Admission Date: [**2121-4-29**] Discharge Date: [**2121-5-5**] Date of Birth: [**2067-12-28**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 759**] Chief Complaint: seizures, hyponatremia Major Surgical or Invasive Procedure: none History of Present Illness: 53-year-old male prisoner who is being admitted for seizures and hyponatremia. He was reportedly on suicide watch at prison when he was noted to have seziure-like activity with bowel and bladder incontinence. He was transported to [**Hospital3 3583**] for evaluation. At [**Hospital3 3583**] he had a negative head/C-spine CT, but was noted to have severe hyponatremia with a serum sodium of 98. He was given 40cc of 3% normal saline and reportedly a liter of normal saline; although, the liter of saline is not documented. He was transfered to [**Hospital1 18**] for further treatment and evaluation. . On arrival to [**Hospital1 18**], he was given 2 mg of versed and started on a propofol gtt(60kg)(1.8ml/hr now). He was given 500cc of NS as well. His urine output at the OSH was approximately 4L and in the ED at [**Hospital1 18**] it was approximately 2-3 liters. On arrival his urine output was approx 1000cc/hour. Past Medical History: Depression Psychosis Traumatic Brain Injury Social History: He is a prisoner at [**Location (un) 3320**] County, and has a history of violence. Is married and has two children. Was a National Merit Scholar in high school and went on to become an electrical engineer before he was in a motor vehicle accident and developed a psychotic disorder. Family History: Unknown Physical Exam: VITALS: T 95.1, HR 67, BP 94/65, RR 19, O2 sat 100% VENT: AC 500/5/rate 10, 50% FiO2 GEN: Intubated. Sedated. HEENT: Supple neck. Slightly dry MM. CV: RRR LUNGS: decreased BS at bases, otherwise clear. ABD: soft, NT, ND EXT: no peripheral edema NEURO: Sedated, responds to pain, pupils equal, round and reactive Pertinent Results: ADMISSION: LABS at [**Hospital3 3583**]: Na 98, K 3.2, CL 61, HCO3 19, BUN 7, Cr 0.5, Gluc 126 WBC 11, HCT 40, PLT 427 . LABS at [**Hospital1 18**]: . ABG = 7.56/25/438 . Na 104, K 2.6, Cl 64, HCO3 20, BUN 5, Cr 0.6, Gluc 155 CK 4368, CK-MB 86, Trop T Ca 8.2, Mg 1.4, Phos 2.0, Albumin 4.4 . Serum osmolality = 223 Urine Osmolality = 82 . Serum Tox Screen = Negative for ASA, EtOH, TCA, benzo, barbs Urine Tox Screen = Negative for cocaine, benzos, barbs, opiates, amphet, methadone Urine Na 14, Cr 4, K 6, Cl 15, . UA: 100 gluc, 50 ket, 0-2 RBC, 0-2 WBC, sp gr 1.002 . DISCHARGE: Na 135 Brief Hospital Course: 53 year old man with seizures from hyponatremia secondary to primary polydipsia. Hospital course outlined by problem: # Hyponatremia with seziures - from excess water intake (primary polydipsia) with a low serum sodium and a very dilute urine. His urine osmolality was less than 100 mosmol/kg and his urine specific gravity was less than 1.003. Attempted to correct slowly with goal increase in Na by 1 Meq q2h by replacing free water 1:1 with UOP to prevent cetral pontine myelinosis. His sodium slowly rose to 135 before discharge. He was drinking normal amounts of ginger ale and boost. He was quickly extubated when he arrived at [**Hospital1 18**], having only been intubated for airway protection in the setting of his seizure. His sodium remained stable and within normal limits for the remainder of his hospital stay. Patient was instructed to limit his fluid intake to 2-3 liters per day at discharge and this was also communicated to the medical officer at his facility. . # Depression: His seroquel was increased to help him with sleep as well as help treat his depression. Psychiatry was consulted who felt that he would be best served at [**Location (un) 1475**] after he was medically cleared. However he could not be transferred there from [**Hospital1 18**] and would have to return to his old prison first. He remained with a 1:1 sitter by a prison guard and was shackled for protection of the staff/patients/and himself. Psychiatry consult will speak to mental health at facility. # Rhabdomyolosis - Improved with hydration. No residual renal failure noted. . # Transaminitis - NO stigmata of chronic liver disease. No obstructive pattern. Medications on Admission: Trazodone 100 mg QHS Seroquel 100 mg QHS Celexa 40 mg daily Discharge Medications: 1. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QID (4 times a day) as needed. 2. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 3. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 4. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). 5. Prochlorperazine 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. 6. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Discharge Diagnosis: Seizure Hyponatremia Primary polydispsia Hepatitis Discharge Condition: medically stable Discharge Instructions: Do not allow him to have free access to water given that he is at risk of trying to harm himself by drinking too much water. He should have up to 2-3 liters of fluids a day TOTAL. Patient should be under constant monitoring given his risk for suicidality. Followup Instructions: Please have psychiatry evaluate the patient for benefit of transfer to [**Location (un) 1475**]. Completed by:[**2121-5-5**] Name: [**Known lastname 399**],[**Known firstname 389**] Unit No: [**Numeric Identifier 11638**] Admission Date: [**2121-4-29**] Discharge Date: [**2121-5-5**] Date of Birth: [**2067-12-28**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2544**] Addendum: Spoke to [**Doctor Last Name **] of Mental Health at facility as well as their Medical Officer over the telephone to communicate the importance of fluid restriction, 1:1 observation, and consideration for inpatient psychiatric treatment for this patient. Discharge Disposition: Extended Care [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2545**] MD [**MD Number(2) 2546**] Completed by:[**2121-5-5**]

[ "780.39", "728.88", "783.5", "311", "276.1" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

6185, 6356

2657, 4326

337, 343

5066, 5085

2045, 2634

5389, 6162

1687, 1696

4436, 4933

4992, 5045

4352, 4413

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13623

Discharge summary

report

Admission Date: [**2134-9-6**] Discharge Date: [**2134-9-14**] Date of Birth: [**2061-3-16**] Sex: M Service: MEDICINE Allergies: Compazine / Reglan Attending:[**First Name3 (LF) 8810**] Chief Complaint: [**Hospital **] transferred from [**Hospital Unit Name 153**] for chemo Major Surgical or Invasive Procedure: PICC line History of Present Illness: This is 73 year old male with multiple medical problems including burkitt's lymphoma, seizure of unclear etiology, afib on amiodarone transferred from [**Hospital Unit Name 153**] to OMED service for induction of chemotherapy. . On evening of [**2134-9-5**] patient had two episodes of "shaking and gurgling," coherent but slurred speech and right mouth droop witnessed by his wife and a third witness by EMS where he received 2mg ativan with resolution of shaking. In [**Name (NI) **] pt felt to be post-ictal, did not remember ambulance ride, neuro consulted and pt loaded with Dilantin. CT head negative, LP performed and pt started on CTX and Vanco for meningitis prophylaxis. . His [**Hospital Unit Name 153**] course was notable for: Neruologic issues relating to possible seziure acitivty for which he recieved an LP, started on CTX/vanc. for broad spectrum meningitis coverage; EEG perfomred, overall not clear what this neurologic process was (stroke vs. seizures vs. infection); also treated for arachnoiditis with dexamethasone. Pt also with F and N, prior micro grew GNR in [**12-29**] bottle during last admission with Stenatropamonas, being treated with bactrim IV tid. While in unit, pt was in NSR, on amiodarone, lasix continued, plavix held [**1-27**] possible chemo. Other issues stable including Hct. . On transfer, patient reports no fever or chills, headache, chest pain, cough, shortness of breath, abdominal pain, nausea, or vomitting. Reports dizziness worsened with sitting up and constipation. . Transferred to OMED/HEME B service for further care. Past Medical History: 1. CAD s/p CABG in 82, stent - lmca-prox lcx (patent [**8-27**]), last stress [**2130**] nl w/o perfusion defects, was on ASA and Plavix until chemo due to low plt. 2. CHF - 67% EF, mild-mod MR, thickened aortic, but no stenosis or insufficiency on echo in [**2130**] 3. S/P R MCA CVA [**12-27**]-- on coumadin for 6mos 4. Parkinson's Disease- followed by Neuro at [**Hospital1 2025**]. On Staleva. 5. Spinal Stenosis 6. S/P L hernia repair [**2134-7-14**] 7. BPH, with known elevated PSA but nl biopsies, followed by urology 8. Hypercholesterolemia 9. GIbleed- [**8-/2131**], presumed small bowel source in setting of coumadin 10. Diverticuli 11. s/p cholecystectomy in 80's 12. s/p right hip replacement . Onc hx: Diagnosis - late [**2134-7-26**], diffuse adenopathy (axilla,chest, abd) Bx - MIB fraction 100%, cytogenetics amp c-myc, no translocation Tx - hyper-CVAD on [**2134-8-19**], complicated by rapid ventricular response atrial fibrillation & hypotension (ICU few days) -> started amiodarone & metoprolol rate control. . Social History: He is a retired judge. He continues to work as a mediator. He has a 40-pack-year smoking history. He quit in [**2098**] but has smoked a periodic cigar or pipe. He drinks wine or beer occasionally. He lives with his wife. Family History: His mother had [**Name2 (NI) 499**] cancer in early 40s. His brother has prostate cancer. His routine healthcare maintenance is significant for colonoscopies and endoscopy without findings of malignancy. Physical Exam: VS afebrile 136/71 63 16 94%RA Gen - Alert, no acute distress HEENT - PERRL, extraocular motions intact, anicteric, mucous membranes moist Neck - no JVD, no cervical lymphadenopathy Chest - Clear to auscultation bilaterally CV - Normal S1/S2, RRR, no murmurs, rubs, or gallops Abd - Soft, nontender, nondistended, with normoactive bowel sounds Back - No costovertebral angle tendernes Extr - No clubbing, cyanosis, or edema. 2+ DP pulses bilaterally Neuro - Alert and oriented x 3, cranial nerves [**2-6**] intact, no focal deficits, motor and sensory grossly intact in UE and LE's. Skin - No rash Pertinent Results: [**2134-9-6**] 06:40AM CEREBROSPINAL FLUID (CSF) PROTEIN-50* GLUCOSE-80 [**2134-9-6**] 06:40AM CEREBROSPINAL FLUID (CSF) WBC-3 RBC-9* POLYS-98 LYMPHS-1 MONOS-1 [**2134-9-6**] 05:31AM LACTATE-3.5* [**2134-9-6**] 03:08AM LACTATE-13.9* [**2134-9-6**] 02:45AM GLUCOSE-117* UREA N-22* CREAT-0.9 SODIUM-136 POTASSIUM-3.4 CHLORIDE-98 TOTAL CO2-14* ANION GAP-27* [**2134-9-6**] 02:45AM CK(CPK)-16* [**2134-9-6**] 02:45AM cTropnT-<0.01 [**2134-9-6**] 02:45AM CK-MB-NotDone [**2134-9-6**] 02:45AM CALCIUM-9.5 PHOSPHATE-3.2 MAGNESIUM-1.6 [**2134-9-6**] 02:45AM WBC-12.2* RBC-4.29* HGB-12.5* HCT-38.8* MCV-90 MCH-29.1 MCHC-32.2 RDW-16.7* [**2134-9-6**] 02:45AM NEUTS-77* BANDS-4 LYMPHS-12* MONOS-3 EOS-0 BASOS-0 ATYPS-1* METAS-2* MYELOS-1* [**2134-9-6**] 02:45AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL OVALOCYT-1+ TEARDROP-OCCASIONAL [**2134-9-6**] 02:45AM PLT COUNT-191# [**2134-9-6**] 02:45AM PT-13.7* PTT-22.2 INR(PT)-1.3 [**2134-9-6**] 02:45AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010 [**2134-9-6**] 02:45AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG . bld cx no growth, CSF negative to date . Studies: [**9-6**] CXR-- Patchy opacity in the left retrocardiac area, likely due to atelectasis. Aspiration is considered less likely. No pleural effusions. . [**9-6**] CT HEAD-- no IC bleed . [**9-6**] FDG scan-- 1. No focal abnormal areas and a increased FDG uptake. 2. Lytic lesions within the right ilium and superior aspect of the left acetabulum as described above. These are of uncertain etiology or significance, but not do not demonstrate any significant FDG uptake. Tiny calcifications which may be present in the right iliac lesion may be related to a focus of treated lymphoma. Correlation with past history is recommended. 3. Diverticulosis without diverticulitis. 4. Bibasilar pulmonary scarring with somewhat more consolidative changes at the right lung base. 5. Marked coronary calcifications Brief Hospital Course: 73 y.o male with Burkitt's lymphoma presents with new seizures after recent intrathecal [**Hospital 3454**] transferred to OMED/BMT B service to initiation of CODOX chemotherapy [**9-7**]. . Plan: ## Neuro: Patient's seizure was likely secondary to intrathecal chemo causing irritation of epileptogenic foci from a prior R MCA stroke, arachnoiditis from chemo, infection or stroke. A MRI/MRA was performed to evaluate for new stroke and carotids for evidence of source. MRA did show moderately significant carotid stenosis bilaterally that will require resumption of Plavix once patient completes chemotherapy. Head CT was negative for new bleed or mass. Patient was started on ceftriazone, vancomycin and acyclovir for possible infectious meningitis. CSF fluid had 4+ PMNs on CSF gram stain and there was no growth on culture. HSV PCR and EEG were negative. For possible arachnoiditis secondary to intrathecal ara-C, patient was continued on dexamthasone and then gradually tapered. Finally, patient was loaded with dilantin and switched over to keppra at the time of discharge. From the time of transfer from the [**Hospital Unit Name 153**] to the discharge day, patient was seizure free and complained only of improving symptoms of left hand weakness (thought to be post-ictal re-expression of stroke symptoms per neurology) and lightheadedness (orthostatics within normal limits). Patient was instructed to wait a couple of minutes before moving after standing up. . ## Lymphoma: Last chemo [**2134-9-3**] with intrathecal ARA-C and prior to this hyper-CVAD on [**2134-8-27**]. CSF on [**2134-9-3**] was negative for malignancy. PET-CT shows no additional areas of abnormal FDG uptake. PETCT also shows lytic lesions within R illium and L acetabulum (previously known). Patient had a porta-cath placed for chemotherapy [**2134-9-8**] am. He started CODOX (cytoxan, decadron, adriamycin, vincristine). Patient tolerated chemo very well. . ## ID: One of four bottles grew GNR his last admission. Patient was discharged on Cipro for coverage for e.coli vs klebsiella. Final cultures grew Stenatropamonas. Since he was febrile and neutropenic on admission, the patient was treated for IV bactrim for a 14 day course which he completed a day after discharge. There was no growth on surveillance cultures. . ## Cardiovascular: Patient went into Afib with RVR after receiving chemo on last admission and was converted to sinus on amiodarone and metoprolol. Pt was continued on these medications until [**8-29**] when he was admitted for bradycardia. Lopressor held at that time and pt did well on amiodarone alone. Amiodarone was scaled down to QD dosing from [**Hospital1 **] dosing in the [**Hospital Unit Name 153**]. Patient's bradycardia improved. Patient has an extensive cardiac history including CABG in the 80's and more recent stent placement for unstable angina. Pt was on plavix prior to chemo which was discontinued due to low platelets. Aspirin was resumed in the [**Hospital Unit Name 153**] however subsequently discontinued for portacath placement and in anticipation of low platelets secondary to chemotherapy. Patient remained in normal sinus rhythm and took PO lasix as needed for pedal edema. . ## Parkinsons: Patient was continued on Carbidopa-Levadopa and Entacapone per outpatient regimen. Pt usually on new Strateva which is non-formulary so usually placed back on this regimen as an inpatient. . ## BPH: A foley was placed during the chemotherapy course since patient was having some difficulty using urinal and voiding secondary to post-ictal left hand weakness. At the completion of chemo, the foley was discontinued and patient was able to use urinal upon discharge. . ## FEN: - low sodium cardiac diet - Sliding scale K, Mg, Ca - non-anion gap acidosis thought to be likely secondary to IVFs since renal function was preserved. . ## Access: PIV x2. Portacath placed [**2134-9-8**]. . ## PPx: PPI and pneumoboots. . ## Communication: Patient and wife. . ## Constipation: lactulose, colace, senna, fleets enema. Resolved after fleets enema. Medications on Admission: 1) acyclovir 800 mg tid 2) ASA 3) lipitor 20 mg qd 4) bisacodyl 5) carbidopa-levadopa 25-100 mg tid 6) CTX 1 gm qd 7) dexamethasone 2 mg iv bid 8) docusate 9) entacapone 200 mg tid 10) finasteride 5 mg qd 11) folic acid 5 mg qd 12) lasix 40 mg qd 13) lactulose 30 ml q3 prn 14) keppra 500 mg [**Hospital1 **] 15) PPI 16) bactrim 450 mg iv tid 17) terazosin 1 mg qhs 18) vancomycin 1 gm iv 12 . Discharge Medications: 1. Amiodarone 200 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. Folic Acid 1 mg Tablet Sig: Five (5) Tablet PO DAILY (Daily). 4. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. Entacapone 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO twice a day: start taper: [**9-15**] take 1 tab by mouth at bedtime [**9-14**] take 1 tab by mouth at bedtime then stop [**9-15**]. Disp:*2 Capsule(s)* Refills:*0* 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Three (3) Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed. 10. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q3H (every 3 hours) as needed for constipation. 11. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. 13. Terazosin 1 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 14. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO qam: Plse take 2 tabs by mouth every morning. Plse take 3 tabs by mouth every evening. Disp:*150 Tablet(s)* Refills:*2* 15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 17. Furosemide 20 mg Tablet Sig: One (1) Tablet PO ONCE (once) for 1 doses. 18. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO twice a day: until [**9-15**]. Disp:*3 Tablet(s)* Refills:*0* 19. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for for sleep. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: 1) Burkitt's lymphoma 2) CAD 3) carotid stenosis 4) Parkinson's Disease 5) Spinal Stenosis 6) BPH Discharge Condition: good Discharge Instructions: [] Please stop taking your Plavix and ASA until you follow-up with your oncologist. [] Please take the rest of your medications as prescribed. [] Please call your PCP or return to the emergency room if you have a seizure, chest pain, nausea/vomitting, fever/chills or any other worrying symptoms. Followup Instructions: [] Please return to 7 Feldburg this Friday [**9-17**] at 9am to continue your chemotherapy. [] Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2442**], MD Date/Time: [**2134-10-27**] 2:30 Where: [**Hospital Ward Name 23**] Clinical Center [**Location (un) 858**] Phone: [**Telephone/Fax (1) 41108**] You are on the cancellation list. The office will call if there is an opening. Completed by:[**2134-9-18**]

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icd9cm

[ [ [] ] ]

[ "03.31", "38.93", "99.25" ]

icd9pcs

[ [ [] ] ]

12679, 12737

6220, 10310

351, 363

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5078+5079

Discharge summary

report+report

Admission Date: [**2162-12-13**] Discharge Date: [**2162-12-18**] Date of Birth: [**2093-4-8**] Sex: M Service: GU ADMISSION DIAGNOSIS: Right renal tumor. POSTOPERATIVE DIAGNOSIS: Right renal tumor. OTHER DIAGNOSES: Diabetes, hypertension, hyperlipidemia, type 2 diabetes, pneumothorax, gout, history of papillary and clear cell renal cell carcinoma. HISTORY AND PHYSICAL: The patient is a 69-year-old male with a history of grade clear cell and papillary renal cell carcinoma on the left side in [**2158**], at which time the patient underwent a left nephrectomy and left adrenalectomy. Followup in the ensuing years has revealed a lesion in the right kidney which - on MRI in [**2162-5-7**] - was a CNS enhancing lesion in the posterior mid portion. The patient underwent a cardiac stent on [**2162-5-13**] and therefore presented for partial right nephrectomy on this admission. Repeat MRI in [**2162-11-6**] showed an enlarging nodular enhancing complex cyst in the posterior right mid kidney. PAST MEDICAL HISTORY: Includes papillary and clear cell renal cell carcinoma, hypertension, hyperlipidemia, type 2 diabetes, lower back pain, sciatica, history of elbow surgery, thyroid disorder, essential tremor, gout, cardiac stent in [**2162-5-7**]. MEDICATIONS AT HOME: Include Norvasc 5 mg p.o. daily, Imdur 60 mg p.o. daily, Toprol 25 mg p.o. daily, Cozaar 25 mg p.o. daily, Lipitor 40 mg p.o. daily, Levoxyl 125 mcg p.o. daily, glyburide 1.25 mg p.o. b.i.d., aspirin 325 mg p.o. daily, Plavix 75 mg p.o. daily. ALLERGIES: None. PHYSICAL EXAMINATION: Revealed a male in no apparent distress room air who was normocephalic and atraumatic, with clear lungs bilaterally, and a regular rate and rhythm, with an abdomen that was soft and obese, with a well-healed scar on the left side and nontender belly, with a circumcised phallus and normal testes, and no extremity defects or neurological defects. HOSPITAL COURSE: The patient presented as above and underwent a right partial nephrectomy on [**2162-12-13**]. Further details can be found in the dictated operative note. Postoperatively, the patient was difficult to extubate immediately postoperatively; most likely due to volume overload. The vent was weaned overnight, and the patient was able to be extubated on postoperative day #1. The patient remained stable cardiovascularly postoperatively, and cardiac enzymes postoperatively were negative. In addition, the patient was found to have a small right apical pneumothorax postoperatively following which was recognized intraoperatively; and a chest tube was placed intraoperatively. A chest tube remained in place for several days postoperatively. Chest tube was placed to water seal which initially showed and increasing of the pneumothorax and went back on suction; but subsequent chest x-rays showed a decreasing pneumothorax, and by discharge pneumothorax was clinically insignificant. The patient was initially kept n.p.o. following the procedure, but was able to be advanced once bowel function returned on approximately postoperative day #3. The patient continued to maintain good urine output initially with IV hydration and then with Lasix diuresis. The patient was maintained on postoperative Ancef while the chest tube was in, and antibiotics were discontinued once chest tube was discontinued. The patient remained stable neurologically throughout with adequate pain control throughout the hospitalization and clear mentation. Physical therapy was consulted during this hospitalization, and no need for acute rehab services was deemed necessary. Therefore, upon discharge, the patient was ambulating, producing adequate urine via Foley, passing flatus and tolerating a regular diabetic diet, and without significant pain or discomfort. The patient's creatinine reached a peak of 3.9 during this hospitalization, but upon discharge was 3.6. In addition, the JP which was placed perirenally continued to have outputs up to 100 cc a day. This JP fluid was sent for creatinine which was consistent with a urine leak. Therefore, the patient is to be discharged home with Foley for bladder decompression and JP in place while the urine leak seals itself. CONDITION ON DISCHARGE: Stable. DISCHARGE DIET: Diabetic diet. DISCHARGE MEDICATIONS: Include oxycodone 5 to 10 mg p.o. q.4.h. p.r.n. pain, Colace 100 mg p.o. b.i.d., Norvasc 5 mg p.o. daily, Imdur 60 mg p.o. daily, Toprol 25 mg p.o. daily, Cozaar 25 mg p.o. daily, Lipitor 40 mg p.o. daily, Levoxyl 125 mcg p.o. daily, glyburide 1.25 mg p.o. b.i.d.. Aspirin and Plavix are to be held until followup in clinic. DISCHARGE ACTIVITY: As tolerated. DISCHARGE DISPOSITION: Home with VNA services for JP and Foley care. Patient and VNA are to record daily drain and Foley outputs. DISCHARGE FOLLOWUP: Followup is with Dr. [**Last Name (STitle) **] in 2 weeks. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 559**] Dictated By:[**Name8 (MD) 20918**] MEDQUIST36 D: [**2162-12-18**] 08:13:39 T: [**2162-12-18**] 08:55:45 Job#: [**Job Number 20919**] Admission Date: [**2162-12-13**] Discharge Date: [**2162-12-18**] Date of Birth: [**2093-4-8**] Sex: M Service: UROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1232**] Chief Complaint: Pt. presented for R partial nephrectomy for renal cell carcinoma Major Surgical or Invasive Procedure: R partial nephrectomy ([**2162-12-13**]) History of Present Illness: Pt. is a 69 y/o retired economics professor [**First Name (Titles) 1023**] [**Last Name (Titles) 1834**] L radical nephrectomy in [**2158**]. Pathologic exam at the time revealed renal cell carcinoma, stage T1a and T1b, of clear cell and papillary types. An MRI performed on [**2162-11-25**] revealed an enlarging nodular enhancing complex cyst in the right kidney with negative lymph nodes and adrenal gland. Past Medical History: HTN angina CHF DJD hiatal hernia DM type II hypothyroidism rheumatoid arthritis h/o renal cell carcinoma in both kidneys PSH: L radical nephrectomy [**6-/2158**] cardiac catheterization [**5-/2162**] Social History: Denies tobacco, EtOH, drug hx. Family History: Non-contributory Pertinent Results: [**2162-12-13**] 11:30PM GLUCOSE-197* UREA N-26* CREAT-3.1* SODIUM-141 POTASSIUM-4.7 CHLORIDE-104 TOTAL CO2-25 ANION GAP-17 [**2162-12-17**] - Cr 3.6 from a peak of 3.9 Brief Hospital Course: The patient was admitted on the day of surgery. His intraoperative course was uneventful. Please refer to the operative report of [**2162-12-13**] for further details of the procedure. He received 3 liters of intraveous fluids during surgery and was admitted to the PACU for recovery. While in the PACU, he failed extubation. A chest xray, EKG and cardiac enzymes exams were obtained. The patient's chest xray showed borderline vascular congestion. The EKG revealed left axis shift that was different that the pre-operative EKG. A cardiology consultation was requested in light of the patient's cardiac history. After discussion with the cardiology fellow, a careful decision was made to diurese the patient with 10mg of IV furosemide. He diuresed 500ml and his arterial blood gas measurements improved. He was admitted to the [**Hospital Unit Name 153**] for mechanical ventilation and close monitoring. Three sets of cardiac enzymes were all within normal limits. By the morning of post-operative day (POD)#1, the patient was comfortable on CPAP. He was weaned of CPAP and was transferred out of the ICU on 3 liters oxygen via nasal cannula, mentating and feeling well. On POD#2, the pt. complained of mild intermittant pain for which he refused pain medication adjustment. He ambulated with physical therapy and did very well. He was weaned of oxygen and was saturating at 92% on room air. His chest tube was placed to water seal but was subsequently reconnected to suction after chest x-ray revealed a larger R apical pneumothorax. Overnight, the patient desaturated to 85% on room air and was placed on oxygen therapy, which brought his saturation up to 95% on 2 liters oxygen. He was given an additional 5mg IV of furosemide x 2, and this seemed to improve his breathing. On POD#3, he passed flatus and was advanced to a regular diet without incident. He was ambulating and breathing well. He was replaced on all of his home medications. The patient was observed while asleep given his desaturations at night. He was noted to have a fairly loud snore with intermittant pauses in respirations, consistent with obstructive sleep apnea. The urology team is recommending follow-up with the patient's primary care physician to have this issue addressed. On POD#4, the patient was relieved of his foley catheter and he voided. His [**Location (un) 1661**]-[**Location (un) 1662**] drainage was sent for creatinine, which came back 76, consistent with a urine leak from his partial nephrectomy bed. To maximize drainage of urine, a 16F Foley catheter was replaced with ease. He was discharged on POD#5 in stable condition with the Foley and J-P drains in place with Visiting nurse set-up for ongoing care. He was given instructions to follow up in clinic with both his primary care physician and with Dr. [**Last Name (STitle) **]. Medications on Admission: amlodipine 5mg po DAILY isosorbide mononitrate 60mg po DAILY metoprolol 25mg po DAILY losartan 25mg po DAILY atorvastatin 40mg po DAILY levothyroxine 12.5mcg po DAILY glyburide 2.5 mg po BID ASA 81 mg po DAILY clopidogrel 75mg po DAILY Discharge Medications: Home medications with the exception of glyburide, ASA and clopidogrel were continued. The following new medications were added: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*2* 3. Glipizide 5 mg Tablet Sig: [**2-7**] tablet Tablet PO twice a day. Disp:*15 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Renal cell carcinoma CHF atelectasis pleural effusion pneumothorax DM type II HTN hypothryoidism Discharge Condition: Stable Discharge Instructions: You may resume your pre-hospital medications. Call Dr. [**Last Name (STitle) **] or come to the emergency room if you have: * fever above 101.0F * nausea, vomiting or diarrhea that doesn't stop * a drastic decrease in the amount of urine you make * difficulty breathing * significant swelling in your legs or other parts of your body. You can shower as you normally would. Just pat your wounds dry afterward. No tub-bathing or swimming for 4 weeks after surgery. Your staples will stay in until you see Dr. [**Last Name (STitle) **] in clinic. He will take them out at that time. You should STOP taking your glyburide until your kidney function improves. We'll give you a medicine called glipizide to take instead. No aspirin or Plavix until you see Dr. [**Last Name (STitle) **] in clinic. Followup Instructions: Provider: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. Phone:[**Telephone/Fax (1) 277**] Date/Time:[**2162-12-29**] 11:00 Completed by:[**2162-12-21**]

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Discharge summary

report

Admission Date: [**2190-5-2**] Discharge Date: [**2190-5-11**] Date of Birth: [**2109-6-24**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 783**] Chief Complaint: Transfer from ERCP suite after episode of Vtach during stenting procedure for obstruction of biliary system sec to head of pancreas tumor. Major Surgical or Invasive Procedure: s/p ERCP s/p VT arrest requiring intubation History of Present Illness: 80 yo gentleman with h/o DM2, HTN, CKD who initially presented to [**Hospital 67456**]Hospital with painless jaundice, found to have hyperbilirubinemia (t. bili 8), LFT elevation and subsequently a 3.2 cm mass in the head of the pancreas on CT [**4-29**]. During course on floor, patient was noted to have temp 100.5. Abx was started to cover for ascending colangitis. Patient was refered to the ERCP suite for evaluation and stent deployment. During proceedure, patient was sedated with Versed and Fent. At the time of sphincterotomy, patient was noted to go into WCT. Was noted to be pulseless. ACLS was initaiated and a CODE was called. Patient was turned sulpine and given DCCV of 200J with return to a narrrow complet tachycardia of ~140. BP rose to SBP 120's. Patient was intubated for airway protection. Patient breifly became hypotesive to 80's that responded to 1 L NS bolus. Given the need to decompress the biliary system, inconjugation with anesthsia, ERCP and MICU, patient underwent successful deployment of metal stent to the biliary system with bile and pus flow noted. SBP on arrival to the floow was ~120. . ROS unable to assess: Labs notable for Mag 2.2 and K 3.5 Past Medical History: - DM II - CKD (Cr baseline 1.6) - pancreatic mass Social History: Married with 3 children. Retired police officer. Wife at home, diabled. Patient is very active, chops wood, walks dog everyday. Sons very concerned and invovled. Etoh very rarely, remote smoking hx over 40 yrs ago, no drugs Family History: Mother died at 93, had HTN, dad died at 78, one brother died at 84 with prostate cancer, other brother died at 58 with ? pancreatic CA, 2 sisters 84 and 86, alive and well. Physical Exam: PE: on admission to [**Hospital Unit Name 2112**]: 96.2 HR:99 BP:127/65 RR:21 Sats:100% on AC (TV600/RR14/PEEP5) Gen: Intubated and sedated: Jaundiced appearing. HEENT: +icterus, Chest: CTA B CVS: nl S1 S2 RR, 2/6 SEM at apex. Abd: Obese, NABS. mildly distended. No cullens or turners. Ext: no c/c/e Neuro: paralysed. Pertinent Results: [**2190-5-2**] 07:00PM BLOOD WBC-8.1 RBC-3.22* Hgb-10.2* Hct-31.3* MCV-97 MCH-31.7 MCHC-32.7 RDW-14.8 Plt Ct-173 [**2190-5-11**] 07:10AM BLOOD WBC-8.8 RBC-3.12* Hgb-9.5* Hct-29.3* MCV-94 MCH-30.5 MCHC-32.5 RDW-15.5 Plt Ct-356 [**2190-5-2**] 07:00PM BLOOD Neuts-89* Bands-0 Lymphs-1* Monos-5 Eos-5* Baso-0 Atyps-0 Metas-0 Myelos-0 [**2190-5-8**] 07:37AM BLOOD Neuts-85* Bands-1 Lymphs-5* Monos-4 Eos-3 Baso-0 Atyps-0 Metas-2* Myelos-0 [**2190-5-2**] 07:00PM BLOOD Hypochr-2+ Anisocy-NORMAL Poiklo-2+ Macrocy-NORMAL Microcy-NORMAL Polychr-1+ Target-2+ [**2190-5-6**] 06:50AM BLOOD Hypochr-1+ Macrocy-1+ [**2190-5-2**] 07:00PM BLOOD PT-16.4* PTT-27.7 INR(PT)-1.5* [**2190-5-6**] 06:50AM BLOOD PT-12.4 PTT-29.1 INR(PT)-1.1 [**2190-5-11**] 07:10AM BLOOD Plt Ct-356 [**2190-5-2**] 07:00PM BLOOD Glucose-222* UreaN-20 Creat-1.5* Na-136 K-4.3 Cl-105 HCO3-21* AnGap-14 [**2190-5-11**] 07:10AM BLOOD Glucose-191* UreaN-16 Creat-1.6* Na-136 K-4.0 Cl-99 HCO3-24 AnGap-17 [**2190-5-2**] 07:00PM BLOOD ALT-166* AST-143* LD(LDH)-143 AlkPhos-486* Amylase-11 TotBili-10.6* [**2190-5-11**] 07:10AM BLOOD ALT-49* AST-30 AlkPhos-346* TotBili-3.8* [**2190-5-2**] 07:00PM BLOOD Lipase-6 [**2190-5-3**] 05:35PM BLOOD CK-MB-2 cTropnT-<0.01 [**2190-5-4**] 01:23AM BLOOD CK-MB-3 cTropnT-0.04* [**2190-5-4**] 04:31AM BLOOD CK-MB-3 cTropnT-0.03* [**2190-5-2**] 07:00PM BLOOD Albumin-2.6* Calcium-8.0* Phos-3.3 Mg-2.0 Iron-23* [**2190-5-6**] 06:50AM BLOOD Albumin-2.2* Calcium-7.9* Phos-3.1 Mg-2.2 [**2190-5-10**] 10:40AM BLOOD Mg-2.1 [**2190-5-2**] 07:00PM BLOOD calTIBC-182* VitB12-1703* Folate-14.8 Ferritn-637* TRF-140* [**2190-5-5**] 04:48AM BLOOD Hapto-309* [**2190-5-3**] 05:35PM BLOOD TSH-0.62 [**2190-5-3**] 05:35PM BLOOD T4-6.5 [**2190-5-4**] 09:47PM BLOOD Vanco-11.7* [**2190-5-8**] 07:37AM BLOOD Vanco-9.9* [**2190-5-3**] 05:57PM BLOOD Type-ART Temp-36.8 Rates-14/ Tidal V-600 PEEP-5 FiO2-100 pO2-349* pCO2-49* pH-7.28* calTCO2-24 Base XS--3 AADO2-318 REQ O2-58 -ASSIST/CON Intubat-INTUBATED [**2190-5-4**] 09:50PM BLOOD Type-ART Temp-37.3 Rates-/18 FiO2-21 pO2-77* pCO2-36 pH-7.42 calTCO2-24 Base XS-0 Intubat-NOT INTUBA [**2190-5-3**] 05:57PM BLOOD Lactate-1.1 [**2190-5-4**] 04:43AM BLOOD Lactate-0.9 CA [**02**]-9 Test Result Reference Range/Units CA [**02**]-9 5005 H 0-37 U/ML BY [**Doctor Last Name **] CENTAUR TEST PERFORMED AT: [**Company **], [**State **], [**Hospital1 **], [**Last Name (LF) **], [**Name6 (MD) **] [**Last Name (NamePattern4) 67457**], M.D., DIRECTOR . EKG [**2190-5-2**] Regular supraventricular rhythm with low amplitude P waves and a single ventricular premature beat. Intraventricular conduction delay. Inferior T wave flattening. No previous tracing available for comparison. . CHEST PORT. LINE PLACEMENT [**2190-5-3**] 7:38 PM CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN Reason: assess placement of OG tube and R subclavian line [**Hospital 93**] MEDICAL CONDITION: 80 yo M with DM2, HTN, CKD admit with painless jaundice, LFT elevation, pancreatic mass here after Vtach arrest during ERCP s/p CVL and OG tube placement. REASON FOR THIS EXAMINATION: assess placement of OG tube and R subclavian line INDICATION: 80-year-old male with diabetes, hypertension, elevated LFT. Check OG tube and right subclavian line. TECHNIQUE: Portable AP chest radiograph. COMPARISON: Chest radiograph taken approximately 2 hours earlier on the same day. FINDINGS: There is right IJ line, terminating in mid SVC. No definite pneumothorax. OG tube is terminating in left upper quadrant, probably in the stomach. Note is made of tube overlying the right lower thorax, probably outside. Cardiac and mediastinal contours are unchanged. Again note is made of increased interstitial markings and pleural calcifications. IMPRESSION: Tubes and lines as described above. Overall unchanged appearance of the chest and upper abdomen compared to the prior study taken approximately 2 hours earlier on the same day. . CT PELVIS W/CONTRAST [**2190-5-3**] 10:31 AM CTA ABD W&W/O C & RECONS; CT PELVIS W/CONTRAST Reason: please eval for neoplasm and metastases Field of view: 40 Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 80 year old man with painless jaundice and 3 cm mass at head of pancreas on osh films REASON FOR THIS EXAMINATION: please eval for neoplasm and metastases CONTRAINDICATIONS for IV CONTRAST: None. CLINICAL HISTORY: Painless jaundice. Mass in pancreas on outside study. Please evaluate neoplasm and for metastases. TECHNIQUE: Multidetector CT with primary axial plane was performed on the abdomen and pelvis prior to and twice after contrast administration of 200 cc Optiray. Coronal and sagittal reformats were made of the arterial and venous phases. ABDOMEN CT WITHOUT AND WITH CONTRAST: There are multiple nodules within the lung bases bilaterally measuring up to 6 mm. These nodules are nonspecific. There are extensive calcified plaques within the lung bases bilaterally, likely reflecting prior asbestos exposure. There is a small left pleural effusion. There are areas of linear atelectasis within the lung bases. There is a mass within the head and uncinate process of the pancreas, primarliy hypoenhancing in relation to the pancreas, that measures 6 x 3.3 x 5 cm, though its margins are somewhat indistinct. There is obstruction of the common bile duct within the pancreatic head and the main pancreatic duct, both of which are dilated. The mass has a small portion that extends between the SMV and SMA and extends for greater than 180 degrees about the SMA just proximal to the origin of its first jejunal branch. It borders the posterior aspect of the SMV and fat plane between the two is loss. There are numerous lymph nodes adjacent to the pancreatic head within the portacaval space, within the porta hepatis, within the root of the mesentery, and a single pericardiac node and multiple hypoenhancing liver lesions, best seen on the portal venous phas,s that are consistent with metastases. The largest lesion within the liver is within segment 6 measuring 1.6 cm. The obstructed bile duct causes extrahepatic biliary ductal dilatation up to 1.5 cm as well as moderate intrahepatic biliary ductal dilatation. The gallbladder is distended and has borderline wall thickness. There is not pericholecystic fluid or fat stranding. There is a 1.3 cm gallstone within the gallbladder neck which is not obstructing. There is a normal CT-enhanced appearance of the spleen, bilateral adrenal glands, and bowel. There are multiple low attenuation lesions within the kidneys bilaterally, some of which are clearly simple cysts but others of which are too small to characterize though likely simple cysts. Largest lesion is a 4.8 cm simple cyst within the right interpolar kidney. There is no ascites. There is scattered atherosclerosis within the abdominal aorta and at the origin of major vessels. CT PELVIS WITH CONTRAST: Visualized portions of the large and small bowel within the pelvis are normal in appearance. No pelvic free fluid. Urinary bladder is normal in appearance. There is moderate iliac artery atherosclerosis bilaterally, though all vessels are patent. No enlarged lymph nodes within the pelvis. BONE WINDOWS: No concerning lesions within the bones for metastases. There is multilevel lower thoracic and lumbar disc degeneration with numerous vacuum discs and disc osteophytes. IMPRESSION: 1. Large obstructing pancreatic head and uncinate process mass with partial encasement of the SMA greater than 180 degrees and loss of fat plane between the mass and the SMV. Multiple adjacent lymph nodes and a pericardial lymph node as well as multiple hepatic lesions concerning for metastases. 2. Distal common bile duct obstruction by pancreatic mass with intrahepatic biliary ductal dilatation. 3. Several small indeterminate pulmonary nodules in the lung bases. Calcified pleural plaques consistent with prior asbestos exposure. 4. Multiple renal cysts. . ERCP BILIARY ONLY BY GI UNIT [**2190-5-4**] 5:39 PM ERCP BILIARY ONLY BY GI UNIT Reason: Wallstent placement [**Hospital 93**] MEDICAL CONDITION: 80 year old man with unrectable pancreatic ca/cholangitis. REASON FOR THIS EXAMINATION: Wallstent placement INDICATION: 80-year-old male with unresectable pancreatic carcinoma and cholangitis. COMPARISON: CTA abdomen dated [**2190-5-3**]. FINDINGS: 10 fluoroscopic spot images obtained from recent ERCP are submitted for review. Retrograde cholangiogram demonstrates opacification of the biliary tree and a narrowed malignant-appearing stricture involving the middle third of the common bile duct. The proximal bile duct appears mildly dilated. Subsequent images demonstrate successful employment of a Wallstent across the stricture. . Echo [**2190-5-4**] 1. The left atrium is moderately dilated. 2. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Regional left ventricular wall motion is normal. 3. The aortic root is moderately dilated. 4. The aortic valve leaflets (3) are mildly thickened. Mild (1+) aortic regurgitation is seen. 5. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. . CT ABDOMEN W/O CONTRAST [**2190-5-5**] 11:49 AM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Reason: DROPPING HCT, R/O INTRA-ABDOMINAL BLEED Field of view: 40 [**Hospital 93**] MEDICAL CONDITION: 80 year old man with painless jaundice and 3 cm mass at head of pancreas on osh films. S/p ERCP. Now with dropping hCT. REASON FOR THIS EXAMINATION: r/o intrabdominal bleed CONTRAINDICATIONS for IV CONTRAST: Cr 1.7 INDICATION: Painless jaundice with mass in head of pancreas, dropping hematocrit. COMPARISONS: Multiphasic CT, [**2189-12-3**]. TECHNIQUE: Axial non-contrast MDCT images were obtained from the lung bases to the symphysis pubis. CT OF THE ABDOMEN WITHOUT IV CONTRAST: There has been interval development of small pleural effusions with increased atelectasis. Pleural plaques are again identified along the lung bases. There has been interval placement of a metallic common bile duct stent with associated pneumobilia and air within the gallbladder. A gallstone is again identified. There is no evidence of retroperitoneal or duodenal hematoma. The large pancreatic head mass is again identified. There are scattered atherosclerotic aortic calcifications. The kidneys again have multiple hypoattenuating areas, which are better characterized on the previous CT. CT OF THE PELVIS WITHOUT IV CONTRAST: There is no evidence of abnormal collection or retroperitoneal hematoma. A Foley catheter with likely iatrogenic air is seen within the bladder. Calcifications are identified of the iliac arteries. BONE WINDOWS: There are no suspicious lytic or sclerotic osseous lesions. Degenerative changes are seen within the spine throughout. IMPRESSION: 1. No evidence of intra-abdominal or retroperitoneal hematoma. 2. Interval development of small, bilateral pleural effusions with reactive atelectasis. 3. Interval placement of a metallic biliary stent with persistent biliary dilatation and new pneumobilia. 4. Stable appearance of large pancreatic head mass. . CHEST (PORTABLE AP) [**2190-5-5**] 5:24 AM CHEST (PORTABLE AP) Reason: intubated, interval progression [**Hospital 93**] MEDICAL CONDITION: 80 yo M with DM2, HTN, CKD admit with painless jaundice, LFT elevation, pancreatic mass here after Vtach arrest during ERCP s/p CVL and OG tube placement. REASON FOR THIS EXAMINATION: intubated, interval progression REASON FOR EXAMINATION: Interval progression in extubated patient. PORATABLE CHEST X-RAY WAS REVIWED AMD COMPARED TO [**2190-5-3**] The patient was extubated in the interval with some new irregularity of the tracheal wall, which may be related to edema. The right subclavian line tip is in distal superior vena cava. The heart size is slightly enlarged but unchanged. The aorta is tortuous with no evidence of focal dilatation. The bilateral widespread calcified plaque remain stable. IMPRESSION: 1. No evidence of pneumonia or congestive heart failure. 2. Narrowing of tracheal lumen above thoracic inlet which may be related to post- intubation edema. . UNILAT UP EXT VEINS US RIGHT [**2190-5-9**] 10:07 AM UNILAT UP EXT VEINS US RIGHT Reason: please evaluate for clot [**Hospital 93**] MEDICAL CONDITION: 80 year old man with pancreatic cancer with asymmetric RUE swelling REASON FOR THIS EXAMINATION: please evaluate for clot INDICATION: 80-year-old male with pancreatic cancer and asymmetric right upper extremity swelling. COMPARISONS: None. RIGHT UPPER EXTREMITY VENOUS ULTRASOUND: Color and [**Doctor Last Name 352**] scale son[**Name (NI) 493**] images of the right internal jugular vein, subclavian vein, axillary, basilic and cephalic veins were obtained. Normal color flow and Doppler waveforms were demonstrated. Normal compressibility was demonstrated where applicable. No thrombus identified. IMPRESSION: No evidence of right upper extremity DVT. . [**2190-5-2**] 10:00 pm URINE **FINAL REPORT [**2190-5-4**]** URINE CULTURE (Final [**2190-5-4**]): NO GROWTH. [**2190-5-3**] 5:35 pm BLOOD CULTURE **FINAL REPORT [**2190-5-9**]** AEROBIC BOTTLE (Final [**2190-5-9**]): NO GROWTH. ANAEROBIC BOTTLE (Final [**2190-5-9**]): NO GROWTH. [**2190-5-4**] 1:24 am URINE **FINAL REPORT [**2190-5-5**]** URINE CULTURE (Final [**2190-5-5**]): NO GROWTH. [**2190-5-4**] 1:49 am BLOOD CULTURE 2 OF 2. **FINAL REPORT [**2190-5-10**]** AEROBIC BOTTLE (Final [**2190-5-10**]): NO GROWTH. ANAEROBIC BOTTLE (Final [**2190-5-10**]): NO GROWTH. [**2190-5-8**] 8:38 pm STOOL CONSISTENCY: SOFT Source: Stool. **FINAL REPORT [**2190-5-9**]** CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2190-5-9**]): FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. Reference Range: Negative. Brief Hospital Course: Mr. [**Known lastname 67458**] is an 80 yo gentleman with h/o DM2, HTN, CKD admitted with painless jaundice found to have a pancreatic mass. His hospital course is summarized below by problem. . # Presumptive Pancreatic CA/Obstructive Jaundice: Patient underwent ERCP on [**2190-5-3**] with stent placement which was complicated by an episode of pulseless VT s/p resuscitation in the ERCP suite, intubated and then a short ICU stay and extubated quickly. Patient returned to the oncology floor in stable condition. His LFTs and bilirubin trended downward. GI continued to follow the patient in house with scheduled outpatient follow up. His CA [**02**]-9 level was dramatically elevated consistent with pancreatic CA however a tissue diagnosis was not obtained since he had a complicated ERCP no biopsies were taken. He may opt to undergo empiric treatment for pancreatic CA vs. outpatient biopsy. Patient was discharged home on po levofloxacin/flagyl. Patient's pain was controlled with long acting oxycontin 10 [**Hospital1 **], short acting oxycodone for breakthrough. . # CKD: Cr elevated to 1.9 at peak and trended down with IV hydration. Patient received mucomyst and IVF w/bicarb prior to CT. ACEI and Metformin were held. . # VT arrest: Patient experienced pulseless VT during ERCP procedure s/p shock and resuscitation. Differential included high adrenergic output vs. CAD ?old scar. There have also been case reports of inducible VT with electrocautery. Initially loaded with Amio then d/ced per cardiology input. ECHO showed normal EF with no WMA. Patient remained cardiovascularly stable, initially monitored on telemetry which was then d/ced. Patient was started on low dose beta blockade. His lytes were stable and repleted as needed for K>4 and Mg >2. . # Anemia: Labs c/w AOCD. CT abd showed no heamtoma, EGD negative. Hct remained stable. . # DM: Elevated FS recently likely due to pancreatic disease. Patient maintained on RISS while in house, diabetic diet. [**Last Name (un) **] metformin. Patient d/c home on Glipizide instead of metformin. . # HTN: Patient was transiently hypotensive s/p cardiac arrest, he was volume resucitated. ACEI was held due to Cr elevation. Patient's BP remained under good control and he was discharged on a beta blocker s/p VT. . Patient was discharged home in stable condition with outpatient Oncology follow up. Medications on Admission: Home Medications: - Diovan 320 mg daily - Meformin 1,000 mg [**Hospital1 **] - ASA 325 mg daily . Medications on Transfer: - Diovan 320 mg QD - Metformin EF 1000 mg [**Hospital1 **] - Asa 325 QD - Insulin R QID - Ampicillin/sulbactam 1.5 gm Discharge Medications: 1. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO Q12H (every 12 hours). Disp:*60 Tablet Sustained Release 12HR(s)* Refills:*2* 2. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days. Disp:*7 Tablet(s)* Refills:*0* 3. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 7 days. Disp:*21 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. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*30 Tablet(s)* Refills:*2* 6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 7. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 8. Glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: 1. Pancreatic Mass likely Malignant 2. Obstructive Jaundice s/p biliary stent placement 3. Type 2 Diabetes 4. Chronic Renal Insufficiency 5. Hypertension 6. Ventricular Tachycardia s/p cardiac arrest requiring shock Discharge Condition: Fair - decreasing LFTs and bilirubin, pain under good control Discharge Instructions: Please take all of your medications as directed. Please ensure to follow up with your Primary Care Doctor in [**11-30**] weeks following discharged. Contact your doctor or come directly to the Emergency Department with any fevers, worsening jaundice, abdominal pain, chills, shortness of breath or any other problems. You are no longer taking Metformin, Diovan or Aspirin. Please discuss restarting these in the future with your primary care doctor. You have diabetes and your glucose has been high here in hospital. We are discharging you on a new medication called Glipizide. Please refrain from eating foods high in unrefined carbohydrates. We are sending you home with a Glucometer to measure your blood surgar twice a day. Your primary care doctor may choose to change this or add another oral medication if your glucose remains elevated after discharge. Please check your glucose twice a day with a glucometer. Followup Instructions: You have the following appointment scheduled in Gastrointestinal Oncology: Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2190-5-17**] 9:00 in the [**Location (un) 8661**] Building Please make an appointment to see your PCP [**Last Name (NamePattern4) **] [**11-30**] weeks. [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**] Completed by:[**2190-11-6**]

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icd9cm

[ [ [] ] ]

[ "96.04", "96.71", "51.85", "51.87", "99.04", "99.62", "38.93", "45.13" ]

icd9pcs

[ [ [] ] ]

20287, 20293

16660, 19028

452, 498

20553, 20617

2571, 5511

21585, 22077

2042, 2216

19320, 20264

14959, 15027

20314, 20532

19054, 19054

20641, 21562

2231, 2552

19072, 19152

274, 414

15056, 16637

526, 1711

19177, 19297

1733, 1785

1801, 2026

26,887

151,964

52681

Discharge summary

report

Admission Date: [**2159-12-3**] Discharge Date: [**2159-12-14**] Date of Birth: [**2113-5-27**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3853**] Chief Complaint: "SOB, respiratory failure." Major Surgical or Invasive Procedure: intubation a-line CVL bronchoscopy thoracentesis History of Present Illness: Pt is a 46M with PMH HTN, benzodiazepine/opiate abuse, who presents with hypercarbic respiratory failure. He was brought in by EMS from home with report of difficulty breathing x 1 day. Of note, he presented to the ED in [**9-/2159**] with cough and fever, and was found to have a RLL pna, and was recommended to be admitted for IV abx. However, he refused and left AMA with a Rx for levoquin 750mg x 2 wks. He returned to the ED in [**10/2159**], and chest XR at that time showed severe emphysema and interval increase in the right basilar opacity, unlikely to be pneumonia. However, given his symptoms, fever, and prior unresponsiveness to levofloxacin, ED physicians felt that he should be admitted with another course of antibiotics. Pt again did not want to be admitted and was discharged with medications for pain control. He called his PCP shortly after and was started on "a repeat course of antibiotics," although which ones are not specified in PCP's note and are not listed in OMR. . On arrival to the [**Hospital1 18**] [**Name (NI) **], pt unable to give history, and initial sat 75% RA. He was noted to have diffuse rhoncorous breath sounds and gurgling upper respiratory sounds as well as pinpoint pupils. Pt was initially awake and talking but not making sense. . In the ED, initial vitals were 102.8, 112, 104/56, O2 sats 75%. EKG showed EKG: SR@115 peaked Ts Qs V1 V2 (no prior). He was intubated immediately for respiratory distress and sedated with fentanyl and versed. His ABG after intubation was 7.20/66/366. There was no prior ABG. NGT was placed and was noted to have dark brown guiac positive output. He was given protonix 80 mg IV x 1. CXR was done showing right infrahilar pneumonia, and per report there was a concern for PCP pneumonia though this is not documented in the final report. He was given zosyn, gentamycin, and azithromycin (ceftriaxone also ordered but unclear if he got this). He was also given 3L of NS. Other labs significant for a K+ of 6.3 (given insulin 10 units, D50, calcium gluconate), and lactate of 6.7. He was also noted to have [**Last Name (un) **] (Cr 2.7 from prior baseline of 0.7), and transaminitis with ALT/AST 1798/3141. INR is up to 1.9 from a recent normal baseline of 1.0. UA showed small blood, protein of 30, trace ketones, few bacteria, 4 granular casts, and 64 hyline casts. Serum tox screen was initially negative in the ED. On transfer, vent settings were AC, 100% FiO2 PEEP 5, TV:500. Access - 2 x 20g PIV. . On arrival to the ICU, Pt's vitals were 37.2C, HR 96, BP 102/49, RR 16, Sat 99%. Past Medical History: -HCV -Opiod and benzodiazepine abuse -RLL PNA tx'd with levofloxacin in [**Month (only) **] and [**2159-10-25**] -HTN -Severe depression -Tobacco use -addiction -allergic rhinitis -anxiety -erectile dysfunction -headache -rosacea Past surgical history: Appendectomy Deviated Septum repair Left shoulder [**Doctor Last Name **], debridement of biceps tendon tear, open Biceps tenodesis [**2159-7-13**] Social History: -lives with and takes care of his mother, who has [**Name (NI) 2481**] dementia in [**Location (un) **]. Used to work as an electrician, but has been unemployed for several years with the exception of one month recently. -tobacco: several packs daily for decades -alcohol: none -drugs: opiates and benzo abuse, heroine use in the past Family History: mother with dementia father - died from lung cancer sister - colon cancer Physical Exam: Admission Exam: Vitals: 37.2C, HR 96, BP 102/49, RR 16, Sat 99%. General: Thin, intubated and sedated middle-aged man, responsive to pain. HEENT: pupils pinpoint but still responsive to light bilaterally. Oral mucosa dry. Missing several teeth. Neck: supple, JVP ~11 cm, no LAD Lungs: unable to listen posteriorly because Pt becomes very agitated w/ movement. Listening anteriorly, Pt's breath sounds are clear bilaterally. 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: foley present Ext: warm, weak pulses radial and dp bilaterally, no clubbing, cyanosis or edema . Discharge PE PHYSICAL EXAM: VS: Tm 97.9 Tc-97.4 HR 71 BP 152/89 RR 16 SaO2-100 RA I/O 24-not recorded GENERAL: AAOX3, in mild amount of discomfort HEENT: CN 2-12 grossly intact, MMM, has a 3X2cm mass in right neck area with overlying erythema, likely traumatic from known fall NECK: no lad, no obvious thyroid masses CVS: RRR, no RMG LUNGS: CTAB, no wrr ABDOMEN: Soft, flat, not TTP, no HSM SKIN: no obvious rashes NEURO: AAOX3, strength is equal and wnl in all extremities, sensation is intact, relfelxes are 1+ and equal, CN's no abnormalities per above Psych: slightly nervous but otherwise wnl Derm: TNTC lesions brown macular on back Pertinent Results: Admission labs: [**2159-12-3**] 06:50AM BLOOD WBC-11.1* RBC-4.05* Hgb-12.7* Hct-38.5* MCV-95 MCH-31.4 MCHC-33.1 RDW-13.0 Plt Ct-284 [**2159-12-3**] 06:50AM BLOOD Neuts-80* Bands-4 Lymphs-8* Monos-8 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2159-12-3**] 06:50AM BLOOD PT-15.7* PTT-37.3* INR(PT)-1.5* [**2159-12-3**] 06:50AM BLOOD Glucose-160* UreaN-39* Creat-2.7* Na-140 K-6.8* Cl-100 HCO3-25 AnGap-22* [**2159-12-3**] 06:50AM BLOOD ALT-1798* AST-3141* LD(LDH)-2520* CK(CPK)-1263* AlkPhos-63 TotBili-0.3 [**2159-12-3**] 06:50AM BLOOD CK-MB-3 cTropnT-0.09* [**2159-12-3**] 06:50AM BLOOD Lipase-10 [**2159-12-3**] 10:29AM BLOOD Calcium-7.1* Phos-5.2* Mg-2.3 [**2159-12-3**] 06:37PM BLOOD Calcium-6.9* Phos-4.7* Mg-2.2 [**2159-12-3**] 06:37PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-POSITIVE [**2159-12-5**] 10:49AM BLOOD HIV Ab-NEGATIVE [**2159-12-3**] 06:50AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2159-12-3**] 06:37PM BLOOD HCV Ab-POSITIVE* [**2159-12-3**] 08:08AM BLOOD Type-ART Tidal V-500 PEEP-5 FiO2-100 pO2-366* pCO2-66* pH-7.20* calTCO2-27 Base XS--3 AADO2-291 REQ O2-54 -ASSIST/CON Intubat-INTUBATED [**2159-12-3**] 06:59AM BLOOD Glucose-153* Lactate-6.7* Na-140 K-6.3* Cl-98 calHCO3-26 [**2159-12-5**] 05:09PM BLOOD freeCa-1.05* Imaging: [**2159-12-4**] Radiology CT CHEST W/O CONTRAST IMPRESSION: 1. Bibasal opacities consistent with multifocal pneumonia. 2. Complete collapse of the right middle lobe and segments of the right lower lobe. There is obstruction of the right middle lobe bronchus as well as the superior and basal bronchi of the right lower lobe, the etiology of which cannot be determined on this study. Mucoid impaction is a possibility; however, other etiologies such as endobronchial neoplasm cannot be excluded. 3. Small bilateral pleural effusions, right greater than left, new since [**2159-10-12**]. 4. Small amount of ascites seen in the visualized upper abdomen, new since [**10-12**], [**2158**]. Micro: [**2159-12-5**] BRONCHOALVEOLAR LAVAGE [**2159-12-5**] BRONCHOALVEOLAR LAVAGE [**2159-12-4**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL {YEAST} INPATIENT [**2159-12-3**] URINE URINE CULTURE-FINAL INPATIENT [**2159-12-3**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [**2159-12-3**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2159-12-3**] BLOOD CULTURE Blood Culture, Routine-PENDING . [**2159-12-12**] CXR IMPRESSION: 1. Decrease in size of right pleural effusion after thoracentesis. No pneumothorax. 2. Persistent marked right lower lobe atelectasis. 3. Near resolution of left basilar atelectasis. . [**2159-12-12**] pleural fluid Pleural fluid: NEGATIVE FOR MALIGNANT CELLS. Mesothelial cells, lymphocytes, and neutrophils Brief Hospital Course: 46 yo M w/ benzo and opiate abuse, recent RLL pneumonia admitted to [**Hospital Unit Name 153**] with hypercarbic respiratory failure and septic shock likely due to multifocal PNA. . # Hypercarbic respiratory failure: Patient was intubated and sedated due to hypercarbia likely due to multifocal PNA, given findings on chest CT. Bronchoscopy showed copious secretions in the right bronchi, however no obvious mucous plugs, per se. No extrinsic compression of bronchi seen, so not likely a post-obstructive component. BAL sent, but only returned 1+ Gm positive cocci and 2+ PMNs in RLL and no organisms, 4+ PMNs in RML. After 3 days of intubation, patient was given a small amount of IV lasix for suspected pulmonary edema and was successfully extubated on [**12-6**] without issue. He was treated with vanc/zosyn/levo (Day 1 = [**12-3**]) to cover for CAP, atypicals, and anaerobes given the severity of his infection, which he will need to continue for 8 days. Pt had no oxygen requirement by [**12-8**] and was transferred to the floor for continued IV antibiotics. The patient continued his course of IV antibiotics in house and his picc line was discontinued prior to discharge. . #Right sided pleural effusion The patient came out of the ICU with a persistent right sided pleural effusion. With his smoking history, we wanted to rule out malignancy as a cause of this. A thoracentesis was done by the IP team. The pleural fluid was negative for malignancy and the patients breathing subjectively improved following the procedure. . #Headaches, likely cluster in etiology The patient has a reported history of migraines in the past. He reports his last migraine headache was about 1 year ago. He says he has had headaches similar to this in the past. He was offered abortive therapy with imitrex and he refused saying this had not worked in the past. He is unable to use NSAID's due to his renal dysfunction. He insisted that narcotics were the only thing that helped. I informed him that narcotics may help short term, but may in fact worsen the headache long term. He persisted in wanting narcotics. He had a slight facial asymmetry during one of the headaches so a neurology consult was placed. They suggested supportive care for the headaches and no neuroimaging. The patients headaches improved somewhat, and he strongly preferred home management of his headaches. He was sent home on tramadol, prochlorperazine and a short course of narcotics, which he was told to use sparingly. . # Septic shock: Likely due to pneumonia. Patient presented with shock liver, AMS and [**Last Name (un) **]. He was maintained on IVFs and pressors which were weaned off after several days. Infection was treated as above. Pt transitioned off pressors rapidly but did have organ dysfunction as a result (shock liver, renal failure). . # Acute Renal failure: Multiple muddy brown granular casts consistent with ATN [**12-27**] sepsis/hypotension. Renal consulted and agreed with ATN; no indications for dialysis. Cr peaked at 4.9 on [**12-7**] and has slowly decreased. ATN expected to improve with time. Pt's electrolytes were monitored and repleted as needed. Discharge creatinine was 3.4. He should follow up closely with Renal physicians. . # Hyperkalemia: Most likely [**12-27**] acute renal failure (see above). K+ 6.8 on presentation, treated with calcium gluconate, insulin/dextrose, and bicarb. K+ monitored and improved over ICU course to 3.4. Pt was not repleted due to renal failure. ECG normal, continued to monitor and replete as renal function improves. . # Transaminitis: Likely shock liver [**12-27**] to hypoperfusion from sepsis vs possible ingestion. HCV positive (confirms on labs), however doubt his hepatitis would cause this degree of transaminitis, given that it is chronic. LFTs peaked on [**12-3**] with ALT 2422, AST 3591, LDH 2610, CK 1228, and continued to trend down over stay. Tbili and alk phos remained normal throughout his ICU course. . # Elevated troponins: Likely [**12-27**] renal failure, CK-MB flat. Trops peaked at 0.14 on [**12-4**] and continued to trend down. Initial cardiac damage possibly related to septic shock and increased demand on the heart. Pt denies any chest pain or discomfort. . # COPD: Pt has severe bullous emphysema evident on CT. Pt is not currently on any outpatient therapy for his COPD. Pt was started on albuterol and tiotropium nebs in house and will need outpatient follow up. # Anxiety: Patient had significant anxiety and panic during his time in the ICU. Psychiatry was consulted as there was concern that the patient might leave AMA and the team was concerned about competency. He was started on haldol in addition to his home clonazepam and his behavior improved significantly. He did not have any episodes of agitation or anxiety after transfer from the ICU. Psychiatry continued to follow the patient on the floor. His haldol was discontinued and the patient was asked about starting an SSRI. He said he was tried on many in the past and refused any attempt at starting a new one currently. He requested an increase back to his home dose of Klonopin. I explained to the patient that this was not an ideal medication for anxiety. He promised to address this with his PCP. . Transitional Issues: -Follow up with PCP [**Last Name (NamePattern4) **] [**11-26**] weeks with repeat labs (lytes, BUN/creatinine) and address starting a SSRI for anxiety and further headache management. Also get a follow up CXR in 2 weeks for his CAP -Follow up with Renal in [**11-26**] weeks for ARF with the above labs drawn (specifically BUN and creatinine) -Consider follow up with Pulmonary for COPD management Medications on Admission: clonazepam 1mg tid prn anxiety Oxycodone 15mg [**Hospital1 **] gabapentin 300mg po tid Discharge Medications: 1. Radiology please get a PA and lateral CXR for follow up for pleural effusion and pneumonia in [**11-26**] weeks prior to follow up with PCP and have results sent to PCP [**Name9 (PRE) **],[**Name9 (PRE) **] [**Name Initial (PRE) **]. [**Telephone/Fax (1) 2205**] 2. Outpatient Lab Work Please have a basic metabolic panel (lytes, BUN/Creatinine) done and send your your PCP [**Name9 (PRE) **],[**Name9 (PRE) **] [**Name Initial (PRE) **]. [**Telephone/Fax (1) 2205**] 3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 4. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 5. clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 14 days. Disp:*42 Tablet(s)* Refills:*0* 6. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*2* 7. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 8. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 9. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for h/a. Disp:*30 Tablet(s)* Refills:*0* 10. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for h/a. Disp:*30 Tablet(s)* Refills:*0* 11. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for headache for 1 weeks: please minimize this medications and use other medications, avoid NSAID's. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Pneumonia Acute renal failure Transaminitis Hepatitis C anxiety migraine headache Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with respiratory failure, likely due to a pneumonia. You were treated in the ICU initially with intubation (mechanical breathing) and antibiotics. You improved slowly and you were transfered out of the ICU. You had a repeat CT scan of the chest to evaluate for fluid around your lung and collapse of the lung and it showed persistent fluid. This fluid was removed and your respiratory sympoms improved. You will need a follow up CXR in about 2 weeks. During this hospitalization you were also diagnosed with acute kidney failure, and acute liver injury. This was likely due to low blood pressure from infection (ie pneumonia). Your labs were monitored and your kidney and liver function improved. It will be important to follow up with a primary care doctor to make sure that these things continue to improve. You will also need to follow up with a Renal physician. . You had headaches and anxiety in the hospital. Neurology evalauted you and felt this was likely a migraine or analgesic withdrawal headache. Please try and limit the amount of percoset you use. Please be sure you follow up with your Psychiatrist about your anxiety and consider starting an SSRI Followup Instructions: Department: WEST [**Hospital 2002**] CLINIC When: WEDNESDAY [**2159-12-19**] at 3:30 PM With: [**Doctor Last Name **] [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 721**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: [**State **]When: FRIDAY [**2159-12-21**] at 9:15 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8428**], MD [**Telephone/Fax (1) 2205**] Building: [**State **] ([**Location (un) **], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: On Street Parking Specialty: PSYCHIATRY With: [**Last Name (LF) **], [**Name8 (MD) **] MD Address: [**University/College 5523**] , STE#508 [**Location (un) **], [**Numeric Identifier 822**] Phone: [**Telephone/Fax (1) 57903**] **We are working on a follow up appointment with Dr. [**First Name (STitle) **] within 1-2 weeks. You will be called at home with the appointment. If you have not heard from the office within 2 days or have any questions, please call the number above.**

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icd9cm

[ [ [] ] ]

[ "34.91", "96.72", "38.93", "96.04", "38.91", "33.24" ]

icd9pcs

[ [ [] ] ]

15555, 15561

7998, 13267

333, 383

15687, 15687

5245, 5245

17050, 18190

3783, 3859

13825, 15532

15582, 15666

13714, 13802

15838, 17027

3266, 3415

4613, 5226

13288, 13688

266, 295

411, 2990

5262, 7975

15702, 15814

3012, 3243

3431, 3767

41,035

127,416

37357

Discharge summary

report

Admission Date: [**2135-2-6**] Discharge Date: [**2135-2-6**] Date of Birth: [**2048-10-7**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Hemoptysis Major Surgical or Invasive Procedure: Intubation IR embolization Bronchoscopy CPR History of Present Illness: This is an 86-year-old gentleman with a history of metastatic renal cell CA metastasized to R lung with endobronchial disease who is OSH transfer for massive hemoptysis. . Pt has history of RCC, first dx 12 yrs ago sp resection, then recurred in [**2132**] with mets to R lung and endobronchial disease sp bronchial stenting in [**2133**] with multiple episodes of non-massive hemoptysis and recent rigid bronchoscopy with balloon dilation of bronchus intermedius. . Pt was seen by Dr [**Last Name (STitle) **] (pulm surgery) last week for hemoptysis (discharged [**2134-2-4**]) where he had scope that showed fractured bronchus intermedius stent with friable tissue around it causing main stem bleeding. The tissue was cauterized. Dr [**Last Name (STitle) **] had plans to open a stent in the near future. . Pt was discharged from hospital on [**2134-2-4**], he was in his usual state of health until this morning when he coughed up 1 pint-1 quart of blood. He was rushed to OSH for hemoptysis. He was intubated there (with double lumen) and then transfered to [**Hospital1 18**] for further management. Of note, patient was formerly DNR/DNI which was reversed on arrival to OSH. . At [**Hospital1 18**] ED: pt was hemodynamically stable with HR 80s, BP 120-140s. Pt noted to have double lumen tube, ventilating through the left lung with right clamped. He was given propofol which dropped his pressures to 60s. Got fluids which improved BP, did not require any pressors. He has two 18 g peripherals. Internventional Pulm was contact[**Name (NI) **] as was IR. IR has plans to embolize first and then allow IP to open stent. Pt was typed/crossed x 2 units. He is being sedated with fent/versed. OG tube was placed which drained 300cc blood, thought likely to be hemoptysis. NG lavage performed, [**Last Name (un) 84019**] after 250cc. GI was consulted to asses whether or not they felt they needed to scope. Pt is guiac positive. Felt this is likely swallowed blood, esp given clear NG lavage after 250cc. Told to call GI again if any fresh blood in OG tube. Made total 350cc UO. . On arrival to the MICU, pt is comfortable, intubated. Spoke to family who said that they want Dr [**Last Name (STitle) **] to evaluate patient to see if any intervention is indeed warranted/reversable. If not, they would want to proceed with DNR/DNI route. As of now, pt is FULL code until evaluated by Dr [**Last Name (STitle) **]. After discussion with Dr [**Last Name (STitle) **], plan is to attempt intervention given this patient's very high functional status. Past Medical History: Oncologic History: - in [**4-/2122**] Mr. [**Known lastname 1968**] had a right-sided kidney lesion found incidentally. He underwent a right nephrectomy at [**Hospital1 84018**]. Pathology noted a 3-cm clear cell lesion, grade I - II, confined to the cortex. Ureteral & vascular margins were free of tumor, no vascular invasion was seen. Right adrenal gland was (-). He was followed serially with CT scans. - in late [**2132**], developed recurrent hemoptysis which prompted ENT evaluation & chest imaging, which showed a compressive mass in the right bronchus. He had a flexible bronchoscopy at [**Hospital1 1562**] complicated by significant bleeding & was transferred to [**Hospital1 18**] [**2133-1-14**]. Chest CT showed a mass encasing the right pulmonary artery & invading the bronchus intermedius. He underwent a rigid bronchoscopy w/ tumor biopsy, debridement, & stent placement [**2133-1-15**]. underwent argon plasma coagulation. - He had brachytherapy at [**Hospital3 2358**]. - on [**2133-5-27**] he had a metal stent placed by IP. - on [**2133-6-8**] started on sunitinib. - on [**2133-6-18**] developed hemoptysis requiring Sutent hold through [**2133-6-23**] & again [**Date range (1) 36573**]. - [**Date range (1) 14706**] Sutent was restarted, completed 1 cycle; but [**2133-7-21**] bloodwork showed low WBC/Plts, drug was again held through [**2133-8-8**]. He returned [**2133-8-25**] & reported scant hemoptysis x 2 days & his Sutent was stopped. He was then on 25mg x14 days of 28 day cycle. - on [**2133-11-25**], saw Dr. [**Last Name (STitle) **] for bronchoscopy which showed stent in good position, no endobronchial lesions were seen. - [**2133-12-29**] with ongoing cough, sputum production. trial of albuterol INH & Pulmonology recommended use of PPI/fluticasone. He was seen again 2 weeks later, w/o improvement in his symptoms. - [**1-9**] Platelets>150 and CT chest showed interval growth of right hilar mass, w/ worse occlusion of the R mainstem bronchus. We then increased Sutent dosing to 37.5mg/day on 2 week on, 2 week off basis. - in follow-up [**2134-2-2**], his cough had improved but plts were low, necessitating hold - on [**2134-2-17**], restarted once plts 98 - follow-up [**2134-3-2**], He was doing well apart from ongoing respiratory symptoms of cough, sputum production & scant hemoptysis/mild epistaxis. His platelets were 109. At that time we discussed possibly resuming Sutent earlier than 2 weeks off therapy if respiratory symptoms persisted. He resumed drug 1 week later & returned [**2134-3-30**]. He did well w/ only scant hemoptysis. He had stopped Flonase due to epistaxis. - on [**2134-4-1**] bronchoscopy w/ Dr. [**Last Name (STitle) **] which showed a large endobronchial lesion in the [**Hospital1 **], friable w/ stent [**03**]% occluded. - on [**2134-5-18**] was doing well apart from scant hemoptysis. platelets were stable at 95. - on [**2134-6-8**], for follow up, doing well apart from 2-3 days of pruritic rash on left sided torso consistent with herpes zoster. We initiated valacyclovir TID for 14 days. He developed pain at the site which continued despite use of Tylenol and was prescribed a lidocaine patch. - On [**2134-7-13**] CT appeared to show overall minimal decrease to affected area and decreased compression of the right main stem bronchus. Stable appearance of the stent within the bronchus intermedius. Notable is interval development of a left adrenal nodule with rim of enhancement given characteristics and rapid growth concerning for metastasis. Interval resolution of the right pleural effusion. - On [**2134-9-30**] pulm rigid bronch revealed his metal stent well-covered with granulation tissue was visualized in the bronchus intermedius. An 80% stenosis to the right lower lobe was seen distal to the stent, and the bronchoscope could not pass. Electrocautery was used in strips along the [**Hospital1 **], then forceps were used to gently open the RLL to 60-70% remaining stenosis. PMH/PSH: Renal cell Carcinoma Hypothyroidism, Lyperlipidemia, Hypertension. Status post partial right adrenalectomy, and right nephrectomy Social History: He is married and he and his wife live on [**Hospital3 4298**]. His wife was recently diagnosed with early stage breast cancer and is being seen by Dr. [**First Name (STitle) **] here at [**Hospital1 18**] from Breast Oncology. Pt worked for an investment firm in [**Location 8398**]and retired 20 years ago. He smoked a pipe one to two times a day for >20 years and smoked cigars for two years. He drinks one scotch every three weeks. Family History: Father mastoid infection and died in his 50s. Mother CHF died in her 70s. Older sister alive and well. Three adult children alive and well. Physical Exam: Vitals: BP 133/65, HR 84, 100% on vent, HR 82 Vent settings: CMV, only ventialting left lung, TV 300, FiO2 50, F 20, PEEP 5. Given 1800 IVF. 300cc UO, 300cc coffee grounds General: sedated, comfortable 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: left lung with good aeration, right lung has decreased breath sounds since clamped. Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: WBC 3.6, Hb 11. HCT 34, PLT 88, INR 1.1, PTT 28 Na 131, K 3.9, Cl 95, Bicarb 28, BUN 12, Cr 1.1. pH 7.29, CO2 63, O2 349, Bicarb 32 UA sh 1009, pH 6.5, Urobil 2. Brief Hospital Course: In brief, Mr. [**Known lastname 1968**] was a lovely 86-year-old gentleman with metastatic RCC (s/p multiple interventional pulmonary procedures for endobronchial bleeding) who was admitted from an outside hospital with hematemesis in setting of right bronchial artery bleed. He was intubated at the OSH with double lumen tube, with right side clamped in an attempt to tamponade active bleeding. He was transferred to [**Hospital1 18**] for interventional radiology and interventional pulmonology evaluation. Mr. [**Known lastname 1968**] was given 1 unit of PRBCs on arrival to [**Hospital1 18**], and another unit was ordered for transfusion during procedures. Patient's family was at bedside upon his admission to MICU. On day of arrival, patient went to IR, where a branch of the right bronchial artery was embolized. He was immediately transferred to the OR, where interventional pulmonary attempted further endoscopic intervention. Family was aware of high risks of this procedure, but wanted to proceed in the event that there was any way to palliate symptoms. Unfortunately, Mr. [**Known lastname 1968**] [**Last Name (Titles) **] during the procedure. Family and medical team were made aware. Medications on Admission: Medications (per recent dc summary): 1. amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day. 2. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. benzonatate 100 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day) as needed for Cough. 4. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Topical once a day as needed for pain. 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 8. sunitinib 12.5 mg Capsule Sig: Three (3) Capsule PO once a day: Daily, two weeks on, one weeks off. (currently NOT taking, stopped few days ago) 9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:*50 Capsule(s)* Refills:*1* 10. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Disp:*50 Tablet, Delayed Release (E.C.)(s)* Refills:*1* 11. codeine sulfate 15 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for cough. Disp:*50 Tablet(s)* Refills:*1* 12. guaifenesin 1,200 mg Tablet, ER Multiphase 12 hr Sig: One (1) Tablet, ER Multiphase 12 hr PO twice a day. Disp:*60 Tablet, ER Multiphase 12 hr(s)* Refills:*2* 13. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Inhalation five times a day as needed for shortness of breath or wheezing. Disp:*2 * Refills:*1* 14. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing/dyspnea. Disp:*20 mL* Refills:*3* Discharge Medications: Patient [**Last Name (Titles) **]. Discharge Disposition: [**Last Name (Titles) **] Discharge Diagnosis: Patient [**Last Name (Titles) **]. Discharge Condition: Patient [**Last Name (Titles) **]. Discharge Instructions: Patient [**Last Name (Titles) **]. Followup Instructions: Patient [**Last Name (Titles) **]. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "401.9", "V15.82", "786.30", "799.02", "284.19", "427.5", "E878.1", "244.9", "V45.73", "996.59", "276.1", "272.0", "V58.69", "197.0", "V10.52" ]

icd9cm

[ [ [] ] ]

[ "88.44", "99.29", "32.01", "96.71", "88.42" ]

icd9pcs

[ [ [] ] ]

11564, 11591

8548, 9759

320, 365

11669, 11705

8362, 8525

11788, 11961

7560, 7706

11505, 11541

11612, 11648

9785, 11482

11729, 11765

7721, 8343

270, 282

393, 2945

2967, 7091

7107, 7544

25,329

191,788

49960

Discharge summary

report

Admission Date: [**2122-7-27**] Discharge Date: [**2122-8-2**] Date of Birth: [**2079-7-20**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 465**] Chief Complaint: Hypoxia, Volume Overload Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: 43 yo M with IDDM, ESRD on HD, poorly controlled HTN, h/o numerous admissions for L flank pain (extensive w/u neg) and for hypertensive urgency, initially presented to ED with acute on chronic L flank pain, epigastric pain, and "chest tightness"/SOB. He also reported cough productive of green sputum x 2 days, as well as nausea/vomiting and not being able to tolerate po's since the evening of presentation. He had not missed any HD treatments. . ED: Initial vitals T 97.9, HR 91, BP 203/99, RR 20 and O2sat 75% on RA. The patient treated for hypertensive emergency/urgency with Captopril 25 mg po and started on Nitro gtt. The patient became hypoxic while lying in Trandelenberg for line placement with O2 sats 89-90% on RA (improved with few liters of NC). The patient continued to be tachypneic with RR in 20's and was placed on BiPAP briefly in the ED. He also received Morphine Sulfate for flank pain, Ondansetron, Furosemide 40mg IV. REJ was placed for access, because no other access could be obtained. CEs trop baseline 0.21, CK 564. MBI WNL. Also hyperkalemic to 6.7. Renal recommended dialysis overnight. . ROS: On the ROS, pt c/o HA that strated after presentation to the ED. No vision changes. No fever/chills. No [**First Name3 (LF) **] contacts at home. No urinary symptoms (making small amount of urine) or bowel habits changes. Past Medical History: 1. DM1 x 17 years, HbA1c 7.0 [**6-22**] 2. ESRD, on HD T,Th,Sa at [**Location (un) **] Dialysis 3. HTN, poorly controlled 4. R foot operation - bone excision 5. R foot ulcer 6. Depression with h/o SA and psych hospitalizations 7. Esophagitis on EGD [**10-21**] with negative H. Pylori 8. h/o L flank pain since [**2119**] with multiple admissions and extensive work-up and no organic etiology for pain found 9. Diastolic CHF: LVEF >55% by echo in [**2-22**] Social History: Lives with mother in subsidized housing. Has four children. Former floor tech. No smoking, EtOH, drugs. Family History: Diabetes in multiple relatives on both sides Physical Exam: VS: T 96.7; BP 202/108l HR100; RR 21; O2 sat 96% on 2L NC General: awake, tired, getting dialyzed, NAD HEENT: anicteric sclera, PERRL, OP clear, MMM Neck: supple, JVD about 10, R EJ in place Pulm: crackles bilaterally, no wheezes CV: RRR, nl S1/S2, no MRGs Abd: + BS, soft, ND, (+) left flank TTP Ext: WWP, 1+ LE edema NEURO: AandO x 3, appropriate, CN 2-12 [**Date Range 5235**], no focal gross motor or sensory deficits. Pertinent Results: Admission laboratories: [**2122-7-27**] 08:08PM WBC-6.1 RBC-4.08* Hgb-11.2* Hct-35.2* MCV-86 MCH-27.5 MCHC-31.9 RDW-16.8* Plt Ct-195 Neuts-70.9* Lymphs-20.3 Monos-5.2 Eos-2.4 Baso-1.2 Glucose-109* UreaN-62* Creat-10.1*# Na-136 K-6.7* Cl-102 HCO3-16* AnGap-25* Calcium-9.1 Phos-4.6* Mg-2.0 ALT-18 AST-20 CK(CPK)-564* AlkPhos-80 Amylase-37 TotBili-0.4 Enzymes: CK-MB-16* MB Indx-2.8 cTropnT-0.21* CK(CPK)-388* CK-MB-12* MB Indx-3.1 cTropnT-0.24* CHEST (PA & LAT) [**2122-7-27**] 9:07 PM, Radiology Read: There is cardiomegaly. There are markedly increased interstitial markings, with smaller more alveolar opacities at both bases. There are small bilateral effusions. Findings are compatible with pulmonary edema and small pleural effusions. Old films to confirm resolution after treatment is recommended. . Echo ([**7-28**]): The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 70%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2122-3-17**], the findings are similar. Brief Hospital Course: A/P: 42M with DM1, ESRD on HD, HTN, presented to the ED with hypertensive crisis and SOB c/w fluid overload, s/p emergent HD in the MICU, subsequently called out to the floor. The following issues were investigated during this hospitalization: . # Hypertension: Pt. has a history of poorly controlled blood pressure and this episode was thought to be due to his inability to tolerate medications secondary to nausea/vomiting. BP improved after HD and patient was on all of his outpatient antihypertensives on discharge. . # SOB. Likely pulmonary edema in the setting of hypertensive urgency/emergency. Pt also reported a cough productive of green sputum raising concern for pulmonary infection, but no fevers elevated WBC were observed during his hospitalization. CXR showed improvement in pleural effusion s/p HD, but could not rule out consolidation. Given lack of symptoms as described, patient was not started on antibiotics. An echo performed showed no significant changes from prior. Patient was also ruled out for an MI with elevated (given ESRD), but stable troponins. With conitnued HD, patient had no additional complaints of shortness of [**Year (4 digits) 1440**]. . # ESRD c/b hyperkalemia: Patient underwent dialysis successfully, the first emergent session notable for removal of 5 kg. He was then continued on his regular regimen of dialysis while in-house with no complications. . # Mental Status: Patient was noted to be occasionally somnolent, which per HD staff, has occurred before. Still, given his persistent somnolence, Klonopin, which the patient was receiving for anxiety, was witheld with noted improvement. Patient was oriented x 3, awake and alert, able to follow commands and well-related on discharge. . # DMI: Patient was maintained on his outpatient regimen of NPH with HISS initially, but his PM NPH was decreased from 30 to 15 U given some episodes of hypoglycemia. . # Depression: Patient was maintained on his outpatient Citalopram 20mg daily. Medications on Admission: (per last d/c summary): 1. Lisinopril 40 mg qd 2. Aspirin 325 mg qd 3. Nifedipine 120 mg po qd 4. Gabapentin 300 mg po qhd 5. Metoclopramide 10 mg PO QIDACHS 6. Calcium Acetate 667 mg 2 PO TID 7. Pantoprazole 40 mg qd 8. Mirtazapine 15 mg po qhs 9. Citalopram 20 mg po qd 10. Docusate Sodium 100 mg [**Hospital1 **] 11. Metoprolol Succinate 200 mg po qd 12. Doxepin 50 mg po hs 13. Clonazepam 0.5 mg PO TID 14. Lanthanum 1000 mg po tid 15. Clonidine 0.2 mg/24 hr Patch Weekly 16. Benzonatate 100 mg PO TID 17. Lidocaine 5 %(700 mg/patch) 18. Insulin (70-30) Suspension 15 units before breakfast and 10 units before dinner. 19. Simethicone 80 mg po qid Discharge Medications: 1. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Nifedipine 60 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO DAILY (Daily). 4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO QHD (each hemodialysis). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 7. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily). 10. Doxepin 25 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 11. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 12. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QTUES (every Tuesday). 13. Lanthanum 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 14. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QID (4 times a day). Disp:*60 Tablet(s)* Refills:*2* 15. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 16. Insulin (70-30) suspension 15units before breakfast and 15 units before dinner 17. Outpatient Occupational Therapy potassium check on [**2122-8-3**] please fax to: [**Last Name (LF) **],[**First Name3 (LF) 251**] R. MD Phone: [**Telephone/Fax (1) 65443**] Fax: [**Telephone/Fax (1) 64448**] Discharge Disposition: Home Discharge Diagnosis: Hypertensive Urgency/Pulmonary Edema Discharge Condition: Stable Discharge Instructions: You were seen and evaluated for high blood pressure and fluid overload, which were thought to be due to a need for urgent hemodialysis. Hemodialysis was performed successfully and you are now safe for discharge home. Take all of your medications as directed. IMPORTANT: your insulin regimen has been changed, please take 70/30 as follows- 15units at breakfast and 15units at suppertime (not at bedtime). Keep all of your follow-up appointments. . You will need to have labwork done on [**2122-8-3**] (potassium check). . Call your doctor or go to the ER for any of the following: chest pain, shortness of [**Date Range 1440**], lightheadedness or headache, fevers/chills, nausea/vomiting or any other concerning symptoms. Followup Instructions: Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] CENTER - NON BILLING Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2122-8-5**] 9:00 Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2122-10-23**] 8:30 [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]

[ "403.01", "311", "585.6", "276.7", "V45.1", "428.0", "799.02", "250.43", "428.30" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

8756, 8762

4443, 5843

338, 352

8843, 8852

2850, 4420

9625, 10116

2346, 2392

7130, 8733

8783, 8822

6453, 7107

8876, 9602

2407, 2831

274, 300

380, 1727

5858, 6426

1749, 2209

2225, 2330

78,700

108,025

5432

Discharge summary

report

Admission Date: [**2115-4-9**] Discharge Date: [**2115-4-13**] Date of Birth: [**2044-10-7**] Sex: M Service: CARDIOTHORACIC Allergies: Plavix / Levaquin Attending:[**First Name3 (LF) 1505**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: coronary artery bypass grafting x 4 (LIMA-LAD, SVG-0M, SVG-Dx, SVG-RCA) [**2115-4-9**] History of Present Illness: 70 year old male with a cardiac history which includes PCI of the RCA in [**2096**] at [**Hospital1 2177**]. Cardiac cath [**2098**] showed patent RCA stent but occlusion of distal circumflex coronary. He has been medically managed since then. Over the years he has had intermittent chest pain. More recently, he describes increasing substernal chest tightness and dyspnea with walking and climbing 2 flights of stairs. Despite negative stress test [**Month (only) 404**] of [**2115**] patient is referred for surgical revascularization after failing medical management and continuation of symptoms. Past Medical History: coronary artery disease PMH: Rt carotid occlusion abdominal aortic aneurysm s/p [**Hospital1 **]-iliac stent graft hypertension hyperlipidemia Chronic VEA retinal vein occlusion of left eye coronary artery disease-s/p percutaneous coronary intervention of right coronary artery [**2096**] Appendectomy gastroesophageal reflux disease Social History: Lives with: wife. 2 children live locally Occupation: retired design engineer Tobacco:denies ETOH:denies Family History: father died of sudden death at age 68, mother died of cardiomyopathy age 84 Physical Exam: 67" 192lbs BSA 2.0m2 BP (R) 141/110 (L) 140/90 HR 70 SR Resp 20 Sat 99% RA GEN: WDWN in NAD SKIN: Warm, dry [**Year (4 digits) 5235**], No C/C/E. Multiple skin tags. HEENT: NCAT, PERRLA, Sclera anicteric, OP benign, teeth in fair repair. HEART: RRR, NlS1-S2, No M/R/G LUNGS: CTA ABD: Soft, NT, ND, NABS. EXT: Warm, well perfused. Small superficial spider varicosities noted but GSV appears suitable on standing. Pulses 2+ throughout. CAROTIDS: Faint left bruit. Pertinent Results: Echo [**2115-4-9**] Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage. Overall left ventricular systolic function is low normal (LVEF 50-55%). Right ventricular chamber size and free wall motion are normal. The ascending [**Month/Day/Year 5236**] is mildly dilated. There are complex (>4mm) atheroma in the descending thoracic [**Month/Day/Year 5236**]. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Post-CPB: Preserved biventricular systolic fxn. No AI. Trace MR. [**First Name (Titles) **] [**Last Name (Titles) 5235**]. Other parameters as pre-bypass. Brief Hospital Course: The patient was admitted to the hospital and brought to the operating room on [**2115-4-9**] where the patient underwent coronary artery bypass x 4. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. Cefazolin was used for surgical prophylaxis. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically [**Date Range 5235**] and hemodynamically stable on no inotropic or vasopressor support. Chest tubes and pacing wires were discontinued without complication. The patient was transferred to the telemetry floor for further recovery. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was evaluated by the physical therapy service for assistance with strength and mobility. Albuterol inhaler was initiated to aid in weaning oxygen. By POD 4, the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged home in good condition with appropriate follow up instructions. Medications on Admission: Norvasc 10mg daily Atenelol 100mg in am , 50mg in pm Lipitor 40mg daily Ativan 0.5mg three times a day Losartan 100mg daily NTG 0.4mg SL as needed Omperazole 20mg daily ASA 325mg daily Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain, fever. 6. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 2-4 Puffs Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. Disp:*qs * Refills:*0* 8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). Disp:*135 Tablet(s)* Refills:*2* 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 1 weeks. Disp:*7 Tablet(s)* Refills:*0* 11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 1 weeks. Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 932**] VNA Discharge Diagnosis: coronary artery disease PMH: Rt carotid occlusion abdominal aortic aneurysm s/p [**Hospital1 **]-iliac stent graft hypertension hyperlipidemia Chronic VEA retinal vein occlusion of left eye coronary artery disease-s/p percutaneous coronary intervention of right coronary artery [**2096**] Appendectomy gastroesophageal reflux disease Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with percocet prn Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Please call to schedule appointments Surgeon Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**] Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 8431**] in [**2-9**] weeks Cardiologist Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 62**] in [**2-9**] weeks Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2115-6-17**] 1:00 Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2115-6-17**] 1:45 Provider: [**Known firstname 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2115-6-17**] 2:20 Completed by:[**2115-4-13**]

[ "414.01", "V45.82", "433.10", "413.9", "272.4", "401.9", "362.30", "530.81" ]

icd9cm

[ [ [] ] ]

[ "39.61", "36.13", "36.15" ]

icd9pcs

[ [ [] ] ]

5584, 5642

2893, 4057

294, 383

6020, 6116

2097, 2870

6656, 7355

1514, 1592

4293, 5561

5663, 5999

4083, 4270

6140, 6633

1607, 2078

244, 256

411, 1016

1038, 1374

1390, 1498

61,667

107,635

27130

Discharge summary

report

Admission Date: [**2160-4-25**] Discharge Date: [**2160-4-30**] Service: MEDICINE Allergies: Amoxicillin Attending:[**First Name3 (LF) 2751**] Chief Complaint: Low Hct Major Surgical or Invasive Procedure: None History of Present Illness: [**Age over 90 **] yo M with Hx of Autoimmune hemolytic anemia and GI bleeds, CAD, CKD, Mechanical Aortic valve on coumadin with recent admission to [**Hospital1 18**] for anemia felt to be secondary to GI bleed ([**Date range (1) 66606**]), who was sent to the ED from [**Hospital 100**] Rehab for persistently low Hct. Per the patient, he has been in his usual state of health and has not experienced any dizziness, syncope, CP, SOB or other symptoms in the last several days, but has felt generally tired. His NH has been closely monitoring his Hct, which has been low but stable for the past several days. He received 2 units prbcs at rehab on [**4-18**] for Hct 22, and did not have an adequate response (Hct [**4-23**] was 23.8 and [**4-25**] was 22.3 with INR 2.2). Patient was also reportedly noted to have a small amount of BRBPR yesterday, but he states he never saw the blood. . Of note, the patient has had extensive workup in the past for GI bleed(EGD x4, [**Last Name (un) **] x2, capsule x3, CT abd/pelvis, bleeding scan) without clear source or site, and felt to be most likely bleeding from an UGI source that is not possible to reach endoscopically. On prior admissions, further invasive testing was discussed, and the patient and HCP opted for more conservative measures including transfusions and iron supplementation. . In the ED, initial vs were: 97.0 86 95/51 14 97% RA, pain 0/10. Labs were significant for Hct 20.5 (down from 22.3 at NH), INR 3.0. He was found to have black guaiac positive stool. No NG lavage was performed given patient's stability and multiple prior similar presentations. Patient was given a protonix bolus and started on a drip. He was typed and crossed 2 units but did not receive any blood prior to transfer. He was admitted to the ICU for further management. . On the floor, patient reports feeling generally tired and thirstly, but otherwise well. Specifically denies dizziness, chest pain, SOB, palpitations or other symptoms currently. . Review of systems: (+) Per HPI, also reports several days of burning with urination. Incontinent of urine and stool at baseline. Also reports left arm pain when his arm "gets cold," which is responsive to tylenol and has been present for several weeks. Does not walk or move much at baseline. (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: # Anemia, multifactorial as below, baseline HCT 28 # Autoimmune hemolytic anemia (Coomb's +, warm autoantibody), on prednisone 10mg Po daily # Listeria Endocarditis s/p AVR, suppressive amoxicillin stopped due to hemolytic anemia # Aortic mechanical valve, recently Coumadin resistant so intermittently on Lovenox bridge, followed by Dr. [**Last Name (STitle) **] # hx recent GI bleeds: colonoscopy [**1-10**]: noted normal colon with melanotic stool in terminal ileum # GERD: EGD [**12/2159**] Polyp in the area of the papilla; found on the wall opposite the ampulla. Small hiatal hernia. Otherwise normal EGD to third part of the duodenum. # H/o presyncope # CKD Cr 1.6-2.0 Stage III # CAD s/p NSTEMI [**7-10**] # Chronic CHF, likely diastolic, ([**9-9**] EF=50%) # Hyperlipidemia # Hypertension # Depression vs adjustment disorder after death of brother # Prostate cancer- s/p radiation # Bladder/bowel incontinence # Right lateral malleolus stage 1 pressure ulcer # Dementia Social History: Never smoked, no EtOH or other drugs. Currently living at [**Hospital 100**] Rehab. Uses wheelchair typically. Requires a significant degree of assistance in all his ADLs and IADLs. Has 2 sons and 4 grandchildren. Family History: No bleeding diatheses. Father had stomach cancer. No other cancers including colon. Physical Exam: Vitals: T: 96 BP: 92/41 P:69 R: 18 O2: 99% on RA General: pale, tired-appearing elderly male, lying in bed in NAD, alert and oriented (although later appeared confused) HEENT: NCAT, PERRL, right ptosis (chronic per patient), sclera anicteric, dry MM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally (anterior only) CV: Regular rate and rhythm, S1 + S2, mechanical ao valve sounds Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or edema Pertinent Results: Admission Labs: [**2160-4-25**] 06:45PM BLOOD WBC-4.3 RBC-2.05*# Hgb-7.0*# Hct-20.5*# MCV-100* MCH-34.1* MCHC-34.0 RDW-22.2* Plt Ct-159 [**2160-4-25**] 06:45PM BLOOD PT-30.4* PTT-29.8 INR(PT)-3.0* [**2160-4-25**] 06:45PM BLOOD Glucose-183* UreaN-50* Creat-1.4* Na-138 K-4.4 Cl-106 HCO3-23 AnGap-13 [**2160-4-25**] 06:45PM BLOOD Albumin-3.0* Calcium-7.7* Phos-3.0 Mg-2.1 [**2160-4-26**] 09:05AM BLOOD WBC-4.6 RBC-2.58*# Hgb-8.4* Hct-24.4* MCV-95 MCH-32.5* MCHC-34.3 RDW-22.1* Plt Ct-108* [**2160-4-26**] 02:48PM BLOOD WBC-4.0 RBC-2.76* Hgb-9.1* Hct-25.7* MCV-93 MCH-33.0* MCHC-35.4* RDW-21.7* Plt Ct-110* [**2160-4-27**] 02:54AM BLOOD WBC-3.6* RBC-2.62* Hgb-8.2* Hct-25.5* MCV-98 MCH-31.4 MCHC-32.2 RDW-22.1* Plt Ct-108* [**2160-4-28**] 04:10AM BLOOD WBC-3.5* RBC-2.71* Hgb-8.7* Hct-26.5* MCV-98 MCH-31.9 MCHC-32.6 RDW-21.6* Plt Ct-118* [**2160-4-29**] 04:28AM BLOOD WBC-4.1 RBC-2.78* Hgb-9.0* Hct-26.5* MCV-95 MCH-32.4* MCHC-34.0 RDW-21.5* Plt Ct-125* [**2160-4-30**] 05:18AM BLOOD WBC-5.1 RBC-3.24* Hgb-10.7* Hct-30.9* MCV-95 MCH-33.0* MCHC-34.6 RDW-20.6* Plt Ct-134* [**2160-4-30**] 05:18AM BLOOD Glucose-86 UreaN-13 Creat-1.3* Na-144 K-3.7 Cl-112* HCO3-25 AnGap-11 [**2160-4-25**] 06:45PM BLOOD Albumin-3.0* Calcium-7.7* Phos-3.0 Mg-2.1 [**2160-4-25**] 06:45PM BLOOD LD(LDH)-182 TotBili-0.2 DirBili-0.1 IndBili-0.1 [**2160-4-30**] 05:18AM BLOOD LD(LDH)-198 [**2160-4-26**] 3:00 pm URINE Source: Catheter. URINE CULTURE (Preliminary): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH FECAL CONTAMINATION. INTERPRET RESULTS WITH CAUTION. GRAM NEGATIVE ROD(S). >100,000 ORGANISMS/ML.. PREDOMINATING ORGANISM. CARDIAC ECHO [**2160-4-29**]: Poor image quality. The left atrium is moderately dilated. 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. Overall left ventricular systolic function is probably mildly depressed (LVEF= 45 %) with a suggesiton of more prominent inferior hypokinesis (difficult to assess due to poor image quality). There is no ventricular septal defect. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. A mechanical aortic valve prosthesis is present. The aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([**2-3**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2159-1-30**], no definite change. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2160-4-29**] 16:28 PORTABLE CHEST, [**2160-4-27**] CLINICAL INFORMATION: Falling hematocrit, question change. FINDINGS: Frontal view of the chest compared to multiple prior examinations. There are low lung volumes. PICC on the right is unchanged. Small left-sided pleural effusion with left lower lobe atelectasis unchanged. Mild congestive failure. Brief Hospital Course: [**Age over 90 **]M with autoimmune hemolytic anemia, mechanical aortic valve on coumadin and recurrent GIB, who presents with low HCT and guaiac positive stool. . #. Anemia: Most likely multifactorial, and mostly from recurrent ongoing GIB. Hemolysis not thought to be a significant factor given the Coombs test was negative and he had a normal LDH. He had dark guaiac pos stools, but has had work up in past including colonoscopy and capsule endoscopy without finding source of bleed. GI was consulted and felt as though, while he is anticoagulated, there is nothing to do. If his anticoagulation could be stopped they would recommend monitoring his HCT over a few months time to evaluate stability. His HCT was 20.7 on admission and he received 2 units PRBCs in the ED and his HCT had an appropriate bump to 25 and remained stable at 25 thereafter. Hematology recommended transfusing to >30 and so he received one more unit on the medical floor. CBC should be monitored periodically as well as stool output for recurrent bleeding. GI team was aware of him, but since prior EGD/Colonoscopy has failed to reveal a source, decided conservative treatment was the best. In the past, blood has been noted in the terminal ileum so a small bowel lesion is suspected. Capsule studies have not revealed a source, though was incomplete (in [**2159-12-3**]). Patient on brdiging IV Hep/Warfarin. . # Mechanical Aortic valve: The patient has a goal INR of [**3-6**] (ideally 2.5). Heme/onc wanted to consider stopping anticoagulation as pt frequently in hospital. Cardiology felt the risk was not well definable and not worth it, so he was continued on anticoagulation. His INR was reveresed in the ICU with Vit K and he was restarted on IV heparin drip (wt based protocol without bolus) to bridge until therapeutic INR on warfarin. Per cardiology, the hep gtt should not be stopped until the INR level is therapeutic at around 2.2. He is discharged to [**Hospital 100**] Rehab where this can be followed appropriately. A TTE was updated and showed no change from prior (see report in results section). # UTI: The patient complained of dysuria on admission and he had a positive U/A. He was started on cipro 500mg Q12H with plans for a 7 day course. He had questionable delerium after ICU stay, and so Cipro was changed to Ceftriaxone. Urine culture [**2160-4-26**] is growing >100K organisms with a predominant GNR, not yet speciated with sensitivities. This needs to be followed by [**Hospital 100**] Rehab by calling [**Hospital1 18**] Micro Lab [**Telephone/Fax (1) 4645**] for results. . # Delerium vs. Hospital Psychosis: When out of ICU on medical floor, he had vivid hallucinations of being visited by Chinese Immigration, and then by 2 men from the mafia who were after his patents. He was otherwise not inattentive as usually seen with acute delierum, and his psychosis was not agitated. He received one nightime dose of Haldol 0.25mg on [**2160-4-29**] and slept very well without PM or [**2160-4-30**] AM recurrent hallucinations (though patient has good recollection of the hallucinations). This should be followed by his medical team and geriatrician at [**Hospital 100**] Rehab. [**Name (NI) **] son [**Name (NI) **] ([**Name2 (NI) **]) is aware. . # Autoimmune Hemolytic Anemia: Chronic - is on Prednisone for this. Not acutely hemolyzing here. At the time this diagnosis was originally made, the patient was on Amoxicillin, so there was some concern at that time that Penicillin associated drug hemolyis was possible. While very unlikely, since he is on Ceftriaxone, hematolgoy team recommends checking LDH periodically while he is taking this drug. . # CKD: On admission his creatinine was at his baseline (1.2-1.5). Medications were renally dosed as needed. Creatinine varied 1.0 to 1.4 during hosptialization. . # GERD: Initially he was treated with PPI IV BID and subsequently transitioned to PO. . # CAD/Hyperlipidemia/HTN: Continued statin. Held carvedilol in setting of GIB and stable blood pressures. . CODE: FULL HCP: [**Name (NI) **] ([**Doctor Last Name **]) [**Known lastname 66590**] Phone number: [**Telephone/Fax (1) 66592**] Cell phone: [**Telephone/Fax (1) 66591**] Medications on Admission: -oxycodone 2.5 mg TID prn -warfarin 3 mg daily -tylenol 650 mg q6h prn -Vitamin B12 [**2149**] mcg daily -folic acid 4 mg po daily -omeprazole 40 mg [**Hospital1 **] -simvastatin 40 mg daily -carvedilol 3.125 [**Hospital1 **] -Bactrim SS daily (400-80) -clindamycin 600 mg prn po -levothyroxine 75 mcg daily -senna daily -prednisone 10 mg daily -acetaminophen 1000 mg [**Hospital1 **] Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for fever or pain. 2. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 3. folic acid 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily): give 1 hour prior to meals and PPI in the morning. 10. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. 11. heparin (porcine) in NS 10 unit/mL Kit Sig: wt based units Intravenous continuous: until therapeutic INR 2.2. 12. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 13. ceftriaxone in dextrose,iso-os 1 gram/50 mL Piggyback Sig: One (1) gram Intravenous Q24H (every 24 hours) as needed for UTI for 6 days. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Acute blood loss Anemia GI Hemorrhage MEchanical Heart Valve Delerium vs. Hospital psychosis Chronic Systolic Heart Failure Autoimmune Hemolytic Anemia (chronic) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. You were admitted with recurrent GI bleed from suspected small bowel source. Your warfarin was held and reversed, you recevied a total of 3 units of blood with appropriate bump. You are on IV heparin bridge while back on coumadin until therapeutic to protect your heart valve. You had mild delerium vs. Hospital psychosis which will be followed by your team at [**Hospital 100**] Rehab. Followup Instructions: By Geriatrician Dr. [**Last Name (STitle) **] at [**Hospital 100**] Rehab.

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Discharge summary

report+addendum

Admission Date: [**2157-11-12**] Discharge Date: [**2157-11-18**] Service: MEDICINE Allergies: Penicillins / Procainamide / Decongestant / Novocain / Beta-Adrenergic Agents / Sulfonamides / Captopril / Enalapril / Hydralazine / Erythromycin Base / Nifedipine / Paroxetine / Sertraline Attending:[**First Name3 (LF) 5827**] Chief Complaint: Hypoxia Major Surgical or Invasive Procedure: PICC line placement History of Present Illness: 85 y.o. female with multiple medical problems, most pertinently, aspiration PNA and restrictive lung disease (on Amiodarone for atrial fibrillation)who presents from her nursing home with desaturation into the 80s. Patient was reported to be in her normal state of health until today when she was noted to be awake and oriented x 3, but withdrawn and lethargic. Patient was noted to be hypoxic to the 80s on room air and was brought into the ED for further evaluation. Patient was also complaining of back and hip pain, which are both chronic, but denied chest pain. In the ED, vitals were significant for: T - 99.3, HR - 70, BP - 118/55, RR - 14, O2 - 100 NRB. A CXR showed a possible PNA and a head CT was ordered for question of mental status changes, but patient was awake, alert and oriented x 3 and refused the head CT. She was given Vancomycin, Levofloxacin and Flagyl for the presumed PNA and admitted to the ICU because of high oxygen requirement - NRB. Patient is DNR/DNI. . Of note, patient was hospitalized here at [**Hospital1 18**] from [**Date range (1) 47017**] for back pain and change in mental status, the latter of which was felt to be due infection as the patient had a UA suggestive of a UTI (no culture was done). She was also noted to be transiently hypoxic at this time, but CXR was unremarkable. She was treated with Levofloxacin for her UTI and on discharge, no longer had an oxygen requirement. Past Medical History: 1. Tachy/Brady s/p DDI pacemaker ([**12-25**]) -[**Company 1543**]. 2. HTN 3. AF with CVA/TIA in [**2153**], on coumadin and amiodarone. Echo [**10/2154**]: mild [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1915**], mild LVH, EF>55%. Mild to mod MR, mild to mod pulmonary HTN PASP 38. 4. Quinidine-induced Lupus c/b pericardial effusion s/p stripping 5. Aspiration Pneumonia 6. Restrictive lung dz on PFTs in [**6-/2156**] FVC and FEV1 near 45% predicted. 7. Psoriasis 8. spinal stenosis s/p L4-5 Laminectomy and spinal fusion ?????? wheelchair bound since [**2141**] 9. ?left hip replacement s/p fall 10. Depression 11. urinary incontinence Social History: Social History: lives in [**Hospital3 2558**], a nursing home. Husband died suddenly at age 50. Has a son and a daughter, and 5 ??????[**Name2 (NI) **]?????? grandkids. Retired 11 years ago from working at [**Hospital1 756**] as a collection officer. 30py history of smoking, quit 35 years ago. No alcohol use, no illegal drug use. Family History: HTN and MI in paternal side??????father died of MI. Mother died of aneurysm. No diabetes. No cancer. Physical Exam: Vitals: T - 96.7, BP - 162/57, HR - 73, RR - 23, O2 - 100% on 15 NRB (92% on RA) General: Awake, alert, NAD HEENT: NC/AT; PERRLA, EOMI; OP clear Neck: Supple, no LAD, no JVD Chest/CV: S1, S2 nl, no m/r/g appreciated Lungs: Poor inspiratory effort, but decreased BS on the left Abd: Soft, NT, ND, + BS Ext: No c/c/e Neuro: Grossly intact Skin: Multiple nevi noted, particularly on back Pertinent Results: EKG: Sinus at 70, LAD, prolonged PR, borderline widened QRS, no acute ST changes . Imaging: CXR ([**11-12**]): AP and lateral views of the chest are obtained in the upright position. Patient rotation somewhat limits evaluation. There is increased pulmonary opacity at the left lung base which may represent evolving pneumonia, though technique is suboptimal, limits assessment. There is stable plate-like atelectasis at the right lung base. Cardiomediastinal silhouette is stable. Atherosclerotic calcification along the aortic knob is noted. A small left-sided pleural effusion is noted. Visualized osseous structures are intact. A left-sided pacer device is seen with lead tips terminating in the approximate location of the right atrium and right ventricle. . 143 104 31 -------------< 118 4.9 30 1.2 . WBC: 16.4 HCT 35 Plt 382 N:83.9 L:11.1 M:3.4 E:1.3 Bas:0.2 . PT: 41.4 PTT: 66.5 INR: 4.5 Brief Hospital Course: Ms. [**Known lastname **] is an 85 y.o. female with desaturations at nursing home and LLL infiltrate with leukocytosis, concerning for PNA. Hosp course by problem: . # Aspiration Pneumonia: Diagnosed via imaging as above. We initiated with levofloxacin, metronidazole, and vancomycin given recent hospitalization and NH status. Recurrent PNA, altered ms, and poor swallow apparatus worrisome for aspiration. Swallow c/s ordered that recommended ground solids and honey-thickened liquids. On discharge, she will continue vancomycin IV for 6 weeks for below. . # Sepsis and presacral abscess.: L-spine showed presacral abscess abutting L5/S1 that probably contributed to of pt's back pain and leukocytosis. Transient MICU stay. Surgical consult was obtained. Source thought to be hematogenous seeding of presacral area. Patient not a candidate for percutaneous CT guided drainage per interventional radiology. Her preoperative functional status precluded surgical intervention, per surgical team. Therefore, we elected medical management with 6 week course of antibiotics, vancomycin, levofloxacin, and metronidazole. She will need repeat CT scan in 6 weeks, which has been scheduled for [**2157-12-26**]. If there is persistence of abscess, then she will need to continue antibiotics longer. . # Atrial Fibrillation/Tachy/Brady: S/P Pacemaker. On Coumadin, initially supratherapeutic and was reversed with oral vitamin K. Warfarin resumed. Additionally, now on Levofloxacin which will interact with Coumadin. Will need to monitor INR closely. Also on Amiodarone, Atenolol and Verapamil. . # Back Pain: Likely secondary to presacral abscess. Continue Lidocaine patch and Gabapentin. .. # Depression: On Phenelzine as an outpatient which was continued. . # Delirium: Pt delirious in MICU which subsequently improved with pain control, antibiotics for infection and relief of constipation. We treated pain with minimally sedating meds and treated her infection. We used low-dose haldol prn. Continued outpatient Zyprexa . # Rigidity and masked facies: seen on MICU rounds. ? parkinson's disease. Will need monitoring as outpatient. . # Code status: DNR/DNI . # Contact: [**Name (NI) **] [**Name (NI) 12056**] [**Telephone/Fax (1) 102830**] Medications on Admission: Lactulose 30 ml PO DAILY Acetaminophen 325-650 mg PO Q6H:PRN Levofloxacin 500 mg PO Q24H Amiodarone 200 mg PO DAILY Multivitamins 1 CAP PO DAILY Atenolol 50 mg PO DAILY Olanzapine 5 mg PO DAILY Bisacodyl 10 mg PR HS:PRN Pantoprazole 40 mg PO Q24H Calcium Carbonate 500 mg PO BID Phenelzine Sulfate 15 mg PO BID Clonazepam 0.5 mg PO QHS Senna 1 TAB PO BID Docusate Sodium 100 mg PO BID Fluticasone Propionate NASAL 2 SPRY NU [**Hospital1 **] Verapamil SR 120 mg PO Q24H Gabapentin 300 mg PO HS Vitamin D 400 UNIT PO DAILY Heparin 5000 UNIT SC TID Warfarin 1 mg PO daily . Allergies/Adverse Reactions: Penicillins / Procainamide / Decongestant / Novocain / Beta-Adrenergic Agents / Sulfonamides / Captopril / Enalapril / Hydralazine / Erythromycin Base / Nifedipine / Paroxetine / Sertraline Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Phenelzine 15 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal [**Hospital1 **] (2 times a day). 8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO DAILY (Daily). 11. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical QD (). 12. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Verapamil 180 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q24H (every 24 hours). 14. Docusate Sodium 50 mg/5 mL Liquid Sig: Five (5) ml PO BID (2 times a day). 15. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY16 (Once Daily at 16). 16. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous Q 24H (Every 24 Hours) for 4 weeks: To complete final dose of antibiotics on [**2157-12-24**]. gram 17. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig: Five Hundred (500) mg Intravenous Q8H (every 8 hours) for 4 weeks: To complete last dose of 6 week course on [**2157-12-24**]. 18. Levofloxacin in D5W 750 mg/150 mL Piggyback Sig: Seven [**Age over 90 1230**]y (750) mg Intravenous Q48H (every 48 hours) for 4 weeks: To complete last dose of 6 week course on [**2157-12-24**]. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Primary: Aspiration pneumonia, bacteremia, presacral abscess. Secondary: Restrictive lung disease, Atrial fibrillation, HTN, Tachy/brady syndrome s/p pacemaker, depression, hearing loss Discharge Condition: Hemodynamically stable and afebrile. Discharge Instructions: You were admitted for low oxygen saturation and delirium. You had aspiration pneumonia, bloodstream infection, and infection in your pelvis. You were started on antibiotics which need to be continued for a total of 6 weeks. Please continue these antibiotics as prescribed. Please continue all your medications as prescribed. You facility will be provided a copy of all your medications and will continue to administer them to you. . Please keep all your outpatient appointments. . Please return to the ED or seek medical care if you notice new fevers, chills, worsening back pain, painful urination, diarrhea, worsening mental status or for any other symptom for which you are concerned. Followup Instructions: You will be followed by your facility physician while at your extended-care facility. Upon discharge, you should schedule an appointment with your primary doctor, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6680**] at [**Telephone/Fax (1) 608**]. You have been scheduled for a follow-up CT scan on [**2157-12-26**] at 2:00 PM at the [**Hospital Ward Name 23**] Clinical Center, [**Location (un) 3387**], [**Location (un) **]. Please do not eat for 3 hours prior to the scan, and please have full bladder 1 hours before scan. Please call [**Telephone/Fax (1) 327**] with any questions. Completed by:[**2157-11-18**] Name: [**Known lastname **],[**Known firstname 16603**] Unit No: [**Numeric Identifier 16604**] Admission Date: [**2157-11-12**] Discharge Date: [**2157-11-18**] Date of Birth: [**2072-2-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Procainamide / Decongestant / Novocain / Beta-Adrenergic Agents / Sulfonamides / Captopril / Enalapril / Hydralazine / Erythromycin Base / Nifedipine / Paroxetine / Sertraline Attending:[**First Name3 (LF) 2191**] Addendum: PERTINENT LABS DURING ADMISSION: ================================ WBC trend: 16.4 - 14.2 - 11.1 - 11.6 - 10.6 - 10.9 - 17.5 - 14.7 . AEROBIC BOTTLE (Final [**2157-11-15**]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 4 R OXACILLIN-------------<=0.25 S PENICILLIN------------ =>0.5 R ANAEROBIC BOTTLE (Final [**2157-11-16**]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. . [**2157-11-12**] 1:55 pm BLOOD CULTURE AEROBIC BOTTLE (Final [**2157-11-15**]): STAPHYLOCOCCUS, COAGULASE NEGATIVE ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 4 R OXACILLIN-------------<=0.25 S PENICILLIN------------ =>0.5 R ANAEROBIC BOTTLE (Final [**2157-11-16**]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. . [**11-12**] UCx: mixed flora [**11-13**] UCx: no growth [**11-14**] BCx: pending [**11-15**] BCx: pending . STUDIES: ======== CT LUMBAR W&W/O CONTRAST [**2157-11-15**] IMPRESSION: 1) Presacral abscess measuring 2.7 x 4 cm which is abutting the L5/S1 disc and the left internal iliac artery and left common iliac vein. 2) No definite evidence of spondylodiscitis at L5/S1. 3) There is a left central epidural lesion at the L5/S1 level which may represent a recurrent disc herniation but an epidural abscess cannot be excluded. MRI with contrast is needed for better evaluation. . TTE (Complete) Done [**2157-11-14**] The left atrium is moderately dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is an anterior space which most likely represents a fat pad. Compared with the prior study (images reviewed) of [**2156-12-14**], the findings are similar. . CXR [**2157-11-17**] IMPRESSION: 1. Right PICC with wire tip at the superior cavoatrial junction. Findings were discussed with IV nurse, [**Doctor First Name 4379**], who states there is 1 cm of catheter beyond the wire tip. Recommendation was made to retract the catheter by at least 1 cm. 2. New small right pleural effusion and stable small left pleural effusion. 3. Left retrocardiac opacity with air bronchograms may represent pneumonia . Staph coag-negative Bacteremia: The patient was found to have 4/4 bottles of Staph coagulase-negative. She did not have any indwelling lines to be the source. An echo was performed that did not reveal any vegetations. Additionally, as she complained of low back pain, a CT of the L-spine was performed (MRI could not be performed due to the patient's pacemaker). This showed a presacral abscess that could either have been the source of the bacteremia or a complication of the bactermia. She was continued on vancomycin as an outpatient to complete a prolonged course of antibiotics. A PICC was placed. Discharge Disposition: Extended Care Facility: [**Hospital3 901**] - [**Location (un) 382**] [**First Name11 (Name Pattern1) 732**] [**Last Name (NamePattern4) 2192**] MD [**MD Number(2) 2193**] Completed by:[**2157-11-19**]

[ "V45.01", "730.08", "V43.64", "515", "293.0", "311", "518.81", "V58.61", "507.0", "790.7", "401.9", "722.93", "427.31", "427.81" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

14912, 15145

4376, 6635

407, 428

9695, 9734

3450, 4353

10474, 14889

2924, 3029

7476, 9372

9486, 9674

6661, 7453

9758, 10451

3044, 3431

360, 369

456, 1881

1903, 2556

2588, 2908

79,400

182,082

36776

Discharge summary

report

Admission Date: [**2176-9-16**] Discharge Date: [**2176-9-24**] Date of Birth: [**2107-8-9**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest pain. Major Surgical or Invasive Procedure: s/p CABGx3(LIMA->LAD, SVG->OM1, OM3) [**2176-9-18**] History of Present Illness: This 69 year old male has a history of several months of exertional angina, relieved with rest. Not stated whatprecipitates pain. EST positive (2mm ST depression inferolat) at Stage I(3min) of [**Doctor First Name **] protocol. Cathed today to show significant LAD/Cx dz, transferred, painfree, to [**Hospital1 18**]. Past Medical History: HTN hypercholesterolemia BPH "reactive airway disease" Social History: Lives with his wife. Cigs: none ETOH: none Family History: Unremarkable Physical Exam: Pulse: Resp:14 O2 sat:100% RA B/P Right:130/72 Left: 130/74 Height: 69" Weight:81kg General:WDWN 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 [x] Irregular [] Murmur no Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] obese Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right:3 Left:3 DP Right:3 Left:3 PT [**Name (NI) 167**]:3 Left:3 Radial Right: Left: Carotid Bruit Right:N Left:N Pertinent Results: [**Known lastname **], [**Known firstname 83131**] [**Hospital1 18**] [**Numeric Identifier 83132**] (Complete) Done [**2176-9-18**] at 1:09:43 PM PRELIMINARY Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] R. [**Hospital1 18**], Division of Cardiothorac [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2107-8-9**] Age (years): 69 M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Left ventricular function. Mitral valve disease. ICD-9 Codes: 440.0, 396.9 Test Information Date/Time: [**2176-9-18**] at 13:09 Interpret MD: [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD Test Type: TEE (Complete) 3D imaging. Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 929**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2009AW02-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *4.6 cm <= 4.0 cm Left Atrium - Four Chamber Length: 4.4 cm <= 5.2 cm Left Ventricle - Septal Wall Thickness: *0.5 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: *0.5 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.6 cm <= 5.6 cm Aorta - Sinus Level: 3.0 cm <= 3.6 cm Aorta - Ascending: 2.6 cm <= 3.4 cm Findings Multiplanar reconstructions were generated and confirmed on an independent workstation. LEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast or thrombus in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is seen in the RA. No ASD by 2D or color Doppler. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Normal LV wall thickness and cavity size. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal ascending aorta diameter. Simple atheroma in ascending aorta. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. Mildly thickened aortic valve leaflets (?#). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. 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. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. Conclusions PRE-BYPASS: The left atrium is mildly dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the ascending aorta. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. 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. Trivial mitral regurgitation is seen. There is no pericardial effusion. POST-BYPASS: Patient is on no inotropic agents post-bypass. No changes from pre-bypass findings. Left ventricular function is normal. The aorta appears to be intact post decannulation. All findings communicated to surgical team. Interpretation assigned to [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD, Interpreting physician Brief Hospital Course: This patient was transferred from [**Hospital6 5016**] on [**2176-9-17**] and underwent CABGx3(LIMA->LAD, SVG->OM1, OM3). The cross clamp time was 51 minutes with a total bypass time of 62 minutes. He tolerated the procedure well and was transferred to the CVIVU in stable condition on Neo and Propofol. He was extubated on the post op night and had his chest tubes discontinued on POD 1. He was transferred to the floor on POD 1. His chest tubes and pacing wires were removed per protocol. The post chest tube removal chest XRAY revealed at PTX and Mr. [**Known lastname 33419**] was also symptomatic with low oxygen saturation. A chest tube was re-inserted into the right pleural space and was placed to suction with lung re-expansion. The chest tube was placed to water seal on POD# 5 without PTX. Chest tube was removed and CXR post removal resulted in a left sided small apical pneumothorax which was stable on multiple subsequent chest radiographs. The patient was discharged to home after review of these radiographs by Dr. [**First Name (STitle) **] [**Name (STitle) **] with the understanding that Mr. [**Known lastname 33419**] should return in three days to repeat a chest radiograph. All follow-up appointments were advised. Medications on Admission: Atenolol 50mg/daily Crestor 10mg/D ASA81mg/D Flomax 0.4mg/D Lisinopril 20mg/D Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 2. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 7 days. Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 3. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*75 Tablet(s)* Refills:*0* 8. Lisinopril 5 mg Tablet Sig: Two (2) Tablet PO once a day: [**2-9**] home dose. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: HTN hypercholesterolemia BPH reactive airway disease coronary artery disease Discharge Condition: Good. Discharge Instructions: Take medications as directed on discharge instructions. Do not drive for 4 weeks. Do not lift more than 10 lbs. for 2 months. Shower daily, let water flow over wounds, pat dry with a towel. Do not use lotions, powders, or creams on wounds. Call our office for temp.>101.5, sternal drainage. Followup Instructions: Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks. Make an appointment with Dr. [**Last Name (STitle) 29065**] for 1-2 weeks. Make an appointment with Dr. [**Last Name (STitle) 83133**] for 2-3 weeks. Please obtain a chest CXR on Friday [**2176-9-27**] at [**Hospital1 18**]. Completed by:[**2176-9-24**]

[ "414.01", "512.1", "600.00", "272.4", "E878.2", "493.90", "401.9", "411.1" ]

icd9cm

[ [ [] ] ]

[ "39.61", "34.04", "36.15", "36.12" ]

icd9pcs

[ [ [] ] ]

7884, 7959

5556, 6801

332, 387

8080, 8088

1563, 5533

8427, 8751

893, 907

6930, 7861

7980, 8059

6827, 6907

8112, 8404

922, 1544

281, 294

415, 737

759, 816

832, 877

69,713

174,618

7389+55829

Discharge summary

report+addendum

Admission Date: [**2181-2-26**] Discharge Date: [**2181-3-14**] Date of Birth: [**2113-1-30**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 165**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: Aortic valve replacement (21mm CE Magma Tissue) [**2181-3-8**] Cardiac cath [**2181-3-2**] History of Present Illness: Ms. [**Known lastname 1683**] is a 68 year-old woman who was transferred from an outside hospital with dyspnea and a chronic obstructive pulmonary disease exacerbation. Work-up for this complaint revealed moderate to severe aortic stenosis, moderate aortic regurgitation, moderate mitral regurgitation, severe pulmonary hypertension, and an ejection fraction of 55% by echocardiogram. She was referred to cardiac surgery for repair of her aortic valve pathology. Past Medical History: Aortic Stenosis, congestive heart failure Hypertension, h/o breast cancer s/p left mastectomy and XRT, Hyperthyroidism - multinodular goiter, Noninsulin dependent diabetes mellitus, Chronic obstructive pulmonary disease, Hyperlipidemia, s/p non ST elevation mycardial infarction Social History: Works in electronics company as tester. Denies alcohol use. 20 pack year, quit 20 years ago. Family History: No valvular disease, no sickle cell. Physical Exam: VS: 80 20 138/57 5'5" 69kg Skin: Left breast removed (well-healed), multiple bruises on arms HEENT: Unremarkable Neck: Supple, full range of motion Chest: Decreased breath sounds bilat. bases Heart: Irregular rhythm with 3/6 systolic murmur radiating to carotids Abd: Soft, non-tender, non-distended, +bowel sounds Ext: Warm, well-perfused, 2+ edema Neuro: Alert and oriented x 3, grossly intact Pertinent Results: [**3-2**] Cath: 1. Selective coronary angiography of this right dominant system revealed no angiographically apparent flow limiting disease. 2. Resting hemodynamics demonstrated moderate pulmonary artery hypertension (PA 49/13 mm Hg), elevated left sided filling pressures (LVEDP 47 mm Hg), and systemic arterial hypertension (central aortic pressure 147/42 mm Hg. 3. Aortic valve calculated at 0.9 cm2, with cardiac output/index 4.37 l/min and 2.39 l/min/m2, mean gradient 21.7 mm Hg, systolic ejection period 23.8, valve flow 183.65 ml/sec. 4. Wide pulse pressure indicative of significant aortic insufficiency. FINAL DIAGNOSIS: 1. Coronary arteries are normal. 2. Moderate aortic mixed stenosis and regurgitation. 3. Severe diastolic ventricular dysfunction. [**3-1**] CNIS: 1. No significant interval change and no evidence of significant ICA stenosis on either side. 2. Antegrade flow in both vertebral arteries. [**3-8**] Echo: PRE-CPB:1. The left atrium is moderately dilated. No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. No thrombus is seen in the left atrial appendage. No thrombus is seen in the right atrial appendage No atrial septal defect is seen by 2D or color Doppler. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. 3. Right ventricular chamber size and free wall motion are normal. 4. There are simple atheroma in the aortic root. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. 5. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. The annulus measures 21 mm. There is moderate to severe aortic valve stenosis (area 0.8-1.0cm2). Mild (1+) aortic regurgitation is seen. 6. The mitral valve leaflets are moderately thickened. There is severe mitral annular calcification. There is mild valvular mitral stenosis (area 1.5-2.0cm2). Moderate (2+) mitral regurgitation is seen at a systolic pressure of 130 that is 1+ at a systolic pressure of 100 mmHg. Drs [**First Name (STitle) 6507**], [**Name5 (PTitle) 3318**] and [**Name5 (PTitle) 5209**] were in the OR to discuss the findings with Dr. [**Last Name (STitle) **]. Dr. [**Last Name (STitle) **] was notified in person of the results. POST-CPB: On infusions of epinephrine, phenylephrine. AV pacing. Well-seated bioprosthetic valve in the aortic position. No AI. Gradient now 34 peak, 20 mean on inotropic support. MR is now trace. Preserved biventricular systolic function. Aortic contour is normal post decannulation. [**2181-2-26**] 04:27PM BLOOD WBC-13.3*# RBC-3.20* Hgb-10.1* Hct-29.8* MCV-93 MCH-31.5 MCHC-33.8 RDW-17.1* Plt Ct-115*# [**2181-3-7**] 06:04AM BLOOD WBC-7.9 RBC-2.65* Hgb-8.4* Hct-26.3* MCV-99* MCH-31.5 MCHC-31.8 RDW-16.0* Plt Ct-167 [**2181-3-13**] 06:01AM BLOOD WBC-10.7 RBC-2.84* Hgb-9.1* Hct-27.1* MCV-96 MCH-31.9 MCHC-33.4 RDW-16.9* Plt Ct-110* [**2181-2-26**] 04:27PM BLOOD PT-13.6* PTT-28.0 INR(PT)-1.2* [**2181-3-7**] 06:04AM BLOOD PT-14.1* PTT-110.9* INR(PT)-1.2* [**2181-3-14**] 05:58AM BLOOD PT-29.1* PTT-33.4 INR(PT)-3.0* [**2181-2-26**] 04:27PM BLOOD Glucose-167* UreaN-76* Creat-1.3* Na-147* K-3.3 Cl-103 HCO3-34* AnGap-13 [**2181-3-7**] 06:04AM BLOOD Glucose-84 UreaN-37* Creat-1.0 Na-147* K-3.5 Cl-105 HCO3-37* AnGap-9 [**2181-3-13**] 06:01AM BLOOD Glucose-95 UreaN-50* Creat-1.3* Na-138 K-3.6 Cl-99 HCO3-32 AnGap-11 [**2181-3-3**] 06:14AM BLOOD ALT-47* AST-16 LD(LDH)-318* AlkPhos-42 TotBili-1.0 Brief Hospital Course: Upon admission to the medicine service, Ms. [**Known lastname 1683**] was treated with a Solu-Medrol taper for a resolving chronic obstructive pulmonary disease exacerbation. She was then transferred to cardiology for cardiac catheterization in preparation for an aortic valve repair. On [**2181-2-28**] she was intubated for respiratory distress and hypoxemia and was transferred to the cardiac care unit. She was diuresed and extubated by the following day. She was seen in consultation by cardiac surgery to evaluate her for aortic valve replacement. Her subsequent cardiac catheterization on [**3-3**] revealed no significant coronary artery disease. She was diuresed with a Lasix drip. She was also seen in consultation by endocrinology for a nodule on her thyroid. It was recommended that after her heart surgery, this nodule be ablated. On [**2181-3-8**] she was taken to the operating room and underwent an aortic valve replacement with a CE magna tissue valve. Please see operative report for surgical details. Following surgery she was transferred to the CVICU for invasive monitoring in stable condition. She did require blood transfusions due to low HCT. Within 24 hours she was weaned from sedation, awoke neurologically intact and extubated. But shortly after she had increased rhonchi with respiratory acidosis and need to be re-intubated. She was again weaned and extubated the following day. she remained int he CVICU for several mores days while receiving aggressive pulmonary toilet and diuresis. On post-op day three chest tubes were removed. Post-operatively she continued to have arrhythmias which were also seen upon admission. Therefore she was started on Coumadin with heparin bridge. Electrophysiology was eventually consulted. Epicardial pacing wires were removed on post-op day four and she was then transferred to the telemetry floor for further care. She continued to slowly recover over the next several days while awaiting for her INR to be therapeutic ([**2-20**]). She worked with physical therapy and appeared ready for discharge on post-op day five. Medications on Admission: Imdur 60 mg, Methimazole 5 mg MTWTFS, Verapamil 240 mg daily, Lasix 40 mg daily, Guafenesin 600 mg [**Hospital1 **], Ecotrin 325 mg daily, Levaquin 750 mg daily, Dyazide 50/25mg? (patient unsure of dose) Discharge Medications: 1. Warfarin 1 mg Tablet Sig: As instructed based on INR Tablet PO DAILY (Daily): Goal INR 2.0-3.0. Dose coumadin accordingly. Likely dose 1mg alternating with 2mg. 2. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a day): Take with lasix and stop when lasix stopped. 3. Furosemide 40 mg IV TID 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 5. Zocor 80 mg Tablet Sig: One (1) Tablet PO QHS. 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months: Or while taking narcotics. 7. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 8. Methimazole 5 mg Tablet Sig: One (1) Tablet PO QMOTUWETHFRSA (). 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Neb IH Inhalation Q6H (every 6 hours). 10. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day): 1 INH IH [**Hospital1 **] . 11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) NEB IH Q6H Inhalation Q6H (every 6 hours): NEB IH Q6H . 12. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 13. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and PRN. 14. Pantoprazole 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: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Aortic Stenosis s/p Aortic Valve Replacement Acute on chronic congestive heart failure Acute Renal Failure Atrial Fibrillation Pneumonia Secondary: Hypertension, h/o breast cancer s/p left mastectomy and XRT, Hyperthyroidism - multinodular goiter, Noninsulin dependent diabetes mellitus, Chronic obstructive pulmonary disease, Hyperlipidemia, s/p non ST elevation mycardial infarction Discharge Condition: good Discharge Instructions: shower daily, no baths or swimming no lotions, creams or powders to incisions no driving for 4 weeks and off all narcotics no lifting more than 10 pounds for 10 weeks report any redness of, or drainage from incisions report any fever greater than 100.5 report any weight gain greater than 2 pounds a day or 5 pounds a week take all medications as directed Followup Instructions: Dr. [**First Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) [**Hospital Ward Name 121**] 6 wound clinic in 2 weeks Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3321**] ([**Telephone/Fax (1) 6699**]) in [**1-19**] weeks Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 27174**]) in 2 weeks Please call for appointments [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2181-3-14**] Name: [**Known lastname **],[**Known firstname 4675**] Unit No: [**Numeric Identifier 4676**] Admission Date: [**2181-2-26**] Discharge Date: [**2181-3-14**] Date of Birth: [**2113-1-30**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 265**] Addendum: The patient was additionally discharged on lopressor 12.5mg [**Hospital1 **]. Discharge Disposition: Extended Care Facility: [**Hospital1 49**] - [**Location (un) 50**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**] Completed by:[**2181-3-14**]

[ "427.31", "272.4", "518.81", "416.8", "428.33", "401.9", "491.21", "250.00", "396.8", "412", "486", "241.1", "584.9", "428.0", "276.2", "V10.3" ]

icd9cm

[ [ [] ] ]

[ "39.61", "88.52", "35.21", "96.04", "88.56", "96.71", "37.23" ]

icd9pcs

[ [ [] ] ]

11293, 11483

5401, 7497

340, 432

9844, 9850

1823, 5378

10254, 11270

1354, 1392

7751, 9321

9437, 9823

7523, 7728

9874, 10231

1407, 1804

281, 302

460, 926

948, 1228

1244, 1338

3,681

148,814

23603

Discharge summary

report

Admission Date: [**2158-10-13**] Discharge Date: [**2158-10-19**] Date of Birth: [**2106-2-3**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 287**] Chief Complaint: hematemesis Major Surgical or Invasive Procedure: Therapeutic paracentesis x2 EGD History of Present Illness: Patient doing well after discharge and was started on xeloda by Dr. [**First Name (STitle) **]. However he noticed that he had 3 episodes of mild coffee ground emesis over the past week. The day of admission he had an episode of emesis with 1 cup of bright red blood which prompted him to come to the ED. Since admission he has had [**3-24**] episodes of hematemesis with only mild amounts of blood. . The patient was transfused 1 unit pRBC in the ED and transfered to the MICU for urgent EGD. The scope demonstrated portal gastropathy but no bleeding or varices. His Hct remained stable and he was transferred to oncology. . On arrival to the floor the patient felt well. He denied nausea, diarrhea, hematochezia, melena, chest pain, shortness of breath, numbness, tingling, confusion, or change in vision/hearing. He did complain of some abd pain consistent with his swelling from ascites. Past Medical History: 1) Hepatoma (likely due to HCV) diagnosed in [**3-23**] with involvement of portal vein and spread to lung. Originally treated with DENSPM (N1, N11-Diethylnorspermine) a polyamine analog. This was stopped secondary to liver toxicity. He was then treated with four cycles of cisplatc/gemcitibine. His cancer progressed though this and he was started on adriamycin with last chemo [**2158-9-25**]. 2)IV drug abuse 3)hepatitis C for at least six years 4) back surgery Social History: He does not drink any alcohol. Smokes ~10 cigarettes per day. IVDU - last use several weeks ago; enrolled in methadone clinic Family History: Mother with breast cancer and skin cancer, grandfather with [**Name2 (NI) 499**] cancer, grandfather on the other side with [**Name2 (NI) 499**] cancer, uncle with prostate cancer, and grandmother with liver cancer. Physical Exam: VS: T 96.8 P 88 BP 148/84 R 18 O2 96 on 2L Gen - A+Ox3, NAD Skin - covered in scars from "skin popping" HEENT - OP clear, scleral icterus, EOMI Neck - No JVD, No LAD, supple, EJ in place Cor - RRR tachy, sys murmur Chest - crackles in R base, site of former line, no erythema, no pus Abd - tense, nt/nd +BS, + fluid wave, + spider angiomata, guiac neg per ED Ext - w/wp, +1 edema bilat Neuro - no asterixis Pertinent Results: Abd U/S w/ doppler [**10-13**]: Continued thrombosis of left portal vein. Main portal vein appears patent. Background ascites and chronic liver disease. . AP CXR [**10-13**]: A right internal jugular vascular sheath has been placed in the interval, terminating in the right brachiocephalic vein. Cardiac silhouette is normal in size. Again visualized are diffuse bilateral pulmonary nodules. Superimposed discoid atelectasis is noted at the right lung base, and there is mild elevation of the right hemidiaphragm. There are innumerable bilateral pulmonary nodules involving all lobes of both lungs, reportedly due to metastatic disease from hepatocellular carcinoma. . CT abdomen w/ contrast [**10-15**]: 1. Dramatic increase in size and number of innumerable pulmonary metastases. 2. Bilateral subsegmental and segmental pulmonary emboli. Presumably, these are new. 3. New ascites. The size of the left lobe hepatoma appears to have increased, though accurate measurements are difficult to obtain. There is also subtle area of hypo attenuation within segment 5, which is of unclear significance, but may represent new disease. There is no biliary dilation. 4. Stable appearance of portal vein thrombosis. The splenic vein remains patent. [**2158-10-13**] 07:45AM BLOOD WBC-9.4 RBC-3.76* Hgb-11.0* Hct-32.2* MCV-86 MCH-29.3 MCHC-34.3 RDW-18.5* Plt Ct-92* [**2158-10-14**] 03:10PM BLOOD WBC-13.3* RBC-4.55* Hgb-13.0* Hct-40.1 MCV-88 MCH-28.5 MCHC-32.4 RDW-18.6* Plt Ct-95* [**2158-10-13**] 07:45AM BLOOD Neuts-92* Bands-1 Lymphs-1* Monos-4 Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-1* [**2158-10-13**] 07:45AM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-2+ Macrocy-1+ Microcy-NORMAL Polychr-1+ Ovalocy-OCCASIONAL Schisto-1+ Burr-1+ [**2158-10-14**] 03:43AM BLOOD PT-16.6* PTT-34.0 INR(PT)-1.9 [**2158-10-13**] 07:45AM BLOOD PT-17.0* PTT-32.8 INR(PT)-2.0 [**2158-10-14**] 03:43AM BLOOD Glucose-88 UreaN-22* Creat-0.8 Na-135 K-4.3 Cl-101 HCO3-23 AnGap-15 [**2158-10-13**] 07:45AM BLOOD Glucose-58* UreaN-16 Creat-0.9 Na-133 K-4.2 Cl-97 HCO3-23 AnGap-17 [**2158-10-14**] 03:43AM BLOOD ALT-65* AST-174* AlkPhos-172* TotBili-14.7* DirBili-9.5* IndBili-5.2 [**2158-10-13**] 07:45AM BLOOD ALT-69* AST-182* AlkPhos-167* Amylase-71 TotBili-11.5* [**2158-10-13**] 07:45AM BLOOD Lipase-60 [**2158-10-13**] 07:45AM BLOOD Albumin-2.7* Calcium-8.4 Phos-3.6 Mg-1.6 [**2158-10-14**] 03:10PM BLOOD AFP-[**Numeric Identifier 60409**]* [**2158-10-13**] 08:10AM BLOOD Hgb-10.5* calcHCT-32 Brief Hospital Course: 52 yo M with HCV, HCC s/p recent admission for enterococcal line infection presents with recent hematemesis and acute on chronic liver failure. . 1) Hematemesis - Noted to have 1 cup bright red blood, then received 1U PRBC in ED and admitted to MICU for emergent EGD on [**10-13**]. The scope did not show varices or other obvious source of bleed. The pt has continued to have 5-6 episodes of emesis but w/ only mild amount of blood. Patient with stable Hct and hemodynamically stable for the remainder of his admission. Has been having some emesis but without bleeding. Last Hct was 40. Nausea was controlled w/ compazine, reglan and anzemet, morphine 2-4mg iv q4prn and ativan iv prn . 2) Liver Failure - Patient with HCV cirrhosis, progressive metastatic HCC, and portal vein thrombosis. On this admission, found to have acutely increasing bilirubin. AFP significantly increased to 23,868 from 14,066 on [**2158-9-25**]. Obtained CT abdomen w/ contrast which showed increased size of hepatoma and increase in size and number of pulmonary mets, as well as bilateral PEs. There was no biliary dilatation to suggest obstruction, but increased infiltration of the tumor may be causing some intrahepatic cholestasis. These findings were shared with the patient and his family and informed them of how this may affect his prognosis. Liver service was consulted, but given the progression of his disease there was nothing further they could offer. Gave lasix/aldactone and started lactulose for asterixis. Performed paracentesis x2 for symptomatic relief w/ removal of 4.5L w/ 1st tap. No additional labs were drawn as pt had difficult access, and there was nothing further to be gained by following his liver function tests. Pt decided to be DNR/DNI w/ transition to [**Date Range **] care. . 3) PE - CT suggested bilateral subsegmental and segmental PE which is new. However, because of recent hematemesis, did not start anti-coagulation. His Hct was stable with no further episodes of bleeding; breathing well on RA. . 4) IVDU: on methadone. Verified with [**Doctor Last Name 35660**] ([**Telephone/Fax (1) 60410**]. Last use of heroin was a few months ago. . 5) Back pain: heating pads. avoid NSAID/APAP. - if has pain can give oxycodone . 6) s/p line infection: abx complete, CIS. . 7) FEN: regular, as tolerated . 8) PPx: PPI [**Hospital1 **], pneumoboots, no heparin given bleed, head of bed at 30 degrees for aspiration ppx . 9) Dispo: home w/ [**Hospital1 **] care . 10) Code: DNR/DNI - sister [**Name (NI) 6818**] [**Name (NI) 60411**] [**Telephone/Fax (1) 60412**] Medications on Admission: xeloda 500 mg tid, started [**10-10**] methadone 130 mg qd ([**Doctor Last Name 35660**] program) zantac 200 mg qd reglan 10mg PO prn spironolactone 100 mg qd lasix 40 mg qd Discharge Disposition: Home With Service Facility: [**Location (un) **] Discharge Diagnosis: Hepatocellular carcinoma HCV IVDU Back surgery Discharge Condition: Stable but w/ tumor progression Discharge Instructions: Please take all your medications as directed. . Please [**Name8 (MD) 138**] MD [**First Name (Titles) **] [**Last Name (Titles) **] provider if you have uncontrolled pain or nausea or other symptoms that are intolerable to you. Followup Instructions: Please call [**Hospital 2188**] if you need further assistance or guidance. . Provider: [**First Name11 (Name Pattern1) 396**] [**Last Name (NamePattern4) 397**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2158-10-31**] 10:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 288**] MD, [**MD Number(3) 289**] Completed by:[**2158-10-19**]

[ "789.5", "197.0", "456.21", "537.89", "452", "578.0", "285.1", "070.54", "415.19", "155.0", "304.01", "571.5" ]

icd9cm

[ [ [] ] ]

[ "99.04", "45.13", "54.91", "38.93" ]

icd9pcs

[ [ [] ] ]

7896, 7947

5081, 7672

327, 361

8038, 8072

2602, 5058

8348, 8739

1938, 2155

7968, 8017

7698, 7873

8096, 8325

2170, 2583

276, 289

389, 1289

1311, 1778

1794, 1922

24,655

144,878

8607

Discharge summary

report

Admission Date: [**2136-10-11**] Discharge Date: [**2136-10-13**] Service: CHIEF COMPLAINT: Malaise and chest discomfort. HISTORY OF PRESENT ILLNESS: The patient is a 77 year old male with coronary artery disease, status post coronary artery bypass graft in 12/99, with peripheral vascular disease, chronic renal insufficiency and congestive heart failure, who is admitted with left sided chest discomfort today, status post taking Lopressor 50 mg for an episode of atrial fibrillation. The patient was in his usual state of health until today when he visited with a visiting nurse who noticed an irregularly irregular pulse. The patient went to congestive heart failure clinic at [**Hospital6 15291**] where he normally goes. He was found to be in atrial fibrillation with a rapid ventricular rate in the 160s. He was given Lopressor 50 mg, Coumadin 5 mg and advised to discontinue his Plavix. He took the Lopressor of 50 mg at 5:00 p.m. At 6:00 p.m., he developed chest tightness, neck tightness and left sided chest pain two out of ten. EMS found him with a heart rate of 72 and regular, blood pressure 60/palpable. He was brought to the Emergency Department where he received a bolus of normal saline 500 cc times one and was placed on a Dopamine drip. PAST MEDICAL HISTORY: 1. Coronary artery disease, status post coronary artery bypass graft [**1-/2135**]. 2. Peripheral vascular disease, status post right femoral popliteal bypass [**1-/2136**]. 3. Temporal arteritis times four years on Prednisone. 4. Status post right toe osteomyelitis, begun on a six week course of Vancomycin [**2136-8-12**]. 5. Chronic renal insufficiency, baseline creatinine 1.9. 6. Status post cholecystectomy. 7. Steroid induced glucose intolerance. 8. Cataract, status post surgery. 9. Anemia. MEDICATIONS ON ADMISSION: 1. Quinidine 324 mg b.i.d. 2. Zocor 20 mg q.d. 3. Celexa 20 mg q.d. 4. Keflex day number seven. 5. Coumadin 5 mg day number one. 6. Enteric Coated Aspirin 325 mg q.d. 7. Captopril 6.25 mg t.i.d. 8. Procrit 20,000 units t.i.week. 9. Prednisone 10 mg q.d. 10. Iron 325 mg q.d. 11. Metoprolol 50 mg b.i.d. day number one. 12. Plavix 75 mg q.d. discontinued the day of admission. 13. Torsemide. ALLERGIES: The patient is allergic to Procainamide with gastrointestinal symptoms, Amiodarone caused agitation and confusion. Intravenous dye caused acute renal failure. The patient is allergic to shellfish. SOCIAL HISTORY: The patient lives at home with his daughter. [**Name (NI) **] has a past tobacco history and quit. He has a history of recent increase in his alcohol consumption, three to five drinks per day. His primary care physician is [**Last Name (NamePattern4) **]. [**Last Name (STitle) 30186**]. Cardiologist is Dr. [**Last Name (STitle) 30187**] and his nurse practitioner [**First Name8 (NamePattern2) **] [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 30188**]. REVIEW OF SYSTEMS: The patient denies fever, chills, no cough, no shortness of breath, no paroxysmal nocturnal dyspnea, no orthopnea, no lower extremity edema, no angina, and positive lower extremity cellulitis. The patient says this chest pain is the first chest pain he has had in at least one year and denies any chest pain prior to his myocardial infarction. PHYSICAL EXAMINATION: On admission, the patient was resting comfortably in a bed, complaining of mild headache. Vital signs revealed pulse 84, blood pressure 95/48 on 5 of Dopamine, respiratory rate 24, saturating 96% on two liters nasal cannula. Head, eyes, ears, nose and throat examination revealed moist mucous membranes. The neck was supple without jugular venous distention. The lungs were clear to auscultation bilaterally. Cardiovascular - regular rate and rhythm, normal S1 and S2, decreased carotid upstroke and jugular venous pressure six centimeters. The abdomen is soft, nontender, nondistended with normoactive bowel sounds. Extremities revealed no cyanosis, clubbing with minimal edema. LABORATORY DATA: On admission, the patient had white count 8.2, hematocrit 39.9, platelets 258,000. Sodium 138, potassium 4.9, chloride 102, bicarbonate 16, blood urea nitrogen 73, creatinine 3.9, glucose 131. INR was 1.1 and partial thromboplastin time was 27.4. The CKs initially was 34 and increased to 38 and troponin was 0.3 increasing to 1.4. Chest x-ray showed cardiomegaly, small left pleural effusion. Electrocardiogram showed normal sinus rhythm at 70 beats per minute with right bundle branch block as well as left anterior fascicular block, Q wave V1 through V3 and ST depressions 1.0 millimeter with T wave inversions in V1 through V6 which are old. OTHER PREVIOUS HISTORY: The patient has a history of an ejection fraction of 35% with 3+ mitral regurgitation, status post coronary artery bypass graft [**1-/2135**] and aortic valve replacement [**1-/2135**]. Coronary artery bypass graft anatomy was left internal mammary artery to the D1, saphenous vein graft to the left anterior descending, saphenous vein graft to the OM1 and saphenous vein graft to the posterior descending artery. ASSESSMENT: The patient is a 77 year old with coronary artery disease, status post myocardial infarction, status post coronary artery bypass graft with aortic valve replacement, paroxysmal atrial fibrillation, dilated cardiomyopathy with ejection fraction of 35% and 3+ mitral regurgitation, 1+ aortic insufficiency, pulmonary hypertension with multiple admissions for right greater than left sided heart failure, status post a recent admission [**8-12**], to the [**Hospital1 882**] for osteomyelitis complicated by a bacteremia on a six week course of antibiotics, recently discontinued two weeks ago, now admitted with hypotension, chest pain in the setting of a beta blocker, treatment for an episode of rapid atrial fibrillation [**2136-10-10**], and likely a hypovolemic state. 1. Cardiovascular - The patient has known coronary artery disease, status post myocardial infarction, coronary artery bypass graft, no angina, with prior myocardial infarction, aura at home over the last year, presents now with complaints of chest discomfort in the setting of atrial fibrillation and hypotension, may be related to atrial fibrillation symptoms or demand ischemia related to decreased blood pressure. Troponin and CKs were negative on admission. Troponin eventually increased to 3.7 possibly consistent with a non Q wave myocardial infarction secondary to a demand ischemia from hypotension. His electrocardiogram was unchanged. His hypotension may be secondary to hypovolemia consistent with diarrhea as well as increasing diuretic dose as well as a beta blocker dose given yesterday. The patient is now in normal sinus rhythm. Quinidine dose was within normal limits at the [**Hospital6 8866**] Clinic yesterday. The plan is to continue Aspirin and Heparin until rule out myocardial infarction, titrate off Dopamine as blood pressure improves with normal saline boluses, hold his ace and diuretic while hypotensive, continue Quinidine, hold Coumadin if remains in normal sinus rhythm, consider echocardiogram to evaluate for any worsening of function to explain worsening paroxysmal nocturnal dyspnea symptoms and weight gain, continue Zocor. 2. Pulmonary - Pulmonary hypertension reportedly increased right greater than left sided heart failure symptoms. The lungs are clear. Saturation within normal limits in room air. 3. Renal - Chronic renal insufficiency with creatinine around 2.0 at baseline. Recently worsening secondary to possibly Vancomycin treatment or Torsemide. Acute renal insufficiency on admission here could be consistent with hypotension in the setting of a prerenal state. 4. Infectious disease - The patient has a history of chronic osteomyelitis of the right toes complicated by recent bacteremia. No active infection evident at this time. Hypotension may also represent possible sepsis if infection inadequately treated. Will send blood cultures, urine cultures. Hold antibiotics at this time. 5. Gastrointestinal - Epigastric discomfort likely secondary to gut edema, abdominal distention from right heart failure, no nausea or vomiting. Positive diarrhea in the setting of long antibiotic course. Reports recent increase in alcohol use. Will send C. difficile, guaiac stools, start Zantac, will check liver function tests given history of ETOH use. 6. Hematology - The patient has chronic anemia on Procrit. Hematocrit increased on admission likely reflecting dehydration. Platelets and coagulation studies are within normal limits. Heparin as above. Follow hematocrit with hydration. 7. Endocrine - On chronic Prednisone for temporal arteritis. The patient was given stress dose steroids in the Emergency Department without effect. Will continue standing dose of Prednisone. 8. Prophylaxis - On Zantac and Heparin. 9. Lines - Will place a left A line, peripheral intravenous times two, Foley. 10. Disposition - Full code. HOSPITAL COURSE: The patient was stable after admission except for mildly decreased systolic blood pressure with decrease to 70s but responded to a fluid bolus at 4:00 p.m. The patient continued to be in normal sinus rhythm with episodes of atrial fibrillation, continued to be treated on Quinidine and anticoagulation was held. The patient was transferred to the floor once he was weaned off Dopamine and his creatinine began to decrease. After arrival to the floor on [**2136-10-12**], the patient was placed on telemetry and noted to have a run of 10 beats of asymptomatic ventricular tachycardia at 4:00 a.m. on [**2136-10-13**]. The patient also went into atrial fibrillation where he remained throughout the remainder of the evening and morning with rates of between 120 to 160. The patient was felt to have possible benefit from electrophysiology study, possibly with an ICD placement. However, since the patient is mainly followed by cardiology at [**Hospital6 1708**], it was decided to discuss transferring the patient to the [**Hospital6 1708**]. Other recommendations that we were considering at this time included changing the Quinidine to Dofetilide or seeing if the patient can tolerate Amiodarone. Also we discussed the possibility of placing the patient on Heparin drip if he was still in atrial fibrillation after 24 hours. For his coronary artery disease, the patient was continually treated with Aspirin and Zocor. The patient continued to deny chest pain although he remained in atrial fibrillation with increasing rate on movement around the room. The patient has a history of pulmonary hypertension, however, he continued to have good oxygen saturation in room air. His creatinine decreased throughout the course of the hospital stay, however, it was still 3.2 on [**2136-10-13**], continue to hold his ace inhibitor for now. The patient has a history of osteomyelitis in his right toes. The patient was started on Keflex during hospitalization which will be continued for seven days. The patient had complained of some bloated feeling that he says he often gets with his congestive heart failure exacerbation and denies diarrhea. DISPOSITION: The patient was decided to be transferred to [**Hospital6 1708**] after attending to attending conversation and the transfer will probably take place in the afternoon of [**2136-10-13**]. CONDITION ON DISCHARGE: Guarded. DISCHARGE STATUS: Transferred to [**Hospital6 15291**]. DISCHARGE MEDICATIONS: 1. Zocor 20 mg p.o. q.d. 2. Celexa 20 mg p.o. q.d. 3. Aspirin 325 mg p.o. q.d. 4. Procrit 20,000 units Monday and Friday. 5. Iron 325 mg p.o. q.d. 6. Zantac 150 mg p.o. q.d. 7. Multivitamin one tablet p.o. q.d. 8. Quinidine 325 mg p.o. b.i.d. 9. Prednisone 10 mg p.o. q.d. 10. Keflex 500 mg p.o. b.i.d. times three days. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7169**] Dictated By:[**Last Name (NamePattern1) 1203**] MEDQUIST36 D: [**2136-10-13**] 15:04 T: [**2136-10-13**] 15:21 JOB#: [**Job Number 30189**]

[ "427.31", "425.4", "443.9", "446.5", "410.71", "424.0", "414.00", "428.0", "584.9" ]

icd9cm

[ [ [] ] ]

[ "38.91" ]

icd9pcs

[ [ [] ] ]

11507, 12133

1838, 2451

9039, 11391

3332, 9021

2963, 3309

104, 135

164, 1280

1302, 1812

2468, 2943

11416, 11484

2,152

127,190

17305

Discharge summary

report

Admission Date: [**2131-4-15**] Discharge Date: [**2131-4-25**] Date of Birth: [**2064-2-11**] Sex: M Service: HISTORY OF PRESENT ILLNESS: This 67-year-old man has a history of coronary artery disease and is status post stent to the left anterior descending artery in [**7-24**] with recurrent angina at rest. He was cathed on [**4-16**], which revealed three vessel disease and a 95% restenosis of his LAD stent. The left main coronary artery had a 50% diffuse stenosis, LAD had an 80% mid instent restenosis, left circumflex had moderate disease and an occluded OM-1. Right coronary artery was occluded and filled by collaterals. His ejection fraction was 55% by echocardiogram. PAST MEDICAL HISTORY: 1. History of coronary artery disease status post LAD stent in [**7-24**], status post permanent pacemaker placement in [**3-24**]. 2. History of hypertension. 3. History of hypercholesterolemia. 4. History of chronic renal insufficiency with a baseline creatinine of 1.7. 5. History of anxiety. 6. History of gastroesophageal reflux disease. MEDICATIONS ON ADMISSION: 1. Peroxetine 20 mg po q day. 2. Amlodipine 10 mg po q day. 3. Pravastatin 20 mg po q day. 4. Metoprolol 75 mg po bid. 5. Protonix 40 mg po q day. 6. Plavix 75 mg po q day. 7. Doxazosin two q hs. 8. Aspirin 325 mg po q day. 9. ........... 3.75 tid. 10. Valsartan 240 mg po q day. 11. Cardura 2 mg po q day. ALLERGIES: No known allergies. SOCIAL HISTORY: He lived in [**State 108**] for eight months and [**Location (un) 18636**] in four months. Lives with his wife. [**Name (NI) **] a remote smoking history and quit 10 years ago. Drinks alcohol socially. REVIEW OF SYSTEMS: Unremarkable. PHYSICAL EXAMINATION: He is a well-developed and well-nourished white male in no apparent distress. Vital signs stable, afebrile. HEENT exam: Normocephalic, atraumatic. Extraocular movements are intact. Oropharynx was benign. Neck was supple, full range of motion, no lymphadenopathy, or thyromegaly. Carotids are 2+ and equal bilaterally without bruits. Lungs were clear to auscultation and percussion. He had a left shoulder pacer site incision which was healing well. Abdomen was soft and nontender with positive bowel sounds, no masses or hepatosplenomegaly. Extremities were without clubbing, cyanosis, or edema. Neurologic examination was nonfocal. Pulses were 2+ and equal bilaterally throughout. Dr. [**Last Name (STitle) 1537**] was consulted and on [**4-19**], the patient underwent a CABG x4 with LIMA to the LAD, reverse saphenous vein graft to the PDA, and reverse saphenous vein sequential to the PL and diagonal. The patient tolerated the procedure well and was transferred to the Surgical Intensive Care Unit in stable condition on Neo and propofol. He was extubated that night. He had a stable postoperative night and he had a pacer check on postoperative day one, which revealed that the insulation on his atrial lead had been slightly damaged, but this was not felt to be an urgent issue. He was transferred to the floor on postoperative day one and he did have pain control issues, which quickly resolved. He had his Foley, chest tube, and pacer wires discontinued that day and Plavix was restarted. He continued to progress, and he was taken to the EP Laboratory on postoperative day #4 for lead revision which was not able to be performed at that time, and he is to return to the EP office in four weeks for checkup on that, and they will probably just wait until his pacer battery fails and change it at that point. After that, he continued to do well, and was discharged to home on postoperative day #6 in stable condition. LABORATORIES ON DISCHARGE: Hematocrit 31.6, white count 7,100, platelets 193. Sodium 144, potassium 4.9, chloride 105, CO2 27, BUN 41, creatinine 1.9, and blood sugar 109. DISCHARGE MEDICATIONS: 1. Protonix 40 mg po q day. 2. Paxil 20 mg po q day. 3. Pravachol 20 mg po q day. 4. Lopressor 25 mg po bid. 5. Colace 100 mg po bid. 6. Aspirin 325 mg po q day. 7. Percocet 1-2 tablets po q4-6h prn pain. 8. Plavix 75 mg po q day. 9. Lasix 20 mg po bid x7 days. 10. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mEq po q day x7 days. FOLLOW-UP INSTRUCTIONS: He will be seen by Dr. [**Last Name (STitle) 48437**] in [**11-23**] weeks, and he will be seen by Dr. [**Last Name (STitle) 1537**] on [**5-29**] at 9:30 am with an appointment at the [**Hospital 19721**] Clinic on [**5-29**] at 10:30 am. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Last Name (NamePattern1) 32413**] MEDQUIST36 D: [**2131-4-25**] 12:02 T: [**2131-4-25**] 12:30 JOB#: [**Job Number 48438**]

[ "593.9", "401.9", "411.1", "414.01", "427.1", "996.72", "996.01" ]

icd9cm

[ [ [] ] ]

[ "36.15", "88.56", "37.22", "36.13", "39.61", "88.72" ]

icd9pcs

[ [ [] ] ]

3864, 4229

1099, 1440

1721, 3679

3694, 3841

1683, 1698

160, 707

4254, 4777

729, 1073

1457, 1663

8,887

177,896

48685

Discharge summary

report

Admission Date: [**2178-12-30**] Discharge Date: [**2179-1-1**] Date of Birth: [**2105-3-21**] Sex: F Service: MEDICINE Allergies: Zestril Attending:[**First Name3 (LF) 3705**] Chief Complaint: SOB and dizziness Major Surgical or Invasive Procedure: endoscopy History of Present Illness: 73 y/o female with h/o metastatic adrenal CA (liver, kidney, thyroid), adrenal insufficiency on steroids since [**2157**], and s/p right hip arthroplasty [**2178-7-29**] secondary to AVN who presents with SOB and dizziness for two days. SHe states that two days ago she noticed the SOB with ambulation and decided to present to the hospital today because the SOB got worse and she also noticed dizziness on ambulation. She denied any abdominal pain or changes in the color of her stool. She checks her stool frequently and never noticed any blood or melena. She also denies any N,V or jaundice. She reports hitting her knee about 2 weeks ago and took Advil 2tbl [**Hospital1 **] for 10 days. She reports having had a colonoscopy many years prior which was normal but does not recall the colonoscopy here at [**Hospital1 18**] in [**2174**] that showed a polyp. ROS: negative for CP, dysuria, jaundice, fever, night sweats, LE edema. positive for chills since yesterday and weight loss since her THR. . In the ED, the patient was found to have a hct of 22. She had a NG lavage that showed old blood in the stomach, that cleared quickly. She also had melena in her vault. SHe was hemodynamically stable the whole time. She received Famotidine 20mg iv, Dexamethasone 10mg iv and 2 U of PRBC. She reports that after the NG tube she developed some mild abominal pain in her lower quadrant. Past Medical History: 1. Metastatic adrenal cortical ca w/ known adrenal insufficiency, on steroids since [**2157**], post bilateral adrenalectomy treated with mitotane, complicated by metastases to the liver status post partial lobectomy in [**4-27**], more recently complicated by metastases to the left supraclavicular region and left retroperitoneum status post surgical resection in [**2178**] 2. Drainage of the left knee for septic arthritis in [**2167**] following a fracture. 3. A lower anterior resection for stage II rectal adenocarcinoma. 4. Resection of 2 parathyroid adenomas. 5. s/p ccy 6. s/p hepatic lobectomy as above for metastases 7. s/p right hip arthroplasty on [**2178-7-27**] secondary to AVN right femoral head 8. Osteoarthritis Social History: She denies tobacco use, denies alcohol use. She lives in [**Location 2312**] with her husband and one son. She has three children, two sons and one daughter and four grandchildren. She is independent in her ADLs. Family History: Father died in his 70s of an aneurysm in his abdomen. Mother died in her 90s of a stroke. She has one sister who died of a heart attack in her 50s and three brothers, one of whom has had bypass surgery and two others who are alive and well. Physical Exam: VS T 99.5 BP 116/53 HR 93 RR 24 O2Sat 100% on 2L Gen: NAD, AAOx3 HEENT: NC/AT, PERRLA, mmm, pale conjunctiva NECK: no LAD, JVD at 6cm COR: S1S2, regular rhythm, no r/g, [**1-30**] high pitched murmur over precordium non radiating PULM: CTA b/l, no wheezing or rhonchi ABD: + bowel sounds, soft, nd, mild tenderness over lower abdomen, no rebound or guarding Skin: warm extremities, no rash, multiple small ecchymosis over the chest and arms EXT: 2+ DP, no edema/c/c Neuro: moving all extremities, following commands, PERRLA . EKG: HR 80, SR, normal axis, LBBB, no changes to prior . CXR: Heart and mediastinum and lungs are unremarkable. No pneumothorax or sizable effusions Pertinent Results: [**2178-12-30**] 10:34PM HCT-24.1* [**2178-12-30**] 05:10PM PT-13.4* PTT-22.5 INR(PT)-1.2* [**2178-12-30**] 04:11PM HGB-7.6* calcHCT-23 O2 SAT-68 CARBOXYHB-2.6 MET HGB-0.1 [**2178-12-30**] 04:00PM GLUCOSE-138* UREA N-55* CREAT-1.0 SODIUM-138 POTASSIUM-4.5 CHLORIDE-106 TOTAL CO2-17* ANION GAP-20 [**2178-12-30**] 04:00PM estGFR-Using this [**2178-12-30**] 04:00PM LD(LDH)-164 CK(CPK)-25* TOT BILI-0.1 [**2178-12-30**] 04:00PM cTropnT-<0.01 [**2178-12-30**] 04:00PM CK-MB-NotDone [**2178-12-30**] 04:00PM CALCIUM-8.9 PHOSPHATE-4.4 MAGNESIUM-2.1 [**2178-12-30**] 04:00PM HAPTOGLOB-55 [**2178-12-30**] 04:00PM WBC-13.4* RBC-2.61*# HGB-7.3*# HCT-22.2*# MCV-85 MCH-28.0 MCHC-33.0 RDW-17.4* [**2178-12-30**] 04:00PM NEUTS-83.9* BANDS-0 LYMPHS-12.7* MONOS-2.0 EOS-0.7 BASOS-0.7 [**2178-12-30**] 04:00PM PLT COUNT-305. . IMAGING: [**12-30**] CTA: CTA OF THE CHEST: There is no evidence of pulmonary embolism. There is atherosclerotic disease of the aorta and great vessels, notably with narrowing of the left subclavian vein lumen proximally unchanged compared to the previous study. There are multiple small mediastinal lymph nodes that do not meet CT criteria for pathologic enlargement. There is no pericardial or pleural effusion. There is no pneumothorax. The airways appear patent to the level of the segmental bronchi bilaterally. Lungs show minimal dependent atelectasis. BONE WINDOWS: There is a stable mild compression fracture of T12 with minimal retropulsion of the superior endplate towards the spinal canal. Note is again made of an atrophic right kidney with a 4.6 cm nonobstructing stone at its lower pole, seen on limited images of the upper abdomen. . [**2178-12-31**] CXR: No acute cardiopulmonary process. Brief Hospital Course: # GIB: upper GIB, secondary to PUD in conjunction with Ibuprofen consumption over the last days. GI was consulted on this patient and did an EGD on the first day of hospitalization which revealed duodenal ulcers one of whichrequired cautery to stop slow ooze of blood. The patient remained hemodynamically stable and without hematemesis. She was transferred to the floor, where her hematocrit remained stable, she tolerated a PO diet and remained symptom free. She was started on a PPI twice daily. H pylori serologies were sent; results were pending at the time of discharge. The patient was instructed to follow up with her PCP for these results. . # Adrenal carcinoma: no evidence of recurrence, but concerning in the context of weight loss since THR. Mitotane was held throughout her hospitalization and restarted upon discharge. . # Adrenal insufficiency: absolute insufficiency in the context of bilateral resection. The patient was given stress dose steroids with hydrocortisone 100mg Q6h, which covers glucocorticoids and mineralocorticoid activity for 24 hours, then was restarted on her home regimen of dexamethasone and fludrocortisone. # Hypothyroid- the patient was continued on her outpatient regimen. FULL CODE Medications on Admission: ASPIRIN E.C. 81mg DEXAMETHASONE 5mg [**Hospital1 **] FLUDROCORTISONE 100 MCG QD LEVOXYL 50MCG QD MITOTANE 500 MG QD NORVASC 10MG QD Discharge Medications: 1. Levothyroxine Sodium 25 mcg IV DAILY 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours): Take 1 tablet twice daily for 1 month, then 1 tablet once daily indefinitely. . Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Dexamethasone 2 mg Tablet Sig: 2.5 Tablets PO Q12H (every 12 hours). 4. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Norvasc 10 mg Tablet Sig: One (1) Tablet PO once a day. 7. Mitotane 500 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary: Upper GI Bleed, PUD, anemia Secondary: Adrenal Insufficiency Discharge Condition: Good- Hct stable, pain free, vitals stable, tolerating PO's, ambulating well. Discharge Instructions: *During this admission you have been treated for anemia due to a bleeding ulcer in your small intestine. *Please continue to take all medications as prescribed. We have started a medication called Pantoprazole. You should take the Pantoprazole twice daily for 1 month, then continue taking one pill daily indefinitely. *Do not take Ibuprofen (also called Advil, Motrin) or Naprosyn (Aleve). You may use Acetominophen (Tylenol) as needed for pain. *Avoid fatty, spicy or acidic foods. *Do not resume taking Aspirin until instructed to do so by your doctor. *Call your doctor or come to the emergency room immediately if you develop dark, black or bloody stools, vomiting, shortness of breath, lightheadedness, dizzyness, chest pain, or any other concerning symptom. Followup Instructions: Follow up with your PCP next week, call to make an appointment. You had serologies for H. Pylori sent while you were in the hospital; your PCP should follow up on these results.

[ "285.1", "V10.88", "198.0", "V58.65", "197.7", "198.89", "532.40", "E935.9", "255.4" ]

icd9cm

[ [ [] ] ]

[ "99.04", "44.43" ]

icd9pcs

[ [ [] ] ]

7521, 7527

5447, 6683

286, 297

7640, 7719

3671, 5424

8534, 8714

2713, 2955

6865, 7498

7548, 7619

6709, 6842

7743, 8511

2970, 3652

229, 248

325, 1712

1734, 2467

2483, 2697

43,812

131,495

37334+58142

Discharge summary

report+addendum

Admission Date: [**2116-9-25**] Discharge Date: [**2116-10-16**] Date of Birth: [**2049-6-1**] Sex: F Service: SURGERY Allergies: Percocet Attending:[**First Name3 (LF) 2597**] Chief Complaint: Acute on chronic mesenteric ischemia Major Surgical or Invasive Procedure: [**Female First Name (un) 899**] angioplasty SMA angioplasty Ex-lap and small bowel resection Chest thoracostomy Angiogram Intubation History of Present Illness: 67M with chronic mesenteric ischemia s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 899**] stent [**11/2115**] ([**Doctor Last Name **]) presents with two week history of central abdominal pain localizing to LLQ. She has also experienced nausea and vomiting following meals. She has lost 17 lbs over the last month. She has not experienced any fever / chills / diarrhea / blood in the stool / constipation / dysuria Past Medical History: PMH: MI early [**2095**], s/p cardiac cath, no intervention PSH: [**Female First Name (un) 899**] stenting [**11-19**], [**Female First Name (un) 899**] stenting [**2116-9-26**], Ex-lap and SBR [**2116-9-26**], take back for bleeding [**2116-9-26**], SMA stenting [**2116-9-28**], hysterectomy Social History: She is retired. She did clerical work in the past. Smokes 1 ppd for approx 40 years. Very rare ETOH intake. Denies illicit drug use. She lives with her eldest daughter. Family History: Brother and mother with DM. Denies any GI disease in her family. Physical Exam: PHYSICAL EXAM on presentation Vital Signs: Temp: 97.2 RR: 20 Pulse: 92 BP: 110/65 Neuro/Psych: Oriented x3, Affect Normal, NAD. Neck: No masses, Trachea midline, Thyroid normal size, non-tender, no masses or nodules, No right carotid bruit, No left carotid bruit. Nodes: No clavicular/cervical adenopathy, No inguinal adenopathy. Skin: No atypical lesions. Heart: Regular rate and rhythm. Lungs: Clear, Normal respiratory effort. Gastrointestinal: Non distended, No masses, No hernia, No AAA, abnormal: Tender LLQ, guarding, no rebound. Extremities: No popiteal aneurysm, No femoral bruit/thrill, No RLE edema, No LLE Edema, No varicosities, No skin changes. Pulse Exam (P=Palpation, D=Dopplerable, N=None) RUE Radial: P. Ulnar: P. Brachial: P. LUE Radial: P. Ulnar: P. Brachial: P. RLE Femoral: P. Popiteal: P. DP: P. PT: P. LLE Femoral: P. Popiteal: P. DP: P. PT: P. Physical Exam on DC: NADS Clear, not labored RRR soft, staples c/d/i, ND, NT No c/c/e Pertinent Results: CT [**2116-10-12**] 1. Marked improvement in appearance of the lungs, compatible with resolution of ARDS. Previously present pneumothorax is also resolved. Small bilateral pleural effusions are decreased in size. There is residual atelectasis, most apparent posteriorly in the right lower lobe. Nodular densities as above may represent resolving inflammatory change, though attention on follow-up examinations is warranted. 2. No evidence of pulmonary embolus, as questioned. 3. Hyperdense collection within the right axilla/right chest wall, with focus of hyperdensity on post-contrast imaging. This is compatible with hematoma with active extravasation, though this may be venous. 4. Diffuse dilation of the small bowel, without definite transition point, and without imaging evidence of ischemia. This most likely reflects ileus. 5. Decreased free fluid in the pelvis, with no loculated fluid collection to suggest abscess formation. 6. Redemonstration of high-grade stenosis at the origin of the celiac axis, patent SMA stent, and occlusion of [**Female First Name (un) 899**] stent. 7. Known right adrenal lesion, previously characterized as an adenoma. CXR: SINGLE PORTABLE UPRIGHT VIEW OF THE CHEST: A right subclavian line has been removed, the left upper extremity PICC terminates with the catheter tip just above the cavoatrial junction in the distal SVC. Bibasilar lung opacities have continually improved, with no current consolidation. Small residual left pleural effusion is seen. A soft tissue density at the right pleural surface laterally is is decreased from prior radiographs. There is no evidence of persistent pneumothorax. Multiple right-sided chronic rib fractures are seen. [**2116-10-15**] 03:56AM BLOOD WBC-4.5 RBC-3.19* Hgb-10.0* Hct-29.5* MCV-93 MCH-31.4 MCHC-34.0 RDW-17.7* Plt Ct-315 [**2116-10-16**] 06:16AM BLOOD Hct-31.3* [**2116-10-14**] 04:02AM BLOOD PT-13.5* PTT-25.7 INR(PT)-1.2* [**2116-10-12**] 01:55PM BLOOD Neuts-65.5 Bands-0 Lymphs-25.5 Monos-7.5 Eos-1.0 Baso-0.6 [**2116-10-16**] 06:16AM BLOOD Glucose-97 UreaN-12 Creat-0.4 Na-136 K-4.2 Cl-105 HCO3-25 AnGap-10 [**2116-10-14**] 04:02AM BLOOD ALT-30 AST-21 AlkPhos-147* TotBili-3.8* [**2116-10-16**] 06:16AM BLOOD Calcium-7.9* Phos-3.7 Mg-1.9 Brief Hospital Course: Patient was admitted to Dr.[**Name (NI) 5695**] [**Name (NI) 1106**] surgery service on [**2116-9-25**]. Her surgeries were as follows - [**2116-9-25**], ex-lap and small bowel resection; [**2116-9-26**], ex-lap and small bowel resection (second look), angiogram, angioplasty of [**Female First Name (un) 899**], take-back later that evening for bleeding; [**2116-9-28**], angiogram, angioplasty and stenting of SMA. Patient stayed in the ICU for monitoring and observation. She was eventually extubated, maintained on TPN for nutrition, and transferred to general floor on [**2116-10-9**]. On discharge, she was tolerating a regular diet with daily TPN (due to inadequate caloric intake) via PICC line access, on room air with normal bowel function. Her hospital course can be summarized by the following review of symptoms - Neuro: Patient with minimal pain and only requiring Tylenol with relief of symptoms on discharge. She was started on Seroquel while in ICU for delirium and ICU psychosis which resolved since transfer from the unit. She continues to take that medication as needed for insomnia. Pulm: Patient did develop an iatrogenic pneumothorax from a central line access change. Chest tube was placed and then removed with resolution. Intubated for respiratory distress from hypovolemic shock. She was treated briefly for ventilator associated pneumonia with broad spectrum antibiotics. Patient self-extubated and did require re-intubation due to respiratory distress. She was eventually extubated and maintained normal oxygen saturations. She is discharged on room air. Cardio: No cardiac issues. Echo performed showing normal biventricular cavity sizes with preserved global and regional biventricular systolic function and prominent epicardial fat pad. Did not require vasopressor support. GI: Had an exploratory laparotomy and small bowel resection. Observed closely in the ICU. Chronic malnourished state, requiring TPN for additional caloric intake. She was advanced to a regular diet on discharge. Tolerating without issues but still taking inadequate amounts. Patient's stool output was followed closely to avoid dehydration. All C.diff stool tests were negative. Pls continue to use famotidine (included in TPN). Renal: Patient auto-diuresing without issues. Renal asked to consult for polyuria. Cultures negative for UTI. Recommendations to decrease the solute concentrate in TPN. Continues to urinate without issues. ID: Treated for ischemic bowel and given antibiotics for ventilator associated pneumonia. Her course was completed. WBC was 4.5 on discharge and continues to be afebrile. Discharged on no antibiotics. Heme: Patient will be discharged on aspirin and Plavix for stent prophylaxis. She should continue to be on subcutaneous heparin for DVT prophylaxis. Endo: Patient placed on an insulin sliding scale for coverage. No issues with hypo/hyperglycemia Dispo: to rehab Medications on Admission: Off clopidogrel [Plavix] for 2 weeks; ranitidine HCl [Zantac]; simvastatin; aspirin Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day): DC when ambulatory. 2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for dyspnea. 5. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 6. quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for sleep. 7. TPN Volume(ml/d) Amino Acid(g/d) Dextrose(g/d) Fat(g/d) 1300 60 280 30 NaCL NaAc NaPO4 KCl KAc KPO4 MgS04 CaGluc 0 130 0 90 70 30 17 9 Famotidine(mg) Insulin(units) Zinc(mg) 40 37 10 Cycle over (hrs.) 8. PICC 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: [**Hospital 38**] Rehabilitation Discharge Diagnosis: Bowel ischemia ARF, resolved Anemia secondary to blood loss, reqiuiring blood transfusions Pneumothorax with chest tube Associated VAP PNA, treated briefly Post op delerim - serequel and geriatric consult. Now resolved Post op illeus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Signs and symptoms of intestinal ischemia may develop suddenly (acute intestinal ischemia) or they may develop gradually over time (chronic intestinal ischemia). Symptoms of acute intestinal ischemia Signs and symptoms of acute intestinal ischemia typically include: Sudden abdominal pain that may range from mild to severe An urgent need to have a bowel movement Frequent, forceful bowel movements Abdominal tenderness or distention Blood in your stool Nausea, vomiting Fever Symptoms of chronic intestinal ischemia Signs and symptoms of chronic intestinal ischemia can include: Abdominal cramps or fullness, beginning within 30 minutes after eating and lasting one to three hours Abdominal pain that gets progressively worse over weeks or months Fear of eating because of subsequent pain Unintended weight loss Diarrhea Nausea, vomiting Bloating Chronic intestinal ischemia may progress to an acute episode. If this happens, you might experience severe abdominal pain after weeks or months of bouts of intermittent pain after eating. When to see a doctor Seek immediate medical care if you have sudden, severe abdominal pain. Pain that makes you so uncomfortable that you can't sit still or find a comfortable position is a medical emergency. If you have other signs or symptoms that worry you, make an appointment with your doctor. Followup Instructions: Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 871**] ([**Doctor First Name **]) [**Doctor First Name **] LMOB (NHB) Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2116-11-23**] 11:30 Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2116-11-23**] 12:30 Dr [**Last Name (STitle) **], [**Telephone/Fax (1) 8792**]. [**2116-10-26**] at 1315 hrs. [**Apartment Address(1) 83982**] West. [**Location (un) **]. Mass. GI doctor who performed surgery Name: [**Known lastname 10682**],[**Known firstname **] Unit No: [**Numeric Identifier 13356**] Admission Date: [**2116-9-25**] Discharge Date: [**2116-10-16**] Date of Birth: [**2049-6-1**] Sex: F Service: SURGERY Allergies: Percocet Attending:[**First Name3 (LF) 1546**] Addendum: Ms. [**Known lastname **] was discharged on IV Vancomycin, PO Flagyl, and PO Ciprofloxacin for two days, to complete a total seven-day course. Brief Hospital Course: Ms. [**Known lastname **] was discharged on IV Vancomycin, PO Flagyl, and PO Ciprofloxacin for two days, to complete a total seven-day course. Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day): DC when ambulatory. 2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for dyspnea. 5. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 6. quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for sleep. 7. TPN Volume(ml/d) Amino Acid(g/d) Dextrose(g/d) Fat(g/d) 1300 60 280 30 NaCL NaAc NaPO4 KCl KAc KPO4 MgS04 CaGluc 0 130 0 90 70 30 17 9 Famotidine(mg) Insulin(units) Zinc(mg) 40 37 10 Cycle over (hrs.) 8. PICC 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. 9. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) g Intravenous Q 12H (Every 12 Hours). Disp:*5 grams* Refills:*0* 10. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*5 Tablet(s)* Refills:*0* 11. Flagyl 500 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. Disp:*7 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital **] Rehabilitation [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1548**] MD [**MD Number(1) 1549**] Completed by:[**2116-10-16**]

[ "584.9", "787.20", "997.31", "458.29", "996.74", "512.1", "557.1", "783.21", "285.1", "998.11", "263.9", "785.59", "412", "518.0", "560.1", "518.81", "789.59", "E878.8", "557.0", "305.1", "293.0", "E878.1", "414.01", "276.3" ]

icd9cm

[ [ [] ] ]

[ "39.50", "45.91", "96.72", "00.40", "34.91", "54.12", "39.90", "00.46", "45.62", "33.24", "99.15" ]

icd9pcs

[ [ [] ] ]

13237, 13452

11726, 11870

305, 441

9153, 9153

2484, 4722

10669, 11703

1424, 1491

11893, 13214

8896, 9132

7687, 7773

9304, 10646

1506, 2465

229, 267

469, 903

9168, 9280

925, 1221

1237, 1408

29,210

118,916

8372

Discharge summary

report

Admission Date: [**2111-1-27**] Discharge Date: [**2111-1-30**] Date of Birth: [**2069-11-5**] Sex: M Service: MEDICINE Allergies: No Drug Allergy Information on File Attending:[**First Name3 (LF) 30**] Chief Complaint: Sepsis Major Surgical or Invasive Procedure: Central venous line placement History of Present Illness: HPI: Mr. [**Known lastname 6174**] is a 41yo male with PMH significant for ITP s/p splenectomy who presented with fever and RUQ abdominal pain. At home pt spiked Temp and wife brought him to [**Name (NI) **]. . In the ED, his initial vitals were T 99.4 BP 82/54 AR 132 RR 16 O2 sat 97% RA. Labs notable for leukocytosis and bandemia, nl LFTs, elevated Cr 1.5, lactate 2.9. Patient given IVF x 3L (NS), Vancomycin 1gm IV x 1, CTX 1gm IV x 1, Azithromycin 500mg IV x1, Dexamethasone 10mg x 1 but SBP remained in 70's, so had placement of CVL (R IJ), a-line, and was started on levophed gtt and transferred to the MICU. . In the MICU patient was found to have pan sensitive strep pneumo bacteremia. Initially treated with vanco, ceftriaxone and transitioned to levaquin when cx and sensitivities returned. BP improved with fluids. Had ECHO negative for vegetations and RUQ u/s with possible with third spacing and fluid but no overt evidence of cholecystitis. Past Medical History: 1)ITP s/p splenectomy in [**2087**] (received Pneumococcal vaccine); ITP reoccurence 3 years ago after taking Augmentin. Received IVIG at this time. Platelets 300-400K since then. 2)Common variable immunodeficiency: Diagnosed 20 years ago; low IgG, A, & M. 3)Right parasagittal meningioma s/p removal and radiotherapy in [**2-17**] 4)Asthma Social History: He works as an IT support personnel. He does not smoke cigarettes. He drinks 1 alcoholic drink per week. He does not use any illicit drugs. Family History: His grandmother had migraines. His mother has Type I insulin-dependent diabetes mellitus and headaches. His father has [**First Name5 (NamePattern1) **] [**Last Name (Prefixes) 29584**] disease and he is a smoker. He does not have any sibling. His son is healthy. Physical Exam: VS: T 98.8 BP 108/80 HR 92 18 99%RA Gen: WDWN male in NAD HEENT: EOMI, PERRL, MMM, Clear OP NECK: erythema at site of prior Central line- non tender Heart: RRR, S1S2, no m,r,g Lungs: CTAB, no crackles/ rales/ rhonchi Abdomen: Soft/NT/ND, normoactive BS Extremities: No LE edema, 2+ DP/PT pulses bilaterally; Pertinent Results: [**2111-1-27**] 04:30AM BLOOD WBC-21.3*# RBC-4.80 Hgb-14.0 Hct-40.8 MCV-85 MCH-29.2 MCHC-34.4 RDW-13.3 Plt Ct-302 [**2111-1-27**] 05:25PM BLOOD WBC-45.1* RBC-4.18* Hgb-11.9* Hct-35.9* MCV-86 MCH-28.5 MCHC-33.2 RDW-13.6 Plt Ct-250 [**2111-1-29**] 03:46AM BLOOD WBC-36.5* RBC-4.33* Hgb-12.2* Hct-36.6* MCV-85 MCH-28.1 MCHC-33.3 RDW-13.7 Plt Ct-208 [**2111-1-27**] 04:30AM BLOOD Neuts-69 Bands-24* Lymphs-4* Monos-1* Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0 [**2111-1-27**] 05:25PM BLOOD Neuts-56 Bands-31* Lymphs-0 Monos-1* Eos-0 Baso-0 Atyps-0 Metas-12* Myelos-0 [**2111-1-27**] 04:30AM BLOOD Plt Smr-NORMAL Plt Ct-302 [**2111-1-27**] 08:26AM BLOOD PT-13.1 PTT-29.3 INR(PT)-1.1 [**2111-1-27**] 04:30AM BLOOD Glucose-151* UreaN-23* Creat-1.5* Na-136 K-3.8 Cl-100 HCO3-27 AnGap-13 [**2111-1-29**] 03:46AM BLOOD Glucose-114* UreaN-12 Creat-0.8 Na-141 K-3.9 Cl-109* HCO3-23 AnGap-13 [**2111-1-27**] 04:30AM BLOOD ALT-28 AST-25 LD(LDH)-173 CK(CPK)-111 AlkPhos-59 Amylase-49 TotBili-0.8 [**2111-1-27**] 05:25PM BLOOD ALT-122* AST-100* AlkPhos-71 Amylase-68 [**2111-1-27**] 04:30AM BLOOD Albumin-4.1 Calcium-9.5 Phos-0.9* Mg-1.4* [**2111-1-27**] 05:25PM BLOOD Calcium-7.6* Phos-2.7# Mg-1.4* [**2111-1-27**] 04:30AM BLOOD Cortsol-47.1* [**2111-1-27**] 04:30AM BLOOD CRP-39.2* [**2111-1-27**] 11:15AM BLOOD Type-ART pO2-184* pCO2-30* pH-7.40 calTCO2-19* Base XS--4 Comment-GREEN TOP [**2111-1-27**] 11:24AM BLOOD Type-[**Last Name (un) **] pO2-62* pCO2-38 pH-7.33* calTCO2-21 Base XS--5 Comment-GREEN TOP [**2111-1-27**] 06:52AM BLOOD Lactate-2.9* [**2111-1-28**] 05:00AM BLOOD Lactate-1.6 . ANALYSIS WBC RBC Polys Lymphs Monos [**2111-1-27**] 09:35AM 61 46* 322 57 11 TUBE #4 1 CLEAR AND COLORLESS 2 60-CELL DIFFERENTIAL [**2111-1-27**] 09:35AM 81 104* 542 38 8 TUBE #1 1 CLEAR AND COLORLESS 2 50 CELL DIFFERENTIAL Chemistry CHEMISTRY TotProt Glucose [**2111-1-27**] 09:35AM 32 83 . [**1-27**] blood culture - [**2111-1-27**] BLOOD CULTURE Blood Culture, Routine-FINAL {STREPTOCOCCUS PNEUMONIAE}; Aerobic Bottle Gram Stain-FINAL; Anaerobic Bottle Gram Stain-FINAL . RUQ U/S - Gallbladder wall edema/thickening in a distended gallbladder, without evidence of stones or son[**Name (NI) 493**] [**Name (NI) **] sign. Wall edema/thickening is most likely secondary to third-spacing of fluid; however, acute cholecystitis could have a similar appearance in the appropriate clinical setting. Nuclear medicine gallbladder scan can be performed for further evaluation. . CT abdomen - 1. Marked mesenteric lymphadenopathy, with lymph nodes measuring up to 13 mm. Major diagnostic considerations would include lymphoma, however, the patient has reportedly previously undergone lymph node biopsy which [**Last Name (un) 19692**] negative for malignancy (all per surgery). Exact results are unknown. Other diagnostic considerations include Castleman's disease, HIV, connective tissue disorders, and mononucleosis, among many other disorders. Correlation with previously acquired test results would be helpful. 2. Incomplete identification of the appendix due to extensive lymphadenopathy, with free fluid in the right lower quadrant at the cecum and within the pelvis . Early and/or tip appendicitis cannot be excluded on the basis of this examination. 3. No pulmonary embolism or acute aortic pathology. 4. Post-splenectomy. 5. Chronic loss of vertebral body height of T7, 8, and 9. . CXR - No acute cardiopulmonary process. . ECHO - The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 10-20mmHg. Left ventricular wall thicknesses and cavity size are normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). There is no ventricular septal defect. The right ventricular cavity is mildly dilated with normal free wall contractility. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. No masses or vegetations are seen on the aortic valve. There is no aortic valve stenosis. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. No masses or vegetations are seen on the tricuspid valve, but cannot be fully excluded due to suboptimal image quality. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: No valvular vegetations seen. Brief Hospital Course: Mr. [**Known lastname 6174**] is a 41yo male with PMH notable for ITP s/p splenectomy presented with with fevers and abdominal pain, initially in septic shock and requiring pressors with blood cultures positive for streptococcus pneumonia, treated with antibiotics, dexamenthasone, and IVIG, with prompt resolution of unstable hemodynamics, with further uncomplicated hospital course. . 1. Sepsis - patient presented with fevers, tachycardia, hypotension, elevated lactate, marked leukocytosis with bandemia, with eventual pneumococcal positive cultures. Abd/pelvis CT showed no acute pathology, with exception of diffuse LAD. Lumbar puncture, urine, and chest xray were all negative for signs of infection. Patient's systolic blood pressures were initially 80, prompting aggressive IVF and levophed, and as per the recommendation of patient's oncologist, IVIG and dexamethasone. Antibiotic regimen initially was vancomycin, ceftriaxone, and flagyl, with change to ceftriaxone upon culture return, with outpatient plan for levofloxacin by mouth to complete 14-day course. . 2. Abdominal pain - patient initially presented with mid-epigastric pain along the level of the umbilicus. CT scan, as above, was unrevealing. Surgery was initially consulted in the ED who did not feel that there was an underlying infectious process. RUQ ultrasound was performed with no acute pathology. Within 8 hours of arrival in hospital, abdominal pain resolved. Liver function tests were mildly abnormal. Issue to be addressed at outpatient follow-up. . 3. Lymphadenopathy - patient was noted to have diffuse mesenteric LAD on CT torso. Per pt, has been worked up in past with LN biopsy. Question as to whether patient has Castleman's disease given immunoglobulin deficiency history. Issue to be addressed as an outpatient. . 4. Common variable immunodeficiency - stable issue. . 5. ITP s/p splenectomy - pneumovax and influenza vaccines should be addressed as an outpatient. Patient unsure if he has received these vaccinations. . Patient discharged to home tolerating PO feeds, ambulating on his own, with stable vital signs, afebrile for 3 days. Pt's outside hematologist - Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 27580**]. Medications on Admission: Neurontin 600 mg Daily Discharge Medications: 1. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 2. Levofloxacin 250 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 10 days. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: Sepsis, Pneumococcal bacteremia Secondary: CVID, ITP, Asthma Discharge Condition: Good, afebrile, other vital signs stable Discharge Instructions: You were admitted to the hospital with an infection. You were treated with antibiotics and should complete a total of 2 weeks duration. Therefore please take your levaquin until it is finished. . You should follow up with Dr. [**Last Name (STitle) **] on [**2111-2-3**]. . Please contact your doctor or return to the emergency room if you develop any worrisome symptoms such as fevers, chills, chest pain, shortness of breath, diarrhea, vomiting, etc. Followup Instructions: Follow up with Dr. [**Last Name (STitle) **] on Tuesday, [**2-3**] at 2:30pm at the [**Location (un) 55**] office.

[ "038.2", "225.2", "493.90", "V45.79", "287.31", "995.91", "518.0" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9497, 9503

6985, 9219

301, 333

9617, 9660

2467, 6962

10160, 10278

1858, 2123

9292, 9474

9524, 9596

9245, 9269

9684, 10137

2138, 2448

255, 263

361, 1320

1342, 1685

1701, 1842

17,919

185,354

11854

Discharge summary

report

Admission Date: [**2169-6-15**] Discharge Date: [**2169-6-20**] Date of Birth: [**2137-12-27**] Sex: M Service: Bone Marrow Transplant CHIEF COMPLAINT: Chief complaint of neutropenia, fever accompanied by volume responsive hypotension. HISTORY OF PRESENT ILLNESS: This is a 38-year-old male with a recurrent B cell mediastinal lymphoma with known high grade SVC compression status post XRT and two autologous stem cell rescues (first in [**2167**] most recently 150 days ago), who had recently completed a five day course of Rituxan and E-CHOP starting [**6-6**]. Patient was well except for some post-chemo nausea and vomiting until three days prior to admission, the patient began to complain of temperatures to 101.0 F, but denied rigors, recent sick contacts, dysuria/frequency, cough, or diarrhea. Of note, the patient had a recent PICC line removal three days prior to admission placed for chemotherapy, but patient denied purulence at the insertion site, erythema, or tenderness. Patient had a problem with candidal esophagitis for the past 4-5 days and was started on fluconazole and has been compliant with his medications. Patient underwent EGD one day prior to admission without complication and fluconazole was increased to 400 mg p.o. q.d. at this time. Patient had almost no p.o. intake over the last 3-4 days secondary to nausea and vomiting from chemotherapy not controlled by his Ativan and Compazine. Patient also avoided p.o. secondary to dysphagia from esophagitis. Patient admits to lightheadedness with rising the past 2-3 days. Patient came to Hematology/[**Hospital **] Clinic on the day of admission for routine hematocrit check and systolic blood pressure was found to be in the 70s. Patient had two peripheral IVs placed, infused with 2 liters of normal saline with systolic blood pressure responsive to 117. Patient had blood cultures taken, urinalysis culture and sensitivity sent, and was given one dose of cefepime. Given his ANC of 250 for neutropenic fever. Transfer to MICU, where patient was sent for further care. Of note, there were no mental status changes with the decrease in blood pressure. PAST MEDICAL HISTORY: 1. Recurrent B cell lymphoma as above (no SVC syndrome). 2. Graft-versus-host disease. 3. Knee arthroscopy. 4. Rhinoplasty. 5. EF of 30-40% at the last admission. ALLERGIES: No known drug allergies. SOCIAL HISTORY: No IV drug abuse, no smoking history. Drinks one six pack of beer per week. PHYSICAL EXAMINATION: General: This was an alert and oriented young male patient, conversant in no apparent distress. HEENT: Notes conjunctival petechiae. Mucous membranes were dry, no JVD, no cervical lymphadenopathy. Cardiac: Normal S1, S2, no gallops or rubs, 3/6 systolic ejection murmur at the right upper sternal border with no radiation. Lungs were clear to auscultation bilaterally. Abdomen was benign. Extremities: No splinter hemorrhages. No perianal abscess. No Osler's nodes. LABORATORIES ON ADMISSION: White blood cell count of 0.7, hematocrit of 32.8, and platelets of 80, ANC was 250. Differential was 16% N, 60% L, 24% eosinophils, and 0% bands. Chem-7 was within normal limits. Urinalysis was negative. LFTs were notable for a LDH of 231. Calcium, magnesium, and phosphorus were within normal limits. Blood cultures x3 were no growth to date. Urine culture no growth to date. Chest x-ray showed no evidence of pneumonia, dilated loops of bowel. Patient spent four days in the MICU, where he responded well to IV fluids and he was treated with Flagyl, cefepime, Vancomycin, and fluconazole with Flagyl for just two days. Patient also received 300 mcg of Neupogen as well as 2 grams of cefepime in outpatient clinic with this episodic hypotension associated with a fever of 102.0 F. Patient was transferred to the Bone Marrow Transplant floor on [**2169-6-19**] from the Fenard ICU on cefepime and AmBisome, the latter for painful esophageal candidiasis. At that point, four days status post Neupogen therapy, initiation of antibiotics, patient's white count was 3.7 with an ANC of 2560, hematocrit was 31.1, platelets were 45. Chem-10 was within normal limits. He had blood cultures x4 on [**2169-6-18**] which were no growth to date. CMV culture was pending. On [**2169-6-12**], GI biopsy showed: 1) squamous epithelium with acute inflammation and ulceration. 2) No viral inclusions or tumor. 3) Fungal stain was negative. Given that on arrival to the floor, patient was no longer neutropenic, was afebrile, and had increasing p.o. intake. Patient was discharged home on [**2169-6-20**]. GM-CSF was discontinued on [**2169-6-19**] and CMV viral load was pending on discharge. CONDITION ON DISCHARGE: Patient was discharged to home in good condition. DISCHARGE INSTRUCTIONS: Advised to return to Emergency Room for failure to take p.o., fever greater than 100.5, and also to followup within the next 2-3 days, Dr. [**Last Name (STitle) **] his oncologist. DISCHARGE MEDICATIONS: 1. Reglan 10 mg p.o. q.i.d. prn nausea. 2. Famciclovir 250 mg p.o. b.i.d. 3. Lansoprazole 30 mg p.o. q.d. 4. Ativan 0.5 mg p.o. q.i.d. prn nausea. 5. Sucralfate 1 gram p.o. q.i.d. prn. 6. Viscus Lidocaine 2% 20 mL p.o. t.i.d. prn esophageal pain. 7. Bowel regimen. 8. Chlorhexidine gluconate 15 mL p.o. t.i.d. prn. 9. Nystatin oral suspension 5 mL p.o. q.i.d. prn. DISCHARGE DIAGNOSES: 1. Neutropenic fever. 2. Hypotension. 3. Recurrent B cell non-Hodgkin's lymphoma status post allogeneic bone marrow transplant. 4. Graft-versus-host disease. 5. Heart failure. [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 31111**], M.D. [**MD Number(1) 31112**] Dictated By:[**Last Name (NamePattern1) 7364**] MEDQUIST36 D: [**2169-10-25**] 14:10 T: [**2169-10-26**] 08:21 JOB#: [**Job Number 37409**]

[ "276.5", "112.84", "287.5", "202.80", "E933.1", "780.6", "V42.81", "288.0" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

5399, 5865

5012, 5378

4807, 4989

2506, 2995

170, 255

284, 2165

3010, 4706

2187, 2389

2406, 2483

4731, 4782

31,982

158,353

25921

Discharge summary

report

Admission Date: [**2156-8-18**] Discharge Date: [**2156-8-26**] Date of Birth: [**2087-3-18**] Sex: M Service: MEDICINE Allergies: Heparin Agents Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: IR-guided double lumen PICC placement. TEE cardioversion. History of Present Illness: 69 year old man with a history of endstage cardiomyopathy (NYHA class 4) and severe CHF with an EF of 15% (EF of 20% on milrinone drip) as well as severe MR p/w increasing shortness of breath an O2 requirements on increasing doses of Lasix. On home scale the pt gained 6 lbs over the week, and was unable to stand prior to admission. His urine output also decreased from 600cc/24hrs on [**8-16**] to 200cc/24hrs on day of admission. The pt's wife also noted increased abdominal girth and pedal edema. + orthopnea, + PND. The patient was recently discharged from [**Hospital1 18**] after an admission for ventricular tachycardia controlled on amiodarone. His course was complicated by episodes of acute pulmonary edema. On [**8-5**], the patient had a right heart catheterization which showed a cardiac index of 1.8 that improved to 2.6 after initiation of milrinone. Appropriate fluid status was maintained with Lasix 20 mg po daily, and patient was able to breathe comfortably on room air at discharge. Following his discharge on [**2155-8-12**], the patient was able to ambulate and breathe comfortably until [**2155-8-16**], when he began to develop shortness of breath and developed an oxygen requirement that was increased from 2L to 4L on the day prior to admission. The pt has also been on spironolactone prior to discharge which was omitted from his discharge medications and then re-started on [**2155-8-16**]. The patient also reports that PICC line for milrinone drip had been leaking. Past Medical History: CAD, s/p CABG x 4 in [**7-/2148**] Ischemic cardiomyopathy s/p ICD, NYHA class 4, on home O2 Atrial fibrillation with a h/o of being treated with dofetelide and coumadin x 1 month only HIT with + Ab screen, treated w/ argatroban in past Depression / memory loss Hyperlipidemia Mitral regurgitation GIB from gastric ulcer in [**3-/2154**] H/o AVMs s/p injection in [**2152**] and [**2153**] Rheumatoid arthritis H/o sacral ulcer-healed S/p right 5th toe amputation S/p right 4th toe ulcer S/p inguinal hernia repair Relative adrenal insufficiency Thrombocytopenia thought to be autoimmune, s/p bone marrow bx H/o C-diff Anemia Chronic renal insufficiency Allergies: Heparin agents (HIT) Social History: Retired orthopedic surgeon, lives at home with wife, quit smoking 50 years ago, social drinker, no other drug use. Family History: Sister with DM, mother died of liver cancer, father has CAD. Physical Exam: VS T 95.0, HR 90, BP 79/54, RR 22, POx 99% on 4L NC Gen: NAD, AOX3 HEENT: +JVD to angle of jaw. No LAD, supple CARD: RRR, diffuse PMI, holosystolic murmur at apex. No thrills, lifts. PULM: Bibasilar rales, + accessory muscle use ABD: Soft, NT, distended, no masses or organomegaly, BS+ EXT: multiple swan neck deformities R and L hands, 1+ pitting edema bilateral lower extremity, R>L, no cyanosis, clubbing, feet cool but bilateral DP pulses palpable Pertinent Results: Labs on admission: [**2156-8-18**] WBC-5.6 RBC-3.59* Hgb-9.3* Hct-28.8* MCV-80* MCH-25.9* MCHC-32.4 RDW-17.8* Plt Ct-121* [**2156-8-18**] PT-16.0* PTT-33.4 INR(PT)-1.4* [**2156-8-18**] Glucose-116* UreaN-61* Creat-1.9* Na-125* K-4.7 Cl-91* HCO3-21* AnGap-18 [**2156-8-18**] Calcium-8.4 Phos-4.2# Mg-2.4 [**2156-8-18**] CK(CPK)-15* [**2156-8-18**] CK-MB-NotDone Labs on discharge: [**2156-8-26**] WBC-3.9* RBC-3.32* Hgb-8.4* Hct-26.1* MCV-79* MCH-25.3* MCHC-32.2 RDW-18.2* Plt Ct-78* [**2156-8-26**] PT-15.0* PTT-29.5 INR(PT)-1.3* [**2156-8-26**] Glucose-96 UreaN-43* Creat-1.1 Na-124* K-4.6 Cl-92* HCO3-28 AnGap-9 [**2156-8-26**] Calcium-7.8* Phos-2.1* Mg-2.3 EKG [**2156-8-18**]: Sinus rhythm with demand ventricular pacing. Compared to the previous tracing of [**2156-8-5**] the findings are similar. CXR [**2156-8-18**]: Severe cardiomegaly is unchanged. The position of the pacemaker defibrillator leads in the right atrium and right ventricle is unchanged as well. Multiple broken sternal wires are seen, with appearances different compared to the prior study being now divided into two parts. The vertical central lucency projecting over the mid of the thoracic spine suggests sternal dehiscence that may be worse compared to the prior film. Bilateral pleural effusions are present, increased since the prior film as well as there is new worsening of the left lower lobe opacity consistent with atelectasis. The upper lungs are unremarkable. There is mild vascular engorgement consistent with mild failure, but unchanged since the prior study. TEE [**2156-8-20**]: The left atrium is dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No thrombus is seen in the right atrial appendage The ascending aorta is mildly dilated. There are three aortic valve leaflets which are mildly thickened. Aortic stenosis is present (not quantified). IMPRESSION: no intra-atrial thrombus. Brief Hospital Course: This is a 69 year old man with a history of end stage cardiomyopathy (NYHA class 4) and severe CHF with an EF of 15% (EF of 20% on milrinone drip) as well as severe MR p/w SOB, DOE, PND, weight gain of 6lbs in a week, likely due to CHF exacerbation. # CHF/Pump: On physical exam the patient appeared to be in volume overload with JVD to angle of the jaw, bibasilar rales, 1+ pitting edema in the lower extremities, and distended abdomen. This was consistent with symptoms of SOB, PND, DOE and likely secondary to systolic and diastolic HF secondary to increased intravascular volume. He was diuresed with Lasix bolus 20mg IV and Lasix gtt at 2mg/hr. Milrinone was increased to 0.75, and he was continued on spironolactone and his ACEi. # CAD: He has a history of CAD, CK negative on this admission with no chest pain and EKG that is unchanged. CHF exacerbation unlikely to be secondary to ACS in this setting. He was monitor on telemetry # Rhythm: The patient was in paced rhythm on telemetry. He has a history of v-tach which responded to amiodarone. Patient also has ICD in place. # Respiratory: SOB and increased O2 requirement were likely secondary to CHF exacerbation and resultant pulmonary edema. # Rheumatoid Arthritis: Swan neck deformities were stable. He was continued on prednisone 5mg po daily for RA control. # Anemia: His HCT was stable. He was continued on ferrous sulfate for anemia. Medications on Admission: Ferrous Sulfate 325 mg DAILY Escitalopram 10 mg DAILY Aspirin 81 mg DAILY Pantoprazole 40 mg Q24H Prednisone 5 mg DAILY Amiodarone 200 mg once a day. Captopril 12.5 TID Milrinone 1 mg/mL infusion 0.5 mcg/kg/min Intravenous continuously. Carvedilol 25 mg twice a day. Furosemide 20 mg once a day. Spironolactone 25 daily Discharge Medications: 1. 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. Pt has HEPARIN ALLERGY- NO HEPARIN FLUSHES 2. Lasix 20 mg Tablet Sig: One (1) Tablet PO as directed as needed. Disp:*30 Tablet(s)* Refills:*0* 3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 8. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). Disp:*30 Tablet(s)* Refills:*2* 9. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 10. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). Disp:*45 Tablet(s)* Refills:*2* 11. PICC PICC care per protocol 12. Milrinone 1 mg/mL Solution Sig: 0.75mcg/kg/min Intravenous continuous infusion. Disp:*qs qs* Refills:*5* Discharge Disposition: Home With Service Facility: [**Hospital6 6689**] VNA Discharge Diagnosis: Primary: - Ischemic cardiomyopathy, status-post ICD, NYHA class 4, on home O2 - Coronoary artery disease, status-post CABG x 4 in [**7-/2148**] - Atrial fibrillation with a history of being treated with dofetelide and coumadin x 1 month Secondary: - HIT with + Ab screen, treated w/ argatroban in past - Depression / memory loss - Hyperlipidemia - Mitral regurgitation - GIB from gastric ulcer in [**3-/2154**] - History of AVMs, status-post injection in [**2152**] and [**2153**] - Rheumatoid arthritis - Relative adrenal insufficiency - Thrombocytopenia thought to be autoimmune, s/p bone marrow bx - Anemia - Chronic renal insufficiency Discharge Condition: Stable. afebrile. Discharge Instructions: You were admitted for increasing shortness of breath and oxygen requirements on increasing doses of Lasix. While you were here, you received a 2 lumen PICC line which you are being discharged with. While you were here, you were diuresed with LASIX and received a CARDIOVERSION for an arrythmia. Please take your medications as written. These include the home MILRINONE. Your ASPIRIN was stopped. Your AMIODARONE was increased to 400mg daily. You were started on a medication called DIGOXIN which you will take every other day. Please adhere to your follow-up appointments. Please weigh yourself every morning, and call you doctor if your weight increases by more than 3 lbs. Please adhere to a 2 gm sodium diet. Please limit your fluid intake to 1.5L. Please return to the hospital or call your doctor if you have temperature greater than 101, shortness of breath, worsening difficulty with swallowing, chest pain, abdominal pain, diarrhea, or any other symptoms that you are concerned about. Followup Instructions: Cardiology follow-up: Please see Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] on [**9-6**], at 2:30pm. His office can be reached at [**Telephone/Fax (1) 62**]. Please see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**10-14**], at 10:00am. His office can be reached at [**Telephone/Fax (1) 62**]. Renal: Please see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4883**], MD [**First Name (Titles) **] [**11-29**] and 2:30pm. His office can be reached at [**Telephone/Fax (1) 435**]. Completed by:[**2156-11-5**]

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icd9cm

[ [ [] ] ]

[ "38.93", "89.49", "88.72" ]

icd9pcs

[ [ [] ] ]

8228, 8283

5271, 6680

303, 363

8969, 8989

3300, 3305

10036, 10631

2749, 2812

7051, 8205

8304, 8948

6706, 7028

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2827, 3281

244, 265

3681, 5248

391, 1890

3319, 3662

1912, 2600

2616, 2733

23,852

127,032

26059

Discharge summary

report

Admission Date: [**2163-12-2**] Discharge Date: [**2163-12-11**] Date of Birth: [**2163-12-2**] Sex: M Service: NB HISTORY: [**Known lastname 64702**] [**Known lastname 55463**] is a full term 38-4/7 week male infant delivered by stat cesarean section due to concern for placental abruption and fetal heart rate decelerations. The infant's mother is a 28 year-old gravida II, para 0, now I mom with an uncomplicated pregnancy. Prenatal screens: Blood type B positive, antibody negative, hepatitis B surface antigen negative, RPR nonreactive, Rubella immune, group beta strep status positive. The mother presented to [**Hospital1 346**] in spontaneous labor. She was noted to have decelerations with recovery on fetal heart monitor tracing. Then with rupture of membranes she was noted to have a large amount of blood in the amniotic fluid. A cesarean section was performed stat under general anesthesia. The infant emerged with decreased tone and no respiratory effort. A large amount of blood clots and bloody amniotic fluid was suctioned from his oropharynx and stomach. He required bag mask ventilation for improvement of heart rate which was below 100 and decreased color and tone. Apgar scores were 5 at one minute and 7 at five minutes of age. The umbilical cord was noted to be blood stained. The infant was transported to the newborn Intensive Care Unit with facial CPAP in 100% oxygen. PHYSICAL EXAMINATION: Admission weight was 3,730 grams (90th percentile), head circumference 35.5 cm (90th percentile), length 54.5 cm (greater than 90th percentile). Vital signs: Temperature 99 rectally, heart rate 156, blood pressure 80/53 with a mean arterial pressure of 61. Initial oxygen saturation was 80%, then 99% after intubation with an FIO2 of 80%. Initial blood glucose 89. The infant was pink centrally. Tone much improved from delivery. Anterior fontanelle open and flat, no molding, sutures mobile, palate intact. Normal red reflex bilaterally, pupils reactive to light. Breath sounds initially reduced with coarse rhonchi but much improved with intubation. Breathing comfortably on ventilator. Normal S1, S2 intensity, no murmur noted, femoral pulses normal. Perfusion to feet initially decreased but improving over time. Abdomen soft with no masses or organomegaly, umbilical cord blood stained. Normal male genitalia, penis slightly small, testes descending bilaterally. Tone symmetrical, initially reduced but much improved over time. Hips increased laxity noted but stable. SUMMARY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: Upon admission to the Neonatal Intensive Care Unit the infant was intubated and placed on the conventional ventilator with settings of PIP 26, PEEP of 6, rate of 20 and FIO2 of 80%. He received 2 doses of Survanta over the first 24 hours of life. His ventilator settings weaned down over the next 3 days and he was ultimately extubated on day of life 3 to room air. His chest x-ray upon admission was significant for patchy infiltrates in the right lower quadrant suggestive of blood aspiration pneumonia. He has not had any issues with desaturations and has not required extra oxygen since he was extubated on day of life 3. His oxygen saturations have been 95 to 100% and his breathing pattern has been comfortable with respiratory rates in the 40 to 60's. CARDIOVASCULAR: [**Known lastname 64703**] blood pressure was low shortly after admission to the Neonatal Intensive Care Unit. He received 1 normal saline bolus and then was started on a Dopamine infusion with a maximum infusion rate of 8 mcg per kilogram per minute. The Dopamine was gradually weaned over the next several days and was discontinued by day of life 3. His blood pressure has been within normal range since. Heart rate has been in the 130 to 160 range and no murmurs have been auscultated. His hematocrit on admission was 42.5. He did not require any blood products during this hospitalization. FLUID, ELECTROLYTES AND NUTRITION: Upon admission to the Neonatal Intensive Care Unit umbilical artery and umbilical venous catheters were placed and IV fluids of D10W were initiated at 60 ml per kilogram per day. The IV fluids were increased to 80 ml per kilo per day on day of life 2 and then to a maximum of 140 ml per kilogram per day on day of life 4. Upon removal of his umbilical lines enteral feeds were started which was on day of life 4. He has been taking ad lib feeds of breast milk of Enfamil without difficulty. His last set of electrolytes on day of life 4 was a sodium of 142, a potassium of 4.8, a chloride of 111 and a bicarbonate of 17. His weight at time of discharge is 3490 grams. GASTROINTESTINAL: Phototherapy was started on day of life 3 for a bilirubin of 18.5/0.4. Maximum bilirubin on day of life 4 was 24.6/0.6 at which time phototherapy was intensified and total fluids were increased. Bilirubin came down nicely over the next 24 hours. On day of life 5 the bilirubin was down to 17.9/0.5 and then down to 11.7/0.3 on day of life 8 at which time the phototherapy was discontinued. Rebound bilirubin on [**12-11**] was 13.7/0.3. He will need a follow up bilirubin as an outpatient. Infant's blood type is B positive, Coomb's negative. Hematocrit was 44.6 with reticulocyte count 5.2 (both within normal limits, without evidence of hemolysis). High bilirubin was thought to be related to swallowing large amounts of bloody amniotic fluid around the time of delivery. Since he responded quickly to intensive phototherapy, exchange transfusion was not required. HEMATOLOGY: As noted before baby's blood type is B positive, direct antibody negative. He has not received any blood products during his hospitalization. INFECTIOUS DISEASE: Upon admission to the Neonatal Intensive Care Unit a CBC with differential and blood cultures were drawn and he was started on Ampicillin and gentamicin. The initial CBC showed a white count of 19,400, a hematocrit of 42.5, a platelet count of 266,000 with 44% polys and 5% bands. Blood culture that was drawn at that time was negative. He did remain on 7 days of antibiotics for presumed aspiration pneumonia. On day of life 2 the gentamicin was changed to Cefotaxime and he finished his course of antibiotics on [**12-8**]. NEUROLOGY: The infant's neurologic examination has been normal throughout his hospitalization and a head ultrasound is not indicated for this full term well acting infant. SENSORY: Audiology: After completion of his phototherapy course a hearing screen was performed with automated auditory brain stem responses and was passed. Ophthalmology: Eye examination not indicated for this full term infant. PSYCHOLOGICAL TESTING: [**Hospital1 69**] social worker has been involved with the family. This contact social worker can be reached at [**Telephone/Fax (1) **]. This family's primary language is Chinese and they have been updated regularly in the Neonatal Intensive Care Unit with the Chinese interpreter. CONDITION ON DISCHARGE: Infant is comfortable from a respiratory standpoint in room air. Stable temperature and open crib. Taking p.o. feeds without difficulty. Resolving hyperbilirubinemia. DISCHARGE DISPOSITION: To home with parents. Name of primary pediatrician is Dr. [**Last Name (STitle) 1256**] at [**Hospital3 **]. Phone number [**Telephone/Fax (1) 40664**]. CARE RECOMMENDATIONS: Feeds at discharge: Ad lib breast or bottle feeding. Medications: None. Car seat position screening not indicated. State Newborn Screening status: [**Known lastname 64703**] first state newborn screen was sent on [**12-6**]. He did have ABNORMAL FINDINGS. These were: C3 (propionylcarnitine=4.75 (high normal), C3/C2= 0.4 (ref <0.25, C3C18:1=-5.13 (ref<5.0), Phe=2.5 (ref<2.3) Recommended metabolic referral. The state screen was repeated on [**2163-12-8**]. The [**Hospital1 **] metabolic service was contact[**Name (NI) **] and recommended sending: phenylalanine, tyrosine, acylcarnitine levels and urine organic acids. All were sent and are pending at the time of discharge. It is possible that the infant's hyperbilirubinemia might have confounded these test results. The metabolic service will follow these tests and contact the pediatrician if they are abnormal and if further evaluation is warranted. Immunizations received: [**Known lastname 64702**] received his first hepatitis B vaccine on [**12-4**]. Immunizations recommended: Synagis RSV prophylaxis should be considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet any of the following 3 criteria: 1) born at less than 32 weeks, 2) Born between 32 and 35 weeks with 2 of the following: Day care during RSV season, smoker in the household, neuromuscular disease, airway abnormalities or school age siblings, or 3) with chronic lung disease. Influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. Before this age and for the first 24 months of the child's life immunization against influenza is recommended for household contact and out of home caregivers. A follow up appointment with Dr. [**Last Name (STitle) 1256**] has been arranged for Monday, [**12-12**] at 1 P.M. Bilirubin level should be checked at this time. VNA referral has been made. DISCHARGE DIAGNOSES: 1. Term male. 2. Perniatal depression. 3. Blood aspiration pneumonia. 4. Hyperbilirubinemia. 5. Abnormal newborn screen. Repeat pending. Specific tests pending. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 54936**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2163-12-8**] 15:35:57 T: [**2163-12-8**] 17:54:26 Job#: [**Job Number 64704**]

[ "762.1", "796.4", "779.89", "774.6", "V29.0", "V30.01", "V05.3", "458.9", "770.16" ]

icd9cm

[ [ [] ] ]

[ "38.92", "99.55", "99.83", "96.6", "96.04", "93.90", "96.71", "99.15", "38.91" ]

icd9pcs

[ [ [] ] ]

7170, 7324

9279, 9710

7347, 7353

2559, 6952

1441, 2530

7367, 8371

8398, 9258

6977, 7146

3,460

119,586

16992

Discharge summary

report

Admission Date: [**2116-4-13**] Discharge Date: [**2116-4-17**] Date of Birth: [**2054-7-14**] Sex: M Service: [**Hospital1 **] MEDICINE HISTORY OF PRESENT ILLNESS: This 61-year-old man is transferred to the floor from the MICU on [**4-15**] after being admitted on [**4-13**] with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **] tear and upper GI bleed. He has a history of significant ethanol consumption and was hospitalized six or seven years ago for withdrawal. Three to four years ago he had an episode of vomiting blood for which he was admitted to an outside hospital. He recalls having a nasogastric lavage, but no EGD, and recalls being told by his doctor he needed to cease drinking alcohol in order to "save his liver." The patient recently traveled in [**Country 6171**] for several weeks, returning about 1.5 weeks ago. He drank [**4-18**] glasses of wine per day in [**Country 6171**], and then resumed his usual three glasses of wine per day upon return. He noted increased lethargy along with dark stools and shortness of breath starting on [**4-11**] or [**4-12**]. He subsequently presented to [**Hospital3 28116**] [**Hospital3 **]. Per report, the patient also had 12 hours of nausea, vomiting, and retching prior to his presentation, but the patient does not recall this at this time. His blood alcohol level was 156. A nasogastric lavage revealed bright red blood and the patient was subsequently taken for EGD. This procedure revealed [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **] tear at the gastroesophageal junction, and an electrocauterization was performed. At time of presentation, the patient's hematocrit was 25.5, and he received a total of three units of packed red blood cells at [**Hospital3 3834**]. By report, he was never hemodynamically unstable. He was subsequently transferred to the [**Hospital1 69**] MICU. The patient was hemodynamically stable and without evidence of further bleeding throughout his entire stay in MICU. A repeat EGD was done which revealed esophagitis at the gastroesophageal junction likely secondary to cauterization as well as Grade II esophageal varices in the lower [**12-13**] of the esophagus, nonbleeding. There was also clotted blood obscuring visualization of the stomach. The patient received further 2 units of packed red blood cells, and had a hematocrit of 31.6 at the time of his transfer to the floor. Prior to his transfer, an abdominal ultrasound was performed revealing a coarsened heterogeneous echotexture of the liver and moderate ascites. The patient was placed on ciprofloxacin for SBP prophylaxis. He has been afebrile and without abdominal pain. PAST MEDICAL HISTORY: 1. Ethanol abuse. 2. History of ethanol withdrawal. 3. Alcoholic hepatitis. 4. History of upper gastrointestinal bleed. 5. Hypertension. 6. Hypercholesterolemia. MEDICATIONS ON TRANSFER: 1. Ciprofloxacin 500 mg [**Hospital1 **]. 2. Protonix 40 mg IV bid. 3. Octreotide 50 mg per hour drip. 4. Multivitamins. 5. Folate. 6. Thiamine. 7. Diazepam per CIWA scale. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient is a retired school teacher. He is single and lives in [**Location **], [**State 350**]. He quit smoking 25 years ago after a 30 pack year history. He drinks about three glasses of wine per day. He has not had any prior blood transfusions or IV drugs. He attended graduate school in foreign languages. PHYSICAL EXAMINATION: Temperature of 98.7, heart rate of 81, blood pressure 142/82, respiratory rate 15, and oxygen saturation is 96%. In general, a well-developed and well-nourished man sitting in his chair, in no acute distress. HEENT: No scleral icterus. Conjunctivae pink. Pupils 4 mm to 3 mm with light, oral mucosa moist. Neck: No JV pulsations seen at 80 degrees, no masses. Lungs are clear to auscultation bilaterally; gynecomastia is present, no spider angiomata are seen. Heart: Regular, rate, and rhythm, 3/3 systolic ejection murmur loudest at the right upper sternal border. Abdomen is obese, soft, nontender, and positive shifting dullness. Palmar erythema present, trace pitting pretibial edema. Neurologic: Alert and oriented times three. No errors on saying days of the week backwards, no asterixis, hyperreflexia biceps and quads bilaterally. LABORATORIES: White count 8.2, hematocrit 312.6, MCV 90, platelet count 98, INR 1.5, APTT 30, sodium 139, potassium 3.7, chloride 109, bicarbonate 21, BUN 16, creatinine 0.8, glucose 102. ALT 26, AST 45, alkaline phosphatase 62, total bilirubin 1.7, calcium 7.7, phosphate 2.7, magnesium 2.0. HOSPITAL COURSE: Patient was transferred to the floor without event. He was continued on the octreotide drip for the possibility of variceal bleeding and the ciprofloxacin for SBE prophylaxis. On [**4-16**], the patient underwent a repeat upper endoscopy, which revealed again grade II varices in the lower third of the esophagus. These varices were nonbleeding and three bands were successfully placed. Also visualized with a single ulcer with surrounding erythema and stigmata of recent bleeding at the gastroesophageal junction corresponding to the site of previous electrocautery. There were findings in the stomach consistent with mild gastritis. After the EGD, the patient's diet was advanced without incident. Nadolol was initiated for management of his esophageal varices as well as his systemic hypertension. The patient was converted to a po proton-pump inhibitor. The octreotide drip was discontinued. The patient was given an appointment in [**Hospital **] Clinic to arrange for repeat banding of his esophageal varices in two weeks. The patient was also counseled to cease drinking alcohol and endorsed an understanding the possible consequences should he continue to drink. DISCHARGE DIAGNOSES: 1. Status post upper gastrointestinal bleed secondary to [**Doctor First Name **]-[**Doctor Last Name **] tear, electrocauterized at [**Hospital3 3834**] [**Hospital3 **]. 2. Alcoholic cirrhosis complicated by portal hypertension with complications including Grade II esophageal varices (banded), ascites, and splenomegaly. 3. Thrombocytopenia secondary to splenomegaly. 4. History of ethanol abuse and withdrawal. 5. Systemic hypertension. 6. Hypercholesterolemia. 7. Acute conjunctivitis. DISCHARGE CONDITION: Fair. DISCHARGE STATUS: Home with followup in [**Hospital **] Clinic with Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] [**2116-4-20**]. DISCHARGE MEDICATIONS: 1. Protonix 40 mg po bid. 2. Ciprofloxacin 500 mg po bid for three additional days. 3. Nadolol 40 mg q day. 4. Ciprofloxacin 0.3% eyedrops one drop [**Hospital1 **] for five days. [**Name6 (MD) 7853**] [**Last Name (NamePattern4) 7854**], M.D. [**MD Number(1) 7855**] Dictated By:[**Last Name (NamePattern1) 5596**] MEDQUIST36 D: [**2116-4-17**] 19:15 T: [**2116-4-21**] 12:07 JOB#: [**Job Number 47794**]

[ "572.3", "303.91", "372.00", "789.5", "571.2", "456.21", "285.1", "287.4", "530.7" ]

icd9cm

[ [ [] ] ]

[ "42.33", "45.13" ]

icd9pcs

[ [ [] ] ]

6423, 6573

5909, 6401

6596, 7041

4705, 5888

3537, 4687

183, 2755

2965, 3177

2777, 2940

3194, 3514

28,765

167,961

44988

Discharge summary

report

Admission Date: [**2146-4-26**] Discharge Date: [**2146-5-1**] Date of Birth: [**2068-12-18**] Sex: F Service: MEDICINE Allergies: Keflex / Codeine / Diltiazem / A.C.E Inhibitors / Tetracycline / Aspirin Attending:[**First Name3 (LF) 348**] Chief Complaint: Hypoxia, dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: This is a 77 year old female with past medical history notable for amiodarone induced restrictive lung disease, asthma, chronic systolic CHF and atrial fibrillation status post pacemaker who presented with progressive dyspnea. Mrs. [**Known lastname **] reported that she had been dealing with chronic cough for the past year as well as intermittent dyspnea on exertion. She was admitted from [**2146-3-15**] to [**2146-3-18**] for pneumonia in the context of worsening cough, dyspnea, and sputum production. She was treated with levofloxacin for pneumonia, albuterol for asthma, and diuretics for some overlying CHF. Steroids were considered but deferred given concern for infection and the patient's concerns about the side effects of steroids. At discharge she had an ambulatory sat of 89-97% on room air and she completed a ten day course of levofloxacin. At home she reported some improvement but that her symptoms never completely resolved and at best she returned to her chronic productive cough, which is productive of clear to yellow-green sputum. Overall, she reported that she felt she was not clearing secretions adequately with her cough and that she had a sense something remained stuck in her throat. Over the past week prior to presentation she once again developed increased shortness of breath, particularly on exertion, wheezing, and productive cough. On the day prior to presentation, she presented to her PCP with an O2 sat 84%RA and was tachypneic and audibly wheezing so she was sent to the ED. In ED VS T 98.8, P 71, BP 124/41, RR 16, O2 Sat 87%RA. Her O2 sat improved on NRB. Chest radiograph showed possible improvement in her previous infiltrate, EKG was unchanged, and labs were notable for slightly worsened Cr (1.6 from 1.2-1.4 at baseline). She received vancomycin/pipercillin-tazobactam and albuterol/ipratroprium nebs with improvement in her O2 sat to 97% on 6L. She had brief hypotension to SBP's of the 80's which improved with 1L IVF. REVIEW OF SYSTEMS: (+) Per HPI , +weight loss 262 lbs (dry) -> 219 over past "months", +chronic arthralgia (shoulders). (-) Denied fever, chills, night sweats, recent weight gain. DenieD headache, sinus tenderness, rhinorrhea or congestion. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied myalgias. Past Medical History: - Asthma - Amiodarone induced interstitial lung disease - Chronic Diastolic Congestive Heart Failure with EF 55% on ECHO from [**3-2**]. - Hypertension - Coronary Artery Disease - Atrial fibrillation status post amio toxicity, status post ablation of the A-V node and pacemaker placement in [**Month (only) 956**] of [**2138**]. - Peripheral vascular disease - Anticoagulated on coumadin for atrial fibrillation - Hypothyroidism. - Lower extremity cellulitis with MRSA. - Venous stasis disease. - Left hip fracture in [**2129**] with multiple complications. - Reported history of DVT per chart though patient denies - Bell's palsy. - Left heel ulcer. - Osteoarthritis status post left total knee replacement. Social History: She lives with her husband upstairs from a daughter who is in health care. She has also had home PT. She no longer ambulates up stairs secondary to osteoarthritis and her family installed a lift to help her upstairs. Never smoker. Never a heavy alcohol user. Family History: Notable for lung cancer in two sisters who were smokers. Physical Exam: Vitals: 98.6 73 123/44 100%6L General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: bilateral diffuse, mild expiratory wheezing, no ronchi, moderate air-movement throughout. no egophany, no crepitus, dullness to percussion. 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, trace bilateral edema. Pertinent Results: LABORATORY RESULTS =================== On Admission: WBC-9.9# RBC-4.00* Hgb-10.8* Hct-32.9* MCV-82 RDW-15.2 Plt Ct-391 ---Neuts-77.6* Lymphs-13.7* Monos-6.3 Eos-2.1 Baso-0.3 PT-24.2* PTT-33.8 INR(PT)-2.4* Glucose-105 UreaN-45* Creat-1.6* Na-136 K-5.3* Cl-98 HCO3-29 AnGap-14 Calcium-9.3 Phos-3.2 Mg-2.2 URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.015 Blood-NEG Nitrite-NEG -Protein-NEG Glu-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG On Discharge WBC-5.5 RBC-3.83* Hgb-10.3* Hct-31.7* MCV-83 RDW-15.2 Plt Ct-390 PT-22.1* PTT-32.4 INR(PT)-2.1* Glucose-83 UreaN-35* Creat-1.2* Na-137 K-4.6 Cl-97 HCO3-32 AnGap-13 Calcium-9.3 Phos-3.8 Mg-2.1 Other Results: CK 27--23 MB ND--ND TropT 0.02--0.02 MICROBIOLOGY ============ Blood Cultures [**2146-4-26**] *2: No growth Urine Culture [**2146-4-27**]: No Growth Legionella urinary antigen [**2146-4-27**]: Negative Sputum Gram Stain and Culture [**2146-4-29**]: GRAM STAIN (Final [**2146-4-29**]): <10 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. PLEASE SUBMIT ANOTHER SPECIMEN. LEGIONELLA CULTURE (Final [**2146-5-6**]): NO LEGIONELLA ISOLATED. ACID FAST SMEAR (Final [**2146-5-2**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. OTHER RESULTS ============= Chest Radiograph [**2146-4-25**]: Mildly improving opacities within the right upper and left lung base compatible with improving multifocal pneumonia. No new areas of consolidation present. Chest Radiograph [**2146-4-26**]: IMPRESSION: Mildly improving opacities within the right upper and left lung base compatible with improving multifocal pneumonia. No new areas of consolidation present. TTE [**2146-4-27**]: Conclusions The left atrium is markedly dilated. The right atrium is markedly dilated. The estimated right atrial pressure is 10-20mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is low normal (LVEF 50-55%). The right ventricular cavity is mildly dilated with depressed free wall contractility. A right ventricular mass cannot be excluded at the apex (clip [**Clip Number (Radiology) **]). The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [**2145-2-27**], the right ventricle seems to be depressed. The detected pulmonary artery systolic hypertension has increased. CT Chest W/O Contrast [**2146-4-27**]: IMPRESSION: Extensive multifocal pulmonary consolidation, with a component of volume loss suggesting this is an organizing pneumonia either post-infectious or cryptogenic. Because there is a one-year interval since the most recent earlier radiographs bronchial or alveolar cell carcinoma is not excluded, but it is unlikely. Central adenopathy is probably reactive. Severe cardiomegaly. Aortic valvular calcification could be hemodynamically significant. paced, with underlying AFIB, unchanged from prior [**3-15**]. ECG [**2146-4-28**]: Ventricular pacing. The underlying rhythm is probably atrial fibrillation. Compared to the previous tracing of [**2146-4-26**] there is no change. Renal Ultrasound [**2146-4-28**]: IMPRESSION: 1) Simple bilateral renal cysts, without evidence of solid mass. 2) Gallstones, with an indeterminant echogenic focus in the fundus of gallbladder. This is incompletely characterized, and could reflect either sludge in the gallbladder or a polypoid lesion. A dedicated gallbladder ultrasound with fasting or a follow up ultrasound in three months may be obtained to assess for any interval changes. Brief Hospital Course: This is a 77 year old female with a history of asthma, chronic restrictive lung disease secondary to amiodarone, chronic diastolic heart failure, and possible history of DVT with previous admission for multifocal pneumonia presenting with exacerbation of chronic dyspnea and cough along with hypoxia at her physician's office. 1) Dyspnea/Hypoxia: The patient was initially admitted to the MICU given concern for her high oxygen requirements and suspicion there may be a need for more invasive ventilation. She was continued on antibiotics there as well as receiving an aggressive bronchodilator regimen and was able to quickly have her supplementary oxgyen weaned down to 2L of O2 by nasal cannula. On transfer out of the intensive care unit antibiotics were stopped because there was no clear indication of an acute bacterial infection. Consolidations on chest CT were thought most likely due to resolving bronchopneumonia given CXR was improved. Given her dramatic improvement overnight with bronchodilators and no other aggressive management the etiology of her initial hypoxia and respiratory worsening was thought to be an exacerbation of her asthma possibly due to a viral infection. She remained afebrile and stable off antibiotics. Pulmonary consultation was obtained and recommended completing another course of levofloxacin given previous course may have been too brief leading to recrudescence and worsening of symptoms. Diuresis was postponed as the patient's creatinine was elevated and there was no significant pulmonary edema on chest radiograph. She continued to improve and prior to discharge was ambulating without dyspnea though with brief hypoxia to O2 saturations in the high 80's. Therefore, after discussion with pulmonary she was discharged home with O2 to use PRN and pulmonary follow up. 2) Chronic diastolic heart failure: The patients cardiac enzymes remained negative and she had no jugular venous distension or edema suggesting an acute exacerbation. TTE showed a stable EF. She was continued on her home diuretic dose as well as her beta blocker and [**Last Name (un) **]. 3)Acute Kidney Injury on Chronic Kidney Disease: On presentation the patient had acute kidney injury of unclear etiology. Likely, in the context of increasing dyspnea the patient had poor PO intake and may have developed a degree of prerenal acute kidney injury. With conservative management (primarily the avoidance of nephrotoxins) the patient's Cr trended back down to 1.2, which is lower than her baseline. 4) Renal Mass: The patient had a renal mass noted on CT that couldn't initially be clearly identified as a cyst. Ultrasound, however, confirmed this was a cyst and no further management was pursued. 5) Coronary artery disease: The patient had an unchanged ECG, cardiac enzymes were negative, and she had no other signs of ACS. She was continued on her home aspirin, beta blocker, and [**Last Name (un) **]. 6) Atrial Fibrillation: The patient has a pacemaker in place. She was continued on her home doses of carvedilol and coumadin and INR remained therapeutic. 7) Peripheral Vascular Disease: Her symptoms were stable so she was continued on her home aspirin. 8) Hypothyroidism: The patient was continued on her home levothyroxine dose. 9) Osteoarthris/Chronic Pain: The patient was continued on her home oxycodone SR dose. 10)Chronic suppression of septic arthritis: The patient was continued on her home dicloxacillin. The patient tolerated a cardiac diet. She got SC heparin for DVT prophylaxis. There was no indication for GI prophylaxis so this was not initiated. Medications on Admission: - Valsartan 80 mg PO DAILY (Daily). - Carvedilol 6.25 mg PO BID - Bumetanide 3 mg PO DAILY (Daily). - Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Inhalation Q6H PRN - Dicloxacillin 250 mg PO BID - Omeprazole 40 PO DAILY - Cholecalciferol (Vitamin D3) 400 unit PO DAILY (Daily). - Levothyroxine 125 mcg PO DAILY - Ferrous Sulfate 325 mg PO DAILY (Daily). - Fluticasone 110 mcg INH [**Hospital1 **] (2 times a day). - Salmeterol 50 mcg/Dose Disk INH Q12H (every 12 hours). - Atrovent HFA 17 mcg/Actuation Aerosol Sig: One (1) 2 puffs Inhalation four times a day as needed for wheezing. - Docusate Sodium 100 mg PO BID - Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). - Zafirlukast 20 mg PO BID - Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for toe pain. - Warfarin 3mg DAILY (except TEUSDAY, then 2mg DAILY) Discharge Medications: 1. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Bumetanide 2 mg Tablet Sig: 1.5 Tablets PO once a day. 4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) nebulizer Inhalation Q4H (every 4 hours) as needed for wheezing. 5. Dicloxacillin 250 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 10. Fluticasone 250 mcg/Actuation Disk with Device Sig: Two (2) puffs Inhalation twice a day: Rinse mouth after each dose to avoid thrush. Disp:*1 inhaler* Refills:*2* 11. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation twice a day. 12. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. 13. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). 14. Docusate Sodium 50 mg/5 mL Liquid Sig: Five (5) ml PO BID (2 times a day) as needed for Constipation. 15. Zafirlukast 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. Warfarin 2 mg Tablet Sig: 1-1.5 Tablets PO once a day: Take 1.5 tabs every day except Tuesday. On Tuesday take 1 tab. 17. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO every other day for 11 days: You were given a dose on [**2146-4-30**], you will need to take your next dose on [**5-2**]. You will finish your course on [**2146-5-11**]. . Disp:*5 Tablet(s)* Refills:*0* 18. Home O2 2 liters home oxygen therapy continous by nasal cannula Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary Diagnoses: -Asthma -Amiodarone lung disease -Multifocal bacterial pneumonia (resolving) Secondary Diagnoses: Chronic diastolic heart failure Coronary Artery Disease Chronic antibiotic suppression for septic arthritis Atrial fibrillation status post AV node ablation and placement of pacemaker Discharge Condition: Good, stable with O2 Sats of >95% on 2L dropping to 88-92% on ambulation on room air Discharge Instructions: You were admitted because you were having increased difficulties with your breathing. We think this was most likely due to a persistent pneumonia as well as an exacerbation of your asthma. We gave you inhalers and antibiotics and you improved. We are discharging you home to complete your recovery. Your medications have been changed. Your Fluticasone (FLOVENT) inhaler dose has been increased. You have also been started on LEVOFLOXACIN (LEVAQUIN) once again for a two week course. Otherwise your medications have not been changed. Please continue all your other medications as previously prescribed. Please call your doctor or come to the ED if you have chest pain, shortness of breath, increased wheezing, increased swelling of your legs or any significant changes in your health. Followup Instructions: Please call and make a follow up appointment with Dr. [**Last Name (STitle) 5444**] in the next 1-2 weeks after being discharged from the hospital. Make sure you tell them this is a follow up visit from a hospital stay. You can reach Dr.[**Name (NI) 96173**] office at [**Telephone/Fax (1) 250**]. You should also call to make a follow up appointment with Dr. [**Last Name (STitle) 575**] 3-4 weeks after you are discharged as you should be followed by a lung doctor. You can reach Dr.[**Name (NI) 4025**] office at ([**Telephone/Fax (1) 513**]. Make sure to mention Dr. [**Last Name (STitle) 575**] saw you in the hospital. Please keep your previously scheduled appointments: [**2146-5-4**] DEVICE CLINIC at 9:30 am. Phone:[**Telephone/Fax (1) 62**] [**2147-7-5**] [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7145**] ORTHOPEDIC PRIVATE PRACTICE at 11:15. Phone:[**Telephone/Fax (1) 11262**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

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4509, 4548

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22751

Discharge summary

report

Admission Date: [**2166-1-29**] Discharge Date: [**2166-2-4**] Date of Birth: [**2108-6-20**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1267**] Chief Complaint: Chest Pain and DOE Major Surgical or Invasive Procedure: CABGx4(LIMA->Diag, SVG->LAD, Ramus, OM) [**2166-1-29**] History of Present Illness: 57 y/o male s/p MI in '[**53**] and stents x2 in [**6-30**] after c/o onging c/p and DOE. Since that time pt. continued to have worsening of symptoms and is now seeking surgical treatment vs. medical. Past Medical History: CAD, s/p MI '[**53**], s/p stents x 2 on [**6-30**] HTN ^Chol DM2 BPH s/p ORIF L. ankle '[**46**] s/p cyst removal on back Social History: Live in [**Country 22390**] with wife, Social drinker and quit smoking 1.5 years ago after <50yr pk hx. Denies recreational drug use. Family History: +FH for CAD - Father died of MI at 67 (first in 50s), Mother died of MI at 76. Brothers (two) had MI at 50 Physical Exam: Ht: 5'6" Wt: 193 lbs BP: 139/71 General: walked into office in NAD Skin: warm, dry HEENT: EOMI, PERRLA Neck: supple, - carotid bruit Chest: CTAB Heart: RRR (bradycardic), +S1/S2, -c/r/m/g Abd: soft, round, NT/ND, +BS Ext: warm, well-perfused, -c/c/e, - varicosities Neuro: A&O x 3, appropriate Pulses: BDP 1+, BPT 1+, BRadial 1+ Pertinent Results: Pre-op CXR: Small nodular opacities in the right lung, probably representing calcified granuloma. Pre-op EKG: Sinus bradycardia at 47. A-V conduction delay. Left atrial abnormality. Pre-op Labs: WBC/RBC/Hct/Hgb/Platelets: 5.8/4.63/13.4/39.5/330 PT/PTT/INR: 12.5/23/1 Glucose/BUN/Creat/NA/K/Cl/HCO3: 188/16/0.9/136/4.1/94/33 AST/ALT/Alk Phos/TotBili: 32/28/122/0.3 HgbA1C: 12.6 Pre-op UA negative [**2166-2-2**] 06:30AM BLOOD WBC-8.5 RBC-3.62* Hgb-10.5* Hct-31.8* MCV-88 MCH-29.1 MCHC-33.1 RDW-13.7 Plt Ct-306 [**2166-2-2**] 06:30AM BLOOD PT-13.1 INR(PT)-1.1 [**2166-2-2**] 06:30AM BLOOD Glucose-122* UreaN-17 Creat-0.9 K-4.3 [**2166-2-4**] 07:15AM BLOOD K-5.0 Brief Hospital Course: Pt. was a direct admit and brought to the operating room on [**2166-1-29**] where a coronary artery bypass graft x 4 procedure was performed. Please see operative not for full details. Pt. tolerated the procedure well with a CPB time of 93min and XCT of 84min. Pt. was transferred to [**Date Range 58879**] in stable condition with a MAP of 68, CVP 12, PAD 14, [**Doctor First Name 1052**] 19, HR 80 A-paced and on Neo, Propofol, and Insulin. In the [**Name (NI) 58879**], pt. required a bronchoscopy to evaluate a collapsed RUL. A mucous plug was removed. Later that day propofol was weaned, pt. became alert and was extubated and breathing on his own. H was also neurologically intact POD #1 - Neo was weaned off. Pt. had rhonchorous bs bilat. Pt. was stable and transferred to [**Name (NI) 58879**]. B-blocker, lasix, plavix started POD #2 - Pt. had elevated glucose. Plan was to increase Insulin to pre-op dose. Remove chest tubes, pacing wires, and foley. POD #3 - Pt. has congested, productive cough. Plan pulm. toilet and increase mobility. VS stable. POD #5 - Pt. doing well, but cont. to have same resp. congestion, but improved with neb rx. MDIs prn and OOB with increased mobility POD #6 - Pt. had good post-op course with some resp. congestion. D/C home/hotel today. Labs stable. Post-op PE: T 100 P 87 BP 106/64 RR 20 Neuro: alert, oriented, non-focal Pulm: CTAB Cardiac: RRR Sternum: -drainage/erythema Abd: soft, NT/ND, +BS Ext: Warm, incision c/d Medications on Admission: 1. Imdur qd 2. Natrilix SR 0.5 mg qd 3. Coversyl 8 mg qd 4. Lopressor 75 mg [**Hospital1 **] 5. Plavix 75 mg qd 6. Vastarel 20 mg tid 7. Glucophage 500 mg [**Hospital1 **] 8. NPH Insulin 30 units qAM, 20 qHS 9. Humalog SS w/ meals 10. ASA 152 mg qd 11. Mono-tildiem SR 200 mg qd 12. MVI qd 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. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 6. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 3 months. Disp:*30 Tablet(s)* Refills:*2* 7. Metformin HCl 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Thirty (30) Units Subcutaneous once a day: 30 U Q am, 20 U Q pm. Disp:*1 vial* Refills:*2* 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 10. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five (5) ML PO Q6H (every 6 hours) as needed. Disp:*qs ML(s)* Refills:*0* 11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 12. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-29**] Puffs Inhalation Q6H (every 6 hours) as needed. Disp:*1 MDI* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: CAD (MI '[**53**]), CABGx4(LIMA->Diag, SVG->LAD, Ramus, OM) [**2166-1-29**] s/p stents x 2 on [**6-30**] HTN ^Chol DM2 BPH s/p ORIF L. ankle '[**46**] s/p cyst removal on back Discharge Condition: good Discharge Instructions: no lifting > 10# or driving for 1 month may shower, no bathing for 1 month no creams or lotions to incisions Followup Instructions: with Dr. [**Last Name (STitle) **] in 3 weeks with primary care physician upon return home Completed by:[**2166-3-3**]

[ "250.00", "401.9", "412", "413.9", "414.01", "V45.82", "272.0" ]

icd9cm

[ [ [] ] ]

[ "36.13", "36.15", "88.72" ]

icd9pcs

[ [ [] ] ]

5453, 5511

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339, 396

5730, 5736

1411, 2072

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5760, 5870

1062, 1392

281, 301

424, 626

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28,749

190,618

49348

Discharge summary

report

Admission Date: [**2145-7-18**] Discharge Date: [**2145-7-28**] Date of Birth: [**2071-5-20**] Sex: M Service: MEDICINE Allergies: Lactose Attending:[**First Name3 (LF) 689**] Chief Complaint: Dyspnea, acute anuric renal failure Major Surgical or Invasive Procedure: Central line placement History of Present Illness: This 74 year old gentleman with a history of type II diabetes, hypothyroidism, and hyperlipidemia presents to the ED on [**7-18**] 5 days after a penile implant with dyspnea. In the ED patient was found to be hypotensive and in profound renal failure with creatinine 10 and K of 6.1 and hyperkalemia, no EKG changes seen. Was fluid resuscitated and briefly required pressors. Recieved broad spectrum abx (vanc/zosyn/ceftriaxone) in ED. Foley was placed with over 1L output initially then became anuric. Patient was admitted to the Surgical ICU. Central line was placed to measure CVP. Fluid resuscitation was initiated. Hyperkalemia was treated with both kaexylate as well as bicarbonate and calcium. Antibiotics changed to ciprofloxacin. Laboratories also notable for elevated CK peak in 900s and FeNa of 140. Nephrology consulted--at this point post-obstructive nephropathy, myoglobinemia (possibly secondary to succinylcholine-related myolysis), ATN from low blood flow. They decided not to dialyse. Urology also consulted--did not believe implant was infected. Renal U/S revealed hydronephrosis. On HD2, echocardiography revealed hyperdynamic EF and IVF inititated. Urine output remained poor. On HD4 1/4 bottles of blood cultures revealed [**Female First Name (un) **] --late speciated as c. glabralta, was started at that time on caspofungin with consultation from ID team was consulted. Ciprofloxacin discontinued. At this time he was also started on lasix gtt per renal team for about 24 hours - urine picked up to 200-400cc/hr. Lasix was dc'd and the patient continued to making urine on his own. NGT dc'd late HD4. Started on clears HD5 and ADAT HD6. Creatinine started to decline on HD6 and at this point was transferred to the medical service for further care of all his medical issues. The patient currently believes he feels better. He continues to deny genital pain. The dyspnea he had on presentation is resolved. His appetite still is not normal. He had a nl bowel movement earlier. He denies fever, chest pain, easy bruising or swelling in legs and ankles. Past Medical History: 1) Diabetes type II 2) Hyperlipidemia 3) HTN 4) Hypothyroid, on replacement 5) BPH 6) elevated amylase, unclear etiology 7) Question coronary artery disease, has mild inferior wall reversible defect seen on [**1-/2145**] P-MIBI Social History: No alcohol or tobacco use. Married, retired public school administrator. Family History: Father with heart disease, mother with breast cancer Physical Exam: T 98.0, P 66, BP 138/64, RR 24, O2 96 on RA Gen: African American gentleman in NAD, pleasant. Eyes: Mild exophthalmos. Cor: RR, 3/6 SEM, no gallop, no rub Chest: Lungs CTA b/l Abd: Obese, Non-tender, tympanic, no peritoneal signs Genital: Foley in place, yellow clear urine, penile edema. Ext: No edema, nl distal pulses Pertinent Results: Discharge Labs (most current): [**2145-7-27**] 06:35AM BLOOD WBC-6.5 RBC-3.32* Hgb-10.7* Hct-32.7* MCV-98 MCH-32.2* MCHC-32.7 RDW-13.9 Plt Ct-316 [**2145-7-27**] 06:35AM BLOOD Plt Ct-316 [**2145-7-28**] 01:18PM BLOOD Glucose-214* UreaN-15 Creat-1.5* Na-142 K-4.2 Cl-106 HCO3-26 AnGap-14 [**2145-7-26**] 07:00AM BLOOD CK(CPK)-395* [**2145-7-27**] 06:35AM BLOOD Calcium-7.4* Phos-2.6* Mg-1.5* [**2145-7-25**] 04:44AM BLOOD TSH-8.0* [**2145-7-25**] 04:44AM BLOOD Free T4-1.1 Cardiology Report ECHO Study Date of [**2145-7-26**] INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal IVC diameter (1.5-2.5cm) with >50% decrease during respiration (estimated RAP 5-10 mmHg). LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global systolic function (LVEF >55%). Transmitral Doppler and TVI c/w normal LV diastolic function. 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: Mildly thickened aortic valve leaflets (3). No AS. No masses or vegetations on aortic valve. No AS. Trace AR. MITRAL VALVE: Normal mitral valve leaflets. No MVP. No mass or vegetation on mitral valve. Mild mitral annular calcification. Trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. No mass or vegetation on tricuspid valve. Moderate PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: No pericardial effusion. Cardiology Report ECG Study Date of [**2145-7-18**] 7:19:54 PM Sinus tachycardia. Otherwise, normal tracing. Compared to tracing of [**2145-6-29**] sinus tachycardia has replaced sinus bradycardia. Read by: [**Last Name (LF) **],[**First Name3 (LF) **] I. Intervals Axes Rate PR QRS QT/QTc P QRS T 114 144 80 300/394 55 45 31 Radiology Report RENAL U.S. Study Date of [**2145-7-19**] 11:09 AM IMPRESSION: 1. Redemonstration of a simple-appearing, large right renal cortical cyst. 2. No evidence of hydronephrosis or renal calculi. Radiology Report CHEST PORT. LINE PLACEM Study Date of [**2145-7-27**] 4:58 PM IMPRESSION: AP chest compared to [**7-20**] and 13: Lung volumes have improved, right pleural effusion and basal atelectasis nearly resolved. Lungs grossly clear. Heart size normal. Tip of the right PIC catheter projects over the mid SVC. Dr. [**First Name (STitle) 7747**] discussed with the PIC position with the IV nurse at 7:15 p.m. on [**7-27**]. Brief Hospital Course: ED/MICU Course: In the ED patient was somewhat hypotensive - recieved fluid and pressors for a few hours only. Recieved broad spectrum abx (vanc/zosyn/ceftriaxone) in ED. Foley was placed with over 1L output initially then was anuric. Patient was admitted to the ICU under the care of the surgical team with input from urology and then from nephrology. Was made NPO, NGT to suction, foley, and IVF. Central line was placed to measure CVP. FLuid resusitation was initiated. Hyperkalemia was treated with both kaexylate as well as bicarb/ca. Hypoglycemia was initially treated with dextrose boluses and then with D10 gtt until it resolved. Highest CK was in 900s and FENA was 140. DDx post-obstructive nephropathy, myoglobinemia, ATN from low blood flow. On HD2 cardiac echo was performed which hyperdynamic left ventricle and underflowed heart, so IVF were resumed in first bolus form and then at a continuous rate. antibiotics were switched to cipro (renally dosed). Renal U/S was performed which did not show much hydronephrosis. Esmolol gtt was started to control tachycardia in the setting of recent stress test showing a reversible defect. On HD4 was started on caspofungin for yest in [**12-10**] bottles of clood cultures - later grew out c. glabralta - ID team was consulted. Was also started on lasix gtt per renal team for about 24hours - urine picked up to 200-400cc/hr. Later dc'd and was making urine on his own. NGT dc'd late HD4. Started on clears HD5 and ADAT HD6. Creatinine started to decline on HD6 and at this point was transferred to the medical service for further care of all his medical issues. Internal Medicine Transfer Course: Briefly, this was a 74 year old diabetic gentleman admitted in renal failure s/p penile implant. Etiology was most likely multi-factorial, including candidal infection, post-obstructive nephropathy, and medication induced renal failure. His creatinine trending down every day, and he never required dialysis. The following treatments were rendered after the patient was transfered to the (floor) internal medicine service. . Problem list . #) Renal failure, multifactorial: The patient was treated with maintaining roughly equal Is and Os. The patient self-diuresed. His elanapril was stopped while he was hospitalized and upon discharge. His PCr trending down daily. Renal originally was consulted, but had signed off by the time he hit the floor. Urology saw the patient and recommended 2 trial voids. He failed both, he was started on flomax and was dishcharged with his foley. A trial void was to be done with urology as an outpatient. . #) Candidemia: The patient was treated with 50mg IV Caspofungin. A PICC line was placed and the patient was discharged with a 7 day course of caspofungin. He remained afebrile throughout his stay. . #) Elevated CK: This was a laboratory finding. The patient's lipitor was stopped during admission and discharge. The patient was told to talk to PCP about restarting. . #) Thyroid disease: The patient was found to have TSH of 8, but free T4 WNL. The patient discharged with a change of 100mcg from 75mcg. He was told to follow-up with PCP about rechecking TSH levels in 4 weeks. . #) Distended abdomen: Patient has mildly distended abdomen. Patient reports no nausea or vomiting. It improved every day since patient hit the floor. The patient was treated with aggressive bowel regimen. Medications on Admission: Home Medications: Aspirin 325 mg--PO daily Chlorpromazine 25 mg--1 tablet(s) by mouth tid prn hiccups Enalapril 20 mg PO daily Folic acid 2 mg once a day Glucophage 1000 mg, twice a day Glucotrol 10 mg [**Hospital1 **] Lipitor 10 mg PO daily Synthroid 75 mcg PO daily Testosterone injections. Triamcinolone 0.1 %--apply [**Hospital1 **] as directed Flomax 0.4 mg daily . Medications on transfer: 1) Caspofungin 50 mg IV daily, day 1=[**7-22**] 2) Metoprolol 25 mg PO BID 3) Regular insulin sliding scale 4) Albuterol/Atrovent Nebulizers q6 hours PRN 5) Famotidine 20 daily 6) Levothyroxine 75 mcg daily 7) Bisacodyl PRN 8) Heparin SC Discharge Medications: 1. Outpatient Lab Work Please check LFTs and CBC on [**2145-8-3**] and [**2145-8-10**] and send the results to Dr. [**First Name4 (NamePattern1) 714**] [**Last Name (NamePattern1) **]. 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Tablet(s) 3. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. Disp:*1000 ML(s)* Refills:*2* 4. Flomax 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. 5. Synthroid 100 mcg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 6. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 7. Glucotrol 10 mg Tablet Sig: One (1) Tablet PO twice a day. 8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. 10. Vit Balanced B-100 Tablet Sig: One (1) Tablet PO once a day. 11. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO once a day. 12. picc line PICC Line care per protocol 13. Caspofungin 50 mg Recon Soln Sig: One (1) Intravenous once a day for 7 days. Disp:*7 * Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 511**] Home Therapies Discharge Diagnosis: Primary: Acute renal failure, hyperkalemia, Candedemia Secondary: Type II diabetes, hypothyroidism, hypertension Discharge Condition: The patient was discharged afebrile, hemodynamically stable, and with appropriate follow-up. Discharge Instructions: You were admitted for acute renal failure. You were also found to have high potassium, low urine output, and bacteremia. Your acute renal failure was probably secondary to post-operative obstruction from your penile implant and complications from the antibiotic treatment for your bacteremia. You will be follwed by urology once you are discharged. You have a scheduled appointment with them listed below. You will also be receiving home nursing services. You will discharged with the following new medications: Caspofungin. Because fungus was found in your blood, you will need to take the Caspofungin for 7 more days as an outpatient. VNA services will assist you with this. Your thyroid medication was increased on discharge. Please follow-up with your PCP [**Last Name (NamePattern4) **] [**3-12**] weeks regarding this change. You will be sent home with a foley catheter. Please follow-up with urology regarding your next trial void. Your elanapril (ACE inhibitor) and Lipitor (statin) were stopped while you were hospitalized. They will also be stopped at time of discharge. Please follow-up with you PCP regarding restarting these drugs. Your aspirin will be restarted when discahrged. If you are still having abdominal distention once discharged, please increase the fiber in your diet, as well as, keep using laxatives such as senna or colace. If you notice any substernal chest pain, extreme shortness of breath, mental status changes, headache, dizziness, acute scrotal/penile swelling, fever, chills, sweats, or abdominal pain please return to the nearest emergency room. Followup Instructions: You should follow-up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in [**1-10**] weeks. Her office will be calling you at home to schedule an appointment. If you do not hear from them, then you may reach call for an appointment at [**Telephone/Fax (1) 904**]. You have a required, scheduled appointment with Urology (Dr. [**Last Name (STitle) **] on Thursday, [**7-29**] @ 10:00am. They will retry a voiding trial then. If you cannot make this appointment, you must call their office immediately to reschedule. You also have the following appointments scheduled for you: Provider: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ENDOSCOPY SUITES Date/Time:[**2145-9-3**] 9:00 Provider: [**Name Initial (NameIs) **] SUITE GI ROOMS Date/Time:[**2145-9-3**] 9:00 Provider: [**First Name8 (NamePattern2) 2206**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. Phone:[**Telephone/Fax (1) 7612**] Date/Time:[**2145-11-3**] 10:00 Completed by:[**2145-7-30**]

[ "584.9", "E878.1", "591", "401.9", "996.39", "272.4", "244.9", "276.7", "250.00", "458.9", "112.5" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

11041, 11110

5812, 9195

303, 328

11267, 11362

3201, 5789

13000, 14049

2791, 2845

9880, 11018

11131, 11246

9221, 9221

11386, 12977

2860, 3182

9239, 9592

228, 265

357, 2434

9617, 9857

2456, 2685

2701, 2775

75,898

112,634

37958

Discharge summary

report

Admission Date: [**2179-11-30**] Discharge Date: [**2179-12-13**] Date of Birth: [**2118-8-2**] Sex: F Service: NEUROSURGERY Allergies: All drug allergies previously recorded have been deleted Attending:[**First Name3 (LF) 1835**] Chief Complaint: brain tumor Major Surgical or Invasive Procedure: [**2179-12-3**]:Left Pterional craniotomy for pituitary mass resection History of Present Illness: Pt is a 61 yo F with known sellar mass was seen in neurosurgery clinic on [**2179-11-30**] with persistent nausea, vomiting, and dizziness. Was referred to the ED for "review by medicine for general failure to thrive as well as SOB, nausea, dizziness." Patient herself reports that she requested to be admitted to the hospital as she was tired of being in the nursing facility because everyone forgot about her there. Patient has been in nursing facility for last 2 months as her dizziness incapacitated her and made it impossible for her to care for herself at home. She is not ambulatory, but can transfer to a wheel chair in order to get around at the nursing facility. Vitals upon presentation to the ED: T 97.2, HR 100, BP 116/69, RR 17, O2Sat 98% RA. Patient wsa having nausea and pain in the ED and was given ondansetron 4 mg, meclizine 25 mg, and 2 tabs percocet. Vitals prior to transfer to the floor were: T afebrile, HR 76, BP 133/77, RR 18, O2Sat 100% RA. REVIEW OF SYSTEMS: (+): blurry vision, nausea, vomiting, diarrhea, rhinorrhea, nasal congestion, cough, arthralgias (-): fever, chills, dysphagia, chest pain, paliptations, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, constipation, hematemesis, hematochezia, melena, focal numbness, focal weakness, myalgias Past Medical History: 1) Seizure disorder, seizure free for the past 20 years 2) hypertension 3) sellar mass 4) Labyrinthine hemorrhage 5) s/p hysterectomy 6) s/p R ankle surgery 7) schizoaffective d/o Social History: Lives in a nursing home (Sachem skilled nursing), not happy there. Tobacco: 1 PPD EtOH: Denies Illicits: Denies Family History: No family history of pituitary or thyroid disorders. Grandmother had [**Name2 (NI) 499**] cancer. Physical Exam: On Admission: VS: T 97.6, HR 91, BP 125/96, RR 18, O2Sat 100% RA GEN: NAD HEENT: PERRL, EOMI, no nystagmus, oral mucosa moist, edentulous, oropharynx benign NECK: supple, no [**Doctor First Name **] PULM: CTAB, occasional cough CARD: RR, nl S1, nl S2, no M/R/G ABD: BS+, soft, ventral scar, NT, ND EXT: R nonpitting ankle edema, L wihtout edema SKIN: no rashes NEURO: Oriented x 3, can stand and transfer to wheelchair unassisted, CN II-XII intact aside from visual field confrontational testing revealing questionable loss of lateral fields PSYCH: Mood and affect appropriate On Discharge: XXXXXX Pertinent Results: Labs on Admission: [**2179-11-30**] 05:15PM BLOOD WBC-5.8 RBC-4.45 Hgb-11.7* Hct-36.0 MCV-81* MCH-26.4* MCHC-32.6 RDW-13.7 Plt Ct-394 [**2179-11-30**] 05:15PM BLOOD Neuts-67.3 Lymphs-25.6 Monos-6.0 Eos-0.8 Baso-0.3 [**2179-12-3**] 04:40AM BLOOD PT-13.8* PTT-36.7* INR(PT)-1.2* [**2179-11-30**] 05:15PM BLOOD Glucose-101 UreaN-7 Creat-0.7 Na-137 K-3.4 Cl-99 HCO3-30 AnGap-11 [**2179-12-3**] 04:40AM BLOOD Calcium-9.3 Phos-3.7 Mg-2.4 [**2179-12-3**] 04:40AM BLOOD Cortsol-19.5 [**2179-11-30**] 05:15PM BLOOD Phenyto-12.9 Labs on Discharge: XXXXXXXXX Imaging: Brief Hospital Course: Medicine Course: 61 yo AAF recently was seen in neurosurgery clinic for sellar mass, now here for chronic symptoms of nausea, headaches and dizziness. - Nausea, HAs, dizziness: Likely [**2-22**] to sellar mass. Pt did not report an acute worsening and did well with symptomatic treatment. Neurosurg plans for surgery this week. - Acute anemia: Hct dropped from 36 to 32 overnight. Repeat Hct is pending. - Microsopic hematuria: UA shows large blood, [**6-30**] RBC. Pt does not report gross hematuria. UA does not indicate infection, but repeat UA/urine culture would be beneficial. - Seizure disorder: Stable, seizure free for more than 20yrs. Pt was continued on home Dilantin (level in therapeutic range). - Hypertension: Well-controlled. Pt was continued on home Amlodipine. - Pt was on a cardiac diet, and on SC Heparin for DVT ppx. At transfer of care to NEUROSURGERY SERVICE([**2179-12-2**]): NSURG assumed care on [**12-2**], in preparation for pituitary mass decompression/resection on [**12-3**]. Plans were made for general anesthesia to be induced prior to obtaining pre-operative imaging due to claustrophobia history. On [**12-3**], patient was electively intubated, and MRI and CT imaging was obtained for surgical planning. Due to the neuroanatomy, transphenoidal approach was not attempted, and resection/decompression was pursued via left pterional craniotomy. Post-operatively, the patient was transferred to the ICU for frequent neurochecks and DI surveillance. At post-op check, the patient was observed to have a dense right sided hemiplegia and was emergently sent for her MRI. An anterior choroidal infarct was appreciated, and stroke neurology was consulted. It was recommended to keep her blood pressure 120-160, obtain additional labs, ECHO, and carotid ultrasound. These were obtained. She was subsequently extubated, however failed her speech and swallow evaluation. In the setting of this, a general surgery consult was obtained to place a PEG. This was done on [**12-7**] without incident. On [**12-8**] the patient was transferred out of the ICU to the neurosurgical floor. She continued to work with PT/OT and was screened for rehab. Endocrine continued to follow the patient and assisted in managing her glucose, Sodium levls and control her hydrocortisone taper. Medications on Admission: 1) Dilantin 100 mg in AM, 100 mg in afternon, 200 mg at bedtime 2) Senna 2 tabs nightly 3) Prilosec 20 mg DAILY 4) Multivitamin DAILY 5) Simethicone 80 mg QID:PRN flatus 6) Meclizine 25 mg PO TID:PRN dizziness 7) Colace 100 mg [**Hospital1 **] 8) Risperidone 0.25 mg PO BID 9) Diazepam 25 mg PO BID 10) Melatonin 2.5 mg QHS 11) Phenergan 25 mg [**Hospital1 **] 12) Amlodipine 5 mg PO DAILY 13) Loratadine 10 mg DAILY 14) Percocet 5/325 Q4H:PRN pain Discharge Medications: 1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 2. Meclizine 12.5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for dizziness. 3. Risperidone 0.5 mg Tablet Sig: .5 Tablet PO BID (2 times a day). 4. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Phenytoin 125 mg/5 mL Suspension Sig: Two (2) PO Q12H (every 12 hours): 200 mg [**Hospital1 **]. 6. HydrALAzine 10 mg IV Q6H:PRN SBP>160 7. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. 9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 11. Diazepam 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. 12. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 13. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 14. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day). 15. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 16. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO DAILY (Daily). 19. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-22**] Drops Ophthalmic PRN (as needed) as needed for DRY EYE. 20. Hydrocortisone 20 mg Tablet Sig: One (1) Tablet PO Q am. 21. Hydrocortisone 10 mg Tablet Sig: One (1) Tablet PO at bedtime. 22. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 23. Metoclopramide 10 mg IV Q6H high residuals please hold if residuals drop below 50cc or if patient develops diarrhea and alert NS team Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Location (un) 701**] Discharge Diagnosis: Sellar Mass Hypernatremia adrental insuficiency Hemiplegia Left ptosis Malnutrition dysphagia hyperglycemia Discharge Condition: Neurologically Stable Discharge Instructions: General Instructions ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? You have been discharged on Prednisone, take it daily as prescribed. ?????? You are required to take Prednisone, an oral steroid, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as this medication can cause stomach irritation. Prednisone should also be taken with a glass of milk or with a meal. CALL YOUR DOCTOR 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. ?????? If you notice your urine output to be increasing, and/or excessive, and you are unable to quench your thirst, please call your endocrinologist. Followup Instructions: Follow-Up Appointment Instructions **Please call [**Telephone/Fax (1) 2731**] to schedule an appointment to be seen for a wound check and suture removal. This appointment should be made for 10-14 days after surgery, and will be made with the nurse practitioner. If you live far away, you may have this done by your PCP [**Name Initial (PRE) **]/or at rehab facility. ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with your surgeon, Dr. [**Last Name (STitle) **], to be seen in 4 weeks. Dr. [**Last Name (STitle) **] will speak with you at this time about when you should restart radiation therapy. You will not need a CT scan or MRI of the brain as this was done during your acute hospitalization. ??????You have an appointment with your endocrinologist, Dr. [**Last Name (STitle) **] [**Name (STitle) **] on Tues. [**2180-1-4**] at 1:40 pm. The phone number is ([**Telephone/Fax (1) 9072**]. ??????Please call ([**Telephone/Fax (1) 5120**] to schedule Formal Visual Field Testing to be done before you are seen in follow-up with your surgeon. The Opthalmology department is located on the [**Hospital Ward Name **] in the [**Hospital Ward Name 23**] building, [**Location (un) 442**]. ?????? You have an appointment with your neurologist, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**] [**Name8 (MD) 83444**], MD on [**2180-1-10**] at 2:30 pm. His office is on the [**Hospital Ward Name 5074**] on [**Hospital Ward Name 23**] 8. Please call [**Telephone/Fax (1) 2574**] with questions. Completed by:[**2179-12-13**]

[ "263.9", "342.90", "401.9", "374.30", "295.70", "434.91", "784.51", "780.4", "E878.8", "599.72", "285.8", "787.01", "790.29", "783.7", "787.29", "276.0", "237.0", "997.02", "345.90", "255.41" ]

icd9cm

[ [ [] ] ]

[ "43.11", "96.6", "07.64" ]

icd9pcs

[ [ [] ] ]

8198, 8280

3385, 5690

334, 407

8432, 8456

2801, 2806

10087, 11658

2068, 2167

6190, 8175

8301, 8411

5716, 6167

8480, 10064

2182, 2182

2774, 2782

1424, 1719

283, 296

3340, 3362

435, 1405

2820, 3321

1741, 1922

1938, 2052

29,131

178,667

31067+57732

Discharge summary

report+addendum

Admission Date: [**2178-8-10**] Discharge Date: [**2178-8-20**] Date of Birth: [**2117-4-8**] Sex: M Service: CARDIOTHORACIC Allergies: Ace Inhibitors / Irbesartan Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2178-8-11**] Cardiac catheterization [**2178-8-13**] Coronary Artery Bypass Graft x 4 (LIMA to LAD, SVG to Diag, SVG to OM, SVG to RCA) History of Present Illness: Mr. [**Known lastname 73352**] is a 61 y/o male w/ h/o HTN, DM, CKD, and 1 episode of CP pain ~1 wk prior to admission who presented to PCP for routine [**Name9 (PRE) 73353**], where EKG obtained which showed TWI and ?STE in V1-2. He was sent to OSH and given Heparin and Plavix and transferred to [**Hospital1 18**] for cardiac cath. Past Medical History: Hypertension Diabetes Mellitus - Insulin Dependent Hypercholesterolemia Chronic Renal Insufficiency Gastroesophageal Reflux Disease Gout Social History: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: VS: 97.7 137/67 57 20 98%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. No femoral bruits. 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: [**2178-8-11**] Cardiac Cath: R dom., 50% LM, 99% mLAD involving diag, 70% prox. LCX, 70% prox RCA, calcified aorta [**2178-8-11**] RENAL ULTRASOUND: Right kidney measures 11.0 cm. Left kidney measures 11.9 cm. No stone, mass, or hydronephrosis is seen on either side. Renal cortical thickness is preserved bilaterally. [**2178-8-12**] CT Chest: 1. Marked coronary artery calcifications. 2. Calcifications of the aorta and great vessels, consistent with atherosclerotic disease. 3. Cholelithiasis. [**2178-8-12**] CXR: FINDINGS: The cardiac silhouette is minimally prominent. The aorta is within normal limits aside from some calcifications of the knob. Lungs are grossly clear. Bony structures are intact. IMPRESSION: No signs for acute cardiopulmonary process. [**2178-8-13**] Carotid US: FINDINGS: Minimal calcific plaque involving the carotid bulbs bilaterally, peak systolic velocities are normal bilaterally as are the ICA to CCA ratios. There is normal antegrade flow involving both vertebral arteries. [**2178-8-13**] Echo: PRE-BYPASS: The left atrium is moderately dilated. No thrombus is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is mildly dilated. Right ventricular systolic function is normal. There are complex (>4mm) atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including phenylepherine. Patient is Atrially paced. Preserved biventricular function LVEF >55%. MR remains mild. Aortic contours intact. Remaining exam is unchanged. All findings discussed with surgeons at the time of the exam. [**2178-8-11**] 12:29AM BLOOD WBC-7.3 RBC-3.45* Hgb-11.7* Hct-33.0* MCV-96 MCH-33.8* MCHC-35.3* RDW-14.0 Plt Ct-156 [**2178-8-19**] 07:15AM BLOOD WBC-10.2 RBC-3.01* Hgb-9.7* Hct-28.3* MCV-94 MCH-32.1* MCHC-34.2 RDW-15.2 Plt Ct-168 [**2178-8-20**] 06:50AM BLOOD PT-15.2* INR(PT)-1.4* [**2178-8-19**] 07:15AM BLOOD PT-12.6 INR(PT)-1.1 [**2178-8-18**] 06:35AM BLOOD PT-11.8 PTT-25.6 INR(PT)-1.0 [**2178-8-20**] 06:50AM BLOOD Glucose-90 UreaN-28* Creat-1.8* Na-135 K-4.6 Cl-97 HCO3-32 AnGap-11 [**2178-8-17**] 06:45AM BLOOD Glucose-98 UreaN-29* Creat-1.9* Na-141 K-4.3 Cl-101 HCO3-31 AnGap-13 [**2178-8-16**] 08:45AM BLOOD Glucose-145* UreaN-28* Creat-1.8* Na-136 K-4.5 Cl-103 HCO3-25 AnGap-13 [**2178-8-15**] 04:41AM BLOOD UreaN-32* Creat-2.0* Na-136 Cl-106 HCO3-23 [**2178-8-12**] 06:55AM BLOOD Glucose-121* UreaN-26* Creat-1.7* Na-143 K-4.5 Cl-108 HCO3-27 AnGap-13 [**2178-8-11**] 06:40AM BLOOD Glucose-67* UreaN-31* Creat-1.7* Na-145 K-4.0 Cl-114* HCO3-22 AnGap-13 [**2178-8-11**] 12:29AM BLOOD Glucose-106* UreaN-34* Creat-2.2* K-4.0 Cl-113* HCO3-24 [**2178-8-17**] 06:45AM BLOOD Calcium-8.7 Phos-3.7 Mg-2.1 [**2178-8-11**] 04:00PM BLOOD %HbA1c-7.8* Brief Hospital Course: As mentioned in the HPI, Mr. [**Known lastname 73352**] was transferred for cardiac cath. Cath revealed severe three vessel coronary artery disease. He was appropriately worked-up prior to coronary revascularization surgery - please see result section. On [**2178-8-13**] he was brought to the operating room where he underwent a coronary artery bypass grafting by Dr. [**Last Name (STitle) **]. See operative report for surgical details. Following surgery he was transferred to the CSRU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. By post-op day two all inotropes were weaned off and he was started on beta blockers and diuretics. He was gently diuresed towards his pre-op weight. All chest tubes were removed without complication and he was transferred to the telemetry floor for further care. On post-op day three he went into rapid atrial fibrillation which was appropriately treated and converted to sinus rhythm. Also on this day he required a blood transfusion for a postoperative anemia. On post-op day four his epicardial pacing wires were removed. During the rest of his post-op course he continued to recover well but had additional episodes of paroxsymal atrial fibrillation. He was eventually started on Amiodarone and Coumadin. He otherwise continued to make clinical improvments with diuresis and was eventually medically cleared for discharge on post-op day seven. Prior to discharge, arrangements were made with Dr. [**Last Name (STitle) 5017**] to monitor Coumadin as an outpatient. At discharge, he was in a normal sinus rhythm in the 60's with a blood pressure of 120/60 and 96% oxygen saturation on room air. Blood sugars were well controlled on Lantus and Humalog sliding scale. Discharge chest x-ray showed small bilateral pleural effusions with bibasilar atelectasis. Medications on Admission: Allopurinol - has not started yet. Colcihicine 0.6mg po qdaily - has not started yet Alphagan 1 drop leeft eye Aspirin 81 mg po qdaily Atenolol 25mg po qdaily Diltiazem (cartia) 360mg po qhs Claritin 1 tab qd prn Cosopt 1 drop left eye Cozaar 100mg [**Hospital1 **] Humalog sliding scale Hyralazine 50mg po BID Lantus 55 QPM Lasix 20mg QMWF, 40mg QTThSatSun Pravachol 80mg po qdaily Prilosec 20mg po qdaily Xalatan 0.005% left eye Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). [**Hospital1 **]:*60 Capsule(s)* Refills:*1* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). [**Hospital1 **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). [**Hospital1 **]:*45 Tablet(s)* Refills:*1* 4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as needed. [**Hospital1 **]:*40 Tablet(s)* Refills:*0* 5. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours). [**Hospital1 **]:*1 * Refills:*1* 6. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). [**Hospital1 **]:*1 * Refills:*1* 7. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). [**Hospital1 **]:*1 * Refills:*1* 8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 4 days: Then drop to 1 tab(200mg) twice daily for 7 days, then drop to 1 tab(200mg) daily. Continue 1 tab(200mg)daily until followup with MD. [**Last Name (Titles) **]:*50 Tablet(s)* Refills:*2* 9. Warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO QPM: Take as directed by MD. Daily dose may vary according to PT/INR. [**Last Name (Titles) **]:*60 Tablet(s)* Refills:*2* 10. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). [**Last Name (Titles) **]:*180 Tablet(s)* Refills:*2* 11. Pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. [**Last Name (Titles) **]:*30 Tablet(s)* Refills:*2* 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). [**Last Name (Titles) **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 13. Lantus 100 unit/mL Cartridge Sig: Fifty Five (55) units Subcutaneous at bedtime. [**Last Name (Titles) **]:*1 month supply* Refills:*2* 14. Humalog 100 unit/mL Cartridge Sig: 0-8 sliding scale Subcutaneous four times a day: Take as directed by sliding scale. [**Name8 (MD) **] MD [**First Name (Titles) **] [**Last Name (Titles) **] greater than 280. [**Last Name (Titles) **]:*1 month supply* Refills:*2* 15. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. [**Last Name (Titles) **]:*14 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Last Name (LF) 486**], [**First Name3 (LF) 487**] Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4 Post-op Atrial Fibrillation PMH: Hypertension, Diabetes mellitus, Hypercholesterolemia, Chronic kidney disease, Gastroesophageal Reflux Disease, Gout Discharge Condition: Good Discharge Instructions: Shower daily and pat incisions dry. No lotions, creams, powders or ointments on any incision. No driving for at least one month. No lifting greater than 10 pounds for 10 weeks. Please call surgeon for fever greater than 100.5 or drainage from sternal incision. ***** Take Coumadin as directed. Dr. [**Last Name (STitle) 5017**] will be managing your Coumadin. PT/INR should be drawn within 48-72 hours of discharge. Initial blood draws performed by VNA with results faxed to Dr. [**Last Name (STitle) 5017**] @ [**Telephone/Fax (1) 73354**].***** Followup Instructions: Dr. [**Last Name (STitle) **] in [**5-14**] weeks, call for appt [**Telephone/Fax (1) 170**] Dr. [**Last Name (STitle) 5017**] in [**3-14**] weeks, call for appt [**Telephone/Fax (1) 5424**] [**Hospital Ward Name 121**] 2 in 2 weeks for wound check Completed by:[**2178-8-20**] Name: [**Known lastname 12193**],[**Known firstname **] Unit No: [**Numeric Identifier 12194**] Admission Date: [**2178-8-10**] Discharge Date: [**2178-8-20**] Date of Birth: [**2117-4-8**] Sex: M Service: CARDIOTHORACIC Allergies: Ace Inhibitors / Irbesartan Attending:[**First Name3 (LF) 741**] Addendum: Pt. had superficial phlebitis of L antecubital area. He was instructed to use warm compresses to area QID and was trated with Levaquin 750 mg daily for 7 days. Discharge Disposition: Home With Service Facility: [**Last Name (LF) 1066**], [**First Name3 (LF) **] [**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**] Completed by:[**2178-8-20**]

[ "458.29", "410.71", "593.9", "250.00", "274.9", "401.9", "451.82", "414.01", "285.9", "272.0", "530.81", "427.31", "997.1" ]

icd9cm

[ [ [] ] ]

[ "99.05", "88.56", "99.04", "36.13", "36.15", "39.61", "89.60", "37.22" ]

icd9pcs

[ [ [] ] ]

11853, 12057

5368, 7250

304, 444

10421, 10427

2021, 5345

11022, 11830

1109, 1191

7731, 10061

10188, 10400

7276, 7708

10451, 10999

1206, 2002

254, 266

472, 808

830, 968

984, 1093

15,631

142,514

11191

Discharge summary

report

Admission Date: [**2128-11-24**] Discharge Date: [**2128-11-29**] Service: HISTORY OF PRESENT ILLNESS: The patient is an 80 year-old male with coronary artery disease status post coronary artery bypass graft, abnormal stress test on [**2128-11-3**] with moderate to severe partially reversible inferior wall defect who presents with a low grade temperature a few days prior to admission subsequently developing a nonproductive cough. On the day of admission he became increasingly short of breath. He denies any chest pain. No nausea, vomiting or diaphoresis. The patient was having difficulty sleeping secondary to his cough and shortness of breath. In the Emergency Department the patient had an oxygen saturation in the 70s in room air and was tachypneic with a respiratory rate in the 40s to 50s. Levofloxacin and Flagyl were administered for possible pneumonia. The patient also received nebulizer treatment of supplemental O2 with an increase in his O2 sats to the 98 to 100% range and decrease in respiratory rate to the 30s. According to the patient's son the patient has had problems with dysphagia and difficulties related to eating. He occasional self induces vomiting to relieve himself. PAST MEDICAL HISTORY: 1. Coronary artery disease status post coronary artery bypass graft in [**2126**], moderate to severe inferior wall defect partially reversible, ejection fraction 60%, status post two myocardial infarctions in the past. 2. Peripheral vascular disease status post fem fem bypass. 3. Cardiac arrest status post coronary artery bypass graft on Amiodarone. 4. Hypothyroidism. No history of diabetes or hypertension. MEDICATIONS ON ADMISSION: Aspirin, Plavix, Levoxyl, Prozac, Lipitor, Coumadin, Lasix, Spironolactone, Protonix, Metoprolol, Amiodarone. ALLERGIES: Fruit. PHYSICAL EXAMINATION ON ADMISSION: Temperature 99.2. Heart rate 60. Blood pressure 110/80. O2 sat 70% on room air, 100% on nonrebreather. In general alert, sitting up in bed tachypneic patient. Pupils are equal, round and reactive to light. No JVP. Rales half way up bilaterally in lungs. Cardiac examination regular rate and rhythm. Normal S1 and S2. Abdomen soft, nontender, nondistended. Extremities +1 pitting edema in both ankles. Distal motor strength grossly intact in the upper and lower extremities. LABORATORY: Arterial blood gases on nonrebreather was pH of 7.47, PCO2 34, PO2 67, sodium 136, potassium 6.3 hemolyzed. Chloride 104, bicarb 23, BUN 26, creatinine 1.1, glucose 122. White count 18.5, hemoglobin 10.5, hematocrit 31.4, platelets 487, PT 13.1, PTT 25.6, INR 1.2. Urinalysis positive for nitrites, 3+ protein, many bacteria. CK 56, troponin less then 0.3. Electrocardiogram showed sinus rhythm rate in the 60s, left atrial abnormality, left axis deviation. No ischemic ST T wave changes. Chest x-ray showed pulmonary congestion, bilateral alveolar infiltrates predominantly in the bases. HOSPITAL COURSE: The patient was admitted to the MICU given his guarded respiratory condition. For several days he continued to be tachypneic and was maintained either on nonrebreather or biPAP machine. He ultimately needed to be intubated given a decompensating respiratory status. He was maintained on an antibiotic course of Levofloxacin and Ceftriaxone for pneumonia. His cardiovascular status also continued to decline. He ultimately needed pressors in order to maintain a mean arteriole pressure above a goal of 60 on [**2128-11-29**]. He was on a total of three pressors, Levo at 10.6, neo at 140 and Vasopressin at .02. During morning rounds the patient continued to decompensate on this day and all three pressors were at their maximum doses and the patient continued to become hypotensive despite this therapy. The patient's family was spoken to by Dr. [**Last Name (STitle) 2146**]. The family agreed to discontinue the pressors as well as ventilatory support and the patient passed away soon afterwards. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**] Dictated By:[**Doctor Last Name 32927**] MEDQUIST36 D: [**2129-2-14**] 10:07 T: [**2129-2-14**] 14:24 JOB#: [**Job Number 36000**]

[ "V45.81", "578.9", "428.0", "486", "414.01", "244.9", "280.0", "038.9", "518.82" ]

icd9cm

[ [ [] ] ]

[ "96.71", "45.13", "96.04" ]

icd9pcs

[ [ [] ] ]

1688, 1840

2967, 4242

113, 1219

1855, 2949

1242, 1661

20,121

126,371

2991+55420

Discharge summary

report+addendum

Admission Date: [**2141-4-27**] Discharge Date: [**2141-5-2**] Date of Birth: [**2082-3-31**] Sex: F Service: VSU CHIEF COMPLAINT: Nonhealing ischemic left foot ulceration. HISTORY OF PRESENT ILLNESS: Patient underwent diagnostic arteriogram on [**2141-2-8**] which demonstrated mild iliac disease, occlude left SFA with reconstitution with a below- knee [**Doctor Last Name **] which is diseased, and disease tibioperoneal trunk and occluded posterior tibial artery with a widely patent DP, and incomplete arch. Recommendations: The patient would require a left common femoral to DP bypass. The patient was discharged to home and returns for elective surgery. PAST MEDICAL HISTORY: History of ischemic heart disease status post myocardial infarction, status post CABG in [**2131**] complicated by sternal wound infection, pulmonary embolus and sepsis, history of asthma, COPD, history of type 2 diabetes with neuropathy--insulin dependent, history of hypothyroid disease, history of hiatal hernia with reflux, history of tobacco use which is current, history of hyperlipidemia, postoperative blood loss anemia--transfuse corrected. ALLERGIES: Include Bactrim, captopril, ACE inhibitors and Alphagan ophthalmic drops--manifestations unknown. MEDICATIONS ON ADMISSION: Include Lopressor 25 mg b.i.d., isosorbide 20 mg t.i.d., NPH insulin 20 units q. a.m. and 16 units at dinner, Lipitor 40 mg once daily, Diovan 80 mg once daily, Plavix 75 mg once daily, folic acid 1 mg once daily, Lasix 40 mg b.i.d. PAST SURGICAL HISTORY: Significant for right extremity bypass graft, breast reduction and a TMA on the right. SOCIAL HISTORY: The patient is a current tobacco user. Denies alcohol or drug use. PHYSICAL EXAM: Vital signs are stable. General appearance is alert, cooperative white female in no acute distress. Neck is supple. Lungs are clear to auscultation. Heart is a regular rate and rhythm. Abdominal exam is unremarkable. Extremities shows a right TMA well-healed. The left foot is cool with an ulcer on the heel and forefoot. Pulse exam shows palpable femorals bilateral. On the right, DP and PT were palpable. On the left, the DP was Dopplerable, and the PT was Dopplerable. The brachial pulses are palpable bilaterally. Neurological exam is unremarkable. HOSPITAL COURSE: The patient was admitted to the preoperative holding area on [**2141-4-27**]. She underwent a left common femoral to anterior tibial bypass with PTFE secondary to limited vein conduit. She tolerated the procedure well and was transferred to the PACU in stable condition. She had a Dopplerable AT at the end of the procedure. Immediately postoperatively, she remained hemodynamically stable. Her wounds were clean, dry and intact. She continued to do well and was transferred to the VICU for continued monitoring and care. Postoperative day 1, she continued on low dose heparin. Her exam remained unchanged. Her diet was advanced. Her fluids were Hep-Locked. Her heparin was continued in therapeutic ranges for goal PTT between 50 and 60. She remained on bedrest and in the VICU. Postoperative day 2, the patient had a low-grade temperature of 100.0-99.4. Incentive spirometry was encouraged. The foot was examined. It was a warm foot with a Dopplerable graft and DP pulse. Diuresis was continued. The patient's hematocrit was 26.8. She was transfused 1 unit of packed red blood cells. Ambulation to a chair was begun. Postoperative day 3, the patient was started on Coumadin the night before. Her Lopressor dosing was required to be adjusted for continued systolic hypertension. Her A-line was removed. Her post-transfusion crit was 29.5. She had a Dopplerable graft and a warm foot. The Percocet controlled her pain. Lasix was continued. Her heparin drip was discontinued for her INR of 2.4. She was evaluated by physical therapy who recommended that the patient would require rehab. She will be discharged to rehab when bed available. INR should be monitored on a daily basis to maintain goal INR between 2.0 and 3.0. Once in a steady therapeutic state, INR should be measured twice a week and thereafter monthly. Patient should follow-up with her primary care physician upon discharge from rehab for continuing monitoring of her INR. Dressings to the wound were dry sterile dressings. She should wear an Ace from foot to knee when ambulating. She may ambulate full weightbearing essential distances. She should follow-up with Dr. [**Last Name (STitle) 1391**] in 2 weeks time for skin clip removal. DISCHARGE MEDICATIONS: Acetaminophen 325 mg tablets [**11-21**] q. 4- 6 h. p.r.n. pain, Plavix 75 mg daily, atorvastatin 40 mg daily, valsartan 80 mg daily, Lasix 40 mg b.i.d., aspirin 325 mg daily, acetaminophen with codeine 30/300 mg tablets [**11-21**] q. [**2-23**] h. p.r.n., folic acid 1 mg daily, quetiapine 100 mg 5 tablets total 500 mg daily, isosorbide mononitrate 20 mg t.i.d., Lopressor 75 mg b.i.d., Dulcolax tablets 2 p.r.n. for constipation, Colace 100 mg b.i.d.--this should be continued while patient is on narcotic medications, NPH insulin at breakfast 22 units and at supper 16 units. DISCHARGE DIAGNOSES: Ischemic left extremity with foot ulceration, postoperative blood loss anemia--transfused corrected, history of ischemic heart disease, myocardial infarction, coronary artery bypass graft in [**2133**], complicated by sternal wound infection, pulmonary emboli and sepsis, history of asthma, chronic obstructive pulmonary disease, history of type 2 diabetes with neuropathy--insulin dependent- -controlled, history of hypothyroidism, history of hiatal hernia with reflux, history of current tobacco use, history of hyperlipidemia. MAJOR PROCEDURES: Include a left common femoral artery to anterior tibial artery bypass graft with PTFE on [**2141-4-27**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**] Dictated By:[**Last Name (NamePattern1) 2382**] MEDQUIST36 D: [**2141-5-1**] 10:52:52 T: [**2141-5-1**] 11:25:20 Job#: [**Job Number 14318**] Name: [**Known lastname 2174**],[**Known firstname 2175**] Unit No: [**Numeric Identifier 2176**] Admission Date: [**2141-4-27**] Discharge Date: [**2141-5-2**] Date of Birth: [**2082-3-31**] Sex: F Service: SURGERY Allergies: Bactrim / Captopril / A.C.E Inhibitors / Alphagan P Attending:[**First Name3 (LF) 231**] Addendum: will be d/c home with VNA and pt services. Discharge Disposition: Home With Service Facility: [**Hospital 136**] Homecare [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 237**] MD [**MD Number(1) 238**] Completed by:[**2141-5-2**]

[ "493.20", "998.11", "E878.8", "305.1", "997.1", "414.00", "785.0", "V45.81", "440.23", "707.15", "357.2", "E849.8", "272.0", "285.1", "250.60" ]

icd9cm

[ [ [] ] ]

[ "99.04", "38.93", "39.57", "38.91", "39.29" ]

icd9pcs

[ [ [] ] ]

6531, 6745

5152, 6508

4548, 5130

1298, 1532

2317, 4524

1556, 1644

1745, 2299

153, 196

225, 686

709, 1271

1661, 1729

236

191,151

25209

Discharge summary

report

Admission Date: [**2139-2-18**] Discharge Date: [**2139-4-8**] Date of Birth: [**2081-12-5**] Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 943**] Chief Complaint: Admission from clinic for CAP Major Surgical or Invasive Procedure: EGD flexible sigmoidoscopy colonoscopy bronchoscopy History of Present Illness: This is a 57 yo male with h/o [**First Name3 (LF) **] for hepatitis C and HCC 4 yrs ago, h/o RFA in [**2134**], cryoglobulinemia, ITP s/p splenectomy, HTN, and DVT who presented to liver clinic today with fever and cough. A CXR was done and he was found to have a multifocal pneumonia. . He reports that he was feeling well until 3 days ago. At that time he developed a cough productive of yellow phlegm. he denies blood in the sputum. He gets pain in his chest only when he coughs. He has developed a mildly sore throat secondary to cough. He started developing chills yesterday and had a temp of 100.9 which he took 2 tylenol for. He always feels somewhat SOB at baseline although this does not limit his activity and has felt mildly more SOB since Sunday. He feels that he is breathing with more effort. He's has a runny nose all winter in the cold but it is normally of clear discharge and is now is of yellow discharge. He has had a mild left sided headache that comes and goes since Sunday. He reports very mild body soreness. He denies sick contact and did get his flu shot this year. . On the floor, he was noted to have SOB with exertion. He had some mild back pain. . Review of systems: (+) Per HPI , + 13 lb weight loss slowly over the last yr, + back pain after he threw it out a few weeks ago. + bruising on knees and left arm (from window slamming into his arm) from work as a carpenter (-) Denies night sweats Denies sinus tenderness, Denied chest tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. No depression/anxiety. Past Medical History: Hepatitis C (VL 55,000,000 in [**6-6**]) Cirrhosis s/p liver [**Date Range **] Hemothorax with complicated pleural effusion HCC with RFA in [**4-5**] for lesions in segment V and VIII HTN (since [**Date Range **] [**2134**]) h/o DVT ([**2129**]) cryoglobulinemia kidney stones ([**2129**]) lumbar spine laminectomy Left partial orchiectomy ITP s/p splenectomy recurrent HCV Social History: Lives at home with his wife. Worked as a carpenter. Smokes 1 ppd x since [**44**] yo and quit a few weeks ago. Denies alcohol or drugs. Used IV drugs >30 years whichh is how he contracted hep C. Family History: M with Alzheimer's. Half sister with diabetes mellitus Physical Exam: His VSS T 101.3, BP 136/72, HR 92 RR 20 90% on RA General: Alert, answering questions appropriately, intermittent coughing HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, no LAD Lungs: + mild rhonci and decreased air movement on right compared to left, no wheezes. No accessory muscle use. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: + surgical scar, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, liver edge at the edge of rib cage. Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. Pink distal toes bilaterally (chronic per pt). Exam at discharge: VS: T 98.4, BP 120/60, P 97, R 20, O2 92% on RA (84% with ambulation) Gen: Well appearing man in NAD HEENT: Erythematous oropharynx, moist mucous membranes Cardiac: [**4-5**] holosystolic murmur Resp: Diffuse rhonchi and expiratory wheezes bilaterally Abd: Distended, non-tender, soft Ext: 1+ edema in LLE Pertinent Results: ADMISSION LABS: WBC-69.2, Hgb-11.6* Hct-36.8* Plt Ct-40* PT-15.0* INR(PT)-1.3* UreaN-36* Creat-1.5* Na-137 K-4.1 Cl-96 HCO3-22 AnGap-23* ALT-32 AST-43* AlkPhos-90 TotBili-1.2 Albumin-4.5 Calcium-9.2 . PERTINENT LABS/STUDIES: . WBC: 69.2 -> 31.9 ([**3-17**]) -> 58.4 ([**4-6**]) Platelets: Ranged from 24K to 40K Troponin: 0.01 -> 0.08 ([**2139-3-21**]) BNP: [**Numeric Identifier 63160**] ([**2-24**]) -> 9625 ([**3-27**]) Total protein: 5.4 TIBC: 204, B12 872, Folate 5.9, Ferritin 541, Hapto 138, TRF 157 HbA1c: 5.6% Total cholesterol: 80, LDL 48, HDL 13 TSH 5.0 ANCA: Negative AFP : < 1 BCR/ABL: Negative . MICROBIOLOGY: Beta glucan: Negative Galactomannan: Negative Strongyloides Ag: Negative Sputum [**2-18**]: >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. RESPIRATORY CULTURE (Final [**2139-2-20**]): MODERATE GROWTH Commensal Respiratory Flora. HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE. HEAVY GROWTH. . Sputum Culture ([**3-11**]): [**11-24**] PMNs and <10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final [**2139-3-13**]): MODERATE GROWTH Commensal Respiratory Flora. KLEBSIELLA PNEUMONIAE. MODERATE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- 16 I CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S . CXR ([**2139-2-18**]): Heterogeneous opacification in the lower lungs, particularly in the middle lobe, is new since [**Month (only) 359**]. Elevation of the right lung base laterally could be due to a small subpulmonic pleural effusion. There is no left pleural effusion, heart size is normal and there is no indication of central adenopathy. Overall, findings are consistent with pneumonia, including nonbacterial causes such as viral infection or even pneumocystis. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**] and I discussed these findings by telephone at the time of dictation. . CT chest with contrast ([**2139-2-19**]): 1. Extensive multifocal parenchymal consolidations, ground-glass and tree-in-[**Male First Name (un) 239**] opacities predominantly in a peribronchial distribution, most severe within the right lower lobe. These findings are consistent with multifocal pneumonia. Small right pleural effusion and mediastinal lymphadenopathy is likely reactive in nature. 2. Mild left hydronephrosis, new compared to prior study of [**2138-11-19**]. 3. Post-surgical changes within the upper abdomen status post splenectomy and liver [**Year (4 digits) **]. . MRI L-spine with gad ([**2139-2-19**]): 1. No evidence of osteomyelitis, discitis or other spinal infection. 2. Chronic post-operative changes at L4-L5 with underlying degenerative disease and congenital stenosis. This is most prominent at L4-L5 and L5-S1, where there is probable impingement upon the left-sided traversing nerve roots in those subarticular zones. 3. Diffusely T1- and T2-hypointense vertebral bone marrow signal may relate to the immunosuppressive medications for hepatic [**Month/Day/Year **] patient's and/or chronic hematologic abnormality (history of ITP, s/p splenectomy); correlate with clinical and laboratory data. 4. Mild paraortic lymphadenopathy and urinary bladder distention with diverticulum, unchanged from [**2138-11-19**] CT. . CTA chest ([**2139-3-10**]): 1. Progression of multifocal opacities suggesting pneumonia with consolidative opacities within the right upper, lower, and left lower lobes. Overall similar to slightly worsened appearance of axillary and mediastinal lymphadenopathy, probably reactive in etiology, although not specific. 2. New left pleural effusion and progressed right pleural effusion. 3. Smooth septal thickening suggesting fluid overload or pulmonary vascular congestion. 4. Unchanged vascular including coronary artery calcifications. 5. Unchanged appearance to post-[**Month/Day/Year **] liver and splenectomy, only partly visualized. . TTE ([**3-20**]): The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF 50%) secondary to severe hypokinesis/akinesis of the basal inferior, posterior, and lateral walls. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened (?#). There is a minimally increased gradient consistent with minimal aortic valve stenosis. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Severe posteriorly directed (4+) mitral regurgitation is seen. The mitral regurgitation is due to centripetal remodelling of the inferior posterior walls with consequent functional tethering of the posterior mitral leaflet. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2139-2-24**], intercurrent inferoposterolateral infarct is evident with consequent severe mitral regurgitation. . Cardiac Catheterization ([**3-20**]): 1. Selective coronary angiography in this right dominant system revealed two vessel disease. The LMCA was normal. The LAD has minimal disease. The LCx had tubular mid disease to 95%. The RCA is dominant but very small vessel with mid disease to 90%. 2. Limited resting hemodynamics revealed normal systemic arterial pressure with central aortic pressure 119/66 with a mean of 75 mmHg. 3. Severe LCX lesion probably culprit for new lateral wall motion abnormality and increased MR - stented successfully. 4. Severe RCA disease suboptimal for PCI in view of long lesion and small caliber - would consider PCI if producing ischemia. 5. Monitor in CCU and follow MR. 6. Aspirin indefinitely, plavix 75mg daily for a minimum of one month FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Successful bare metal stenting of LCX. . . TTE ([**2139-3-21**]): The left atrium and right atrium are normal in cavity size. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. 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. Moderate to severe (3+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2139-3-20**], the findings are similar. . CT Chest ([**2139-3-22**]): CT chest ([**2139-3-22**]): 1. Improving, though still extensive, multifocal pneumonia. 2. Improved pulmonary edema which is now mild, including decreased pleural effusions. 3. Extensive coronary artery calcifications. 4. Retention of IV contrast in the renal cortices, likely from cardiac catheterization two days prior, compatible with renal dysfunction. . CT Chest ([**4-7**]): 1. Persistent multifocal right-sided patchy airspace consolidations, compatible with persistent multifocal pneumonia. However, there is slight improvement of aeration since [**2139-3-22**]. Near-complete resolution of left-sided pneumonia with only small patchy focal airspace consolidations in the left base. No cavitary lesion. The constellation of findings is compatible with continued improvement without acute complication. 2. Likely reactive mediastinal and bihilar lymph nodes. 3. Status post liver transplantation and splenectomy. EGD ([**3-27**]): Varices at the lower third of the esophagus. Food in the stomach. Angioectasias in the antrum (thermal therapy). Duodenal bezoar Otherwise normal EGD to third part of the duodenum . Colonoscopy ([**4-1**]): 1. Estimated blood loss: none. 2. Specimens: none 3. Final diagnosis: small punctate lesions in rectum, without active bleeding, consistent with proctitis. Otherwise normal colonoscopy to cecum. Brief Hospital Course: The patient is a 57 yo male with h/o HCV cirrhosis c/b HCC s/p distant OLT, ITP s/p splenectomy and myelofibrosis admitted with H. flu PNA. His hospital course was complicated by Klebsiella pneumonia, worsening mitral regurgitation s/p cardiac catheterization with BMS x2 to the LCx, lower GI bleed and recurrent epistaxis, now clinically stable. . #. Community Acquired Pneumonia: The patient presented with productive cough and fever on [**2139-2-18**]. He was initially treated with Ceftriaxone/Azithromycin/Vanc for presumed HCAP, and he was also started on Tamiflu for presumed influenza. His sputum eventually grew out H. flu, so he completed a course of Ceftriaxone/Azithromycin. He continued to have a leukocytosis and productive cough and was found to have Klebsiella PNA on [**2139-3-11**]. He was then started on Ciprofloxacin, for which he completed the course of antibiotics. He had a repeat Chest CT on [**3-22**], which demonstrated improvement of the multifocal pneumonia and he had a bronchoscopy on [**2139-3-27**], from which the cultures were negative. His CXR prior to discharge remained consistent with multifocal pneumonia. He has a follow-up appointment with his outpatient pulmonologist, Dr. [**Last Name (STitle) 63161**], on [**2139-4-23**]. He should have a repeat CT Chest performed in [**2-1**] weeks to assess for radiographic improvement. . #. Gatrointestinal Bleeding: The patient developed a lower GI bleed on [**2139-3-27**]. He had an EGD, which demonstrated grade I varcies and AVM and flexible sigmoidoscopy showed fresh blood in colon without source of bleeding. He received 5 [**Location **] during his hospital stay, and he remained hemodynamically stable without evidence of bleeding for one week prior to discharge. He will be followed in the liver [**Location **] center after discharge. . # Mitral regurgiation: The patient developed worsening shortness of breath and chest pain on [**2139-3-20**]. He had a TTE performed, which demonstrated worsening mitral regurgitation, and there was concern for inferolateral hypokinesis, thought to be secondary to ischemia. He was taken to the cath lab on [**2139-3-20**], where he had the two bare metal stents placed to the left circumflex artery. After the cath lab he was transferred to the CCU due to hypoxia post procedure. During his stay in the CCU he was aggressively diuresed with improvement in his oxygen saturations. Cardiology recommended not repairing valve now, and there is also no indication for PCI in RCA at this time. A repeat echo was done on [**2139-3-21**] which showed improvement in his MR and wall hypokinesis, somewhat unclear if this was related to the intervention in the cath lab or to improvement in cardiac function with diuresis. He was started on Metoprolol, which was uptitrated to 37.5 mg TID by the time of discharge. He was also started on Plavix 75 mg daily and Aspirin 325 mg daily, which should be decreased to 81 mg daily on [**2139-4-19**]. He was not started on a statin given his history of HCC. He should have a repeat TTE performed in [**3-5**] weeks. He will follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**State 792**]Hospital on [**5-6**] for management of his MR. # Epistaxis: The patient developed a nose bleed on [**2139-3-30**]. Packing was placed in his nostril to tamponade the bleeding, and this was removed on [**2139-4-5**]. He also completed a 5-day course of Keflex for the bleeding. He was started on Afrin nasal spray on [**2139-4-5**] for a three day course, which was completed at the time of discharge. . # Myelofibrosis, ITP w/ residual splenule: He was seen by hematology who confirmed that he had myelofibrosis. His peripheral smear was notable for eosinophils and hematology was concerned that he could have chronic eosinophilic pneumonia. Flow cytometry, BCR-ABL, and FISH for PDGFR-alpha and RAR-alpha were sent. The patient's transfusion goals were set at: Hct < 30 and platelets < 15K. He did not receive any platelets during his hospital course, but he was given 5 [**Location **] for his lower GI bleed. Of note, his baseline WBC is in the 30s and his baseline platelet count is in the 40s. He will follow-up with his outpatient hematologist on discharge. . # HCC s/p OLT: The patient was continued on Tacrolimus and his levels were checked daily with a goal of [**5-6**]. . # Chronic LBP: The patient has a history of low back pain, for which he takes Tylenol at home. During this hospital stay, his pain was controlled with Oxycodone, Morphine, Tylenol, Gabapentin, and a Lidocaine patch. . # BPH: No active issues. He was continued on his home dose of Tamsulosin 0.4mg daily . #. Hydronephrosis on CT chest: His creatinine was 1.6 on arrival and improved to 1.2. It was later elevated to 1.5. The wet read of his renal ultrasound showed no hydronephrosis or stone. . #. Hepatitis C: He had a history of HCC with RFA in [**4-5**] for lesions in segment V and VIII. He is s/p liver [**Date Range **] 4 yrs ago and on prograf. His Hep C viral load was high during this admission and his CT scan in [**Month (only) 359**] showed no evidence of local recurrence or metastatic disease. His CT of the chest did reveal multiple perigarstric varices. He was continued on his home prograf dose and home nadolol. . #. Hyponatremia: His home HCTZ was held in the setting of his hyponatremia. . #. h.o DVT: He had a DVT in [**2129**] but given his low platelet count he remained on pneumoboots during his hospitalization. . # Code: Full . # Communication: wife [**Name (NI) **] [**Name (NI) 63157**] [**Telephone/Fax (1) 63162**] Medications on Admission: TriCor 48 mg. 1x daily Hydrochlorothiazide 12.5 mg. 1x daily Nadolol 40 mg. 1x daily Omeprazole 40 mg. daily (2, 20mg caps) Prograf 1 mg. b.i.d., level 3.8 Calcium 500 mg. 2x daily Vitamin D 400 units 2x daily Tylenol yesterday Discharge Medications: 1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 2. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. oxygen Sig: Two (2) liters per minute Nasal continuous: pulse dose for portability Dx: pneumonia. Disp:*1 unit* Refills:*0* 5. Tricor 48 mg Tablet Sig: One (1) Tablet PO once a day. 6. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day) for 2 months. Disp:*1 inhaler* Refills:*2* 7. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) for 1 months. Disp:*1 bottle* Refills:*0* 8. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). Disp:*90 Capsule(s)* Refills:*2* 9. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for to area of back pain. Disp:*30 Adhesive Patch, Medicated(s)* Refills:*1* 10. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*2* 11. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing for 2 months. Disp:*1 inhaler* Refills:*1* 12. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day for 9 days: Please take daily until [**2139-4-17**]. Disp:*9 Tablet(s)* Refills:*0* 13. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 14. sodium chloride 0.65 % Aerosol, Spray Sig: [**2-1**] Sprays Nasal [**Hospital1 **] (2 times a day). Disp:*1 vial* Refills:*2* 15. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 16. tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). Disp:*60 Capsule(s)* Refills:*2* 17. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). Disp:*135 Tablet(s)* Refills:*2* 18. phenol 1.4 % Aerosol, Spray Sig: One (1) Spray Mucous membrane Q4H (every 4 hours) as needed for sore throat. Disp:*1 bottle* Refills:*0* 19. oxycodone 10 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain for 1 weeks. Disp:*36 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: VNS of RI Discharge Diagnosis: Primary diagnosis: Community Acquired Pneumonia Acute renal failure Myelofibrosis Back pain with nerve compression Hyponatremia Secondary diagnosis: Hepatitis C cirrhosis Hepatocellular carcinoma Hypertension ITP Discharge Condition: Alert and oriented x3 Ambulates independently Discharge Instructions: You were admitted to the hospital on [**2139-2-18**] with a productive cough and fever, and you were found to have a pneumonia. You were treated with antibiotics for this pneumonia, but when your clinical picture did not improve, you were found to have another bacteria causing an infection in your lungs. During the course of this treatment, you had worsening shortness of breath, and a cardiac ultrasound demonstrated that your mitral valve was no longer functioning as well as it once had. You had a cardiac catheterization performed, during which two metal stents were placed into one of the blood vessels around your heart. After this procedure, you had an episode of bleeding from your GI tract, for which you underwent a sigmoidoscopy and EGD. You received 5 units of blood during this hospital stay, and your hematocrit has remained stable for the past week. Finally, you had a nose bleed while you were here, for which our ENT doctors saw [**Name5 (PTitle) **]. Your nose was packed and you were given antibiotics and a nasal spray. . While you were here, the following changes were made to your medications: 1. We STOPPED your HCTZ 2. We STARTED you on home O2 3. We STARTED you on Aspirin 325 mg daily. You should take this until [**2139-4-18**], at which time you should decrease your aspirin dose to 81 mg daily. You should take Plavix every day, and please follow-up with your cardiologist regarding this medication. 4. We STARTED you on Fluticasone and Albuterol inhalers 5. We STARTED you on a Lidocaine patch, Neurontin and Oyxcodone for pain 6. We STARTED you on Metoprolol for your blood pressure and heart 7. We STARTED you on Tamsulosin for your benign prostatic hypertrphy 8. We STARTED you on a cough syrup for your cough 9. We STARTED you on a saline nasal spray, given your nose bleed 10. We DECREASED your Tacrolimus to 0.5 mg twice daily 11. We STOPPED your Nadolol Please take all medications as prescribed and please keep all follow-up appointments. It was pleasure taking care of you during this hospital stay. Followup Instructions: Please call your hematologist's office to make a follow up appointment. Department: [**Month/Day/Year **] When: WEDNESDAY [**2139-4-15**] at 2:20 PM With: [**Year (4 digits) **] [**Hospital 1389**] CLINIC [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Name: [**First Name8 (NamePattern2) 674**] [**Last Name (NamePattern1) **], MD Specialty: Internal Medicine When: Monday [**4-13**] at 9:30am Location: [**Hospital 63163**] MEDICAL Address: [**Street Address(2) 63164**], [**Hospital1 **],[**Numeric Identifier 63165**] Phone: [**Telephone/Fax (1) 63166**] Name: [**First Name11 (Name Pattern1) 275**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD Specialty: Pulmonary When: Thursday [**4-23**] at 2:30pm Address: 1407 [**Location (un) **] TRAIL BLDG 4 STE A, [**Location (un) 63167**],[**Numeric Identifier 63168**] Phone: [**Telephone/Fax (1) 63169**] Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 63170**], MD Specialty: Cardiology When: Wednesday [**5-6**] at 9:20am Address: 1377 [**Location (un) **] Trail, [**Location (un) **], [**Numeric Identifier 63171**] Phone: [**Telephone/Fax (1) 63172**] Fax: [**Telephone/Fax (1) 63173**] This appointment is in Dr. [**Last Name (STitle) **] office in [**Location (un) **]. You will need to get ALL of your medical records sent to Dr. [**First Name (STitle) **] for this appointment so that Dr. [**First Name (STitle) **] is aware of your medical history. You also must get a copy of your cardiac catheterization done here at [**Hospital1 18**] on a disc and bring that disc to Dr. [**First Name (STitle) **] at this appointment. Completed by:[**2139-4-8**]

[ "276.1", "788.20", "V10.07", "070.70", "428.0", "276.7", "288.60", "289.83", "401.9", "V45.79", "584.9", "424.0", "724.2", "V12.51", "V15.82", "338.29", "578.9", "569.49", "428.31", "414.01", "537.82", "591", "287.31", "482.2", "784.7", "482.0", "996.82" ]

icd9cm

[ [ [] ] ]

[ "00.40", "00.46", "00.66", "45.23", "88.56", "36.06", "44.43", "21.01", "37.22", "33.24" ]

icd9pcs

[ [ [] ] ]

20841, 20881

12492, 18156

320, 373

21139, 21187

3724, 3724

23286, 25050

2663, 2720

18434, 20818

20902, 20902

18182, 18411

12342, 12469

21211, 23263

2735, 3383

3397, 3705

1598, 2037

251, 282

401, 1579

21052, 21118

3740, 10365

20921, 21031

2059, 2435

2451, 2647

17,949

190,859

3708

Discharge summary

report

Admission Date: [**2185-4-8**] Discharge Date: [**2185-4-14**] Date of Birth: [**2120-9-24**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 9554**] Chief Complaint: abdominal aorta anuerysm Major Surgical or Invasive Procedure: none History of Present Illness: 63 year old African American man with history of hypertension, diabetes, chronic renal insufficiency, benign prostatic hypertrophy and medication non compliance who was just recently admitted to the CCU for intramural aortic hematoma requiring esmolol and nipride drip. At this time, blood pressure was controlled and followed by serial CT scans which showed no dissection. As outpatient, he has repeated CT scans most recently on [**3-21**] which showed increased size of descending thoracic aortic aneurysm and resolution of intramural hematoma. patient asked to see CT surgery by PCP but never made the appointment. He was seen in PCP office today with BP in 180s/110s and sent to ED for further evaluation. In ED, repeat CT scan showed increased size of perfortating ulcer(2.3 to 3.1cm, no dissection, increased caliber of descending aorta(5.7 to 6.1cm), He was given esmolol and nipride with BP in 12s. He currently denies chest pain/SOB. He does c/o mild back pain which he had had for 3 weeks. He claims to be compliant to his medication. Past Medical History: obstructive sleep apnea pulmonary nodule BPH anemia aortic mural thrombosis chronic renal insufficiency hypertension hyperlipidemia Diabetes mellitus II Social History: retired; [**Company 16714**] @ airport6 children; 30 grandchildren; 4 great grandchildren no etoh, drug use, tobacco use Family History: family history of hypertension Physical Exam: Gen- NAD, obese AA HEENT-anicteric, mmm, neck supple CV-RRR, no r/m/g resp-CTAB [**Last Name (un) 103**]- active BS, NT/ND extremities-no pitting edema, warm to palpation, DP 2+ bilaterally Pertinent Results: CTA3/18: Pentrating ulcer of the descending thoracic aorta has increased in size (2.3 cm to 3.1 cm across). No extravasation of contrast. Intimal flaps of aortic arch unchanged. Overall caliber of aorta up to 6.1 cm in descending thoracic aorta unchanged. [**2185-3-21**] CTA: 1. Compared to prior studies of [**2184-9-14**] and [**2184-9-20**], there has been resolution of the intramural hematoma although now there is aneurysmal dilatation of the proximal descending thoracic aorta and enlargement of the penetrating ulcer. Small intimal flaps are also noted in the arch. These findings are worrisome for potential rupture and thoracic surgery consultation is advised. CTA Repeated on [**9-20**]: 1) Decrease in thickness of para-aortic hematoma. Entire hematoma not visualized, and there is a questionable intimal flap, raising suspicion for aortic dissection, but evaluation is limited due to bolus timing. Further evaluation with MRA is recommended. 2) Nonspecific area of ground-glass opacity in the right upper lobe, not present on prior study, and could be due to early infection or inflammation. 3) Small bilateral pleural effusions, increased in size, with bibasilar atelectasis. MRA ([**2184-9-21**]): IMPRESSION: Peri-aortic hematoma involving the descending aorta without evidence of an intimal flap. echo [**9-15**]: The left atrium is moderately dilated. The right atrium is markedly dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated. The ascending aorta is moderately dilated but is not well visualized (cannot adequately assess for aortic dissection). The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal.with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. [**2185-4-8**] 12:55PM GLUCOSE-108* UREA N-21* CREAT-1.9* SODIUM-140 POTASSIUM-3.6 CHLORIDE-103 TOTAL CO2-29 ANION GAP-12 [**2185-4-8**] 12:55PM CK(CPK)-148 [**2185-4-8**] 12:55PM CK-MB-3 [**2185-4-8**] 12:55PM NEUTS-61.0 LYMPHS-33.2 MONOS-4.2 EOS-0.9 BASOS-0.8 [**2185-4-8**] 12:55PM NEUTS-61.0 LYMPHS-33.2 MONOS-4.2 EOS-0.9 BASOS-0.8 [**2185-4-8**] 12:55PM PT-13.1 PTT-28.9 INR(PT)-1.1 Brief Hospital Course: 63 year old African American man with history of hypertension, diabetes, chronic renal insufficiency, benign prostatic hypertrophy and medication non compliance who was just recently admitted to the CCU for intramural aortic hematoma. He is currently admitted for expansion of AAA in the setting of high blood pressure. His blood pressure has been very resistant to medication throughout hospital stay. He was initially in the ICU on IV medication which included esmolol and nipride drip. He was finally controlled with the BP in 120s-140s on Labetalol 1200mg, nifedipine CR 90mg, lisinopril 40 [**Hospital1 **], clonidine 0.3, imdur and dyazide. The importance of medication complaince was stressed repeatedly. He was seen by social services and was sent home with VNA service for that purpose. Due to the size of his AAA, he was initially considered for surgery. GIven that he was asymptomatic, he will be followed up as outpatient by vascular surgeon and be considered for elective surgery. Although he has risk factors for CAD, he was not started on aspirin given the ulceration in AAA. Of note, he is also noted to have obstructive sleep apnea but refuses to have CPAP at night. This might be one of the factors contributing to the hypertension and will need to be addressed as outpatient. He will also need potassium follow up given that he has just been started on dyazide. Medications on Admission: labetolol 600 [**Hospital1 **] lipitor 10 lisinopril 20 lasix 40 Discharge Medications: 1. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 2. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). Disp:*30 Tablet Sustained Release(s)* Refills:*2* 3. Labetalol HCl 200 mg Tablet Sig: Six (6) Tablet PO TID (3 times a day). Disp:*540 Tablet(s)* Refills:*2* 4. Clonidine HCl 0.3 mg/24 hr Patch Weekly Sig: One (1) Transdermal once a week. Disp:*4 qs* Refills:*2* 5. Blood Pressure Kit Kit Sig: One (1) Miscell. once a day. Disp:*QS 1* 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). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 7. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 8. Dyazide 37.5-25 mg Capsule Sig: One (1) Capsule PO once a day. Disp:*30 Capsule(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: aortic aneurysm hypertension anemia Discharge Condition: good Discharge Instructions: Take all your medications as listed. Do not forget to take them or you could die. You should be taking your blood pressure every day and recording it. Take your record to your doctor's appointment. Your goal blood pressure is 110-120 systolic. Call your doctor if it is higher. Please return to the hospital if you have back pain/chest pain or if there are any concerns at all Eat a low salt diet and try to get regular exercise. Have your potassium checked in 4 days. Followup Instructions: Provider: [**Name10 (NameIs) **],[**Last Name (Prefixes) 413**] CARDIAC SURGERY LMOB 2A Where: CARDIAC SURGERY LMOB 2A Date/Time:[**2185-4-14**] 3:30 Make an appointment to see your PCP [**Last Name (LF) 5647**],[**Name9 (PRE) **] [**Name Initial (PRE) **]. [**Telephone/Fax (1) 16719**] within 2 weeks. Your potassium should be checked in 4 days. [**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2139**] Completed by:[**2185-4-14**]

[ "285.9", "600.00", "428.0", "593.9", "518.89", "441.4", "414.01", "780.57", "250.00", "401.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7080, 7138

4536, 5919

339, 345

7218, 7224

2013, 4513

7746, 8252

1755, 1787

6034, 7057

7159, 7197

5945, 6011

7248, 7723

1802, 1994

275, 301

373, 1424

1446, 1601

1617, 1739

32,754

140,826

901

Discharge summary

report

Admission Date: [**2114-7-13**] Discharge Date: [**2114-7-20**] Date of Birth: [**2034-8-12**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 613**] Chief Complaint: Pt transferred from OSH for treatment of odontoid fracture Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 6105**] is a 79yo male with PMH significant for CHF, atrial fibrillation, and CRI who presents from OSH with odontoid fracture s/p mechanical fall. Per patient, he fell on Thursday after he tried to get up from his bed. He admits to hitting his head on the floor. He was brought to [**Hospital **] [**Hospital 1459**] Hospital and was found to have an odontoid fracture. He was transferred to [**Hospital1 18**] for further work-up. . In the [**Hospital1 18**] ED his initial vitals were T 96.2 BP 81/60 AR 106 RR 16 O2 sat 92% RA. He received Levaquiin 750mg IV x1 and was started on Levophed which was turned off upon transfer to the floor. He had repeat imaging which confirmed the fracture. He denies any fevers, chills, chest pain, SOB, dizziness, abdominal pain, or bloody/black tarry stools. He does admit to a productive cough over the past 3-4 weeks. . Of note, patient was recently admitted to [**Hospital **] [**Hospital 1459**] Hospital from [**Date range (1) 6106**] after he oresented with history of recurrent dizziness and his blood pressure was found to be in the low 70's. He underwent several studies including a Holtor monitor, echo, and PFTs. He was suggested to be discharged to rehab but the patient refused. Past Medical History: 1)Hypertension 2)Atrial fibrillation s/p ICD placement @ [**Hospital1 2025**] 3)CHF 4)COPD 5)Type 2 DM 6)Chronic renal failure, secondary to tubulointerstitital nephritis 7)Anemia 8)Bilateral pleural effusions 9)Hypothyroidism 10)Hx of gastrointestinal bleed secondary to anticoagulation 11)Hiatal hernia 12)GERD 13)hx of abnormal LFTs 14)Osteoporosis 15)Gout 16)Hx of lead poisoning, job related Social History: Lives with nephew in [**Name (NI) 3786**], MA. Bedbound at baseline. Denies current tobacco, alcohol, or IVDA. Family History: Non-contributory Physical Exam: Physical Exam vitals T 97.4 BP 90/47 AR RR 24 O2 sat 97% Gen: Patient lying in bed, does not appear to be in acute distress HEENT: MMM, cervical collar in place, unable to assess JVD Heart: Lungs: Course breath sounds anteriorly, scattered crackles posteriorly, decreased BSs at bases posteriorly R>L Abdomen: soft, NT/ND, +BS Extremities: [**12-23**]+ pitting edema bilaterally, 2+ DP/PT pulses Pertinent Results: [**2114-7-13**] 03:35AM PT-13.1 PTT-28.0 INR(PT)-1.1 [**2114-7-13**] 03:35AM PLT COUNT-237 [**2114-7-13**] 03:35AM NEUTS-95* BANDS-0 LYMPHS-0 MONOS-5 EOS-0 BASOS-0 [**2114-7-13**] WBC-25.4* HGB-12.7* HCT-37.0* MCV-92 [**2114-7-13**] CALCIUM-8.1* PHOSPHATE-3.9 MAGNESIUM-2.5 [**2114-7-13**] GLUCOSE-155* UREA N-109* CREAT-3.9* SODIUM-133 POTASSIUM-4.4 CHLORIDE-97 TOTAL CO2-20* [**2114-7-13**] TSH-5.5* [**2114-7-13**] LACTATE-1.9 [**2114-7-13**] URINE negative . Relevant Imaging: 1)CT Head ([**7-13**]): No acute intracranial hemorrhage. Abnormal orientation of the dens corresponds to dens fracture, visualized on the C-spine CT. . 2)CT C-spine ([**7-13**]): Type II dens fracture. Posterior offset of C1 over C2 could indicate possible ligamentous injury. . OSH Imaging: 1)CT C-spine ([**7-12**]): Odontoid base fracture with 3mm posterior displacement of the odontoid tip. . 2)CT Head ([**7-12**]): No acute intracranial abnormality is present. There are small vessel ischemic changes of periventricular white matter and findings of atrophy. . 3)Holtor monitor ([**7-3**]): Patient appears to be in a-fib with V paced rhytm with occasional PVCs, rare ventricular couplets, no VT. . 4)PFTs ([**7-6**]): FEV1 markedly reduced. FEV1/FVC ratio is normal. No improvement with bronchodilators. Severe restrictive and obstructive lung defect. . 5)ECHO ([**7-4**]): Diffuse cardiomyopathy. EF~ 10-15%. Moderate RA/RV chamber size abnormality. No pericardial effusion. Severe mitral regurgitation and severe tricuspid regurgitation. Mild to moderate aortic imcompetence. . 6)RUQ U/S ([**7-4**]): No acute abnormalities. Brief Hospital Course: A/P: Mr. [**Known lastname 6105**] is a 79yo male with PMH as listed above who presents with odontoid fracture and hypotension. His admission was complicated by MRSA parotitis and MRSA bacteremia. He failed evaluation by speech and swallow secondary to aspiration. The patient made it clear to family and the medical team that he did not want any "tubes" or to be kept alive by a machine. He had an episode on [**2114-7-18**] when he desaturated to the low 80's with SBP in the 70s. He declined intubation and transfer to the MICU. His goals of care were advanced to CMO. Below is a brief summary of his hospital course by problem. . 1)Hypotension: The patient was found to be hypotensive with SBPs~80 in ED. He was given 3L of NS and BP now in 90's. Per PCP's office and OSH records, baseline SBP is 80-90's. Of note, he was recently admitted to OSH with hypotension and dizziness. He had multiple imaging tests as described above, none of which were very revealing. Despite this, there was concern for possible underlying infection given his leukocytosis with WBC elevated to 25. He was found to have parotitis with cultures positive for MRSA. He also had [**11-23**] positive blood cultures for MRSA. . #) MRSA bacteremia/parotitis: As above. He was started on vancomycin. He received 1mg IV vancomycin x 2 on [**7-17**] due to communication errors (dose should have been x1) and his dose was elevated on [**7-18**] to 150. Given his depressed renal function and decreased ability to clear the vancomycin, he will likely have the antibiotic in his system at a supra/therapeutic level for several days. His vancomycin level on discharge was 18.3. To receive one dose tonight ([**7-20**]) and one final dose on [**2114-7-23**]. . 2)Odontoid fracture: Patient found to have odontoid fracture as a result of a mechanical fall. He was transferred to [**Hospital1 18**] for further management. He was seen by Dr. [**Last Name (STitle) 363**] (ortho-spine) who did not feel that the patient is candidate for halo given his age and morbidity associated with this procedure. Therefore, it was decided to treat conservatively with cervical collar. When goals of care were changed to CMO, the patient requested to have the collar removed. He is fully aware of the potential risks associated with this. . 3)Bilateral pleural effusions: Patient has history of bilateral pleural effusions since [**10-25**] as per OSH records. He presented on this admission with predominantly R sided effusion, which is likely loculated on his CXR. He admits to productive cough over past few weeks but denies any fevers, chills, or other systemic symptoms. It was thought most likely secondary to CHF and no further work-up was pursued. . 4)Chronic renal insufficiency: Patient is known to have renal insufficiency, thought to be secondary to tubulointerstitial nephritis and longstanding hypertension. Per OSH reports, he is refusing dialysis. He confirmed his decision on admission. . 5)Hyponatremia/Hypernatremia: He presented with Na~131 on admission. Baseline Na per OSH records is in mid-high 130's. Patient appeared volume overloaded on physical exam, and his hyponatremia was thought most likely secondary to underlying CHF. Could also be abnormal in light of CRI. Over the course of admission, the patient became hypernatremic, likely secondary to volume depletion due to decreased PO intake. He was repleted gently with IVF given his low EF and Na was slowly trending back down. . 6)Anion gap metabolic acidosis: He also presented with an elevated anion gap of 17. Uremia is the most likely cause given elevated creatinine. He had a normal lactate. . 7)CHF: Patient known to have dilated cardiomyopathy. Recent echo reveals EF~10-15%. He is on diuretics as outpatient. There is also evidence of volume overload which is suggested by bilateral LE edema. His recent complaint of dizziness and chronic hypotension is likely due to underlying CHF and very poor cardiac output. Home indapanide was held for hypotension. . 8)Atrial fibrillation: Patient in sinus rhythm on admission. Per OSH records he self converts in and out of AF. s/p ICD placement at [**Hospital1 2025**]. He has been anticoagulated in the past but was stopped secondary to severe bleeding. Well rate controlled. Patient on Amiodarone as outpatient. Amiodarone was continued. . 9)COPD: Per recent PFTs has severe restrictive and obstructive disease at baseline. He is on several inhalers as an outpatient. He has excellent oxygen saturations on physical exam. He was treated here with atrovent nebs. . 10)Type 2 DM: Last hemoglobin A1C ~6.2. Diet controlled at home. He was controlled by a humalog insulin sliding scale here. . 11)Hypothyroidism: Patient on Levoxyl as outpatient. Per OSH records he has been found to be subtherapeutic. He was continued on levothyroxine at 50mcg daily. . 12)GERD/hiatal hernia: He was continued on a PPI, as per his outpatient regimen. . 13) Comfort care: Goals of care were advanced to comfort measures only. His medication regimen was adjusted accordingly but all PO meds and antibiotics continued. ICD was deactivated by EP. He is written for PO liquid morphine, though he continues to deny symptoms of pain. He is being transferred to [**First Name4 (NamePattern1) 6107**] [**Last Name (NamePattern1) **] for hospice care. Medications on Admission: Medications at home: Amiodarone 400mg PO BID Allopurinol 100mg PO daily Levoxyl 0.05mg PO daily Indapamide 2.5mg PO daily Omeprazole 20mg PO daily Lipitor 80mg PO daily Spiriva Discharge Medications: 1. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation every 4-6 hours as needed. 2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 4. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr Transdermal every seventy-two (72) hours as needed for cough. 5. Morphine Concentrate 20 mg/mL Solution Sig: 1-5 mg PO Q2H (every 2 hours) as needed for pain. 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain/fever. 7. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily) as needed. 8. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 9. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO once a day. 10. Vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous q3 days for 2 doses: please give one dose tonight ([**7-20**]) and one dose on [**2114-7-23**]. Discharge Disposition: Extended Care Facility: [**Location (un) 169**] Discharge Diagnosis: Primary 1) Odontoid fracture 2) Failure to thrive . Secondary 1) Hypertension 2) Atrial fibrillation 3) CHF 4) Type II Diabetes 5) Chronic kidney disease secondary to tubulointersitial nephritis 6) Anemia 7) Hypothyroidism 8) GERD 9) Osteoporosis Discharge Condition: fair Discharge Instructions: You were admitted to the hospital for a neck fracture after a mechanical fall. You were evaluated by orthopedic surgery who felt that you were not a surgical candidate and recommended a cervical collar for stabilization of your neck. It was also noted during your hospitalization that you have parotitis that is culture positive for MRSA. You also had positive blood cultures with 1/4 bottles growing MRSA. You were started on vancomycin for this. You were evaluated by speech and swallow therapists who determined that you are at high risk of aspirating food. After discussion with you and your nephew the decision was made to transfer goals of care to keeping you comfortable. You will be discharged today to a medical facility closer to your family for hospice care. Followup Instructions: n/a [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

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icd9cm

[ [ [] ] ]

[ "96.08" ]

icd9pcs

[ [ [] ] ]

10930, 10980

4341, 9654

373, 380

11271, 11278

2680, 3162

12096, 12224

2230, 2248

9882, 10907

11001, 11250

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191,642

13761

Discharge summary

report

Admission Date: [**2122-12-23**] Discharge Date: [**2122-12-31**] Service: NEUROSURGERY Allergies: Lasix / Triazolam Attending:[**First Name3 (LF) 1854**] Chief Complaint: Subdural Hematoma Major Surgical or Invasive Procedure: Craniectomy and evacuation of left sided subdural hematoma History of Present Illness: [**Age over 90 **] y/o female transferred from [**Hospital6 **] with left SDH on MRI and 1 week history of unsteadiness. The patient was found down yesterday at 1100 by here daughter. She had been well, but had been more unsteady over the past week. Her daughter noticed that a spoon fell out of her hand yesterday. She fell back on [**2122-11-2**], but denies any other falls. The patient had an MRI scan today and was referred to [**Hospital1 18**] for neurosurgical evaluation. Past Medical History: -CHF -CAD -Renal insufficiency (10% function left) -Ovarian mass/Cancer -Bilateral DVTs -Osteoarthritis -Bilateral cateracts -Chronic lower extremity edema -GERD -Gout -Hiatial hernia -Bladder suspension surgery -Septic hip -Right hip replacement Social History: Social Hx: lives at home with her sister. Functional baseline activity. Family History: Not known Physical Exam: O: T: 98.0 BP: 127/80 HR: 93 R 18 98% O2Sat on room air. Gen: WD/WN, comfortable, NAD. HEENT: Pupils: unreactive EOMs intact Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. +3 systolic murmor. Abd: Soft, NT. Large abdominal mass. Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person. Recall: Able to state 3 different objects. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to mm bilaterally. 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 4/5 on right side of body. [**3-27**] of left side. Difficult to assess pronator drift due to sore shoulder. Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Reflexes: B T Br Pa Ac Right +2 +2 +2 +2 +2 Left +2 +2 +2 +2 +2 Toes downgoing bilaterally Coordination: unable to assess. Pertinent Results: [**2122-12-23**] 07:30PM PT-12.4 PTT-25.3 INR(PT)-1.1 [**2122-12-23**] 07:30PM MACROCYT-1+ [**2122-12-23**] 07:30PM NEUTS-75.4* LYMPHS-17.1* MONOS-4.8 EOS-2.4 BASOS-0.3 [**2122-12-23**] 07:30PM CK-MB-NotDone [**2122-12-23**] 07:30PM CK(CPK)-72 [**2122-12-23**] 07:30PM estGFR-Using this [**2122-12-23**] 07:30PM GLUCOSE-99 UREA N-99* CREAT-4.7* SODIUM-140 POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-22 ANION GAP-21* [**2122-12-23**] 10:04PM freeCa-1.11* [**2122-12-30**] 07:06AM BLOOD WBC-6.3 RBC-2.78* Hgb-9.2* Hct-27.6* MCV-99* MCH-33.1* MCHC-33.5 RDW-15.8* Plt Ct-195 [**2122-12-29**] 08:21AM BLOOD WBC-5.8 RBC-2.73* Hgb-8.9* Hct-27.4* MCV-100* MCH-32.4* MCHC-32.4 RDW-15.4 Plt Ct-185 [**2122-12-29**] 08:21AM BLOOD PT-12.3 PTT-27.1 INR(PT)-1.1 [**2122-12-29**] 08:21AM BLOOD Plt Ct-185 [**2122-12-30**] 07:06AM BLOOD Glucose-158* UreaN-127* Creat-5.3* Na-141 K-4.0 Cl-110* HCO3-19* AnGap-16 [**2122-12-29**] 08:21AM BLOOD Glucose-112* UreaN-118* Creat-5.2* Na-141 K-3.8 Cl-111* HCO3-19* AnGap-15 [**2122-12-28**] 02:57AM BLOOD Glucose-169* UreaN-112* Creat-4.8* Na-141 K-4.0 Cl-110* HCO3-18* AnGap-17 [**2122-12-24**] 03:26PM BLOOD ALT-6 AST-16 AlkPhos-67 Amylase-108* TotBili-0.4 [**2122-12-24**] 03:07PM BLOOD ALT-6 AST-15 AlkPhos-66 Amylase-105* TotBili-0.4 [**2122-12-24**] 03:26PM BLOOD Lipase-33 [**2122-12-24**] 03:07PM BLOOD Lipase-34 [**2122-12-24**] 03:07PM BLOOD Albumin-3.7 Calcium-9.1 Phos-5.2* Mg-2.1 [**2122-12-24**] 03:26PM BLOOD Ammonia-37 [**2122-12-24**] 03:26PM BLOOD TSH-2.9 [**2122-12-24**] 03:26PM BLOOD Phenyto-35.3* [**2122-12-29**] 08:21AM BLOOD Phenyto-11.5 [**2122-12-23**] 10:04PM BLOOD Type-ART Rates-/7 Tidal V-462 pO2-220* pCO2-35 pH-7.42 calTCO2-23 Base XS-0 Intubat-INTUBATED Vent-CONTROLLED [**2122-12-23**] 10:04PM BLOOD Glucose-127* Lactate-1.2 Na-137 K-3.9 Cl-104 [**2122-12-23**] 10:04PM BLOOD freeCa-1.11* . CT [**12-23**] - 1. Large left subdural hematoma, acute-on-chronic, measuring 3 cm in maximal thickness. 2. Subfalcine herniation with 7 mm of rightward midline shift. 3. Significant mass effect on subjacent gyri, with effacement of the frontal and temporal horns of the left but no definite trapping of the right lateral ventricle. Results were relayed to the ED dashboard at the time of dictation. . CT [**2122-12-24**] - Postoperative changes, with a moderate size residual left subdural hematoma containing some acute blood. Left-to-right subfalcine herniation is slightly decreased in the interim. . CT [**2122-12-27**] - Stable appearance of left-sided subdural collection with interval decrease in component of pneumocephalus. Stable subfalcine herniation to the right. No new intracranial hemorrhage. . EEG - This is an abnormal EEG due to the right temporal more then left frontocentral slowing, slow and disorganized background and bursts of generalized slowing. The right temporal and left frontocentral slowing suggests subcortical dysfunction in these regions. Given the patient's age, the most common etiology is stroke. The slow background and bursts of generalized delta slowing suggest an encephalopathy. An encephalopathic pattern is frequently seen with infections, toxic metabolic abnormalities, medication effect and ischemia. . CXR - PA/LAT: Comparison is made to earlier on the prior day. The weighted tip of the Dobhoff tube terminates at the gastroesophageal junction, but may just enter the stomach. This should be advanced further for better purchase within the stomach. A central venous catheter again terminates in the superior vena cava. Its course is somewhat unusual, with the left brachiocephalic vein taking a relatively low and horizontal course. The heart is enlarged. The cardiac and mediastinal contours are unchanged. There is persistent asymmetric airspace opacity in the right lung, not significantly changed. There is no pneumothorax or definite effusion. IMPRESSION: Slight malpositioning of new feeding tube. Stable right-sided airspace disease. Findings discussed with Dr. [**Last Name (STitle) 26321**] on the same evening. Brief Hospital Course: Ms. [**Known lastname 15513**] was taken immediately to the OR where she underwent a craniectomy for evacuation of a left sided chronic with acute component. She had a craniectomy due to the fact that the piece of her skull that was removed was contaminated. She was sent to the ICU for the post operative period and extubated in the OR without difficulty. She was awake, alert and orientated X3, now moving her right extremties with full strenght. She was re loaded with Dilantin for goal of 10. She appeared to have a mental status change on [**12-24**] and a repeat CT showed no change but a Dilantin level was 35. Toxicology was called and recommended just allowing rate to decrease on it's own. She became slight more awake on a daily basis, she would follow commands intermittently. She was monitored in the ICU for 3 days. Her renal function remained at baseline 4.4, ruled out for an MI and TSH was 2.9. A repeat head CT on [**12-27**] showed improved shift and effacment of ventricles slight reduced subdural. A CXR showed a right lower lobe pneumonia, she was started on Levaquin. Patient was transferred to Medicine service 3 days prior to her passing for management of her hypertension, renal failure, and moderate tachypnea. Patient continued to decompensate clinically with mutli-system organ failure, namely her neurological system was severely compromised, her cardiovascular system became more unstable as she required large quantities of diuretics and aggressive hypertensive medical management, and her renal failure progressively worsened. Two days prior to her passing, after a discussion with the primary medical team, the neurosurgeons, and the patient's family and healty care proxy, it was decided it would be in the patient's best wishes to puruse comfort measures only. Pain and palliative care contributed to end-of-life care. Patient in the AM hours on [**2122-12-31**], hopefully with minimal pain and discomfort. Medications on Admission: Allopurinol 5. Bisacodyl 6. Bumetanide 7. Docusate Sodium 8. Dolasetron Mesylate 9. Epoetin Alfa 10. HydrALAzine 11. Insulin 12. Isosorbide Mononitrate 13. Levothyroxine Sodium 14. Loperamide HCl 15. Magnesium Oxide 16. Metoprolol XL (Toprol XL) 17. Morphine Sulfate 18. Nitroprusside Sodium 19. Oxycodone-Acetaminophen 20. Pantoprazole 21. Phenytoin 22. Phenytoin 23. Senna 24. Sodium Chloride 0.9% Flush 25. Terazosin HCl Discharge Disposition: Extended Care Discharge Diagnosis: Patient expired. Discharge Condition: Patient expired.

[ "428.0", "274.9", "486", "585.6", "183.0", "366.9", "453.40", "403.91", "432.1", "414.01" ]

icd9cm

[ [ [] ] ]

[ "01.31", "38.93" ]

icd9pcs

[ [ [] ] ]

9158, 9173

6723, 8682

249, 310

9233, 9252

2661, 6697

1200, 1211

9194, 9212

8708, 9135

1226, 1506

192, 211

338, 822

1784, 2642

1521, 1768

844, 1094

1110, 1184

71,878

176,473

23537

Discharge summary

report

Admission Date: [**2148-9-1**] Discharge Date: [**2148-9-5**] Service: MEDICINE Allergies: Penicillins / Optiray 350 / Lactose Attending:[**First Name3 (LF) 2610**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: thoracentesis History of Present Illness: [**Age over 90 **] yo M h/o PD, DM, HTN, ?CHF, p/w worsening dyspnea and hypoxia for the past week. He saw his PCP Tuesday, Five days prior to admission who diagnosed him with CAP. He was started on azithromycin, atrovent and benzonatite cough drops. Through the course of the week he reportedly developed hypoxia in the 80s (per his son and home health aide). His PCP then prescribed 20 po lasix daily with home oxygen on Friday. Through the weekend, he developed worsening sob and productive cough. His son gave him 60 mg po lasix the morning prior to admission with little effect in his sob. EMS was called. He was noted by EMS to be saturating to the low 80s with decreased breath sounds bilaterally. He was given 20 IV lasix and 2 SL NTG with improvement of SOB. . In ED VS were 97.0 70 154/68 26 99 on 10L. No breath sounds on right. 1200 cc UOP without further lasix. portable cxr showed new large right pleural effusion. Gave vanc/ctx (was on azithro at home). Layering effusion seen on Left lateral decub. Refused asa. trop .03 in setting of Cr of 1.9. BNP 4600, unclear baseline. EKG: SR, 72, new T wave inversion in V2. 92-95% % on 40% venturi mask. Vitals prior to transfer: BP: 155/77 HR: 56 RR: 16 O2 sat: 94% 40% FIO2 . Upon arrival to the MICU, Patient is breathing comfortably on a venturi mask at 40% with O2 sats in the mid-90s. He denies chest pain. Admits to nausea over the past week. Denies chills/fevers. He has chronic diarrhea/constipation that is unchanged. Past Medical History: Parkinson's disease DM2 c/b neuropathy on gabapentin Diplopia x one year, horizontal, no clear etiology per patient, followed by ophtho HTN CKD (baseline c1.4-1.6) H/O migraines s/p Silent MI [**57**] yrs ago s/p cataract [**Doctor First Name **] bilat s/p laminectomy in [**2089**] multiple right sided rib fracture after fall on [**7-8**] (no surgical intervention) Treated for a PNA mid-[**2148-6-20**] with levofloxacin Social History: Wife of 69 years died in [**2-28**]. Lives with 24 hour home health aide. His son, [**Name (NI) 2092**] (his HCP) lives nearby. 30 pack year history of smoking, quit >30 years ago. Denies EtOH. Was a professional swimmer and reached the semi-finals of the olympic trials in the [**2067**]. Family History: Father with strokes, no seizures, no parkinsons, sons are healthy Physical Exam: VS: 96.9 65 163/55 16 95% venturi face mask at 40%. GA: AOx3, NAD HEENT: PERRLA. MMM. no LAD. JVP to mid neck, neck supple. Cards: PMI palpable at 5/6th IC space. No RVH. RRR S1/S2 heard. no murmurs/gallops/rubs. Pulm: Decreased breath sounds on right base, positive egophony, dull to percussion on right base. Crackles at left base. no wheezes, no rhonchi Abd: soft, NT, +BS. no g/rt. neg HSM. Extremities: wwp, 1+ edema in BLE 1/3 up leg. DPs, PTs 2+. Skin: no rashes Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities. Gait not assessed Pertinent Results: ADMISSION LABS: [**2148-9-1**] 08:55PM BLOOD WBC-9.6 RBC-3.63* Hgb-9.7* Hct-29.8* MCV-82 MCH-26.6* MCHC-32.3 RDW-16.4* Plt Ct-433 [**2148-9-1**] 08:55PM BLOOD Glucose-193* UreaN-40* Creat-2.0* Na-134 K-7.9* Cl-104 HCO3-20* AnGap-18 [**2148-9-1**] 08:55PM BLOOD cTropnT-0.03* [**2148-9-1**] 08:55PM BLOOD proBNP-4607* [**2148-9-2**] 05:24AM BLOOD CK-MB-3 cTropnT-0.03* [**2148-9-2**] 09:04AM BLOOD CK-MB-3 cTropnT-0.03* [**2148-9-1**] 09:45PM BLOOD Albumin-2.8* . Labs during hospital course . [**2148-9-2**] 05:24AM BLOOD WBC-8.3 RBC-3.53* Hgb-8.8* Hct-29.4* MCV-83 MCH-24.8* MCHC-29.8* RDW-16.5* Plt Ct-476* [**2148-9-3**] 04:28AM BLOOD WBC-8.7 RBC-3.53* Hgb-8.9* Hct-29.2* MCV-83 MCH-25.1* MCHC-30.3* RDW-16.6* Plt Ct-471* [**2148-9-4**] 05:21AM BLOOD WBC-8.7 RBC-3.33* Hgb-8.5* Hct-26.9* MCV-81* MCH-25.4* MCHC-31.5 RDW-16.0* Plt Ct-409 [**2148-9-5**] 05:55AM BLOOD WBC-8.4 RBC-3.22* Hgb-8.1* Hct-26.7* MCV-83 MCH-25.3* MCHC-30.4* RDW-16.4* Plt Ct-531* [**2148-9-1**] 08:55PM BLOOD Neuts-70.8* Lymphs-19.0 Monos-5.7 Eos-3.7 Baso-0.7 [**2148-9-5**] 05:55AM BLOOD Neuts-66.8 Lymphs-22.5 Monos-6.2 Eos-3.7 Baso-0.8 [**2148-9-2**] 05:24AM BLOOD PT-14.2* PTT-31.9 INR(PT)-1.2* [**2148-9-4**] 05:21AM BLOOD PT-14.1* PTT-33.8 INR(PT)-1.2* [**2148-9-5**] 05:55AM BLOOD PT-13.3 PTT-32.2 INR(PT)-1.1 [**2148-9-1**] 09:45PM BLOOD Glucose-185* UreaN-40* Creat-1.9* Na-135 K-4.7 Cl-102 HCO3-22 AnGap-16 [**2148-9-2**] 05:24AM BLOOD Glucose-119* UreaN-38* Creat-1.8* Na-139 K-5.1 Cl-102 HCO3-25 AnGap-17 [**2148-9-3**] 04:28AM BLOOD Glucose-141* UreaN-33* Creat-1.7* Na-137 K-5.3* Cl-102 HCO3-24 AnGap-16 [**2148-9-4**] 05:21AM BLOOD Glucose-130* UreaN-39* Creat-1.9* Na-141 K-4.8 Cl-103 HCO3-26 AnGap-17 [**2148-9-5**] 05:55AM BLOOD Glucose-128* UreaN-44* Creat-2.1* Na-141 K-5.3* Cl-104 HCO3-28 AnGap-14 [**2148-9-2**] 05:24AM BLOOD ALT-6 AST-14 CK(CPK)-39* AlkPhos-60 TotBili-0.2 [**2148-9-2**] 09:04AM BLOOD LD(LDH)-164 CK(CPK)-37* [**2148-9-5**] 05:55AM BLOOD ALT-3 AST-11 AlkPhos-55 TotBili-0.2 [**2148-9-2**] 05:24AM BLOOD Albumin-3.0* Calcium-8.4 Phos-4.9* Mg-2.5 [**2148-9-2**] 09:04AM BLOOD TotProt-5.9* [**2148-9-3**] 04:28AM BLOOD Calcium-8.3* Phos-4.1 Mg-2.2 [**2148-9-4**] 05:21AM BLOOD Calcium-8.4 Phos-4.0 Mg-2.1 [**2148-9-5**] 05:55AM BLOOD TotProt-5.3* Albumin-3.0* Globuln-2.3 Calcium-8.8 Phos-4.2 Mg-2.3 . Other labs . [**2148-9-1**] 09:45PM BLOOD TSH-3.1 [**2148-9-5**] 05:55AM BLOOD CRP-94.5* [**2148-9-5**] 05:55AM BLOOD PEP-NO SPECIFI [**2148-9-1**] 09:01PM BLOOD Lactate-1.6 . . Urine . [**2148-9-1**] 09:50PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.007 [**2148-9-1**] 09:50PM URINE Blood-NEG Nitrite-NEG Protein-75 Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2148-9-1**] 09:50PM URINE RBC-0-2 WBC-0-2 Bacteri-RARE Yeast-NONE Epi-0-2 [**2148-9-2**] 02:05AM URINE Hours-RANDOM UreaN-182 Creat-18 Na-103 K-20 Cl-107 [**2148-9-2**] 02:05AM URINE Osmolal-312 PLEURAL FLUID ANALYSIS: [**2148-9-2**] 03:20PM PLEURAL WBC-3444* Hct,Fl-2.5* Polys-46* Lymphs-23* Monos-4* Eos-8* Meso-4* Macro-15* [**2148-9-2**] 03:20PM PLEURAL TotProt-4.6 Glucose-140 LD(LDH)-337 . . Microbiology . BCs x2 [**2148-9-1**] - NO GROWTH UCx [**2148-9-1**] - NO GROWTH MRSA screen [**2148-9-2**] negative . [**2148-9-2**] 10:27 am SPUTUM Source: Expectorated. **FINAL REPORT [**2148-9-4**]** GRAM STAIN (Final [**2148-9-2**]): >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2148-9-4**]): SPARSE GROWTH Commensal Respiratory Flora. . Radiology . CXR [**2148-9-1**]: 1. Interval increase in size of right pleural effusion, which is now large, with adjacent right basilar atelectasis. 2. Left basilar opacity, which could represent an infection, atelectasis, or aspiration. . CXR [**2148-9-2**] Portable AP chest radiograph was compared to [**2148-9-1**]. There is significant interval decrease in the right pleural effusion with no definite evidence of pneumothorax. Multiple left rib fractures are redemonstrated. Cardiomediastinal silhouette is unchanged. . CT CHEST [**2148-9-2**]: 1. New large right pleural effusion since [**2148-7-8**] on a background of subacute healing right comminuted rib fractures. 2. Moderately severe centrilobular emphysema. 3. Healed left rib fractures with associated pleural thickening. 4. Mixed solid and ground-glass left lower lobe nodule, concerning for bronchoalveolar carcinoma with a central adenocarcinoma, stable since [**2148-7-8**] but enlarged since [**2147-3-9**]. . Renal U/S [**2148-9-5**] FINDINGS: The right kidney measures 10.7 cm and the left kidney measures 11.1 cm. There is no hydronephrosis and no stone or solid mass is seen in either kidney. Multiple simple cysts are identified bilaterally. One contains thin septations within the right kidney, however, this cyst demonstrates no vascularity within these septations. The largest cyst in the right kidney measures 9.2 x 7.5 x 7.7 cm and the largest cyst in the left kidney measures 4.8 x 2.8 x 4.6 cm. The pre-void bladder is minimally distended and unremarkable. The prostate median lobe is noted to be bulging into the bladder base, however, the prostate gland could not be clearly visualized and thus could not be measured. Large right pleural effusion. IMPRESSION: 1) Multiple simple renal cysts bilaterally. 2) Large right pleural effusion. The study and the report were reviewed by the staff radiologist. . . Cardiology . Cardiology Report ECG Study Date of [**2148-9-1**] 8:47:38 PM Sinus rhythm. Intraventricular conduction delay. Prior anterior wall myocardial infarction. Compared to the previous tracing of [**2148-7-8**] the findings are similar. TRACING #1 . Cardiology Report ECG Study Date of [**2148-9-2**] 8:25:06 AM Sinus bradycardia. Multiple abnormalities are as previously described on [**2148-9-1**]. Compared to the previous tracing of [**2148-9-2**] findings are similar. TRACING #3 Read by: [**Last Name (LF) **],[**First Name3 (LF) **] V. . Cardiology Report ECG Study Date of [**2148-9-2**] 1:31:12 AM Sinus bradycardia with borderline A-V conduction delay. Multiple abnormalities are as previously described. Compared to the previous tracing of [**2148-9-1**] there is no change. TRACING #2 Read by: [**Last Name (LF) **],[**First Name3 (LF) **] V. . Echocardiogram [**2148-9-2**] Findings left pleural effusion. This study was compared to the prior study of [**2147-1-26**]. LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global systolic function (LVEF>55%). No resting LVOT gradient. No VSD. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. Paradoxic septal motion consistent with conduction abnormality/ventricular pacing. AORTA: Normal diameter of aorta at the sinus, ascending and arch levels. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No MS. Mild (1+) MR. LV inflow pattern c/w impaired relaxation. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No TS. Mild to [**Year (4 digits) 1192**] [[**12-23**]+] TR. [**Month/Day (2) **] PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: No PS. PERICARDIUM: Trivial/physiologic pericardial effusion. Conclusions The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). 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 but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. There is [**Month/Day (2) 1192**] pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [**2147-1-26**], the degree of pulmonary hypertension detected has slightly increased. Brief Hospital Course: [**Age over 90 **] yo M h/o Parkinson's disease, DM, HTN, p/w progressive hypoxia, shortness of breath, treated for CHF exac and possible pneumonia (briefly received empiric antibiotics) and requiring MICU stay. Found to have markedly increased R pleural effusion and had thoracocentesis after which he had considerable symptomatic improvement. Pleural fluid was exudative with many WBCs and negative for malignant cells. CT chest was concerning for left lower lobe nodule which was stable since [**Month (only) 205**] but increased since [**2146**]. Pt felt clinically at baseline and discharged home with 24[**Hospital 8018**] home health aide. . # Shortness of Breath/Hypoxia and R pleural effusion: Presented [**9-1**] with hypoxia and dyspnea for 1 week. Saw PCP, [**Name10 (NameIs) **] azithromycin for CAP and nebs. he was seen again and given furosemide and latterly homeoxygen by PCP. [**Name10 (NameIs) **] son called EMS due to worsening symptoms. He was given S/L nitroglycerine and furosemide and had some improvement. On presentation to the [**Hospital1 18**], clinically (given mild LE edema, elevated JVP) and with raised proBNP 4607 there was likely an element of CHF in addition to large right pleural effusion. Upon arrival to the ED he was sO2 99% on 10L and 92-94% on a 40% Venturi mask. He was given IV furosemide and admitted to the MICU for further work up and management. He was ruled out for a cardiac event and there was no history of chest pain or arrythmia and CEs were stable and essentially normal (max 0.03 and stable in the setting of CRF) with a generally unchanged ECG. Echocrdiogram on [**2148-9-2**] showed a mildly dilated LA, mild LVH and a normal EF>55%, mild MR [**First Name (Titles) **] [**Last Name (Titles) 1192**] pulmonary hypertension which had increased since [**2146**]. While in the MICU, he continued to sat in the mid 90s on a 40% Venturi. He was started on empiric antibiotics (ceftriaxone and vancomycin) in the setting of a large R-sided pleural effusion seen on CXR of unclear etiology. On [**2148-9-2**], the patient underwent a thoracocentesis after which 1800ccs of exudative fluid was aspirated (results WBC 3444* HCt 2.5* Polys 46* Lymphs 23* Mono 4* Eos 8* Meso 4* Macro 15* Protein 4.6 Glc 140 LDH 337 pH 7.38). After the thoracocentesis, his symptoms improved dramatically and his O2 requirement decreased over the next 24 hours to 2L NC. He had a CT-chest which showed the large right pleural effusion which was new since [**2148-7-8**], emphysema, healed rib fractures and more worryingly, a mixed solid and ground-glass left lower lobe nodule, concerning for bronchoalveolar carcinoma with a central adenocarcinoma but which has been stable since [**2148-7-8**] but enlarged since [**2147-3-9**]. His antibiotics were stopped given normal WBCs and no evidence of fevers. Blood cultures were negative. He was not diuresed any further. He was transferred to the medical floor on [**2148-9-4**] where he continued to be generally at his baseline. On discharge, there was still a large right-sided effusion present both clinically and radiologically. Prior to discharge, he was restarted on his home furosemide. His nodule will be followed up by his PCP and will likely require biopsy. His pleural effusion will likely re-accumulate and this may necessitate a further aspiration in the future. The cause of his right pleural is unclear as the effusion was not present on CT in [**2148-6-20**]. Possible causes of this exudative effusion include 1) A malignant effusion given the left lower lob nodule although this has been present since [**2146**] but latterly stable this year. Of note, the pleural fluid cytology showed no malignant cells. His PCP was informed about the nodule by the gerontologists and will follow-up this in the community. 2) an inflammatory effusion given recent hemothorax following rib fractures 3) a parapneumonic effusion although WBCs were normal throughout his stay and sputum was negative (NB no culture or gram stain seem to have been done on pleural fluid). An effusion due to CHF is less likely given the exudative nature. . # Chronic Renal Failure: Remained at baseline despite diuresis. His renal function was monitored daily and had strict Input/Output measured. Given previous renal cysts, he had an U/S renal tract which showed multiple simple renal cysts bilaterally and no evidence of frank malignancy in addition to a persistent large right pleural effusion. . # Anemia: Hb around 8 in hospital as opposed to 9 which was his baseline. there were no signs of active bleeding. He had previous low Fe and high haptoglobin. His PCP can consider further investigations as an out-patient. . # Diabetes: His glipizide was held while in house and received an insulin sliding scale while in hospital. His normal regime was restarted on discharge. . #.Parkinson's Disease: This remained at baseline in house. We continued memantine, carbidopa/levodopa in addition to donepezil. Given his worsening PD symptoms over several months and several falls including one which resulted in significant injury when he sustained several rib fractures a neurology review will be organised as an out-patient in case his PD treatment can be further optimised. . #.Hypertension: We continued Lisinopril and while in house received Metoprolol Tartrate 12.5mg [**Hospital1 **] which was changed to Metoprolol Succinate 25mg qd on discharge. Medications on Admission: Allopurinol 100 daily Donepezil 10 mg qhs Memantine 10 mg daily Carbidopa-Levodopa 25-100 mg One QID Glipizide 5 mg [**Hospital1 **] Gabapentin 300 daily Simvastatin 30 mg DAILY Mirtazapine 30 mg qhs Omeprazole 20 mg DAILY Atenolol 25 daily Lisinopril 7.5 daily Tylenol prn oxycodone prn Finasteride 5 mg qhs lasix 20 mg daily Fluticasone 50 mcg , 1 spray per day Ipratropium Bromide 2 puffs QID Albuterol prn Tramadol 25 mg PO Q6H prn pain Benefiber 1 powder [**Hospital1 **] Astelin 2 sprays [**Hospital1 **] [**Last Name (un) 7139**] 128 eye ointment daily Calcium 500 [**Hospital1 **] Cholecalciferol 1000 units daily MVI Discharge Disposition: Home With Service Facility: [**Hospital1 100**] Senior Life Discharge Diagnosis: Primary Diagnoses: Large right pleural effusion - exact cause uncertain Congestive cardiac Failure . Secondary diagnoses: Parkinson's disease Type 2 Diabetes Mellitus complicated by neuropathy on neurontin Diplopia Hypertension Chronic Kidney Disease (baseline creatinine 1.4-1.6) Migraines s/p Silent MI [**57**] yrs ago s/p cataract [**Doctor First Name **] bilat s/p laminectomy in [**2089**] multiple right sided rib fracture after fall on [**7-8**] (no surgical intervention) Treated for a Pneumonia mid-[**2148-6-20**] with levofloxacin Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: It was a pleasure looking after you during your stay at the [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **]. You presented to the [**Hospital1 18**] with increasing shortness of breath and a productive cough. Your PCP had [**Name9 (PRE) 60251**] treated you for possible pneumonia with antibiotics and also treated you for worsening heart failure with furosemide and home oxygen. Despite these, your symotoms worsened and you required admission to the ED. There, you were treated with further furosemide (lasix) to treat fluid on the lung (pulmonary edema) due to your heart failure and due to your oxygen level being low, you were transferred to the Intensive Care Unit for observation and further investigation. You were found to have a large amount of fluid in the right side of your chest and this was drained by insertion of a needle into your chest. Following this procedure, you felt much better and your shortness of beath in particular was dramatically improved. You were briefly treated with antibiotics and these were stopped as your blood tests showed no evidence of infection and you did not have any fevers. You were stable on the intensive care unit and were stable enough to transfer to the medical [**Last Name (un) 5355**]. There, you were stable and felt well enough to go home. You were assessed by Physical Therapy who felt that you would be safe to go home with your current package of care in addition to oxygen. You will be followed up by your PCP. [**Name10 (NameIs) **] to the cause of your fluid in your chest, the exact cause is uncertain however it is likely due to irritation of the lining of the lung following blood in the chest after your rib fractures. Also it is possible that a resolved infection may have contributed in combination with worsening heart failure. . In addition, you had noted worsening of your Parkinson's Disease and have felt unsetady on your feet and this has resulted in falls during which you have injured yourself. Most notably, you sustained rib factures after your last fall which required you to be admitted to hospital back in [**Month (only) 205**]. To see if we can improve your Parkinson's symptoms, we are in the process of organizing a follow-up with neurology. Changes to medications: We stopped your atenolol and changed this to metoprolol succinate at 25mg once daily . Patient instructions You still have fluid in the right side of your chest that remains following the drainage. If you feel more short of breath you should seek medical attention. If you have any fevers you should also seek medical attention as you may require antibiotics. There is also the chance that the fluid in your chest will re-accumulate. You will be monitored by your PCP. Followup Instructions: You should see your PCP within the next week. We are working on a follow up appointment in our Neurology Movement Disorders Department. The office will be calling your son on [**Name (NI) 766**] to help book an appointment within 1 month.

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Discharge summary

report

Admission Date: [**2164-4-10**] Discharge Date: [**2164-4-27**] Date of Birth: [**2114-1-16**] Sex: M Service: MEDICINE Allergies: Iodine / IV Dye, Iodine Containing Contrast Media / Penicillins / flu shot / Remeron / Zoloft Attending:[**First Name3 (LF) 2186**] Chief Complaint: Abdominal pain, anorexia Major Surgical or Invasive Procedure: J tube placement History of Present Illness: This is a 50 year old man with previous history of substance abuse and chronic pancreatitis with previous pancreatic necrosis who is admitted with increased abdominal pain, anorexia, and weight loss. The patient reports approximately one month of increased chronic abdominal pain. This is diffuse to his perception. Nothing in particular makes this better or worse and patient reports that in particular eating (of clears, which is almost all he has been taking in) does not seem to clearly worsen this. He denies any nausea or vomiting. He has chronic anorexia and reports he has been not eating much of anything except clears over the past weeks. He does not relate this directly to pain just saying solid food is extremely unappealing to him. He has been working on this with his PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **] who has attempted trials of increasing his PPI and dronabinol without much effect. He has been steadily losing weight though is not able to well quantify how much. Of note, patient has recently relapsed in his alcoholism and reports most recently drinking approximately 1.4 pint of vodka a day. His last drink was this morning when he had two vodka shots. He denies any fevers, chills, night sweats. Not much nausea nd no vomiting. Denies dysuria. He does endorse a productive cough over the past week with green sputum but no fevers or dyspnea. No chest pain. Today he had a visit with his PCP who sent him for evaluation in [**Location (un) 620**] ED. His vital signs were stable there but labs were notable for a lactate of 6 and lipase of >900. He had no signs of organ hypoperfusion, however, so he was sent here after being seen by surgery there given his complexity and plan for an ERCP tomorrow for reassessment of a metallic stent in place. In our ED all vital signs were stable. He received 50 mg of prednisone for presumption of need for abdominal imaging. He was admitted to the floor. Currently, he reports abdominal pain is [**8-10**] severity. His mouth is very dry. He denies other complaints. ROS: Positive per HPI. Otherwise full review of systems performed and unremarkable. Past Medical History: -severe necrotizing alcoholic pancreatitis -chronic alcoholic pancreatitis -? IPMN -History of splenic vein thrombosis -CBD stricture s/p ERCP with stent placement (most recently metal stent due to multiple restenosis) -malnutrition with previous percutaneous J tube (not since end of [**2163**] - discontinued due to pain and the tube getting blocked reportedly due to inadequate flushing.) -depression -anxiety -GERD with Barrett's esophagus -DM -Spinal stenosis -History of polysubstance abuse (alcohol, cocaine, benzos) -Reports history of complicated alcohol withdrawal with DTs and seizures -history of substance and bacteremia Social History: History of alcohol abuse, marijuana abuse, cocaine use, benzodiazepine abuse. 50+ pack year smoker, still smoking two packs per day. Recent alcohol use [**1-4**] pint per day of vodka. Family History: Denies family history of gastrointestinal disorders or pancreatitis. Physical Exam: VS: T 98.5, P 81, BP 115/91, RR 18, O2 99% on RA Appearance: cachectic, pale middle aged man in NAD Eyes: EOMI, Conjunctiva Clear ENT: Extremely dry appearing, no ulcers or lesions appreciated CV: [**Last Name (un) **], normal S1 and S2; no murmurs/rubs/gallops; no lower extremity edema; PIV for vascular access Respiratory: Clear to auscultation bilaterally with no wheezes, rhonchi, or rales GI: Scaphoid abdomen with small circular scar in left upper quadrant (old GJ site), Diffusely tender to palpation most in epigastrum and RUQ; no guarding or rebound, bowel sounds +; no hepatomegaly or splenomegaly appreciated but exam somewhat limited by tenderness MSK: Globally diminished bulk; Upper Extremity Strength 4/5 and symmetrical; no cyanosis / No clubbing / No joint swelling Neuro: Normal attention; Fluent speech Integument: Warm, Dry, no rash Psychiatric: Appropriate, pleasant Hematologic / Lymphatic: No Cervical [**Doctor First Name **], Thyroid WNL Pertinent Results: ================== LABORATORY RESULTS ================== OSH Labs Na 134, K 3, Cl 93, HCO3 30.2, BUN 4, Cr 0.9, Glu 260 WBC 10, Hb 13.3, Hct 41.6, Plt 446 ALT 42, AST 56, TBili 0.28, AlkPhos 238 Lactate 6 Lipase 967 EtOH 206 etoh 206 UA: Glucose >500, Bld-Trace, Otherwise WNL Urine tox: +BZD, +THC, +Opioids; otherwise negative Admit Labs: [**2164-4-10**] 09:05PM GLUCOSE-224* UREA N-4* CREAT-0.5 SODIUM-137 POTASSIUM-4.4 CHLORIDE-100 TOTAL CO2-29 ANION GAP-12 [**2164-4-10**] 09:05PM ALT(SGPT)-24 AST(SGOT)-75* LD(LDH)-161 ALK PHOS-172* TOT BILI-0.3 [**2164-4-10**] 09:05PM CALCIUM-7.8* PHOSPHATE-3.6 MAGNESIUM-1.6 [**2164-4-10**] 09:05PM WBC-8.4 RBC-4.20* HGB-11.3* HCT-35.9* MCV-86 MCH-26.9* MCHC-31.4 RDW-19.3* [**2164-4-10**] 09:05PM PLT COUNT-475* [**2164-4-10**] 09:05PM PT-12.3 PTT-31.2 INR(PT)-1.1 ============== OTHER RESULTS ============== Chest Radiograph [**2164-4-10**]: Right lower lobe opacities are likely atelectasis. There is no pneumothorax or pleural effusion. Cardiac size is normal. . [**2164-4-11**] ABD US: IMPRESSION: 1. Heterogeneous and edematous appearance of the pancreatic head with multiple calcifications is highly suggestive of acute on chronic pancreatitis. A neoplastic process is less likely given that the pancreatic duct is not dilated. If clinically indicated, further assessment with CT or MR could be pursued. 2. Pneumobilia and gallbladder gas might be related to common bile duct stent. . [**2164-4-13**] MRCP: IMPRESSION: 1. Mild left intrahepatic duct dilation, which is unchanged from previous ultrasound. Biliary stent in situ within the distal CBD which limits evaluation of the CBD. The CBD proximal to this does not appear dilated. 2. Diffusely enlarged pancreatic head and uncinate process with multiple small phlegmonous areas which are increased in size from previous CT. Findings in keeping with known pancreatitis. 3. Significant duodenal wall thickening with luminal narrowing. 4. 3.7-cm partially necrotic portacaval lymph node with other notable retroperitoneal lymph nodes. 5. Small amount of intra-abdominal ascites. 6. The SMV is not visualized and is probably obliterated by surrounding inflammatory process. This is a new finding. . 4/15/12CXR: FINDINGS: In comparison with the study of [**4-10**], the patient has taken a better inspiration. There is no evidence of acute pneumonia or vascular congestion. Brief Hospital Course: 50 year old man with history of chronic pancreatitis and necrotic pancreatitis presenting with increased abdominal pain, anorexia with malnutrition, weight loss and failure to thrive. He also recently began drinking again and developed acute on chronic pancreatitis. Hospital course was complicated by transfer to the ICU for EtOh withdrawl. # Acute on chronic pancreatitis: Patient had abdominal pain and significant anorexia with a lipase >900 in the context of chronic pancreatitis most consistent with acute pancreatitis. [**Last Name (un) **] score was [**1-2**] indicating low risk of mortality at this time and appropriate for initial admission to floor. Bili is negligible and strongly suspect that etiology of recurrence of acute pancreatitis is continued alcohol abuse. Case discussed with surgery consult. Pt received antibiotics at OSH but no clear source of infection and these were stopped. Surgery recommended keeping patient NPO, continuing IVF and providing supportive care (including optimizing nutrition). Given his contrast allergy, he was prepped for a CT scan with prednisone but surgery did not feel any further imaging was necessary. Given his history of a CBD stent, he was evaluted by the ERCP team who recommended MRCP, which was performed on evening of [**2164-4-13**]. MRCP showed some areas of phelgmonous changes consistent with known pancreatitis. There was significant duodenal wall thickening with luminal narrowing but not obstruction. Attempts to advance the patient's diet were unsuccessful. He was severely malnourished on presentation and ultimately [**Date Range 1834**] J tube placement. See below. His pain was managed with oxycodone which he required q 3 hours. In discussion with his PCP, [**Name10 (NameIs) **] was started for longer term relief. The patient reported some improvement in his pain. The aim was to eventually wean off the oxycodone and the marinol as well. The patient was also evalauted for malabsorption with fecal elastase and fecal fat which were both unremarkable. # Malnutrition, severe with anorexia; The patient's malnutrition was likely multifactorial [**2-2**] anorexia due to continued pancreatitis, alcoholism and depression. Patient appears cachectic. Nutrition was consulted, and gave recommendations about starting D5W at 50 cc/hr given concern patient at risk for re-feeding syndrome. GI did not recommend PICC placement for TPN, and also did not feel that starting tube feeds again was warranted. They felt the best option was to encourage PO intake with supplementation as patient can tolerate. Calorie count was started and was not taking in sufficient calories. After extensive conversation with the pt and family, as well as discussion with his PCP and GI, it was decided that the best way to provide nutrition to Mr.[**Known lastname 77312**] was via a Jtube. He had a GJ tube placed in the past and had complications from it, but as he was not a good candidate for TPN (given psych and substance abuse history and risk of line infection), and as nutrition is ideally given enterically in pancreatitis, we felt the benefit far outweighed the risks and he [**Known lastname 1834**] IR guided J Tube placement on [**4-23**]. During his hospitalization he did advance his diet to solids but he had persistent pain, so it was restarted on clears and then advanced to clears. He is taking full liquids with glucerna shakes. He will require J-tube feeds overnight - 12 hours - with Peptamen 1.5 at 100 cc/hr. His discharge weight was 53.2 kg with a BMI of 17. He was repleted with lytes PRN . # Hypotension - After transfer to the floor, the patient had an episode of hypotension 64/40 on [**4-15**] that responded to IVF. The patient had a broad work up for this and it showed a normal lactate, normal cortisol, clear CXr. UA was unremarkable. He was started on meropenem for coverage of pacnreatic necrosis and biliary flora. Cultures remained negative and it was d/ced on [**4-20**]. . # Alcohol abuse/Dependence: Last drink morning of admission and EtOH level was 206. He was placed on a CIWA scale with diazepam. Due to increasing benzo requirements, he was transferred to the ICU for further monitoring. He was transferred back to the floor on [**4-14**]. Extensive discussions with psych and Social work was initiated to help Mr. [**First Name (Titles) 77313**] [**Last Name (Titles) 77314**] healthier dynamics in both familial and colleague relationships. There is are extensive patterns of difficulties with confrontation and manipulative behaviors (including with the pt's AA sponsor). Please see social work notes regarding this. The patient himself is highly dependent and still lives at his parents house - relying on quick fixes to relieve any anxiety/depression. The mother's brother committed suicide and the fear of her children committing similar acts continue to underly the mother's difficulty in confronting difficult situations. Despite an extensive social work meeting with the patient and the family, it was unclear whether this dynamic will change. . # Depression Patient was evaluted by psychiatry who recommended medical/alcohol rehab, continuing citalopram and minimizing benzos. . # Diabetes Mellitus: pt was placed on insulin sliding scale and started on lantus as his AM sugars were consistently elevated. . # Transitional issues -follow up blood cultures, fecal fat and elastase -J tube placed Medications on Admission: citalopram 10 mg PO daily dronabinol 2.5 mg by mouth twice a day Lipase-Protease-Amylase 5,000 unit-[**Unit Number **],000 unit-[**Unit Number **],000 unit Capsule, Delayed Release(E.C.) by mouth three times a day lisinopril 5 mg by mouth once a day Lorazepam 0.5 mg Q afternoon and 1 mg QHS pantoprazole 40 mg by mouth twice daily trazodone 150 mg Tablet by mouth at bedtime aspirin 81 mg by mouth once a day nr B complex vitamins [B Complex] cholecalciferol multivitamin Discharge Medications: 1. lorazepam 1 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). Disp:*15 Tablet(s)* Refills:*0* 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 3. lipase-protease-amylase 5,000-17,000 -27,000 unit Capsule, Delayed Release(E.C.) Sig: One (1) Cap PO TID (3 times a day). 4. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. ipratropium-albuterol 18-103 mcg/actuation Aerosol Sig: [**1-2**] Puffs Inhalation [**Hospital1 **] (2 times a day). 6. [**Hospital1 **] 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. 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* 8. insulin glargine 100 unit/mL Solution Sig: Fifteen (15) units Subcutaneous at bedtime. Disp:*1 month supply* Refills:*0* 9. oxycodone 5 mg/5 mL Solution Sig: Five (5) mg PO every eight (8) hours as needed for abdominal pain. Disp:*50 mg* Refills:*0* 10. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp:*20 Patch 24 hr(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 **] VNA Discharge Diagnosis: acute on chronic pancreatitis alcohol withdrawl malnutrition Discharge Condition: Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent, no assistance devices needed. Nutritional status: significantly malnourished, BMI 17, 53.2 kg Discharge Instructions: You were evaluated for abdominal pain and found to acute on chronic pancreatitis. You also were in the ICU for alcohol withdrawl. You [**Hospital1 1834**] Jtube placement and initiated tube feeds. Followup Instructions: You should follow up with your PCP 2-3 weeks. You should follow up with gastroenterology for further discussion regarding a repeat ERCP. You were scheduled for one this month but missed your appointment.

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icd9cm

[ [ [] ] ]

[ "96.6", "46.39" ]

icd9pcs

[ [ [] ] ]

14130, 14181

6955, 12392

381, 400

14286, 14472

4542, 6932

14719, 14928

3472, 3542

12919, 14107

14202, 14265

12418, 12896

14496, 14696

3557, 4523

316, 343

428, 2594

2616, 3251

3267, 3456

11,037

187,352

53216

Discharge summary

report

Admission Date: [**2126-11-13**] Discharge Date: [**2126-11-28**] Date of Birth: [**2074-9-2**] Sex: F Service: Medicine HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old female with no known cardiopulmonary history who presented with a chief complaint of dyspnea on exertion as well as exertional chest tightness which was acute-on-chronic. The patient stated her symptoms began in [**2123**] and have increased in intensity and frequency every since then. She reports dyspnea on exertion and chest tightness daily which worsened significantly one day prior to admission. Says that she could not walk a few yards without developing symptoms. She describes the chest tightness as substernal and epigastric. She denied any associated nausea, vomiting, diaphoresis, lightheadedness, or dizziness. She does have radiation of the pain to her neck and jaw bilaterally. She also describes a fast heart rate and palpitations. She stated her symptoms improved with rest, and she denied any symptoms beginning when she was at rest. The patient reports a previous workup which included a negative exercise treadmill test, a normal MIBI in [**2123-3-21**], and a normal echocardiogram in [**2124**] (except some borderline mild pulmonary hypertension) with an ejection fraction of 55%. REVIEW OF SYSTEMS: Review of systems was significant for menopausal symptoms (for which she has attempted hormone replacement therapy, discontinued in [**2126**]). She also reports difficulty sleeping, daytime sleepiness. She sleeps on elevated pillows secondary to her gastroesophageal reflux disease. Occasional paroxysmal nocturnal dyspnea in the past but none recently. Occasional lower extremity edema, left greater than right. No abdominal or urinary complaints. PAST MEDICAL HISTORY: 1. Gastroesophageal reflux disease. 2. Grave's, status post radiation resulting in hypothyroidism. 3. Migraines. MEDICATIONS ON ADMISSION: Synthroid, Prilosec 20 mg p.o., Fioricet, Celebrex. ALLERGIES: PENICILLIN causes a rash. FAMILY HISTORY: Diabetes, Grave's disease, but no history of cardiopulmonary disease. SOCIAL HISTORY: The patient lives with her husband, and they have no children. She denies any tobacco or alcohol history. She does use herbal remedies including Primrose oil, Siberian ginseng, and has a history of use of wallerian root. PHYSICAL EXAMINATION ON PRESENTATION: Vital signs were temperature of 98.4, heart rate 74, blood pressure 130/91, respiratory rate 21, satting 98% on room air. HEENT revealed pupils were equally round and reactive to light. The oropharynx was clear. Neck was supple, no lymphadenopathy, no thyromegaly, no jugular venous distention, and no bruits. Lungs had scant crackles at the left base and middle field; otherwise clear. Cardiovascular had a regular rate and rhythm. No murmurs. No fourth heart sound or third heart sound. No parasternal heave. Gastrointestinal revealed soft, nontender, and nondistended. No hepatosplenomegaly. No masses. No bruits. Normal active bowel sounds. Extremities had no edema, 2+ distal pedis. Neurologically, grossly nonfocal. LABORATORY DATA ON PRESENTATION: At the time of admission, white blood cell count 11.1, hematocrit 37.7, platelets 326. Sodium 140, potassium 4, chloride 105, bicarbonate 28, BUN 17, creatinine 0.8, glucose 76. Creatine kinase 100, MB 4, troponin of less than 0.3. RADIOLOGY/IMAGING: Electrocardiogram revealed left atrial hypertrophy, right ventricular hypertrophy, and poor R wave progression which were new. Also, T wave inversions in II, III, aVF, V1 through V5; new evolving right bundle-branch block. HOSPITAL COURSE: The patient is a 52-year-old female with no known history of cardiac disease presenting with dyspnea on exertion and chest tightness, who was admitted for evaluation and management of her symptoms. 1. CARDIOVASCULAR: The patient was admitted for complaints of dyspnea on exertion and chest pressure which could be consistent with angina. However, given the long duration of the symptoms and negative workup in the past, it was thought to be unlikely. However, the patient was started on an aspirin as well as a beta blocker, and a rule out myocardial infarction protocol was initiated. A stress thallium was planned for the day following admission. However, on the night of admission the patient was found lying in her bed diaphoretic and obtunded, and a code was called. Further examination revealed a strong palpable pulse with a systolic blood pressure in the 130s and a heart rate in the 80s. Over the course of the next few minutes the patient became increasingly more responsive. She was treated with a fluid bolus. The patient quickly responded to a fluid bolus and became interactive. She reported that she was sitting on the commode urinating and began to feel nauseous and presyncopal. She was able to get to bed at which point she passed out. She denied any chest pain or pressure, and no shortness of breath during this event. A rhythm check obtained during the time of this event demonstrated a pause of six seconds followed by a junctional escape rhythm. An electrocardiogram obtained after the code demonstrated no acute changes. Her acute bradycardic event was felt likely secondary to her new beta blocker in conjunction with a vagal response. It was determined to stop the beta blocker, and atropine was placed at the bedside. On the following day the patient underwent an echocardiogram which demonstrated dilated right ventricle secondary to chronic dysfunction and a pulmonary artery pressure of greater than 100. Her stress test was cancelled. A CT angiogram was ordered to evaluate for chronic thromboembolic disease as a potential cause of her pulmonary hypertension. She was ruled out for myocardial infarction with three sets of normal enzymes and continued to be monitored on telemetry. A Pulmonary consultation was obtained to evaluate for possible etiology of the patient's hypotension. There was little evidence to suggest any cardiac disease, and given the patient's Grave's disease an autoimmune process was felt to be possible. In addition, consideration was given to sarcoidosis, human immunodeficiency virus, and drug-induced given her history of herbal medication use. It was recommended that the patient begin anticoagulation given the severity of her pulmonary hypertension. It was also planned to undergo a right heart catheterization with a vasodilation trial by the catheterization laboratory. A right heart catheterization was performed on [**2126-11-15**]. A pharmacologic pulmonary vasodilator challenge was performed with a positive response. In addition, a CT angiogram of the chest with pulmonary embolism protocol showed no intravascular filling defect but did show a right upper lobe ground-glass and scattered adenopathy. Therefore, in the end left atrial hypertension was essentially ruled out as a primary cause. Chronic pulmonary embolus was less likely given her negative CT angiogram. Chronic lung disease was unlikely given the patient's normal pulmonary function tests and DLCO in [**2124**] as well as a normal CT angiogram. Collagen vascular disease could not be definitively ruled out; however, given the patient's lack of connective tissue disorder stigmata it was thought to be less likely, and the patient's human immunodeficiency virus test was negative. Therefore, it was felt that the patient was most likely experiencing a primary pulmonary hypertension. Consideration was given to treating the patient with a course of calcium channel blocker; however, given the patient's poor response to Lopressor, it was determined that this would not be optimal treatment for the patient's pulmonary hypertension. Therefore, her insurance company was contact[**Name (NI) **] regarding the potential of Flolan as a treatment. Plans were made for placement of a Hickman catheter and initiation of Flolan treatment. However, on [**11-17**], the patient once again experienced an episode of unresponsiveness. Upon arrival by the physician the patient was awake, alert, and oriented with a pulse in the 80s, with pressure in the 80s, and satting 100% on room air. She described this episode as an uncomfortable feeling in her chest. The patient was treated with 2 liters of intravenous fluids with a bump in her systolic blood pressure to the 90s. Review of telemetry revealed an 8 to 9 beat episode of nonsustained ventricular tachycardia followed by an episode of bradycardia to 60 beats per minute. The etiology of these cardiovascular episodes was unclear, but was felt likely secondary to the patient's tenuous cardiovascular status given the fact that she had clear pulmonary hypertension, was very preload dependent, and had an intact left ventricular function but with cardiac output limited due to left ventricular compression by a dilated left ventricle. Given the patient's persistent hypotensive episodes, and decreased urine output, she was transferred back to the Medical Intensive Care Unit for management prior to initiation of Flolan therapy. On [**11-18**], the Hickman catheter was placed in preparation of Flolan administration. During the [**Hospital 228**] Medical Intensive Care Unit stay, the patient was found to exquisitely preload dependent and responded well to aggressive fluids as needed to maintain her blood pressure with a systolic of greater than 90. She had no further episodes of bradycardia during her Medical Intensive Care Unit stay. In addition, the patient's urine output improved dramatically with hydration therapy, suggesting her low urine output was secondary to decreased cardiac output secondary to low preload. The patient continued to be followed by the Electrophysiology Service, who determined that the patient was demonstrating severe vasal sensitivity with bradycardia necessitating pacemaker placement. This was to be deferred until after the patient had her Hickman in place. Because the patient's pulmonary pressures responded so well to adenosine during right heart catheterization, it was thought that the patient would be a good candidate for Flolan therapy. Flolan was initiated on [**11-18**] at 5 nanograms per kilogram per minute. The patient was monitored for symptoms of Flolan therapy including nausea, vomiting, first bite jaw claudication, or hypotension. Over the course of the hospital stay the patient's Flolan dose was titrated to receive maximum benefit without precipitating symptoms of Flolan overdose. The patient was felt to be stable on her current Flolan dose and was therefore transferred back to the floor. A high resolution CT was requested to further evaluate for possible secondary cause of her primary pulmonary hypertension; however, the patient refused it at this time. Plans for placement of a pacemaker were initiated. However, on the night prior to the planned surgical date the patient suffered an episode of bleeding from her Hickman catheter site. Surgery was notified and pressure was applied; however, it did not stop oozing. A surgicel dressing was placed and prolonged pressure resulted in resolution of the bleeding. In addition, an extra stitch was placed in an effort to stop the bleeding. Following this episode the patient felt like she was "too stressed" for pacemaker placement. Therefore, she was monitored over the next few days for any further bleeding events. Over the course of the next few days the patient became more accustomed to her Flolan, and Flolan teaching was continued. She continued to have occasional episodes of dizziness, shortness of breath, and hypotension whenever the alarm sounded suggesting that the Flolan bag needed to be changed. However, over the course of the hospital stay these decreased both in frequency and severity. On [**11-25**], the patient went for placement of a pacemaker. She had dual-mode, dual-pacing, dual-sensing pacemaker placed with a lower rate at 60 ppm, and upper rate of 120 ppm with a paced AV of 150 msec. The patient recovered well from her surgery for pacemaker placement. At the time of discharge, the patient was tolerating her Flolan therapy well. She had received a full course of Flolan teaching and reported that she and her husband felt comfortable with the administration of the medication at home. She was set up with a primary pulmonary hypertension support group, and home services were arranged to help her in the initiation of Flolan therapy. Following pacemaker placement the patient had no further episodes of bradycardia on telemetry, and therefore she was discharged in satisfactory condition. 2. INFECTIOUS DISEASE: The patient had no signs or symptoms of infection at the time of admission. However, she was noted to have a relatively elevated white blood cell count that remained stable over the course of her hospital stay. However, near the end of her hospitalization the patient began describing increased urinary frequency which persisted once her Foley catheter was removed. A urinalysis was positive and urine culture grew enterococcus which was pan sensitive. Therefore, the patient was started on levofloxacin therapy to complete a 10-day course. Following initiation of the antibiotic the patient's white blood cell count quickly came down, and she remained afebrile. At the time of discharge, the patient still had a mildly elevated white blood cell count but was asymptomatic with a normal temperature. She will complete two more days of Levaquin therapy as an outpatient. 3. RENAL: The patient's BUN and creatinine were followed over the course of her hospital stay. These remained stable and within normal limits. It was felt that the decreased urine output was secondary to her preload dependence, and that her urine output increased significantly when she was adequately hydrated in the Medical Intensive Care Unit. 4. GASTROINTESTINAL: The patient has a history of gastroesophageal reflux disease. She was continued on Protonix over the course of her hospital stay and had no further gastrointestinal issues. 5. HEMATOLOGY: The patient's hematocrit remained stable over the course of her hospital stay. Despite bleeding from the Hickman site, she did not require any transfusion therapy. 6. FLUIDS/ELECTROLYTES/NUTRITION: The patient tolerated a regular diet throughout the course of her hospital stay. Her electrolytes were checked on a daily basis and remained within normal limits, being replaced as needed. She was discharged to home on a regular diet. 7. ENDOCRINE: The patient with a history of hypothyroidism. She was continued on her regular Synthroid dose. She will need a TSH and T4 checked as an outpatient. 8. CODE STATUS: The patient is a full code. 9. FLOLAN ADMINISTRATION: At the time of discharge, the patient was tolerating a Flolan dose of 5 nanograms per kilogram per minute. A Physical Therapy consultation was obtained to initiate a 6-minute walk test. On room air, the patient's oxygen saturation was 95% and dropped to 88% following a 6-minute walk. The patient was discharged to home with appropriate Flolan teaching and supplies. She was to follow up with Dr. [**Last Name (STitle) **] in the Clinic the following week. CONDITION AT DISCHARGE: The patient was stable. DISCHARGE STATUS: She was discharged to home. DISCHARGE FOLLOWUP: She has follow up with Dr. [**Last Name (STitle) 4127**] in the Clinic on Monday, [**12-2**], at 2:30 p.m. to check her INR and digoxin level. She also has follow up with Dr. [**Last Name (STitle) **] in the Pulmonary Clinic on [**12-5**] at 12:15 p.m. for management of her pulmonary hypertension. MEDICATIONS ON DISCHARGE: 1. Coumadin 2 mg p.o. q.6h. 2. Tylenol No. 3 one to two tablets p.o. q.4h. p.r.n. for pain. 3. Digoxin 0.125 mg p.o. q.d. 4. Levofloxacin 500 mg p.o. t.i.d. times two days. 5. Protonix 40 mg p.o. q.d. 6. Tylenol 650 mg p.o. q.4-6h. p.r.n. for fever or pain. 7. Synthroid 125 mcg p.o. q.d. 8. Colace 100 mg p.o. q.d. 9. Lactulose 30 cc p.o. q.6h. p.r.n. for constipation. 10. Flolan 5 nanograms per kilograms per minute, continuous infusion. 11. Oxygen per nasal cannula as needed. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**] Dictated By:[**Name8 (MD) 8860**] MEDQUIST36 D: [**2126-11-28**] 18:32 T: [**2126-12-1**] 10:44 JOB#: [**Job Number 109561**] (cclist)

[ "416.0", "346.90", "599.0", "530.81", "997.1", "244.9", "443.0", "041.04" ]

icd9cm

[ [ [] ] ]

[ "37.23", "88.57", "37.72", "38.93", "37.83" ]

icd9pcs

[ [ [] ] ]

2061, 2132

15732, 16510

1952, 2044

3679, 15294

15309, 15382

1330, 1786

15404, 15705

167, 1309

1808, 1925

2149, 3660

10,511

137,774

13262

Discharge summary

report

Admission Date: [**2115-5-29**] Discharge Date: [**2115-6-17**] Date of Birth: [**2049-8-3**] Sex: F Service: MEDICINE Allergies: Morphine / Oxycontin / Percocet Attending:[**First Name3 (LF) 465**] Chief Complaint: Unresponsive, hypoglycemic Major Surgical or Invasive Procedure: Intubation and mechanical ventilation x 2 PICC line placement and removal History of Present Illness: 65 y/o female with a h/o T2DM, HTN, and PVD who was found down by home health aid. EMS was called and patient's blood sugar was found to be 12. She had an IV placed in her left shin and received glucagon and 1 amp D50 as well as thiamine. Her BS increased to 202 and patient became more responsive. When she arrived to the ED, she had copious secretions and was satting 100% on RA but she was intubated in the ED because it was felt she could not protect her airway. CXR was done which was consistent with asymetric CHF vs. an infectious process such as aspiration PNA. Patient received a dose of vanc/flagyl/levo in the ED. . In the ICU, she was extubated on HOD #2 but re-intubated several days later for hypoxemic respiratory failure, possibly from bilateral upper-lobe PNA vs BOOP. She was treated with steroids and received a course of Vanc/Zosyn and was extubated approx 2 days later. At time of transfer to the floor, her O2 sats were 99% on 2L. BP had been difficult to control and was on NTG gtt briefly. She also became hyperglycemic requiring an insulin gtt but was transitioned to SC insulin. . She was transferred to the medical floor hemodynamically stable. Past Medical History: Gout T2DM since [**2080**], using insulin since [**2089**]. Osteoarthritis Hypertension "Temporary paralysis", ? TIA vs CVA Left parietal lacunar stroke in [**2106**] causing right hemiparesis Cholecystectomy Cervical cancer, s/p TAH Chronic renal failure (baseline creatinine 1.8-2.0) Diabetic retinopathy Planum sphenoidale meningioma Social History: She does not smoke cigarettes or drink alcohol. Family History: NC Physical Exam: Upon arrival to MICU: T 99.8 BP 161/68 HR 78 RR 30 AC 500x14 PEEP 5 FiO2 100% Gen: Sedated Heent: ETT and and OG tube in place Lungs: Vent airway noise Cardiac: RRR S1/S2 no murmurs Abd: obese, soft, +bs Ext: Left IO IV in place Neuro: Sedated Pertinent Results: Labs: . Micro: Multiple Blood cultures - negative Urine cultures - negative C. diff - negative x 4 C. diff Toxin B assay pending at time to discharge to rehab . Imaging: [**2115-5-30**]: CT head - No cranial hemorrhage, shift of normally midline structures, or evidence of acute major vascular territorial infarct is apparent. Mild-to-moderate periventricular white matter hypodensity predominates in the frontal lobes and is likely the sequelae of chronic small vessel infarction. Sulcal and ventricular prominence is likely related to age-related atrophy. Mucosal thickening involving several ethmoid air cells and the sphenoid sinus is noted. Surrounding osseous structures are unremarkable and no fracture is seen. . [**2115-5-30**]: TTE - The LA is normal in size. There is mild symmetric LVH. The LVcavity size is normal. Overall LV systolic function is normal (LVEF 70%). Tissue Doppler imaging suggests an increased LVfilling pressure (PCWP>18mmHg). Transmitral Doppler and tissue velocity imaging are consistent with Grade II (moderate) LV diastolic dysfunction. There is no VSD. RV chamber size and free wall motion are normal. The AV leaflets (3) are mildly thickened but AS is not present. No aortic regurgitation is seen. The MV leaflets are mildly thickened. There is no MV prolapse. Trivial MR is seen. There is moderate PA systolic hypertension. There is no pericardial effusion. . [**2115-6-4**]: CT Chest - 1. Diffuse bilateral airspace disease, upper lobe predominant, concerning for pneumonia. 2. Mediastinal lymphadenopathy, which may be reactive. 3. Left PICC line distal tip at the level of the left brachiocephalic vein. 4. Stable left adrenal thickening. 5. No acute inflammatory process within the abdomen or pelvis. 6. Heterogeneous thyroid, correlation with thyroid ultrasound is recommended in a nonemergent basis . [**2115-6-14**] CT Abdomen and Pelvis W/O Contrast No specific CT finding to explain patient's abdominal pain. Unchanged appearance of left adrenal thickening. Unchanged appearance of age-indeterminate compression deformity of the superior endplate of T12. . [**2115-5-29**] WBC-6.8 RBC-4.00* Hgb-10.4* Hct-31.7* MCV-79* MCH-25.9* MCHC-32.6 RDW-16.7* Plt Ct-170 [**2115-6-17**] WBC-10.3 RBC-3.30* Hgb-8.5* Hct-26.2* MCV-79* MCH-25.6* MCHC-32.3 RDW-18.3* Plt Ct-438 [**2115-5-29**] Glucose-132* UreaN-57* Creat-1.8* Na-140 K-4.2 Cl-107 HCO3-24 AnGap-13 [**2115-6-17**] Glucose-132* UreaN-33* Creat-1.7* Na-143 K-4.4 Cl-109* HCO3-26 AnGap-12 [**2115-6-14**] ALT-29 AST-42* LD(LDH)-300* AlkPhos-104 TotBili-0.1 [**2115-6-17**] Calcium-9.1 Phos-4.2 Mg-1.6 Brief Hospital Course: 65 y/o female with a h/o T2DM, PVD, and hypertension who was found down at home with a blood sugar of 12 complicated by aspiration PNA. She was initially intubated for airway protection with rapid extubation. However her intensive care course was further complicated by progressive respiratory distress thought secondary to hospital acquired pneumonia. She was subsequently transferred to the medical floor after improvement in her respiratory status. The following issues were addressed during this hospitalization. . 1. Hypoglycemia/T2DM The trigger to the pt's initial hypoglycemia was most likely an medication error as patient has a long standing h/o T2DM and takes insulin at home. Her blood sugars responded to glucagon and 1 amp D50. With monitoring the patient improved and slowly NPH was added. It was titrated up as tolerated to maintain excellent glycemic control. . 2. Respiratory distress The patient intubated in the ED for copious secretions and it was felt she would be unable to protect her airway. She was diuresed with lasix to improve pulmonary function. Patient was extubated successfully on [**2115-5-31**]. She was treated for 5 days with levo/flagyl for aspiration pna. The patient continued to have episodes of hypertension and flash edema. With CPAP and lasix she initially responded and her blood pressure meds were increased to prevent flash pulmonary edema. She required aggressive diuresis given her fluid overload. However, on [**6-4**] she continued to have worsening respiratory status and presumed ARDS secondary to HAP. She was intubated and treated with vanc/zosyn. Given CT scan, she completed 10 days total of vanc/zosyn. She was initially started on steroids for concern of BOOP, however these were rapidly tapered. Pulmonary was consulted and felt that her clinical picture was most consistent with pneumonia. She was changed to levofloxacin on [**2115-6-12**] and will complete a five day course. Pulmonary recommended an outpatient pulmonary follow up, CT chest 4-6 weeks, outpatient sleep study, and outpatient echocardiogram to assess for pulmonary hypertension. She will need continued pulmonary toilet upon discharge to acute rehab. . 3. Anemia Patient's anemia is [**2-15**] to iron deficiency anemia along with anemia of chronic disease. She had no evidence of bleeding. Her blood count was monitored and was stable. . 4. HTN The patient had persistently elevated blood pressures requiring a nitroglycerine drip initially. She continued on her outpatient anti-HTN medications: metoprolol, amlodipine, hydralazine, Imdur at increased doses where able. Her diuretic was held with regard to her acute on chronic renal failure as below. . 5. CAD/chest pain Patient had chest pain that seemed MSK given reproducibility but upsloping of ST in III and aVF was intially concerning for ischemia. However, she completed a rule-out for MI. . 6. Gout Patient has a history of gout. The patient remained on her allopurinol. She did experience a gout flare in her left foot and colchicine was added with success. She will be discharged to rehab on colchicine but it will be stopped once her flare resolves. . 7. CRI with ARF Patient admitted at baseline creatinine, which is most likely secondary to diabetic nephropathy. She developed ARF, with a normal renal US and lytes consistent with intrinsic renal failure. The patient's renal function worsened and was likely related to diuresis. She received IVF and improved. She is currently at baseline. . 8. Diffuse Abdominal pain/Diarrhea The pt developed some diffuse abdominal discomfort. She also developed some diarrhea. She was treated empirically for C.diff infection with Flagyl. Diarrhea resolved. Abdominal discomfort persisted. GI was consulted and agreed with treating for C. diff. She will finish her course of Flagyl at rehab. She has a known h/o gastroparesis [**2-15**] to her T2DM. she was started on Reglan with good effect. CT Abdomen/Pelvis were unrevealing and did not explain a cause for her abdominal discomfort on 2 different studies. . 9. Thyroid heterogeneity This was an incidental finding on a CT torso. TFTs were consistent with sick euthyroid. These imaging abnormality should be followed up as an outpatient with ultrasound and consideration for biopsy. . 10. Code: Full . 11. Comm: [**Name (NI) **] [**Name2 (NI) **] [**Telephone/Fax (3) 40393**] Medications on Admission: Allopurinol 100 mg po daily, amlodipine 10 mg po daily, aspirin 81 mg po daily, cacitriol 0.25 mcg po daily, Colace 100 mg po twice daily, folic acid 1 mg po daily, Humulin-N 45 units q a.m. and 25 units q bedtime, sliding scale Humulin-R during the day, hydralazine 50 mg po 4 times daily, HCTZ 25 mg po daily, Imdur 30 mg po daily, Lipitor 20 mg po daily, methotrexate 10 mg po weekly, metoprolol 50 mg po daily, multivitamin 1 tab po daily, Neurontin 400 mg po 3 times daily, Prilosec 40 mg po twice daily, Paxil 30 mg po daily, sorbitol po daily, Tramadol 50 mg po q 4 to 6 hours po prn. Discharge Medications: 1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Hydralazine 50 mg Tablet Sig: 1.5 Tablets PO Q6H (every 6 hours). 7. Isosorbide Dinitrate 20 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 8. Atorvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 10. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 11. Paroxetine HCl 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 13. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 14. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 16. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) nebulizers Inhalation Q4H (every 4 hours). 18. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer Inhalation Q4H (every 4 hours). 19. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 20. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 21. Loperamide 2 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed for diarrhea. 22. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 days. 23. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 2 weeks. 24. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Forty (40) units Subcutaneous qAM (in the morning. 25. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Fourteen (14) units Subcutaneous qPM (in the evening). 26. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: As per attached sliding scale units Subcutaneous three times a day. 27. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 28. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for Cough. 29. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Until resolution of acute gout attack in left foot. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 86**] Discharge Diagnosis: Hypoglycemia Type II Diabetes Chronic renal failure Acute renal failure Bilateral pneumonia Hypoxic respiratory failure requiring intubation/ventilation Diarrhea, possible c.diff infection ? gastroparesis Discharge Condition: The patient was discharged hemodynamically stable afebrile with appropriate follow up. Discharge Instructions: You were diagnosed with hypoglycemia, severe aspiration pneumonia, and presumptive c.dif colitis. You were treated with 2 weeks of Zosyn/Vancomycin(antibiotics) for your pneumonia and are being treated with Flagyl for presumed c.diff colitis (intestinal infection). You had an abnormality on the imaging of your thyroid. Please work with your primary care doctor to have a thyroid ultrasound arranged. Take your medications as below. If you develop chest pain, shortness of breath, fever, chills, or any other concerning symptoms, please contact your rehab doctor or report to the nearest ER. While you were in the hospital, the pulmonary team evaluated you for your cough and pneumonia. You will need to have a CT scan of your chest in [**4-19**] weeks, have a sleep study, and have a follow up appointment with pulmonology. The rehab facility and your PCP will help to arrange the above issues. Followup Instructions: Please make an appointment to see your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 9474**] 1 month after discharge. Call [**Telephone/Fax (1) 9251**] to schedule your appointment. Please call the Pulmonary clinic at ([**Telephone/Fax (1) 513**] to schedule an outpatient pulmonary follow up in [**4-19**] weeks. They would like to have a repeat Chest CT in [**4-19**] weeks, outpatient echo, and outpatient sleep study arranged as an outpatient. Your previously scheduled appointments: Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2115-8-15**] 11:30 Provider: [**Name10 (NameIs) 640**] [**Name11 (NameIs) 747**] [**Name12 (NameIs) **], M.D. Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2115-8-22**] 11:00 [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**] Completed by:[**2115-6-17**]

[ "403.91", "516.8", "008.45", "V10.41", "585.6", "537.9", "584.9", "250.50", "362.01", "428.0", "280.9", "440.20", "507.0", "274.9", "250.80", "276.1", "518.81", "250.70" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71", "88.72", "99.04", "38.93" ]

icd9pcs

[ [ [] ] ]

12579, 12650

4944, 9310

317, 393

12899, 12988

2321, 4921

13938, 14859

2037, 2041

9953, 12556

12671, 12878

9336, 9930

13012, 13915

2056, 2302

251, 279

421, 1595

1617, 1956

1972, 2021

3,686

126,660

8262

Discharge summary

report

Admission Date: [**2184-8-2**] Discharge Date: [**2184-8-16**] Date of Birth: [**2128-2-18**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Increasing angina Major Surgical or Invasive Procedure: [**2184-8-3**] Four vessel coronary artery bypass grafting utilizing left internal mammary artery to left anterior descending; vein grafts to right coronary artery, obtuse marginal and diagonal. [**2184-8-2**] Cardiac catheterization with insertion of IABP History of Present Illness: Mr. [**Known lastname **] has a known history of dilated cardiomyopathy, with an EF of 20%. Previous workup at [**Hospital3 **] Hospital in [**2179**] showed a large area of infarct involving the apex, anteroseptal and inferobasal wall on Cardiolite study. Viability studies at that time revealed no viability in the apex and anteroseptal wall but there was viability in the inferior wall. An echocardiogram in [**2180**] showed an LVEF of 20% with mild mitral and tricsupid regurgitation. During this past year the patient has been experiencing chest pressure that occurs with exertion such as during sexual intercourse or when he is emotionally stressed (ex. when he is gambling). His chest pain is relieved with nitroglycerin. The pain does not radiate to his arm or jaw. He denies any DOE, but does get SOB when he lays himself flat or on his left side. He sleeps with 2 pillows at night. Denies lower extremity edema, palpitations, dizziness, difficulty with erection, or claudication. Past Medical History: Dilated cardiomyopathy, Hypertension, Chronic obstructive pulmonary disease - active smoker, Mild mitral regurgitation Social History: Married, works as [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 86**] Cab Driver. Speaks Russian primarily. Wife works at [**Hospital1 18**] in the chemistry lab. He drinks vodka on weekends, smokes 40 pk-years. Family History: No premature CAD Physical Exam: Vit: 96.8 55 149/67 16 99%RA Gen: middle aged male, lying flat, in NAD HEENT: PERRLA, EOMI, MMM Neck: no JVD CV: RR, soft heart sounds, Pulm: CTAB anteriorly, no w/c/r Abd: + BS, soft, NT, ND Ext: 2+ DP pulses B, no peripheral edema Skin: No rashes or excoriations Pertinent Results: [**2184-8-15**] 04:30AM BLOOD WBC-6.8 RBC-3.54* Hgb-10.7* Hct-33.7* MCV-95 MCH-30.2 MCHC-31.7 RDW-15.0 Plt Ct-315 [**2184-8-13**] 05:55AM BLOOD Glucose-130* UreaN-24* Creat-1.1 Na-139 K-4.4 Cl-104 HCO3-28 AnGap-11 [**2184-8-13**] 05:55AM BLOOD Calcium-8.5 Phos-3.7 Mg-2.2 Brief Hospital Course: Mr. [**Known lastname **] was admitted and underwent elective cardiac catheterization which was significant for severe three vessel disease with severely depressed left ventricular function. Coronary angiography showed a right dominant system with complex 90% lesion in the left anterior descending involving a large diagonal; 70% stenosis of the first obtuse marginal and 70% stenosis of the mid right coronary artery. Left ventriculography showed 2+ mitral regurgitation and a LVEF of 15-20%. Based on the above results, an IABP was placed to augment diastolic coronary filling. Cardiac surgery was subsequently consulted for urgent surgical coronary revascularization. Further evaluation included a TTE which confirmed a dilated left ventricule and severe global left ventricular hypokinesis with relative thinning/akinesis of the antero-septum and anterior walls. The LVEF was estimated at 20%; and there was only 1+ mitral regurgiation. The aortic valve was normal. He otherwise remained pain free on medical therapy and was cleared to proceed with surgery. Given the IABP, he was maintained on intravenous Heparin. On [**8-3**], Dr. [**Last Name (STitle) **] performed four vessel coronary artery bypass grafting utilizing left internal mammary artery to left anterior descending; with vein grafts to right coronary artery, obtuse marginal and diagonal. His operative course was uneventful and he transferred to the CSRU for further invasive monitoring. Due to a postoperative coagulopathy and copious amounts of airway secretions, he remained intubated and sedated for several days. His bleeding eventually improved with multiple blood products and required no operative intervention. He went on to experience bouts of paroxsymal atrial fibrillation which was treated with Amiodarone. The IABP was removed on postoperative day four. He maintained stable hemodynamics as he successfully weaned from inotropic support. He was eventually extubated on postoperative day six following diagnostic/therapeutic bronchoscopy. Sputum cultures eventually grew out Klebsiella pneumoniae and MRSA for which antibiotic therapy was adjsted accordingly. A PICC line was placed for intravenous Vancomycin while he was concomitantly placed on contact precautions. Following extubation, he continued to require aggressive chest physiotherapy and suctioning. With diuresis, pulmonary toilet and antibiotics, his pulmonary status gradually improved. Due to concern for aspiration, a bedside swallow study was performed on [**8-11**]. This showed a normal, functional swallow with no signs of aspiration. On postoperative day nine, he transferred to the SDU. His pulmonary status continued to improve. By discharge, his secretions were significantly less and he was satting 96% on room air. Just prior to discharge, the PICC line was removed and Vancomycin was discontinued. He will need to remain on Levofloxacin for another two weeks. He remained in a normal sinus rhythm with first degree AV block - no further atrial arrhythmias were noted. Amiodarone was titrated accordingly. He maintained stable hemodynamics and tolerated an ACEI. Given his depressed LV function, he will need to remain on an ACEI as an outpatient. He continued to make clinical improvements, and was eventually discharged to home on postoperative day 13. Medications on Admission: Lasix 40 or 20 [**Hospital1 **], Carvedilol 6.25 [**Hospital1 **], Ramapril 5 [**Hospital1 **], Isosorbide mononitrite 30 qd, Combivent Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*30 Capsule(s)* Refills:*2* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 4. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day for 1 weeks: [**Hospital1 **] for one week, then QD. Disp:*60 Tablet(s)* Refills:*0* 8. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO once a day. Disp:*30 Packet(s)* Refills:*2* 9. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 weeks. Disp:*14 Tablet(s)* Refills:*0* 10. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 11. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-18**] Puffs Inhalation Q4H (every 4 hours). Disp:*1 qs 1 month* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Coronary artery disease - s/p coronary artery bypass grafting, Dilated cardiomyopathy, Hypertension, Chronic obstructive pulmonary disease, Mild mitral regurgitation, MRSA and Klebsiella Pneumonia Discharge Condition: Stable, good Discharge Instructions: 1)[**Month (only) 116**] shower. No baths. No creams, lotions, ointments to incisions. 2)No driving for at least 4 weeks. 3)No lifting no more than [**10-27**] lbs for 10-12 weeks. Followup Instructions: Dr. [**Last Name (STitle) **] in 4 weeks Dr. [**Last Name (STitle) 3357**] in 2 weeks Local cardiologist in 2 weeks Completed by:[**2184-9-2**]

[ "285.9", "428.0", "V09.0", "424.0", "414.01", "724.5", "428.40", "305.1", "412", "413.9", "425.4", "041.3", "496", "401.9" ]

icd9cm

[ [ [] ] ]

[ "99.04", "88.53", "96.04", "00.13", "38.93", "36.15", "34.04", "39.64", "96.05", "39.61", "37.61", "36.13", "88.56", "99.05", "88.72", "99.07", "37.23", "96.72" ]

icd9pcs

[ [ [] ] ]

7587, 7645

2643, 5962

338, 597

7886, 7900

2347, 2620

8129, 8275

2023, 2041

6149, 7564

7666, 7865

5988, 6126

7924, 8106

2056, 2328

281, 300

625, 1623

1645, 1765

1781, 2007

14,472

136,494

2624+2625

Discharge summary

report+report

Admission Date: [**2176-11-15**] Discharge Date:[**2176-12-18**] Service: Cardiac Sx HISTORY OF PRESENT ILLNESS: This is a 78 year old male transferred from an outside hospital. The patient was at an Alcoholics Anonymous Meeting on the evening of [**11-14**]. The patient began experiencing chest pain radiating to the left arm and neck while walking up a [**Doctor Last Name **]. The patient drove himself home, called 911. He was found to be in ventricular tachycardia by the paramedics and was cardioverted with 200 joules in the ambulance. Lidocaine was given. The patient was transferred to [**Hospital6 33**] and by the time he arrived to the Emergency Room he was chest pain free. Upon arrival at [**Hospital6 33**], initial CPK was 64 and troponin was 0.02. Second CPK was 253. Echocardiogram done at [**Hospital6 33**] showed globally decreased left ventricular function with ejection fraction of 35 to 40%, minimum mitral regurgitation, no aortic stenosis. Cardiac catheterization showed two vessel coronary artery disease. While the patient was at [**Hospital6 33**] he developed another episode of ventricular tachycardia/pulmonary edema, requiring aggressive diuresis and was transferred to [**Hospital1 1444**] for evaluation of cardiac surgery. PAST MEDICAL HISTORY: 1. Angina. 2. Diabetes mellitus. 3. Hypertension. 4. Hypercholesterolemia. 5. Remote history of ETOH abuse. 6. Peripheral vascular disease. 7. History of cerebrovascular accident with residual right hand weakness. 8. Hypothyroidism. 9. Osteoarthritis. 10. The patient has a history of tobacco abuse. MEDICATIONS: 1. Mevacor 40 mg p.o. q. day. 2. Synthroid 200 micrograms p.o. q. day. 3. Glucophage 500 mg p.o. three times a day. 4. Advil. 5. Aspirin. 6. Multivitamin. 7. Analopril 10 mg p.o. q. day. 8. Glyburide 10 mg three times a day. 9. Pentoxifylline 400 mg p.o. q. day. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: On initial physical examination, the patient is afebrile; heart rate 78; sinus rhythm; blood pressure 140/50; respiratory rate 16; oxygen saturation 99%. The patient is alert and oriented times three. Sclerae are anicteric. Lungs are clear to auscultation bilaterally. There is a II-III/VI systolic ejection murmur. Abdomen is benign. Extremities are with Doppler-able pulses, dorsalis pedis and posterior tibial bilaterally. LABORATORY: EKG shows [**Street Address(2) 2051**] depressions in V3, V4, V5. HO[**Last Name (STitle) **] COURSE: The patient was taken to the Operating Room on [**2176-11-18**], with Dr. [**Last Name (Prefixes) **]. In the Operating Room the patient was found to have severe aortic stenosis with aortic valve area 0.5 to 0.6 cm2. The aortic valve leaflets by transesophageal echocardiogram were found to be moderately thickened and demonstrated a commissural fusion and limited excursion with the gradient across the aortic valve, peak was 49 mm of Mercury, mean gradient was 30 mm of Mercury. It was decided that the patient was to undergo an aortic valve replacement at the time. The patient underwent aortic valve replacement with a #21 [**Last Name (un) 3843**]-[**Doctor Last Name **] and a coronary artery bypass graft times three, SVG to obtuse marginal, SVG to left anterior descending, SVG to PDA. The patient had a prolonged operative course and was transferred to the Intensive Care Unit on Levophed, Milrinone, epinephrine, Propofol, Aprotinin, amiodarone. Postoperatively, by transesophageal echocardiogram, the patient's ejection fraction was found to be 35 to 40% with normal right ventricular systolic function, trace mitral regurgitation. On [**2176-11-19**], the patient was noted to have seizure activity in his left upper extremity. A neurologic consultation was obtained. The patient underwent a CT scan of his head which showed chronic right temporal lobe infarction, possible infarction at the level of genu of internal capsule, and a left frontal hypodensity. The patient was loaded with Dilantin for seizure prophylaxis and there was no more seizure activity observed. On postoperative day number two, the patient was noted to be in atrial fibrillation and controlled ventricular response. The patient was started on amiodarone. The patient continued on Milrinone and Levophed for inotropic support. The patient was also noted to have an elevated creatinine which peaked at 2.4 on [**2176-11-22**]. A renal consult was obtained; this was thought to be due to low-flow during cardiac surgery. The patient was started on enteral nutrition. A sputum culture was sent on [**2176-11-20**], which grew out Methicillin sensitive Staphylococcus aureus and Hemophilus. The patient was started on Levaquin for presumed aspiration pneumonia. On postoperative day number five, it was noted that the patient's white blood cell count to be elevated at 18. The patient was pan-cultured with a new central line placed. Sputum at that time was positive for Methicillin sensitive Staphylococcus aureus. Catheter tip was negative. The patient also underwent a repeat head CT scan which was unchanged from previous. The patient was noted to be moving his left upper extremity although not following commands. On postoperative day number seven, Milrinone was weaned off. Cardiac index greater than 2. The patient underwent transesophageal echocardiogram to re-evaluate ventricular function in light of the prolonged inotropic need. The ejection fraction was found to be 35%. Right ventricular volume overload, mild to moderate mitral regurgitation, trace to mild tricuspid regurgitation, aortic valve prosthesis with good function. No pericardial effusion, no aortic dissection. The patient remained intubated at this time for increased sputum production. The patient was also experiencing periods of agitation. The patient was started on low-dose Klonopin for control of agitation. The patient still required Propofol for his safety as the patient was a difficult intubation. The patient continued to have a moderate amount of serous drainage from his pleural chest tubes which remained in postoperatively. On postoperative day number ten, the patient was noted to have a white blood cell count of 30,000 and an Infectious Disease consult was obtained. The patient received one dose of empiric Vancomycin for his previous Staphylococcus aureus sputum cultures. Infectious Disease requested to change the antibiotics to Oxicillin and continued to follow him. By postoperative day number 14, the patient's white blood cell count had risen to 41.7. The patient underwent a CT scan of his chest, abdomen and pelvis which showed bilateral lower lobe pneumonia, moderate right pleural effusion, pericardial effusion, mild bilateral pneumothoraces. In his abdomen it was noted that he had a short segment of small bowels with thickened wall, non-specific changes. The patient was pan-cultured. Blood cultures were negative. Sputum was positive for Pseudomonas. The patient underwent bronchoscopy which showed thick white sputum, left greater than right. Cultures from the bronchoscopy also grew out Pseudomonas as well as Gram positive rods. The catheter tip central line from [**2176-12-2**], was negative. Infectious Disease discontinued Oxicillin and started Zosyn for coverage of Pseudomonas. A Hematology consult was also obtained. Hematology recommended discontinuing the Dilantin as it was felt that the patient had a leukemoid reaction responsible for elevated white blood cell count. Per Neurology's recommendation, the Dilantin was changed to Trileptal. On postoperative day number 15, the patient underwent percutaneous tracheostomy as well as PEG placement for continued respiratory failure, bilateral pneumonia. The patient was started on Ciprofloxacin for double coverage of the Pseudomonas pneumonia. The patient had a C. difficile culture sent on [**2176-12-3**], which was negative. On postoperative day number 16, the patient underwent ultrasound guided thoracentesis for the loculated right pleural effusion seen on CT scan. Cultures from that fluid were positive for coagulase negative Staphylococcus, Pseudomonas lactobacillus as well as [**Female First Name (un) 564**] albicans. The patient was placed on Diflucan at that time and a pigtail catheter was left in the pleural space. On postoperative day number 18, the patient had placement of a PICC for continued antibiotic treatment. On postoperative day number 20, it was noted once again that the patient's white blood cell count was climbing. The patient underwent a repeat CT scan of chest, abdomen and pelvis which showed another loculated right sided pleural effusion, one with some gas bubbles present, a left sided pleural effusion and a moderate to large pericardial effusion. Another pigtail catheter was placed in the loculated right sided pleural effusion. Cultures from that fluid grew Pseudomonas, two types of coagulase negative Staphylococcus, enterococcus and lactobacillus. The patient's white blood cell count was noted to decrease dramatically after that. The patient was able to be weaned from the ventilator and able to do tracheostomy mask trials. The patient was also able to use a Passe Muir valve to communicate. The patient was undergoing Physical Therapy and awaiting placement for Rehabilitation. The patient underwent a swallowoing study by Speech and Swallow Service on [**2176-12-12**], which showed clinical signs and symptoms of aspiration. The patient was determined to be made NPO and continue on his tube feeds via his PEG. On [**2176-12-14**], the patient was noted to have a decrease in oxygen saturation, increase in respiratory rate, increase in ventilatory support. The patient went for a repeat CT scan of chest, abdomen and pelvis which showed a loculated left sided pleural effusion, a 8 cm simple cyst on his left kidney in the interpolar region. A pigtail catheter was placed in the loculated left sided pleural effusion. Cultures of that fluid are so far negative. The patient is currently awaiting placement at rehabilitation facility and addendum discharge summary will follow. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Last Name (NamePattern1) 3870**] MEDQUIST36 D: [**2176-12-16**] 15:47 T: [**2176-12-16**] 16:36 JOB#: [**Job Number 13196**] Admission Date: [**2176-11-15**] Discharge Date: [**2176-12-20**] Service: CARDIOTHORACIC This is an addendum to the previously dictated discharge summary up to [**2176-12-14**]. ADDENDUM TO HOSPITAL COURSE: On [**2176-12-14**] the patient's medications were Zosyn, Ciprofloxacin, Fluconazole, regular insulin sliding scale, amiodarone, Lopresor, Hydralazine, Lasix, potassium chloride, Colace, Clonidine, Lactulose, vitamin C, zinc and Ativan. The patient was somewhat more agitated and remained in the hospital. He remained on pressure support for his ventilatory support. His abdomen was somewhat distended, so his tube feeds were held. His glucose was controlled with his insulin sliding scale. He was making adequate urine. His hematocrit had dropped somewhat to 26.6 and the patient was transfused one unit. His wounds remained clean, dry and intact. Over the ensuing days the patient's neurological status returned to his baseline and his ventilatory support was weaned. His right chest tube pigtail drain continued to put out fluid. On [**12-19**] a left chest tube was placed, which the patient pulled out on the following day. Compute tomography was obtained of the chest, which revealed bilateral pleural catheters present. The right loculated pleural effusion was decreased in size and the left pleural effusion was stable. His pericardial effusion was stable. On the day of discharge [**2176-12-21**], Mr. [**Known lastname **] was afebrile with a temperature max of 98.2, heart rate of 70 and first degree AV block, blood pressure 139/50 beating 20 times per minute, sating at 98%, pressure support and CPAP of 10 and 5 with FIO2 of 50%. He was tolerating tube feeds and had tolerated 780 cc over the previous 24 hour period. He received some intravenous fluids making adequate urine. His pigtail drains put out 125 cc. He was sleeping, but restless. Chest was clear to auscultation bilaterally. Cardiac was regular rate and rhythm. Abdomen was soft, nondistended, nontender. Extremities were warm and well perfuse. The patient was deemed stable by the cardiothoracic staff and was discharged to rehabilitation. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: The patient was discharged to ventilatory rehabilitation. DISCHARGE DIAGNOSES: 1. Status post coronary artery bypass graft. 2. Status post aortic valve replacement complicated by seizures, acute renal failure, respiratory failure. 5. Status post tracheostomy and percutaneous intragastrostomy. MEDICATIONS ON DISCHARGE: Lactulose 30 cc per G tube q day, Fluconazole 200 mg per G tube q.d., NPH insulin 30 units subQ q.a.m., 25 units subQ at hour of sleep. Trileptal 600 mg per G tube b.i.d., Lopressor 25 mg per G tube b.i.d., Zosyn 2.2 grams intravenous q 6 hours, Vancomycin 1 gram intravenous q 12 hours. Aspirin 325 mg per G tube q.d., Colace elixir 100 mg per G tube b.i.d., Nystatin swish and swallow 5 cc po q 6 hours, heparin 5000 units subQ b.i.d., Hydralazine 10 mg per G tube t.i.d., regular insulin sliding scale. For glucoses of 121 to 150 2 units, 151 to 175 3 units, 176 to 200 4 units, 201 to 250 5 units, 251 to 300 6 units, 300 to 350 7 units and for blood glucoses greater then 351 a medical doctor should be called. Zantac 50 mg intravenous q.d., Ciprofloxacin 200 mg intravenous q 12 hours, Nitrophos one packet per G tube t.i.d. for 24 hours at which point this will be discontinued. Lasix 80 mg per G tube b.i.d., Amiodarone 200 mg per G tube q.d. The patient also has prn orders of magnesium sulfate 2 grams intravenous prn of magnesium less then 2, potassium chloride of 40 mg intravenous prn K less then 4, calcium gluconate 2 grams intravenous prn ionized calcium less then 1.1. Tylenol 650 per G tube or pr prn. Morphine sulfate 1 to 2 mg intravenous subQ or IM q 2 hours prn. Dulcolax suppository 1 pr q.d. prn, Hydralazine 10 mg intravenous prn systolic blood pressure greater then 160. Ativan 0.5 mg per G tube q.h.s. prn, Combivent four puffs q 4 hours prn, Albuterol one to two puffs q 2 hours prn. Th[**Last Name (STitle) 1050**] is to follow up with infectious disease to determine the course of the antibiotics. The patient is to follow up with Dr. [**Last Name (Prefixes) **] for any further surgical intervention. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Last Name (NamePattern1) 13197**] MEDQUIST36 D: [**2176-12-20**] 13:43 T: [**2176-12-20**] 14:27 JOB#: [**Job Number 13198**]

[ "780.39", "518.5", "396.2", "482.1", "584.9", "427.1", "423.9", "398.91", "250.00" ]

icd9cm

[ [ [] ] ]

[ "96.6", "36.13", "43.11", "96.72", "96.56", "88.72", "39.61", "31.1", "35.22" ]

icd9pcs

[ [ [] ] ]

12732, 12951

12978, 14992

10659, 12599

1966, 10641

125, 1283

1305, 1943

12624, 12711

28,540

119,175

9175

Discharge summary

report

Admission Date: [**2104-5-8**] Discharge Date: [**2104-5-14**] Date of Birth: [**2051-4-19**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: CABG X 4 (LIMA > LAD, SVG>diag, SVG> OM, SVG>PDA) on [**5-9**] History of Present Illness: 52 yo F admitted to MWMC with chest pain on [**5-7**]. Cardiac catheterization showed 3VD and she was transferred for CABG. Past Medical History: cad s/p IMI [**2095**], s/p stent PCI distal RCA ([**2095**]), s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) **] mid RCA in [**1-/2100**] DM HTN hypercholemia Social History: no alcohol, tobacco, or illicit drugs Family History: ? Physical Exam: HR 82 RR 18 BP 110/67 NAD Lungs CTAB Heart RRR Abdomen benign Extrem warm, no edema Pertinent Results: [**2104-5-14**] 05:38AM BLOOD Hct-30.3* [**2104-5-13**] 05:48AM BLOOD WBC-8.8 RBC-3.28* Hgb-9.8* Hct-28.0* MCV-85 MCH-29.9 MCHC-35.1* RDW-14.1 Plt Ct-215# [**2104-5-9**] 06:18PM BLOOD PT-13.7* PTT-35.1* INR(PT)-1.2* [**2104-5-14**] 05:38AM BLOOD UreaN-17 Creat-0.4 K-4.1 [**2104-5-13**] 05:48AM BLOOD Glucose-112* UreaN-19 Creat-0.5 Na-141 K-4.1 Cl-104 HCO3-30 AnGap-11 CHEST (PORTABLE AP) [**2104-5-11**] 7:40 AM CHEST (PORTABLE AP) Reason: evaluate for bleeding [**Hospital 93**] MEDICAL CONDITION: 53 year old woman s/p cardiac surgery REASON FOR THIS EXAMINATION: evaluate for bleeding PORTABLE CHEST [**2104-5-11**] AT 08:01 INDICATION: Followup after cardiac surgery. COMPARISON: [**2104-5-10**]. FINDINGS: Right introducer sheath remains in place. The only interval change is an increased pleural fluid layering out on the left, which could be related to positioning differences. Left basilar atelectasis is seen and persistent retrocardiac density noted but not significantly different. Left abdominal pigtail catheter is again noted. IMPRESSION: No significant interval change. [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 31544**] (Complete) Done [**2104-5-9**] at 5:35:55 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] R. Division of Cardiothoracic [**Doctor First Name **] [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2051-4-19**] Age (years): 53 F Hgt (in): 62 BP (mm Hg): 101/50 Wgt (lb): 150 HR (bpm): 74 BSA (m2): 1.69 m2 Indication: Intra-op TEE for CABG ICD-9 Codes: 440.0 Test Information Date/Time: [**2104-5-9**] at 17:35 Interpret MD: [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD, MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6507**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2008AW01-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 60% >= 55% Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic function (LVEF>55%). RIGHT VENTRICLE: RV not well seen. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Normal aortic arch diameter. Normal descending aorta diameter. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. TRICUSPID VALVE: Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. See Conclusions for post-bypass data The post-bypass study was performed while the patient was receiving vasoactive infusions (see Conclusions for listing of medications). Conclusions PRE-BYPASS: No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. Dr. [**Last Name (STitle) **] was notified in person of the results. POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including phenylephrine and is A paced 1. Bi ventricular function is normal 2. Aorta is intact post decannulation 3. Other findings are unchanged. Brief Hospital Course: She was taken to the operating room on [**5-9**] where she underwent a CABG x 4. She was transferred to the ICU in stable condition. She was extubated on POD #1. She was transfused for HCT 23. Wires and chest tubes were dc'd without incident. She was cultured for a fever all of which returned negative. She was transferred to the floor on POD #3. She otherwise did well postoperatively and was ready for discharge home on POD #5. Medications on Admission: Cozaar 50', Toprol XL 50', Humulin 70/30 50 qam, 20 qpm, Plavix 75', Zocor 40', ASA 325', Metformin 1000' Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 2. 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* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 5. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 9. 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:*0* 10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 5 days. Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 5 days. Disp:*10 Tablet(s)* Refills:*0* 12. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension Sig: 50 units in am/20 units in pm Subcutaneous twice a day. Disp:*qs 1month* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital **] Hospice and VNA Discharge Diagnosis: CAD now s/p CABG DM, HTN, CAD, s/p PCT stent distal RCA ([**2095**]), s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) **] RCA ([**1-/2100**]) Discharge Condition: Stable. Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Shower, no baths, no lotions, creams or powders to incisions. No lifting more than 10 pounds or driving until follow up with surgeon. Followup Instructions: Dr. [**Last Name (STitle) 20222**] 2 weeks Dr. [**Last Name (STitle) **] 4 weeks Completed by:[**2104-5-14**]

[ "518.0", "V70.7", "272.0", "285.9", "V58.67", "414.01", "401.9", "412", "V45.82", "250.01" ]

icd9cm

[ [ [] ] ]

[ "36.13", "39.64", "36.15", "88.72", "39.61", "34.04", "38.91", "89.64", "99.04" ]

icd9pcs

[ [ [] ] ]

7275, 7337

5009, 5442

331, 396

7564, 7574

969, 1438

7873, 7985

846, 849

5598, 7252

1475, 1513

7358, 7543

5468, 5575

7598, 7850

864, 950

281, 293

1542, 4986

424, 549

571, 774

790, 830

26,798

166,740

8677

Discharge summary

report

Admission Date: [**2103-8-27**] Discharge Date: [**2103-9-4**] Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 29767**] Chief Complaint: headache Major Surgical or Invasive Procedure: none History of Present Illness: source: chart Ms. [**Known lastname 30414**] is an 88 year old woman with history of hypertension, ?stroke, and dementia transferred from her living facility due to complaints of headache, nausea, and vomiting on [**8-27**]. She apparently had an unwitnessed fall. Per report she is ambulatory at baseline and oriented to person only. In the ED, her vitals were T 99.8 P 81 BP 158/54 RR 12 O2 94% on room air. She underwent CT scanning which showed an acute right sided subdural hematoma, right temporal parenchymal bleed with subarachnoid hematoma. There was a 5mm midline shift as well as right parietal bone fracture. CT of the neck was notable for epidural hematoma at C2. She was said to be slightly lethargic but interactive and verbal. In the ED she was loaded with dilantin and a cervical collar was placed. She was admitted to the neurosurgical service and initially in the TICU. Her course there was notable for fever (101.2 on [**8-28**]). This was initially attributed to her intracerebral bleed. On [**8-29**] she was noticed to have some wheezing on exam (in the setting of a positive fluid balance) and given lasix. A chest film showed mild fluid overload with RML and RLL consolidations thought be atelectasis or pneumonia. Her white count climbed however reaching 17 on [**8-30**]. She was empirically started on ceftriaxone and azithromycin [**8-31**]. Her mental status remain depressed throughout her stay. Nursing notes describe minimal gag reflex. Past Medical History: dementia HTN Hypothyroid High cholesterol Anxiety Recent increasing confusion the past 2 months ?stroke per son [**2103**] c/b left parietal subdural, facial fx, humeral fx afib with rvr [**9-1**] hospitalization Social History: Lives in [**Location (un) **], son involved Family History: n/a Physical Exam: Transfer to medicine: T 99.2 (Tmax 100.9) P 84 Bp 120/72 RR 22 96% 2L General: Pale elderly woman lying in bed, somnolent and unarousable HEENT: Bruising around right [**Last Name (LF) **], [**First Name3 (LF) **], poor dentition. right nares with feeding tube Neck: Cervical collar in place Pulm: Snoring loudly, can't appreciate crackles, wheezing, or rhonchi on anterior exam CV: Irregular ?systolic murmur no m/r/g Abd: Soft, +BS, nontender Extrem: Warm, tr/1+ edema, 2+ distal pulses Neuro: PEARL, withdraws LE to Babinski stimulation, DTRs brisk bilaterally Skin: warm Has foley, dark yellow urine No [**Name6 (MD) 30415**] [**Name8 (MD) **] RN (will confirm this myself this evening) Pertinent Results: [**2103-8-27**] PTT 25.4 / INR 1.1 WBC 13.6 / Hb 12.6 / Hct 35.4 / Plt 250 CK 171 / MB 4 / Trop T <. 01 Na 140 / K 3.3 / Cl 101 / CO2 27 / BUN 18 / Cr .6 / BG 135 . EKG SR at 66bpm, normal axis, LBBB (old), ST depressions laterally new compared to [**2102-9-9**] . micro 10/5 blood culture negative [**8-31**] urine culture coag negative staph . [**8-27**] CT head 1. Acute subdural hematoma along the right cerebral hemisphere with possible epidural component. Right inferior temporal lobe parenchymal hematoma andadjacent subarachnoid hematoma with associated edema. Mass effect on the right cerebral hemisphere results in 5mm shift of midline. 2. Non-displaced fracture of the right parietal bone. . [**8-27**] CT cervical spine 1. New epidural soft tissue at the level of C2 on the left which may represent an epidural hematoma. Further evaluation with MRI is recommended. 2. No evidence of fracture or subluxation. . [**8-27**] CT abd 1. No evidence of traumatic injury to abdomen or pelvis. 2. Cardiomegaly and coronary artery atherosclerotic calcifications. 3. Multifocal plate-like atelectasis at the lung bases bilaterally. 4. 7 x 11 mm hypoattenuating lesion in the left lobe of the liver, too small to accurately characterize. Further evaluation with ultrasound or MRI could be performed. 5. Multiple hypoattenuating lesions in both kidneys, too small to characterize. 6. Multiple calcified splenic granulomas. . [**8-29**] RUQ ultrasound IMPRESSION: Hypodensity on CT has US findings likely representing hepatic cyst. No other focal hepatic abnormalities are seen. . [**8-29**] CT head 1. Stable right subdural hematoma and right temporal intraparenchymal hemorrhage. Stable small left subarachnoid hemorrhage in frontoparietal sulcus. 2. Stable biventricular hemorrhage. Brief Hospital Course: 88yo female with h/o dementia was admitted after unwitnessed fall and was found to have right SDH and SAH. She developed fevers after she was hospitalized and found to have a likely aspiration pneumonia. She was started on levofloxacin and flagyl for coverage of presumed aspiration pneumonia. Due to increasing secretions and increasing somnolence patient was transferred from the medicine service to the intensive care unit. While in the ICU, patient had worsening mental status and increased suction requirement. Given patient's worsening clinical status, she was changed to comfort measures only and expired within the next 24 hours. Medications on Admission: prilosec 20' colace senna vit b 1000mcg one tab wed and sat 12noon simvastatin 20 hs HCTZ 12.5' metoprolol xl 25' ketoconazole cream to face and neck buspirone 5''' asa 325' vit d 400iu '' tylenol 500'' tums 500'' levoxyl .15' actonel 35mg q sunday sertraline 50mg two tabs q 12 noon seroquel 25 mg at 8pm Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: PRIMARY DIAGNOSIS: 1. s/p fall 2. Acute subdural hemorrhage 3. Acute Subarachnoid hemorrhage . SECONDARY DIAGNOSIS: Dementia HTN Hypothyroid High cholesterol Anxiety Recent increasing confusion the past 2 months ?stroke per son [**2103**] c/b left parietal subdural, facial fx, humeral fx Afib with rvr [**9-1**] hospitalization Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired

[ "427.31", "401.9", "507.0", "E888.9", "800.26", "812.09", "244.9", "530.81", "599.0", "272.0", "300.00" ]

icd9cm

[ [ [] ] ]

[ "99.04" ]

icd9pcs

[ [ [] ] ]

5634, 5643

4605, 5245

228, 234

6016, 6025

2781, 4582

6081, 6091

2049, 2054

5602, 5611

5664, 5664

5271, 5579

6049, 6058

2069, 2762

180, 190

262, 1735

5780, 5995

5683, 5759

1757, 1972

1988, 2033