ChanBeDu/relevant_section_length · Datasets at Hugging Face

13,778

124,646

44108

Discharge summary

report

Admission Date: [**2130-3-16**] Discharge Date: [**2130-3-17**] Date of Birth: [**2051-10-9**] Sex: M Service: MEDICINE Allergies: Tetanus,Diphther Toxoid Adult / Aggrenox Attending:[**Last Name (NamePattern1) 495**] Chief Complaint: hypoglycemia, weakness Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname **] is a 78 y/o M with PMH significant for type 2 DM, CAD s/p CABG, and hyperlipidemia who presents to the ED complaining of slurred speech, total body weakness, and unsteady gait. He states that he was in his usual state of health last night. This morning, he had some dizziness with waking, which is typical for him. Otherwise, he felt fine. The patient was late for his EP appointment with Dr. [**Last Name (STitle) 1911**] this morning and took his full dose of NPH insulin, 45 U, and did not eat breakfast. At his EP appointment, the patient was noted to be "foggy" with slurred speech and unsteady gait. His BP at that time was 165/80, pulse was 60 and regular. EKG at that time showed primarily sinus rhythm, a sensed & V paced alternating with fully AV paced rhythm. . Pacemaker interrogation at the appointment revealed appropriate pacemaker function and no evidence for atrial fibrillation since the last interrogation of [**10-20**]. He was given sugar with water after which the slurred speech cleared immediately. As his weakness and gait unsteadiness persisted, the patient was referred to the ED for further evaluation. . In the ED, the patient was afebrile with HR 66 and BP 166/65. His O2 sat was 98% on RA. His fingerstick was 71 on initial presentation, and he was treated with 1/2 amp d50 with increase in BS to 97. Forty-five minutes later, he was found to have a BS of 86 and was started on D10 at 100 cc/hour. This was discontinued 2.5 hours later when his fingerstick was 167. In the ED, he was found to have a UTI with UA showing 11-20 WBCs, [**3-6**] RBCs, few bacteria, and 0 epis. A culture was not sent, and he did not receive antibiotics. A CT head was performed and showed likely old lacunar infarcts. The patient was evaluated by Neurology who felt that this could represent a new lacunar infarct but could also be seen due to his previous infarct ([**2129-9-2**]). . On arrival to the [**Hospital Unit Name 153**], the patient denies any dizziness or lightheadedness. His speech is much improved per his report. He denies fever/chills, night sweats, chest pain, respiratory difficulties, weakness of either arm or leg, abdominal pain, changes in bowel habits, and blood in his stools. He sleeps on 2 pillows chronically; he denies snoring or paroxysmal nocturnal dyspnea. He does admit to recent [**4-6**] pound weight loss. He also has some difficulty with sensation of solid foods, "getting stuck." This has been going on for months and is less pronounced with liquids. He does endorse early satiety. He also endorses bilateral hand "swelling," numbness, and difficulty making a fist; this has been going on for some time. Past Medical History: * DM type 2 complicated by neuropathy & retinopathy, Hgb A1c 6.7% in [**9-7**] * CAD s/p 4v CABG ([**2119**]) * PVD s/p bypass grafting (s/p L popliteal to DP bypass w/ R arm vein ([**8-3**]) ; failed - s/p revision ([**3-4**]); RLE claudication - s/p R SFA to DP saphenous vein bypass ([**5-5**]) ; stenosed distal graft - s/p atherectomy ([**9-5**])) * 2nd & 3rd degree AV block s/p pacemaker in [**2123**] * hypertension * s/p L carotid endarterectomy in [**2128**] * hyperlipidemia * known infrarenal aortic aneurysm s/p graft repair ([**12/2119**]) * anxiety/depression * osteoarthritis * chronic back pain * cataracts * chronic renal insufficiency (recent creatinine values 1.3-2.1) * H/o intermittent slurred speech with CVA diagnosed in [**9-/2129**] * H/o vertigo, uses meclizine occasionally as outpatient Social History: The patient is a retired carpenter/builder. He lives with his wife. [**Name (NI) **] 6 children who are grown. He quit smoking >25 years ago. Smoked 1ppd x20 years. He has a scotch and a shot of brandy only occasionally. He uses a walker to ambulate due to leg pain. Family History: Mother with coronary artery disease and hypertension and stroke, 2 brothers with CAD s/p CABG. No seizures. Physical Exam: PE: T: 94.1 ax BP: 182/52 HR: 66 RR: O2 98% RA Gen: Pleasant, elderly, obese male in NAD. HEENT: No conjunctival pallor. No icterus. MMM. OP clear. NECK: Supple, No LAD, JVD not appreciated but neck quite thick. No thyromegaly. CV: Irregular rhythm. No murmurs. LUNGS: clear bilaterally, no wheezes or crackles heard ABD: Soft, obese, nontender. NL BS. EXT: WWP, [**1-3**]+ pitting edema bilaterally. DP pulse 2+ on left, 1+ on right. Healing incision on medial plantar aspect of right foot. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact with some mild defect in abduction of the right eye. Decreased sensation bilateral feet in stocking distribution to the ankle. Sensation intact to pinprick in bilateral upper extremities. 5/5 strength in bilateral upper and lower extremities. No reaction to Babinski. No pronator drift. Gait assessment deferred. PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: . LABS: WBC 5.8 (67% neutrophils, 23% lymphs, 7% monos, 3% eos), Hct 29.9, Plt 226 Chem 10 showing creatinine 1.9, BUN 47, glucose 63, potassium 4.4, magnesium 2.8 INR 1 . STUDIES: EKG: v paced at ~ 60, frequent PVCs. . CT head without contrast ([**3-16**], report not finalized): 1. Old lacunar infarct in the left caudate and old infarct in the left medial occipital lobe with compensatory ex vacuo dilatation of the occipital [**Doctor Last Name 534**] in the left lateral ventricle. 2. No CT evidence of acute infarction, however, given evidence of prior infarcts and atherosclerotic disease, MRI with diffusion-weighted imaging is recommended to exclude acute ischemia. . Brief Hospital Course: Mr. [**Known lastname **] is a 78-year-old man with a history of DM2, CAD s/p CABG, and heart block s/p pacemaker placement who presents with slurred speech, total body weakness, and hypoglycemia in the setting of UTI. His brief hospital course is as follows: . 1. Hypoglycemia with type 2 DM. This was due to his taking a full dose of NPH insulin with poor subsequent PO intake. He was admitted to the ICU for frequent blood glucose checks. Overnight, his fingersticks improved as he ate. He was discharged with his usual dose of NPH and told to eat regularly while he's taking insulin. He indicated his understanding of this. . 2. Slurred speech/weakness/dizziness. He was evaluated by neurology. These symptoms were felt to be the re-expression of his old stroke in the setting of hypoglycemia. His symptoms resolved overnight as his blood sugar improved. Per neurology, he was restarted on 81 mg ASA in combination with his Plavix. His statin was increased to 80 mg due to an LDL of 126 and a total cholesterol 198. . 3. Possible UTI. Although his U/A from the ED suggested this infection, a repeat urinalysis in the ICU was negative. His antibiotics were discontinued. . 4. Elevated creatinine. His creatinine was slightly higher than on recent labs but it did improved from the ED result. As he had poor PO intake prior to admission and takes Lasix at home, this likely was pre-renal in etiology. He was continued on calcitriol, and as he appeared euvolemic, his Lasix was restarted. . 5. Hypertension. Per Neurology recommendations, his [**Last Name (un) **] was held. This was restarted on discharge as he remained free of neurologic symptoms. He was continued on his beta blocker given his cardiac history. . 6. Depression/anxiety. He was continued on his home celexa and ativan 2 mg QHS for insomnia/anxiety. . 7. Osteoarthritis. He normally takes darvocet and indomethacin prn per his report at home. He was monitored for pain and did not have any, and so this was not treated. It was thought that perhaps indomethacin is not the best choice of agents given his age and renal insufficiency. . 8. History of vertigo. No complaints. He was continued on his outpatient meclizine. . 9. Neuropathy. In light of elevated creatinine, his dose of gabapentin was adjusted accordingly (Gabapentin 300 Q12H). . 10. CODE: Full code, does not want to be conscious if intubated due to childhood experience with tonsillectomy . 11. COMM: With the patient and his wife, [**Name (NI) 1123**], [**Telephone/Fax (1) 94678**]. . 12. DISP: He was discharged to home from the ICU on the morning following his admission from the ED. . Medications on Admission: CALCITRIOL 0.25 mcg every other day Citalopram 20 mg daily Clopidogrel 75 mg daily DARVOCET-N 100 100 mg-650 mg Q6H prn pain FUROSEMIDE 80MG QAM, 40 mg QPM GABAPENTIN 600MG TID HUMULIN N 100 U/ML--45qam and 40u every evening INDOMETHACIN 25 mg TID with meals prn pain LORAZEPAM 1 mg daily prn anxiety, 2 mg at night NITROGLYCERIN 0.4MG SL prn PROTONIX 40MG daily SIMVASTATIN 40 mg daily TOPROL XL 100 mg daily VALSARTAN 160 mg daily . ALLERGIES: Aggrenox - diarrhea Tetanus toxoid - anaphylaxis . Discharge Medications: 1. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). 2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 3. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 4. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY OTHER DAY (Every Other Day). 5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Darvocet-N 100 100-650 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 8. Gabapentin 300 mg Tablet Sig: Two (2) Capsule PO three times a day. 9. Indomethacin 25 mg Capsule Sig: One (1) Capsule PO TID with meals as needed for pain. 10. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO once a day as needed. 11. Lorazepam 2 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 12. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual Once as needed for chest pain. 13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 14. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 15. Valsartan 160 mg Tablet Sig: One (1) Tablet PO once a day. 16. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Forty Five (45) units Subcutaneous qam. 17. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Forty (40) units Subcutaneous qpm. Discharge Disposition: Home Discharge Diagnosis: Hypoglycemia Discharge Condition: Good Discharge Instructions: Please take all medications as prescribed. . No new medications. Changed medications: simvastatin . Call your doctor or return to the ED immediately if you experience worsening chest pain, shortness of breath, nausea, vomiting, sweating, fevers, chills, bleeding, numbness, tingling, weakness, visual changes, or other concerning symptoms. Followup Instructions: You are scheduled for the following appointments. Please contact the [**Name2 (NI) 11686**] provider with any questions or if you need to reschedule. . Provider: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) 2352**] [**Last Name (NamePattern1) 2352**] - ADULT MEDICINE (SB) Date/Time:[**2130-3-20**] 11:30 . Provider: [**First Name11 (Name Pattern1) 3688**] [**Last Name (NamePattern4) 33346**], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2130-4-4**] 11:00 . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4853**], M.D. Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2130-4-5**] 10:00 . Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) **] Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2130-4-20**] 1:00 Completed by:[**2130-3-17**]

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46180

Discharge summary

report

Admission Date: [**2187-8-20**] Discharge Date: [**2187-9-3**] Date of Birth: [**2105-9-13**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name8 (NamePattern2) 812**] Chief Complaint: chest pain and shortness of breath Major Surgical or Invasive Procedure: Right external jugular line placement PICC line placement History of Present Illness: 81 year old female with type II diabetes, HTN, and hyperlipidemia who presented to OSH with intermittent chest pain and shortness of breath for several weeks, worse in past 3 days. The chest pain was substernal/epigastric, and would last for 2-3 hours. The patient saw her PCP and was started on Prevpak and an US showed gallstones. However, three days before admission to [**Hospital3 **], around [**2187-8-15**], the patient's chest pain began to worsen. The chest pain was assoicated with palpitations, diaphoresis, dizziness, and shortness of breath. She went to the [**Hospital3 **] ED and on admission, vital signs were as follows: HR 98, BP: 146/68 RR: 18, O2sat: 97% on 2L. Exam showed lungs CTAB and no lower extremity edema. EKG showed LBBB but no ST segment changes. Cardiac enzymes were cycled and found to be negative. The patient's symptoms were attributed GI sources and she was started on Protonix 40mg PO BID and Maalox. . On [**2187-8-19**], the patient's chest pain worsened and was accompanied by palpitations, nausea, diaphoresis, and shortness of breath. Vital signs were as follows: HR : 100-130, BP: 150/70, RR: 20-35, and O2sat: 82-89% on 2-3L. Exam was notable for a JVP of 8-10cm, crackles on respiratory exam, and trace lower extremity edema. The patient's EKG was unchanged but cardiac enzymes became positive (CK-74 on admission 198 on [**8-20**], Trop I going from 0.01 on admission to 1.03 on [**8-20**], and BNP of 922.) CXR showed bilateral infiltrates. The patient was placed on non-rebreath O2 with sats in the 80%, given a total of 120mg IV Lasix with 1L urine output, ASA, beta blocker, heparin drip, plavix 600mg PO, nitro, and prn morphine. She was transfered to the [**Hospital1 **] for futher management. . On review of symptoms, denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, myalgias, joint pains, cough, hemoptysis, black stools or red stools. Denies recent fevers, chills or rigors. All of the other review of systems were negative. . *** Cardiac review of systems is notable for presence of chest, fatigue on exertion, orthopnea, absence of PND, palpitations, syncope or presyncope. Past Medical History: 1) PVD s/p cath 2) HTN 3) DMII-HgAlc 6.1% on [**2187-8-20**] at OSH 4) hypercholesterolemia 5) Rheumatic Fever 6) hypothyroidism 7) peptic ulcer disease 8) Recent Urinary Tract Infection-On admission to OSH, patient moderate leukocyte esterase and 30-40 WBC. Treated with bactrim. 9) s/p thyroidectomy 10) s/p hysterectomy 11) s/p R mastectomy [**3-16**] breast ca [**92**]) Chronic renal insufficency-Baseline Cr of 2.0. At OSH, Cr trended upwards from 2.0 on admission to 2.6 at discharge. Social History: Ms. [**Known lastname **] is a widow who lives alone. She denies current tobacco, alcohol, or drug use. In the past, she smoked and has a thirty pack year history. Family History: Non-contributory Physical Exam: VS: Temp 97.8 HR 108 BP 136/108 RR 28 94% on 14L face mask Wt: 69.4kg Gen: Awake, alert. Oriented x3. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with JVP of 10-11cm. CV: Regular rate. Prominent S2. II/VI systolic murmur loudest at left sternal border. Chest: Right mastectomy. Bilateral crackles. Abd: Obese, soft, NTND, No HSM or tenderness. No abdominal bruits. Ext: No lower extermity edema. Warm and well perfused. Pulses: Right: Carotid 2+ without bruit; 2+ DP Left: Carotid 2+ without bruit; 2+ DP Pertinent Results: EKG at OSH: NSR, LBBB . CXR [**2187-8-20**]: Bilateral infiltrates and blunting of the left costophrenic angle read as more suggestive of an infectious process. . CXR [**2187-8-23**]: Improving pulmonary edema. PICC line in place. . 2D-ECHOCARDIOGRAM performed on [**2187-8-20**]: Symmetric LVH with nml LV cavity size and LVEF>55%. [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] size. RA nml size. RV nml size with free wall paradoxic septal motion consistent with conduction abnormality. No AS, AR, trivial MR, trivial TR. . Renal US [**2187-8-23**]: No masses, stones, or hydropnephrosis. There is a 5mm echogenic focus in the mid pole of the left kidney cortex that may represent an angiomyolipoma. . [**2187-8-20**] WBC-10.7 RBC-3.72* Hgb-10.3* Hct-29.6* MCV-80* MCH-27.8 MCHC-35.0 RDW-14.6 Plt Ct-468* Neuts-78.2* Lymphs-15.3* Monos-6.1 Eos-0.3 Baso-0.1 [**2187-8-24**] WBC-8.9 RBC-3.56* Hgb-9.8* Hct-29.2* MCV-82 MCH-27.4 MCHC-33.4 RDW-14.5 Plt Ct-493 . [**2187-8-20**] PT-13.5* PTT-101.6* INR(PT)-1.2* [**2187-8-24**] PT-12.6 PTT-53.3* INR(PT)-1.1 . [**2187-8-20**] Glucose-203* UreaN-36* Creat-3.0* Na-132* K-4.4 Cl-96 HCO3-21* Calcium-8.7 Phos-4.6* Mg-2.6 [**2187-8-21**] UreaN-43* Creat-3.3* [**2187-8-22**] UreaN-53* Creat-3.6* [**2187-8-23**] UreaN-79* Creat-4.5* [**2187-8-24**] UreaN-90* Creat-4.8* . [**2187-8-20**] 05:28PM BLOOD ALT-11 AST-21 . [**2187-8-20**] 05:28PM CK(CPK)-231* CK-MB-8 cTropnT-0.19* proBNP-[**Numeric Identifier 98206**]* [**2187-8-21**] 05:00AM CK(CPK)-346* CK-MB-6 cTropnT-0.26* [**2187-8-21**] 02:07PM CK(CPK)-361* CK-MB-5 cTropnT-0.25* [**2187-8-21**] 10:21PM CK(CPK)-337* CK-MB-5 . [**2187-8-21**] calTIBC-196* VitB12-211* Folate-17.9 Ferritn-241* TRF-151* [**2187-8-20**] %HbA1c-6.3* [**2187-8-21**] Triglyc-143 HDL-46 CHOL/HD-4.0 LDLcalc-109 [**2187-8-20**] TSH-0.68 . [**2187-8-20**] Urine cx-no growth [**2187-8-22**] Urine cx-no growth . [**2187-8-20**] BNP: [**Numeric Identifier 98206**] 7/13/07BNP: [**Numeric Identifier 98207**] After transfer to medicine: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2187-9-3**] 07:00AM 10.3 3.29* 9.0* 27.8* 85 27.5 32.5 15.8* 738 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2187-9-3**] 07:00AM 84 21* 1.3* 141 4.8 106 24 16 [**2187-8-31**] WBC-12.2* RBC-3.34* Hgb-9.0* Hct-27.8* MCV-83 MCHC-32.6 RDW-15.3 Plt Ct-667* [**2187-8-24**] Glucose-104 UreaN-90* Creat-4.8* Na-130* K-4.2 Cl-89* HCO3-27 AnGap-18 [**2187-8-27**] Glucose-96 UreaN-92* Creat-3.4* Na-137 K-4.4 Cl-99 HCO3-28 AnGap-14 [**2187-8-30**] Glucose-185* UreaN-57* Creat-2.1* Na-135 K-4.3 Cl-101 HCO3-25 AnGap-13 [**2187-8-31**] Calcium-8.6 Phos-3.3 Mg-2.4 [**2187-8-26**] Calcium-9.3 Phos-5.0*# Mg-3.3* [**2187-8-21**] calTIBC-196* VitB12-211* Folate-17.9 Ferritn-241* TRF-151* Studies: Right wrist film: Three radiographs of the right wrist demonstrate normal mineralization. There is marked irregular joint space narrowing with associated periarticular erosion involving the first CMC joint. Chondrocalcinosis is seen to involve the proximal and middle carpal compartments. Chondrocalcinosis likely involves the second, third, fourth, and fifth MCP joints. Ulnar styloid is normal. Mild joint space narrowing and marginal osteophyte formation involves the interphalangeal joint of the thumb. The interphalangeal joints of the second through fifth digits are excluded on these wrist radiographs. No discrete fracture. There is likely mild subchondral cyst formation involving the lunate, capitate, and triquetral bones . [**2187-8-29**] Stress mibi: IMPRESSION: Anginal type symptoms with an uninterpretable EKG for ischemia. Nuclear report: Septal hypokinesis, likely related to the patient's known LBBB. 2. Normal myocardial perfusion of the left ventricle. 3. EF 55%. . [**2187-8-30**]: CT abd/pelvis No evidence of retroperitoneal hematoma. No specific CT finding to explain episode of hypotension and hematocrit drop. 2. Cholelithiasis, without evidence of cholecystitis. 3. Small hiatal hernia. 4. Likely left breast fibroadenoma. Status post right mastectomy. Microbiology: [**2187-8-30**] : URINE CULTURE (Preliminary): YEAST. >100,000 ORGANISMS/ML.. ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML. AMPICILLIN------------ <=2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- =>16 R VANCOMYCIN------------ <=1 S . [**2187-9-1**] 4:54 am URINE Source: CVS. **FINAL REPORT [**2187-9-2**]** URINE CULTURE (Final [**2187-9-2**]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. [**2187-8-30**] 12:10 pm BLOOD CULTURE Source: Line-PICC. AEROBIC BOTTLE (Pending): ANAEROBIC BOTTLE (Pending): . [**2187-8-28**] 5:35 pm BLOOD CULTURE AEROBIC BOTTLE (Pending): ANAEROBIC BOTTLE (Pending): No growth at the time of discharge. Brief Hospital Course: 81 year old female with history of type II diabetes, HTN, and hyperlipidemia who was transferred from an OSH with chest pain, shortness of breath found to have non ST elevation MI and infiltrates on CXR. #NSTEMI: CK peaked at 361 on [**8-21**] and trended down. CK-MB peaked on [**2187-8-20**] and was 8 and has since trended downward. Patient has left bundle branch block at baseline making EKG interpretation difficult for ST changes difficult. An Echo was done, but without focal wall motion abnormality and with a preserved ejection fraction. The patient was continued on aspirin 325mg, plavix 75mg, heparin drip, nitro drip, morphine, metoprolol, and atrovastatin 80mg. Catheterization was delayed due to the patient's worsening renal function and her inability to lay flat eventually cardiology decided to perform a Stress mibi. . The stress mibi showed Anginal type symptoms with an uninterpretable EKG for ischemia and Septal hypokinesis, likely related to the patient's known LBBB. Normal myocardial perfusion of the left ventricle. 3. EF 55%. She will be followed up by Dr [**Last Name (STitle) 171**] from cardiology as an outpatient. Cardiology have decided to postpone a cardiac catherterization for now. Given the poor study determined by inadequate maximal heart rate, cardiology has advised that another stress test should be repeated in [**3-17**] weeks. . #CHF: The patient was found to have diastolic CHF. On admission, she presented in respiratory distress with bilateral infiltrates on chest x-ray and a BPN in the 16,000's. ECHO showed a left ventricular ejection fraction of greater than 55% and left ventricular hypertrophy. She was on lasix drip which was transitioned over to IV lasix. She was weaned off oxygen to room air. Her metoprolol dose was optimized. A most recent BNP was 4309 on [**2187-8-30**]. #A-fib: She had single documented evidence of AFib while in the CCU. An extensive appraisal of her past medical record which involved calling her PCP's office and looking through OSH records did not reveal any history of Afib. The decision was made by cardiology to anticoagulate her, however it should be noted that she has had no other episode of Afib. In the future her cardiologist can decide if she needs to remain anticoagulated. Of note patient had short runs of SVT presumably MAT,while on the medicine floor with up to three differing p-waves. . #Acute on chronic renal failure: The patient has a baseline Cr of 2.0. On admission, the patient's Cr was 2.6 and gradually rose to 4.8 while on diuresis. Subsequently, her lasix was held and her creatinine came down to 1.3 on discharge. Her Lisinopril was also held during the hospitalization. . #UTI: She was intially covered by Levofloxacin which she responded to. She developed another UTI which showed enterococcus and was placed on ampcillin for 7 day course. . #HCt drop: On [**8-29**]: Pt was found to have a drop in her hematocrit from 27 to 25 after some fluid repletion and then to 22 following 500 cc of fluid. Pt was transfused with 1 unit PRBC, a CT of abdomen was negative for retroperitoneal bleed, she was guiac negative. Her hct was stable at a hematocrit of 27.8 on discharge. . #Hypotension: On [**8-30**], Ms. [**Known lastname **] had a hypotensive episode with systolic BP in the 80's, she was asymptomatic during this period. On that same day, she had a low grade temp af a 100.1, Blood cultures were collected and sent from the peripheral and from her PICC line and sent, cultures are still pending with no growth. She received 500 cc of fluid and her blood pressure subsequently was stable in the 100's. . #Metal Status Changes: Ms. [**Known lastname **] became increasingly frightened and paranoid at night while in the Cardiac care unit. She was seen by psych on [**2187-8-23**] and started on Olanzapine 2.5mg [**Hospital1 **] with improvement. She had no more episodes of paranoia and Olanzapine was discontinued. . #Diabetes Type II-During this hospitalization, the patient's HbAlc was found to be 6.3%. She was managed on sliding scale insulin and was switched back to her metformin 500 [**Hospital1 **] on discharge. . #Hypothyroidism-The patient is status post thyroidectomy. Her TSH was found to be normal at 0.68. Ms. [**Known lastname **] continued on her home dose of 150mcg levothyroxine PO Daily. . #Right wrist pseudogout: On [**2187-8-25**], she c/o of pain in her right wrist and fore arm and had some swelling, xrays were taken that showed no acute fracture. A rheumatology consult was obtained, a fluid aspiration was done and pseudogout was diagnosed. She no longer has any signs of wrist pain. On discharge patient was afebrile with stable vital signs. . Code: Full code with her son [**Name (NI) 32342**] as her health care proxy Medications on Admission: HOME MEDS: prevpac metformin 500mg po bid levothyroxine 150mcg daily nifedical 60mg daily lisinopril 40mg daily Discharge Medications: 1. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) Intravenous once a day for 3 days. 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Levothyroxine 100 mcg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 7. Cyanocobalamin 500 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Wrist pain. 9. Atorvastatin 80 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 10. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 11. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 12. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q4H (every 4 hours) as needed. 14. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**2-13**] Sprays Nasal QID (4 times a day) as needed. 16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 17. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Discharge Disposition: Home With Service Facility: [**Location (un) 701**] VNA Discharge Diagnosis: NSTEMI Pulmonary Edema Acute renal failure Anemia Urinary Tract Infection Secondary Hypertension Diabetes Mellitus Discharge Condition: Good Discharge Instructions: You were admitted for a small heart attack and fluid in your lungs You also suffered from acute renal failure while in the hospital, your kidney function improved during your stay has returned back to baseline. You received 1 unit of Packed red blood cells for a low blood count. Your blood count has remained stable since the transfusion. . You will be followed by a cardiologist who will continue to monitor your heart. . Please take all your medications as prescribed and follow up with all your appointments. . If you experience any chest pain, shortness of breath not improved by nebulizer and inhaler, fevers, sweats, a worsening headache, leg swelling or any other symptoms that concern you, please call your PCP or go to the emergency room. Followup Instructions: You have an appointment with a cardiologist who saw you in the hospital, Dr [**Last Name (STitle) 98208**]: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2385**], MD Phone:[**Telephone/Fax (1) 2386**] Date/Time:[**2187-9-17**] 8:40 Please make an appointment to see your PCP in the next 1 week. [**First Name8 (NamePattern2) **] [**Name6 (MD) **] [**Name8 (MD) **] MD, DMD [**MD Number(2) 821**] Completed by:[**2187-9-4**]

[ "719.03", "585.9", "285.9", "403.90", "599.0", "410.71", "428.30", "250.00", "584.9", "428.0" ]

icd9cm

[ [ [] ] ]

[ "81.91", "38.93" ]

icd9pcs

[ [ [] ] ]

15438, 15496

9018, 13826

358, 417

15656, 15663

4011, 8226

16461, 16936

3354, 3372

13988, 15415

15517, 15635

13852, 13965

15687, 16438

3387, 3992

284, 320

8261, 8797

8929, 8929

8957, 8995

445, 2638

2660, 3155

3171, 3338

49,780

100,307

47635

Discharge summary

report

Admission Date: [**2161-10-29**] Discharge Date: [**2161-11-2**] Service: SURGERY Allergies: Codeine / Keflex Attending:[**First Name3 (LF) 4691**] Chief Complaint: right hip pain Major Surgical or Invasive Procedure: [**10-29**] pelvic arteriogram History of Present Illness: HPI: [**Age over 90 **]F s/p fall at [**Hospital3 **] c/o R hip pain. Patient was in usual state of health until this AM when she notes mechanical fall in bathroom. Walks w assistance of cane at baseline but did not have cane this AM at time of fall. Denies syncope, lightheadedness, chest pain or shortness of breath at time of fall. Denies head strike. Patient brought to [**Hospital1 18**] ED by ambulance for evaluation. Surgery consultation is obtained for traumatic injury. At time of evaluation patient complains of severe R hip pain but denies associated symptoms as per above. Denies headache, blurry vision, fever, chills, blurry vision, double vision, chest pain, shortness of breath, abdominal pain, dysuria. Past Medical History: 1. Breast cancer, bilaterally. 2. Hypertension. 3. History of recurrent urinary tract infection. 4. Inferior myocardial infarction [**2126**]. 5. Osteoporosis. 6. Depression. 7. Rectocele. 8. Left arm lymph edema secondary to breast cancer treatment. 9. Herpes zoster [**2157**]. 10. Memory loss. 11. Status post CVA [**2157**] 12. Cystocele 13. History of falls. 14. Hemorrhoidectomy. 15. Left cataract surgery. 16. Right carotid endarterectomy [**2148**]. 17. Left dermoid ovarian cyst removal. 18. Two lumpectomies of the left breast, followed by XRT. 19. CAD (per nursing home records) Social History: The patient is currently a resident at [**Location (un) **] [**Hospital3 400**]. She is widowed since [**2148**] and has a son [**Name (NI) 449**] [**Name (NI) **] who lives in [**Name (NI) 7349**]. Tobacco: Quit many years ago, cannot quantify use ETOH: None Illicits: None Family History: Non-contributory Physical Exam: PHYSICAL EXAMINATION upon admission: [**2161-10-29**] Temp: 98.3 HR: 93 BP: 114/56 Resp: 18 O(2)Sat: 95 Normal Constitutional: Uncomfortable. HEENT: Normocephalic., Pupils equal, round and reactive to light, Extraocular muscles intact Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Soft Extr/Back: Tenderness over right greater trochanter. Decreased ROM, , No cyanosis, clubbing or edema Neuro: Speech fluent. Alert and oriented x 3. Psych: Normal mood, Normal mentation Pertinent Results: [**2161-11-2**] 04:40AM BLOOD WBC-5.6 RBC-2.81* Hgb-9.0* Hct-26.6* MCV-95 MCH-31.9 MCHC-33.8 RDW-14.8 Plt Ct-184 [**2161-11-2**] 12:31AM BLOOD WBC-5.9 RBC-2.76* Hgb-8.5* Hct-26.5* MCV-96 MCH-31.0 MCHC-32.2 RDW-13.9 Plt Ct-238 [**2161-11-1**] 09:10PM BLOOD WBC-5.7 RBC-2.61* Hgb-8.3* Hct-24.4* MCV-94 MCH-32.0 MCHC-34.2 RDW-14.4 Plt Ct-183 [**2161-10-31**] 05:00PM BLOOD Hct-22.5* [**2161-10-29**] 09:21PM BLOOD WBC-7.9 RBC-3.30*# Hgb-10.5*# Hct-30.8*# MCV-93 MCH-31.6 MCHC-33.9 RDW-14.1 Plt Ct-185 [**2161-11-1**] 04:45AM BLOOD Neuts-77.6* Lymphs-15.4* Monos-3.4 Eos-2.9 Baso-0.6 [**2161-10-29**] 07:45AM BLOOD Neuts-85.9* Lymphs-9.7* Monos-2.6 Eos-1.1 Baso-0.8 [**2161-11-2**] 04:40AM BLOOD Plt Ct-184 [**2161-11-2**] 04:40AM BLOOD PT-15.5* PTT-49.3* INR(PT)-1.4* [**2161-11-2**] 04:40AM BLOOD Glucose-100 UreaN-23* Creat-1.2* Na-139 K-5.1 Cl-105 HCO3-24 AnGap-15 [**2161-11-1**] 04:45AM BLOOD Glucose-94 UreaN-26* Creat-1.3* Na-142 K-4.3 Cl-106 HCO3-28 AnGap-12 [**2161-10-31**] 08:40AM BLOOD Glucose-127* UreaN-26* Creat-1.2* Na-139 K-4.3 Cl-104 HCO3-28 AnGap-11 [**2161-10-29**] 07:45AM BLOOD Glucose-114* UreaN-25* Creat-1.2* Na-138 K-5.9* Cl-102 HCO3-24 AnGap-18 [**2161-11-2**] 04:40AM BLOOD Albumin-3.4* Calcium-8.6 Phos-2.9 Mg-2.4 [**2161-11-1**] 04:45AM BLOOD Albumin-3.3* Calcium-8.3* Phos-2.8 Mg-2.3 [**2161-10-31**] 08:40AM BLOOD Calcium-7.9* Phos-2.8 Mg-2.1 0/29/11: EKG: Normal sinus rhythm. Leftward axis. Non-specific ST segment depression in leads I and aVL and ST segment elevation in leads II, III, aVF and V6. There are only tiny R waves or small QR deflections in leads V3-6 consistent with an extensive anterior wall myocardial infarction of undetermined age. Consider left ventricular hypertrophy. Consider inferior wall myocardial infarction. Compared to the previous tracing of [**2161-6-3**] the voltage in leads V3-V6 has decreased with tiny R waves or tiny Q waves. Consider anterior wall myocardial infarction and inferior wall infarction of undetermined age. [**2161-10-29**]: hip x-ray: IMPRESSION: Comminuted fracture of the right iliac [**Doctor First Name 362**] with no associated widening or diastasis of the right sacroiliac joint which is better seen on the subsequent CT of the pelvis. [**2161-10-29**]: chest x-ray: IMPRESSION: Low lung volumes without acute cardiopulmonary abnormality [**2161-10-29**]: cat scan of the head: IMPRESSION: 1. No acute intracranial process. 2. Age related global atrophy. 3. Soft tissue swelling overlying the left posterior vertex and left frontal bone without underlying fracture. [**2161-10-29**]: cat scan hip: IMPRESSION: 1. Comminuted fracture of the right iliac [**Doctor First Name 362**] involving the right sacroiliac joint without widening or diastasis of the sacroiliac joint. There is an overlying extraperitoneal hematoma measuring 7 x 3 cm which extends into the right hemipelvis measuring 6 x 6 cm and displaces the urinary bladder to the left. Active extravasation cannot be assessed on this unenhanced study. 2. Degenerative changes of the bilateral femoroacetabular joints and visualized portion of the lumbar spine without fracture. 3. Sigmoid diverticulosis without evidence of diverticulitis. 4. Calcified atherosclerosis of the visualized distal infrarenal abdominal aorta extending into the bilateral common iliac, internal iliac and femoral arteries [**2161-10-29**]: CTA pelvis: IMPRESSION: Focus of active extravasation in the pelvis adjacent to the right superior pubic ramus with surrounding extraperitoneal hematoma concerning for active arterial bleed. [**2161-10-29**]: pelvic arteriogram: CONCLUSION: No evidence of active arterial extravasation on pelvic arteriogram with targeted catheterization of the right internal iliac artery, right superficial pudendal artery in addition to bilateral common iliac artery angiograms [**2161-10-29**]: arteriogram: CONCLUSION: No evidence of active arterial extravasation on pelvic arteriogram with targeted catheterization of the right internal iliac artery, right superficial pudendal artery in addition to bilateral common iliac artery angiograms Time Taken Not Noted Log-In Date/Time: [**2161-10-30**] 5:31 am URINE Site: NOT SPECIFIED 0603C. **FINAL REPORT [**2161-11-1**]** URINE CULTURE (Final [**2161-11-1**]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Piperacillin/tazobactam sensitivity testing available on request. GRAM POSITIVE BACTERIA. >100,000 ORGANISMS/ML.. Alpha hemolytic colonies consistent with alpha streptococcus or Lactobacillus sp. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 8 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-------- <=16 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R Brief Hospital Course: [**Age over 90 **] year old female presents to the acute care service after a mechanical fall. Upon admission, she was made NPO, given intravenous fluids, and underwent radiographic imaging. She was reported to have a comminuted fracture of the right iliac [**Doctor First Name 362**] with note of an extraperitoneal hematoma. Because of these findings, she underwent a pelvic angiogram which was negative for extravasation and she required no embolization. She was evaluated by orthopedics who recommmended non-surgical intervention at this time with follow-up in 2 weeks. Her head cat scan did not show a inter-cerebral bleed. She was admitted to the intensive care unit for monitoring of her hematocrit. She required additional intravenous fluids for hemodynamic support, but her hematocrit stablized without blood products. Initial EKG did show q waves in V3-V6 with normal CPK. She did resume her aspirin and plavix. She was transferred to the surgical floor on HD #2. Her vital signs remained stable and she is afebrile. She is tolerating a regular diet and voiding without difficulty. She was evaluated by physical therapy who recommended discharge to a rehabilitation facility where she can regain her strength and mobility. She will be discharged to an extended care facility with instructions to follow up with the acute care service, orthopedics, and her primary care provider. Of note: she was started on ciprofloxacin [**11-2**] for UTI. Medications on Admission: MED: [**Last Name (un) 1724**]: AMLODIPINE 2.5', CITALOPRAM 15', PLAVIX 75', MIRTAZAPINE 30', 15 prn, ASA 325', CALCIUM CARBONATE-VITAMIN D3 600-400'', VITAMIN D-3 400', CO Q-10 (unknown), MVI' Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): hold for loose stools. 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 3. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 4. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 5. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed for pain. 6. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 5 days: started [**11-2**]. 7. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): hold for systolic blood pressure <110. 8. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 10. mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 11. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 12. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Celexa 10 mg Tablet Sig: One (1) Tablet PO once a day. 15. Celexa 10 mg Tablet Sig: 0.5 Tablet PO once a day. 16. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q3H (every 3 hours) as needed for pain: hold for increased sedation, resp. rate <12. Discharge Disposition: Extended Care Facility: [**Hospital1 599**] Senior Healthcare of [**Location (un) 55**] Discharge Diagnosis: Trauma: fall right posterior ring pelvic fracture (large iliac [**Doctor First Name 362**] fx) UTI extra-peritoneal hematoma Discharge Condition: Mental Status: Clear and coherent ( HOH) Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hosptial after you fell at home. YOu reported right hip pain and you were brought to the hospital. You had x-rays of your hip taken and found to have a smalll fracture in your pelvis with a small amount of bleeding around your hip. Your hematocrit stabilzed and you did not need any further intervention. You were seen by Orthopedics and they recommended that you not put weight on that leg, but no surgery was warrented at this time. You will need follow-up visit with Orthopedics in 2 weeks and with your primary care provider Followup Instructions: Please follow-up with Orthopedics, Nurse Practitioner, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], in 2 weeks [**Hospital 1957**] clinic with AP pelvis radiograph. The telephone number is#[**Telephone/Fax (1) 1228**] Please follow up with the acute care service in 2 weeks. You can schedule this appointment by callling # [**Telephone/Fax (1) 600**] You will need to follow up with your primary care provider, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] # [**Telephone/Fax (1) 719**] in 1 week Completed by:[**2161-11-2**]

[ "599.0", "780.93", "V12.54", "733.00", "401.9", "041.49", "V13.02", "V10.3", "715.90", "V15.3", "311", "412", "V15.82", "414.01", "V15.88", "E885.9", "808.41" ]

icd9cm

[ [ [] ] ]

[ "88.47", "88.49" ]

icd9pcs

[ [ [] ] ]

10968, 11058

7826, 9299

239, 272

11228, 11228

2553, 7803

11991, 12597

1954, 1972

9545, 10945

11079, 11207

9325, 9522

11410, 11968

1987, 2010

185, 201

300, 1031

2025, 2534

11243, 11386

1053, 1645

1661, 1938

22,754

103,177

3262

Discharge summary

report

Admission Date: [**2119-5-26**] Discharge Date: [**2119-5-27**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2297**] Chief Complaint: CC:[**CC Contact Info 15218**] Major Surgical or Invasive Procedure: None. History of Present Illness: HPI: 81M w/recent subdural hematoma s/p evacuation in [**3-30**], CHF, Afib, aortic aneurysm, recently ([**4-29**]) admission to [**Hospital Unit Name 153**] for altered mental status and hypoxia ([**2039-5-11**]) found to have RML MRSA PNA plus CHF with intubation. Sent to ED for evaluation for somnolence, and apnea from [**Hospital1 599**] at [**Location (un) 55**]. This am pt's RR fluctuated from 24/min to periods of 30-40 sec apneic episodes with O2 sats ranging from 88-94% on RA. In the ED, found to be somnolent but arouseable and able to eat and answer questions. Weight is stable at 126 lbs on lasix 40 mg PO daily. His Vancomycin course is due to end [**5-27**]. Dose is 500 mg IV q24h due to high troughs. In ED afebrile, BP 110/70 P 80 O2 97% RA. . Also in his hospitalization in [**3-30**] at [**Hospital1 18**] he was found to have an Enterobacter UTI and a LLL pneumonia (treated with Levoflox). . Pt denies any complaints at this time. Endorses feeling confused this morning and reports that sometimes he "loses days" and that bothers him. . ROS: Denies CP, SOB, orthop, PND, palpitations, cough, fevers, new weaknesses, changes in sensation or vision, nausea, vomiting, diarrhea, abdominal pain, hematuria, dysuria, blood in the stools. Past Medical History: 1. CHF: [**2-27**] echo: mild symm LVH, EF 55% but likely overestimation with degree of MR 2. 3+ mitral regurgitation 3. Atrial fibrillation 4. Ascending aortic aneurysm- [**11-27**] CTA: 5.7 x 5.4 cm stable (pt. currently not interested in surgery) 5. DM2 6. Gout 7. Inflammatory Colitis (?)on chronic sulfasalazine. No prior surgeries or recent flares. 8. Hypertension 9. GERD 10. h/o Asbestosis 11. Recent B12 and Fe def. anemia 12. ?progressive dementia Social History: Married, lives with wife, no prior [**Name (NI) **]/ETOH. Worked as a salesman. h/o asbestosis exposure when in the service (?shipyards). Family History: no Alzhemer's or Parkinson's Physical Exam: VS: T 96.9 HR 109/41 HR 71 R 19 98% 3L Gen: NAD, A&O X 2 Skin: no rash HEENT: EOMI, PERRL, O/P clear Neck: supple, no LAD CV: RRR nl s1 s2 2/6 sem at llsb Pulm: CTAB Abd: soft, NT, ND +BS Ext: cachetic, no edema Neuro: A&O X [**1-27**], moves all 4, sensation intact to LT, 2+ DTR at [**Name2 (NI) 15219**] b/l, [**Last Name (un) **] down b/l Pertinent Results: Studies: [**5-26**]: CT Head: no intracranial hemorrhage, unchanged hypodense fluid collection subdural R frontal lobe. [**5-26**]: CXR: no new infiltrate Brief Hospital Course: A/P: 81M w/recent subdural hematoma s/p evacuation in [**3-30**], CHF, Afib, aortic aneurysm, recent MRSA PNA and CHF flare now admitted with somnolence and periods of apnea. . # Somnolence: Now seems to be resolved. Pt's family noted him to be unresponsive, or minimally responsive this morning. DDx includes infection, hypercarbia, extension of subdural hematoma. UA, CXR clear, ABG without hypercarbia, CT head OK. ?Worsening of baseline dementia vs. post-ictal from seizure? Likely secondary to severe sleep apnea and daytime sleepiness. . # Apnea: Unclear if this is new, or newly recognized. Pt has characteristic findings of [**Last Name (un) 6055**]-[**Doctor Last Name **] breathing. Will need outpt sleep study for titration of CPAP if necessary. Pt reports that he would not want CPAP, can be discussed with PCP. . # hx CHF: Currently euvolemic, no evidence of CHF flare. last echo ([**2119-4-3**]) w/EF >55%, 2+ MR, mod AR. -- Continue home doses of lasix, BB, ACE-I . # PNA: Hx MRSA PNA during last admission. - CXR shows resolving infiltrate. - No leukocytosis or febrile episodes. Last thoracocentesis in [**4-29**] showed transudative fluid c/w CHF exacerbation - Recent sputum grew MRSA ([**5-12**] & [**5-14**]), sensitive to vanco. 10 day course to end [**5-27**]. . # Subdural hematoma: - No change on today's head CT - On Keppra for seizure prophylaxis post-craniotomy (to be continued until out-pt neurology or neurosurgical follow-up). . # AAA: ascending; measured >5cm in [**11-27**] & pt refused surgical intervention at that time. . # CRI: (baseline creatinine 1.2-1.6) Today 1.1. . # Paroxysmal Afib: -- continue metoprolol for rate control -- No anticoagulation with warfarin given recent subdural hematoma and h/o frequent falls. . # DM2: -- RISS -- Diabetic diet. . # Anemia: iron studies most c/w chronic dz (ferritin 86). Hct stable. Cont ferrous sulfate. Guaiac all stools. . # Hypothyroidism: clinically euthyroid. Continue synthroid. . # Depression: remained stable. Continue celexa. . # FEN: PO diet, monitor lytes, replete prn. # Prophylaxis: protonix and pneumoboots. bowel regimen. # Communication: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (daughter) [**Telephone/Fax (5) **] 248 2146 # Code: DNR/I, confirmed with pt and last d/c summary # Dispo: back to rehab. Medications on Admission: 1. Ferrous Sulfate 325 PO DAILY 2. Docusate Sodium 100 mg PO BID 3. Furosemide 40 mg PO DAILY 4. Levetiracetam 250 mg PO QAM 5. Levetiracetam 250 mg PO HS 6. Citalopram 10 mg PO DAILY 7. Ascorbic Acid 250 mg PO DAILY 8. Vancomycin 500 mg IV q24h 9. Levothyroxine 25 mcg PO DAILY 10. Metoprolol Tartrate 50 mg PO BID 11. Lisinopril 5 mg PO once 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). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Levetiracetam 250 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 6. Levetiracetam 250 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 7. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 8. Ascorbic Acid 250 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) Intravenous Q 12H (Every 12 Hours) for 1 doses: pt has one dose left in his course for [**5-27**] evening. Discharge Disposition: Extended Care Discharge Diagnosis: [**Last Name (un) 6055**]-[**Doctor Last Name **] breathing pattern Sleep Apnea CHF Resolving MRSA PNA. Discharge Condition: Stable. Discharge Instructions: Call your primary care physician or return to the emergency room if you have shortness of breath, chest pain, or any other symptom that bothers you. Followup Instructions: Please call [**Hospital1 18**] Sleep Lab for a sleep study [**Telephone/Fax (1) 15220**]. Please call your primary care physician for an appointment at [**Telephone/Fax (1) 3070**].

[ "780.57", "427.31", "786.04", "250.00", "441.4", "428.0", "585.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6680, 6695

2838, 5174

292, 300

6843, 6853

2658, 2679

7050, 7235

2248, 2278

5575, 6657

6716, 6822

5200, 5552

6877, 7027

2293, 2639

223, 254

328, 1593

2688, 2815

1615, 2076

2092, 2232

26

197,661

5042

Discharge summary

report

Admission Date: [**2126-5-6**] Discharge Date: [**2126-5-13**] Date of Birth: [**2054-5-4**] Sex: M Service: CCU HISTORY OF PRESENT ILLNESS: Patient is a 72-year-old male with coronary artery disease status post myocardial infarction, CHF with an ejection fraction of 15% and ICD for DF/VT. Here for possible ICD malfunction after he was shocked three times at home the night before admission to an outside hospital. The first shock occurred on the morning prior to admission with no preceding symptoms. The second shock occurred while walking downstairs, and he reported reaching out his arm. Third shock occurred shortly after this when he was reaching out with his left hand, and the final and fourth shock occurred when he was reaching out in bed with his left arm and received multiple shocks in a row. At the outside hospital, the patient had a magnet placed over his ICD, and was given magnesium sulfate. He was hemodynamically stable, and had no complaints otherwise. On review of symptoms, the patient reported occasional orthostatic hypotension, but denied chest pain, shortness of breath, nausea, or vomiting. The patient denies fever or chills. Denied bloody stools or black stools. The patient denied orthopnea, PND, or dyspnea. PAST MEDICAL HISTORY: 1. Coronary artery disease status post myocardial infarction and ischemic cardiomyopathy. 2. ICD for VF with second SVC coil because of high DFTs with three-lead fracture in 03/99. 3. Atrial fibrillation. 4. Chronic renal insufficiency. 5. CHF with an EF of 15%. 6. Hypercholesterolemia. 7. Obesity. 8. History of unsuccessful VT ablation. 9. Osteoarthritis. 10. BPH. 11. Reactive airway disease. 12. Diabetes mellitus type 2. MEDICATIONS: 1. Toprol 50 b.i.d. 2. Vasotec 10 b.i.d. 3. Lasix 40 b.i.d. 4. Imdur 60 q.d. 5. Lanoxin 125 mcg. 6. Levoxyl 125 mcg. 7. Lipitor 40. 8. Plavix 75. 9. Spironolactone 25. 10. Dofetilide 250 q.d. 11. Coumadin 10 two days a week, 7.5 five days a week. SOCIAL HISTORY: Patient reports coronary artery disease in his father. [**Name (NI) **] also has a 50 pack year smoking history, but quit 34 years ago. He denies alcohol use. ALLERGIES: Shellfish and IV dye, which causes hives, and amiodarone which caused edema. PHYSICAL EXAM ON ADMISSION: Temperature 97.7, heart rate of 80, blood pressure 86/52, respiratory rate 16. Saturating 97% on room air. Patient was alert and oriented times three in no acute distress. Neck was supple. Pupils are equal, round, and reactive to light. Clear oropharynx. There was no JVD and no carotid bruits. Cardiovascular reveals regular, rate, and rhythm with occasional irregular beats. Faint systolic ejection murmur at the left lower sternal border. Respiratory: Lungs are clear to auscultation bilaterally. The abdomen was soft, nontender, nondistended. Extremities revealed trace bilateral lower extremity edema. SUMMARY OF HOSPITAL COURSE: 1. Cardiac rhythm: Patient is admitted with multiple shocks from his ICD. The shocks had occurred when the patient was using his left arm predominantly. This is likely due to the fact that there was a device malfunction. The device was interrogated, and found to be oversensing noise from certain arm movements. The device was turned off and programmed DDD. The INR was 2.5, so the patient was given vitamin K with plan for future need revision. Overnight the patient had a four-second pause on telemetry, although the patient was asymptomatic. The patient returned to the Electrophysiology Laboratory and had a pacing catheter placed. The patient was transferred to the CCU on [**2126-5-7**] for further monitoring in the setting of transvenous pacing. The patient remained comfortable and when his INR trended down, he returned to the EP Laboratory for device revision and lead revision. Patient tolerated the procedure well. After this, the patient returned to the [**Hospital3 **] floors and received multiple shocks on the morning, which were appropriate for ventricular tachycardia. The patient's pacemaker was interrogated and found to be functioning well. It was reprogrammed to over pace out of ventricular tachycardia prior to shocking. The patient had additional episodes of ventricular tachycardia, which were successfully paced out of by his pacemaker. Patient was started on lidocaine drip given his significant ventricular tachycardia and the episodes of VT diminished significantly. The patient was transitioned to mexiletine on the next day, and tolerated this well. The patient had no further episodes of significant ventricular tachycardia. 2. Coronary artery disease: The patient currently had no symptoms. He was continued on his Plavix, statin, beta-blocker, and Imdur. Patient was not admitted on an aspirin, although he was given an aspirin during his hospitalization given the fact that was Coumadin was held. Plan for no aspirin on discharge with resuming his Coumadin as per his prior home regimen. 3. Congestive heart failure: Patient has an ischemic cardiomyopathy with an ejection fraction of less than 20%. An echocardiogram on this hospitalization again revealed an ejection fraction of 15-20%. While the patient was NPO during episodes of this hospitalization, his Lasix and aldactone was held; however, he was continued on his Lasix, aldactone, digoxin, and ACE inhibitor. Patient had no evidence of congestive heart failure during this hospitalization and he resumed his prior medications before discharge. 4. Endocrine: Patient with hypothyroidism: The patient was continued on his Levoxyl. He was also maintained on a regular insulin-sliding scale. Blood sugars remained in normal levels, and he did not require significant amounts of insulin. 5. Renal: Patient with chronic renal insufficiency. Remained stable throughout this hospitalization. 6. Heme: Patient's INR was reversed with vitamin K, and the patient was instructed to resume Coumadin dosing on the evening following discharge. The patient will follow up with his cardiologist or primary care physician for further monitoring of his INR and adjustment of his Coumadin dose. 7. ID: The patient had a temperature greater than 101.5 following his pacemaker placement, and therefore was continued on his cephalosporin, which was originally given for prophylaxis. The patient was transitioned to p.o. antibiotics, plan for seven-day course. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSES: 1. ICD firing. 2. ICD revision. 3. Ventricular tachycardia. DISCHARGE MEDICATIONS: 1. Furosemide 40 b.i.d. 2. Spironolactone 25 q.d. 3. Plavix 75 q.d. 4. Atorvastatin 40 q.d. 5. Levothyroxine 125 mcg. 6. Digoxin 125 mcg q.d. 7. Mexiletine 150 p.o. b.i.d. 8. Isosorbide mononitrate 30 q.d. 9. Enalapril 2.5 q.d. 10. Dofetilide 125 b.i.d. 11. Ibuprofen prn. 12. Metoprolol succinate 25 q.d. 13. Keflex 500 t.i.d. for three days. 14. Coumadin 7.5 mg p.o. q.d. FOLLOW-UP PLANS: The patient will follow up with his primary care physician in the week following discharge. In addition to this, the patient will follow up with the electrophysiologist, Dr. [**Last Name (STitle) **], on [**6-7**] in addition to his appointment in Device Clinic on [**5-29**]. [**Doctor First Name 900**] [**Name8 (MD) 901**], M.D. [**MD Number(1) 2144**] Dictated By:[**Name8 (MD) 12502**] MEDQUIST36 D: [**2126-5-15**] 20:55 T: [**2126-5-17**] 08:54 JOB#: [**Job Number 20814**]

[ "996.04", "427.31", "428.0", "412", "272.0", "593.9", "427.1", "600.00", "414.01" ]

icd9cm

[ [ [] ] ]

[ "37.94", "89.59" ]

icd9pcs

[ [ [] ] ]

6483, 6544

6567, 6942

2926, 6399

6960, 7480

159, 1271

2280, 2898

1293, 1982

1999, 2265

6424, 6462

13,329

168,424

51849

Discharge summary

report

Admission Date: [**2184-8-13**] Discharge Date: [**2184-8-18**] Date of Birth: [**2112-8-23**] Sex: F Service: MEDICINE Allergies: A.C.E Inhibitors / Neurontin Attending:[**First Name3 (LF) 5037**] Chief Complaint: Abdominal Pain, Shortness of Breath Major Surgical or Invasive Procedure: None History of Present Illness: 71yoF ESRD s/p transplant, CAD, COPD, mod pulmonary HTN (TR gradient 49 to 57 mm, chronic diastolic CHF, recent admission ([**7-30**] - [**8-9**]) for SOB/Cough requiring admission to the MICU [**12-27**] COPD vs viral bronchitis and acute dCHF flare for which she received multiple antibiotics and placed on a steroid taper, that yesterday presented from renal clinic to ED with 10/10 sharp, global abdominal pain since Tuesday [**8-10**] that was out of proportion to her physical exam. Pt subsequently brought to the ED where she received IVF (200cc/hr), and underwent two CT scans, following which she acute onset of SOB and RR 36-40, HR 110, SBP to 202/96. Given Kayexalate for K 5.9. Pt also given 1 dose of Levaquin. . Overnight the pt was transfered to the unit, received lasix, bipap and started on NTG drip which dropped her pressures. She had good UOP, weaned off 02 and transferred to the floor. Upon further history the pt notes her abdominal pain began Tuesday night, one day after discharge. The pain woke her from sleep [**9-3**], had one episode of dark stool, but then 1 normal BM daily. Radiation throughout abdomen with some to the back. Took tylenol which mildly relieved her symptoms. Pt recently on completed steroid taper for ?COPD flare, on full strength ASA, no other NSAIDS or EtOH, one cup of coffee per day. Patient reports decreased PO this week. No fevers, chills, BRBPR. No dysuria, hematuria. Decreased cough from last week with decreased productivity. Past Medical History: 1. ESRD [**12-27**] NSAID induced nephropathy, s/p living related donor transplant in [**9-/2181**], on tacrolimus, cellcept, and bactrim prophylaxis. 2. HTN 3. CAD s/p cath [**2177**] with no intervention and 99% RCA blockage; MIBI [**8-29**] - Fixed defect of the base of the inferior wall & a calculated left ventricular ejection fraction is 59%. 4. COPD 5. chronic aortic dissection 6. enteroccocus line infx 7. s/p TAH/BSO 8. s/p appy 9. anemia 10. GERD 11. s/p ventral hernia repair [**3-30**] Social History: Lives at home by herself, but temporarily living with daughter while her apartment is getting renovated, ambulates with assistance of cane. Tobacco h/o [**11-26**] ppd x >40+ years. No EtOH or illicits. Family History: non-contributory Physical Exam: Vitals 145/49, 70, 21, 94% Gen Gen: NAD, A0x3, HEENT: PERRL, EOMI, Mildly tender scant lymphadenopathy bilaterally. Heart: S1S2 No MRG Lungs: Scant rales at right base, otherwise CTA without wheezes of rhonchi Abdomen: Soft, Obese, Multiple well healed scars, multiple ecchymoses that appear to be [**12-27**] to prior SQH. LLQ mildly tender at site of kidney transplant. Otherwise non-tender, without rebound or guarding. Extremities: No cynaosis, clubbing or edema. Pertinent Results: Admission Labs: [**2184-8-13**] 10:50PM CK(CPK)-56 [**2184-8-13**] 10:50PM cTropnT-0.05* [**2184-8-13**] 08:45PM TYPE-ART PO2-380* PCO2-52* PH-7.26* TOTAL CO2-24 BASE XS--4 [**2184-8-13**] 08:45PM K+-5.2 [**2184-8-13**] 06:36PM K+-6.2* [**2184-8-13**] 04:17PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.019 [**2184-8-13**] 04:17PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-TR [**2184-8-13**] 04:17PM URINE RBC-0-2 WBC-[**1-28**] BACTERIA-MOD YEAST-MOD EPI-[**5-4**] [**2184-8-13**] 01:11PM K+-5.7* [**2184-8-13**] 01:08PM K+-5.7* [**2184-8-13**] 11:05AM LACTATE-1.0 K+-5.9* [**2184-8-13**] 10:50AM GLUCOSE-131* UREA N-49* CREAT-2.3* SODIUM-136 POTASSIUM-6.1* CHLORIDE-103 TOTAL CO2-20* ANION GAP-19 [**2184-8-13**] 10:50AM ALT(SGPT)-13 AST(SGOT)-15 CK(CPK)-64 ALK PHOS-139* TOT BILI-0.4 [**2184-8-13**] 10:50AM LIPASE-14 [**2184-8-13**] 10:50AM cTropnT-0.05* [**2184-8-13**] 10:50AM CK-MB-NotDone proBNP-[**Numeric Identifier 107384**]* [**2184-8-13**] 10:50AM PHOSPHATE-5.5* MAGNESIUM-1.6 [**2184-8-13**] 10:50AM WBC-12.7* RBC-2.72* HGB-8.0* HCT-25.3* MCV-93 MCH-29.3 MCHC-31.5 RDW-16.8* [**2184-8-13**] 10:50AM NEUTS-89.7* LYMPHS-6.5* MONOS-3.4 EOS-0.3 BASOS-0 [**2184-8-13**] 10:50AM PLT COUNT-283 . Pertinent Labs: [**2184-8-15**] 05:50AM BLOOD WBC-8.1 RBC-2.46* Hgb-7.1* Hct-22.8* MCV-93 MCH-28.9 MCHC-31.3 RDW-16.8* Plt Ct-303 [**2184-8-18**] 06:30AM BLOOD WBC-7.0 RBC-3.18* Hgb-9.3* Hct-28.1* MCV-89 MCH-29.3 MCHC-33.1 RDW-17.3* Plt Ct-328 [**2184-8-14**] 05:58AM BLOOD Neuts-89.6* Lymphs-6.4* Monos-3.6 Eos-0.4 Baso-0 [**2184-8-17**] 06:05AM BLOOD PT-14.4* INR(PT)-1.3* [**2184-8-18**] 06:30AM BLOOD PT-13.8* INR(PT)-1.2* [**2184-8-14**] 11:54AM BLOOD Glucose-137* UreaN-43* Creat-2.4* Na-139 K-5.0 Cl-100 HCO3-23 AnGap-21* [**2184-8-16**] 06:05AM BLOOD Glucose-121* UreaN-42* Creat-2.8* Na-139 K-4.5 Cl-102 HCO3-23 AnGap-19 [**2184-8-18**] 06:30AM BLOOD Glucose-126* UreaN-31* Creat-2.1* Na-133 K-4.5 Cl-103 HCO3-21* AnGap-14 [**2184-8-17**] 06:05AM BLOOD ALT-9 AST-9 AlkPhos-136* TotBili-0.3 [**2184-8-18**] 06:30AM BLOOD ALT-8 AST-9 AlkPhos-142* TotBili-0.2 [**2184-8-13**] 10:50PM BLOOD cTropnT-0.05* [**2184-8-14**] 11:54AM BLOOD cTropnT-0.07* [**2184-8-15**] 05:50AM BLOOD cTropnT-0.07* [**2184-8-14**] 11:54AM BLOOD Calcium-8.0* Phos-5.8* Mg-1.8 [**2184-8-15**] 05:50AM BLOOD Calcium-7.6* Phos-5.2* Mg-2.6 Iron-25* [**2184-8-18**] 06:30AM BLOOD Calcium-8.0* Phos-4.1 Mg-2.0 [**2184-8-15**] 05:50AM BLOOD calTIBC-200* Ferritn-711* TRF-154* [**2184-8-16**] 06:05AM BLOOD VitB12-529 Folate-6.9 Hapto-383* [**2184-8-15**] 05:50AM BLOOD tacroFK-8.0 [**2184-8-16**] 06:05AM BLOOD tacroFK-8.5 [**2184-8-17**] 09:57AM BLOOD tacroFK-14.5 [**2184-8-18**] 06:30AM BLOOD tacroFK-7.6 [**2184-8-13**] 08:45PM BLOOD Type-ART pO2-380* pCO2-52* pH-7.26* calTCO2-24 Base XS--4 [**2184-8-14**] 06:17AM BLOOD Type-[**Last Name (un) **] pO2-41* pCO2-43 pH-7.38 calTCO2-26 Base XS-0 [**2184-8-14**] 12:05PM BLOOD Type-[**Last Name (un) **] pH-7.31* [**2184-8-13**] 01:08PM BLOOD K-5.7* [**2184-8-13**] 06:36PM BLOOD K-6.2* [**2184-8-13**] 08:45PM BLOOD K-5.2 [**2184-8-14**] 12:05PM BLOOD Lactate-1.2 [**2184-8-14**] 12:05PM BLOOD freeCa-0.98* [**2184-8-15**] 01:14PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.029 [**2184-8-16**] 10:30AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.021 [**2184-8-16**] 10:30AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.021 [**2184-8-15**] 01:14PM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2184-8-16**] 10:30AM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-SM [**2184-8-16**] 10:30AM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-SM [**2184-8-15**] 01:14PM URINE RBC-10* WBC-12* Bacteri-FEW Yeast-NONE Epi-0 [**2184-8-16**] 10:30AM URINE RBC-21* WBC-9* Bacteri-NONE Yeast-FEW Epi-1 [**2184-8-16**] 10:30AM URINE Eos-NEGATIVE [**2184-8-16**] 10:30AM URINE Hours-RANDOM UreaN-808 Creat-184 Na-71 . Blood Culture, Routine (Final [**2184-8-20**]): NO GROWTH , CXR ([**2184-8-13**]) Here is atelectasis at the lung bases. There is stable cardiomegaly. There is stable prominence of the right hilum, most likely combination of pulmonary artery and calcified right hilar lymph nodes. There are no focal pulmonary consolidations. There is no free air under the diaphragm. . CXR: ([**2184-8-14**]) CT Abdomen and Pelvis: IMPRESSION: 1. There is stable fat-containing incisional hernia 2. There is a stable small right adrenal adenoma. 3. Extensive atherosclerosis throughout the abdominopelvic vasculature, which cannot be further assessed due to lack of intravenous contras . CTA Abdomen and Pelvis: IMPRESSIONS: 1. Appearance of the abdominal aorta is unchanged, with chronic aortic dissection which is unchanged from the prior study of [**2179**]. Again, a circumferential ring of calcification is noted which is predominantly filled with thrombus. The presumed false lumen on the left fills with contrast and feeds the iliac arteries. No evidence of acute aortic dissection is seen. 2. No evidence of ischemic bowel. Vessels feeding the transplant kidney appear patent. 3. Patchy opacities in the right middle lobe may represent inflammatory or infectious process. Bibasilar atelectasis. Trace left pleural effusion . pMIBI Stress Test: IMPRESSION: No anginal type symptoms and no ischemic ST segment changes. Nuclear report to be sent separately. . CARDIAC PERFUSION PERSANTINE INTERPRETATION: The image quality is good. Left ventricular cavity size is normal. There is a fixed perfusion defect at the base of the inferior wall, unchanged. Gated images reveal normal wall motion. The calculated left ventricular ejection fraction is 51%. Compared with the study of [**2182-4-24**], the reversible defect of the apical and mid inferior wall is not apperent on the current scan. IMPRESSION: Fixed perfusion defect at the base of the inferior wall, unchanged. . Brief Hospital Course: A/P: 71yoF ESRD s/p transplant, CAD, COPD, mod pulmonary HTN, presented with Acute Pulmonary Edema, Hypertensive Urgency and Severe Abdominal Pain. . # Abdominal Pain: The patient presented with abdominal pain with symptoms initially out-of-proportion with exam. A CT without contrast was performed (details above) without evidence acute GI process. Subsequently the patient underwent a CTA of the abdomen for which she received IVF and was laid flat during which she became short of breath and subsequently hypertensive to the 200's (details given below). The pt was seen by Vascular Surgery in the ED that felt the symptoms were not consistent with acute mesenteric ischemia and in addition she had a normal lactate. The final read of the CTA was unreaveling for any acute process. During the patients hospital course her pain appeared to localize to the site of the kidney transplant in the LLQ. Transplant surgery was called to evaluate her transplant kidney, but subsequent ultrasounds were unrevealing for perinephric collections, hydronephrosis or signs of ischemia. The patients abdominal pain resolved by the time of her discharge of which the differential still remains: Gastritis (possibly secondary to a recent steroid taper, PUD, Chronic Mesenteric Ischemia secondary to abundant mesenteric calcifications and chronic aortic disection. . # Acute Pulmonary Edema: Patient with known dCHF with preserved EF as well as moderate pulmonary HTN. Acute pulmonary edema was likely excerbated in the setting of hypertensive urgency following her IVF (given at a rate of 200cc/hr prior to CTA) as well as HTN secondary to panic as evident by her saying "I need air" in the ED. The patient was brought to the ICU for closer monitoring and was placed on BiPap as well as given IV Lasix. Upon transfer to the floor the patients lungs were mostly clear to ausculation with scant crackls R>L. The pt was clinically euvolemic and breathing comforatbly on room air. Of note this presentation very similar to prior admission where pt recieved fluids and subsequently reqiured tranfer to the unit. The patient remained on room air for the duration of her hospitalization. . # Hypertensive: Following the patients work-up in the ED the pt was admitted to the MICU with hypertensive urgency with SBP to the 200s . The patient was given Labetalol and subsequently transfered to floor on PO Labetalol for SBP control. The patient uses Labetalol as a single [**Doctor Last Name 360**] as an outpatient. The patient was started on low-dose calcium blocker (amlodipine) in the setting of SBPs 140-160s as an inpatient. . # ESRD s/p Transplant: The patient was followed by transplant surgery service while in-house. K+ was 5.9 on admission, and the pt subsequently received Kayexelate which improved to levels WNL. The patients had a baseline creatinine of 1.8 in early [**Month (only) **]. On admission the patients Cr was elevated at 2.3, peaking at 2.8 and returning to 2.1 with gentle hydration. The patient was continued on home regimen of azathioprine/tacrolimus while following Tacrolimus levels. . # Anemia: The patients HCT ranged from 23 through 28 from approximately 30s at her baseline in the setting of one recent episode of dark stools, without frank melena, BRBPR. Patient chronically on Epogen from long term renal disease. B12 and folate were WNL and haptoglobin was not decreased. . # CAD: Pt with known CAD, followed by cards as outpatient with known distal RCA occlusion. No symptoms of angina on admission and was ruled out with unchanged EKG. The patient then subsequently developed one episode of chest pain. The patient was sent for a pMIBI ( as detailed above) that showed no new lesions. The pt was continued on ASA and beta-blocker. . # Chronic Aortic Disection: Chronic in nature. CT abd with contrast performed overnight. Pt reporting back pain. Hct has been slowly decreasing. CT unchanged from prior studies. . # COPD: Pt with 40 pack-yr hx. Not on home 02. Recently completed steroid taper for likely COPD flare. The pt was continued Nebs PRN. Medications on Admission: Benzonatate 100mg PO TID prn cough. Guaifenesin 100mg/5 mL Syrup Sig: 5-10 MLs PO Q6H prn cough Azathioprine 50mg PO DAILY Labetalol 200mg PO BID Menthol-Cetylpyridinium 3 mg Lozenge prn cough. Aspirin 325mg PO DAILY Cinacalcet 30mg PO BID Codeine Sulfate 30mg PO Q6H prn cough Tacrolimus 5mg PO q12h Albuterol 90mcg/Actuation Aerosol 1-2 Puffs Inhalation Q4H Ipratropium Bromide 17mcg/Actuation Aerosol 2 Puff q6h Diphenhydramine 25mg PO HS Furosemide 20mg PO DAILY Calcium Carbonate 500mg 2 PO QID Pantoprazole EC 40mg PO Q12H Cholecalciferol (Vitamin D3) 400U 2 tab PO DAILY Docusate Sodium 100mg PO BID Senna 8.6mg PO BID Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 2. Azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: Two (2) Inhalation Q4H (every 4 hours) as needed for dyspnea. 4. Ipratropium Bromide 0.02 % Solution Sig: Two (2) Inhalation Q6H (every 6 hours) as needed. 5. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*0* 6. Labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 8. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Sublingual once a day as needed for chest pain: ONE UNDER THE TONGUE Q5MIN X3 AS NEEDED FOR CHEST PAIN. 9. Tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO Q12H (every 12 hours). Disp:*240 Capsule(s)* Refills:*5* 10. Procrit 20,000 unit/mL Solution Sig: One (1) Injection q2 weeks. 11. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*3* 12. Shower Chair with use in the shower as directed 13. Amlodipine 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 14. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO QID WITH MEALS (). 16. Outpatient Lab Work Please draw CBC, Chem 10, and Tacrolimus level on Wednesday, [**8-25**]. Please fax results to "Attn: Dr. [**Last Name (STitle) **]" at ([**Telephone/Fax (1) 28179**]. 17. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 18. Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary Diagonsis - Atypical Abdominal Pain - Acute Pulmonary Edema . Secondary Diagnoses - Coronary Artery Disease - COPD - ESRD s/p kidney transplant Discharge Condition: Stable. Patient weak with ambulation. Taking good PO and at her mental baseline. Discharge Instructions: You were admitted to hospital with abdominal pain. You underwent a number of imaging studies that did not reveal the source of your pain. In addition, you were given IV fluids to protect against kidney damage; however, you developed shortness of breath and required diuretics to decrease the fluid in your lung. . We have started the following medication: 1) Calcitriol 0.25mcg By Mouth Daily 2) Amlodipine 2.5 mg by mouth daily . We have changed the following medication: 1) Protonix 40mg by mouth Twice Daily 2) Tacrolimus 4 mg by mouth daily . We have discontinued the following medication: 1) Sensipar 60mg PO Daily . Please restart your lasix at 20 mg daily. . Please keep all of your appointments as listed below. . Please return to the hospital or call your primary care doctor if you experience chest pain, shortness of breath, abdominal pain, decreased urine output, diarrhea, fevers, chills, back pain. Followup Instructions: We will call you with an appointment with Dr. [**Last Name (STitle) **] in the next two weeks. . Please have your labs drawn next week. A prescription has been given to you for your labs to be drawn. You can have them drawn by VNA services or at [**Hospital6 733**] on [**Hospital Ward Name 23**] Building, [**Location (un) **]. . Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Name (STitle) **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2184-8-26**] 11:00 . Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2184-8-27**] 9:00 . Provider: [**First Name8 (NamePattern2) 1238**] [**Last Name (NamePattern1) 1239**] [**Name8 (MD) **], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 250**] Date/Time:[**2184-9-28**] 9:40 [**Name6 (MD) 2105**] [**Name8 (MD) 2106**] MD [**MD Number(2) 5038**]

[ "584.9", "428.33", "285.21", "E947.8", "585.9", "275.41", "530.81", "789.07", "428.0", "491.22", "441.02", "416.8", "403.00", "V42.0" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

15911, 15969

9275, 13345

325, 332

16165, 16248

3130, 3130

17209, 18139

2609, 2627

14022, 15888

15990, 16144

13371, 13999

16272, 17186

2642, 3111

250, 287

360, 1848

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79,184

195,178

41243

Discharge summary

report

Admission Date: [**2174-5-23**] Discharge Date: [**2174-5-31**] Service: MEDICINE Allergies: Codeine / Nitrofurantoin Attending:[**First Name3 (LF) 1515**] Chief Complaint: dyspnea on exertion Major Surgical or Invasive Procedure: Percutaneous Aortic Valve replacement Temporary pacing wire placement History of Present Illness: 89F CAD, s/p 5 vessel CABG in [**2162**], HTN, hyperlipidemia, and hypothyroidism. Of note the pt is s/p evaluation for percutaneous aortic valve replacement at the [**Hospital6 13185**] with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] transcatheter aortic valve prosthesis last year but they felt her iliofemoral arteries were too small and tortuous for percutaneous approach. . Pt currently notes SOB with exertion with minimal activity and ongoing fatigue. Although she does not appreciate her breathing, her son notes significant shortness of breath with minimal activity. She has occasional dizziness but no presyncope or syncope. She sleeps with one pillow and denies any PND. She wakes up frequently to urinate. She denies any LE edema. . On review of systems, s/he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. S/he denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: - s/p Myocardial infarction [**6-5**] - CABG: Coronary artery disease s/p CABG x 5 in [**2162**] at CMC - PERCUTANEOUS CORONARY INTERVENTIONS: ([**8-/2173**]) - PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: # Hypothyroidism # Anemia # History of TIA # Peripheral artery disease # s/p Pessary # UTI's in past, denies present symptoms # Psoriasis # Sciatica # Mild Arthritis # Mild Anxiety; related to loss of her husband and 2 sons Social History: She lives in [**Location **] with her 57 y.o. son who is disabled secondary to a "bad back". She lost one son at the age of 50, she is unsure why but possibly related to his heart. Her other son died in his late 50's of unclear reasons. She does not use any assistive devices and denies any falls. Contact upon discharge: [**First Name4 (NamePattern1) **] [**Known lastname **]; he does not have cell phone Home Care Services: none currently but previous followed by the [**Location (un) 5450**] VNA. - Tobacco history: none - ETOH: rare - highball when she goes out for a special occasion - Illicit drugs: none Family History: - No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION EXAM: General: NAD, WGWN, appears stated age Skin: Dry. Small psoriatic plaque on abdomen HEENT: PERRLA. Neck: Supple. Full ROM. Chest: Lungs clear bilaterally Heart: RRR. III/VI late peaking systolic murmur. Abdomen: Soft, non-distended Extremities: Warm [x] without edema. Varicosities: None [] moderate Neuro: Grossly intact x Femoral Right: 2+ Left:2+ DP Right: 2+ Left:2+ PT [**Name (NI) 167**]: 2+ Left:2+ Radial Right: 2+ Left:2 DISCHARGE EXAM: VITALS: Temp current:98.3 HR: 71-80 RR: 18 BP:99-146/62-71 O2 Sat: 97% RA Gen: resting comfortably in bed HEENT: MMM, dressing in place on left neck, C/d/i CV: RRR, Soft [**12-2**] holosystolic murmur at LLSB RESP: CTA BL, no wheezes/rales/ronchi ABD: soft, NT, pos BS. EXTR: no edema, palp pulses NEURO: A/O, no focal defects Right: DP 1+ PT 1+ Left: DP 2+ PT 1+ Skin: intact Access: PIV left forearm Tubes: none Pertinent Results: ADMISSION LABS: [**2174-5-23**] 03:30PM BLOOD WBC-9.6 RBC-4.01* Hgb-12.2 Hct-37.4 MCV-93 MCH-30.3 MCHC-32.6 RDW-12.9 Plt Ct-180 [**2174-5-23**] 03:30PM BLOOD PT-13.2 PTT-24.3 INR(PT)-1.1 [**2174-5-23**] 03:30PM BLOOD Glucose-160* UreaN-22* Creat-1.4* Na-138 K-4.1 Cl-107 HCO3-22 AnGap-13 [**2174-5-23**] 03:30PM BLOOD Albumin-3.7 [**2174-5-23**] 03:30PM BLOOD ALT-11 AST-14 CK(CPK)-50 AlkPhos-78 TotBili-0.4 [**2174-5-23**] 03:30PM BLOOD CK-MB-4 proBNP-8962* DISCHARGE LABS: [**2174-5-31**] 07:00AM BLOOD WBC-8.9 RBC-3.40* Hgb-10.6* Hct-32.3* MCV-95 MCH-31.3 MCHC-32.9 RDW-13.3 Plt Ct-294 [**2174-5-31**] 07:00AM BLOOD PT-12.2 PTT-23.6 INR(PT)-1.0 [**2174-5-31**] 07:00AM BLOOD Glucose-107* UreaN-13 Creat-1.3* Na-138 K-4.2 Cl-102 HCO3-27 AnGap-13 [**2174-5-31**] 07:00AM BLOOD Calcium-9.8 Phos-3.2 Mg-2.0 [**2174-5-31**] 09:20AM BLOOD proBNP-1522* IMAGING/STUDIES: ECHO ([**5-24**]) PRE VALVE DEPLOYMENT The left atrium is dilated. Mild spontaneous echo contrast is seen in the body of the left atrium. No mass/thrombus is seen in the left atrium or left atrial appendage. Mild spontaneous echo contrast is present in the left atrial appendage. The left atrial appendage emptying velocity is depressed (<0.2m/s). No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is moderate global left ventricular hypokinesis (LVEF = 35 %). The right ventricular free wall demonstrates mild global free wall hypokinesis. There are complex (>4mm) atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Drs. [**Last Name (STitle) **], [**Name5 (PTitle) **], and [**Doctor Last Name 914**] were notified in person of the results in the operating room at the time of the study. POST VALVE DEPLOYMENT Both right and left ventricular systolic function are improved. The mitral regurgitation is improved - now trace mild. The percutaneous aortic valve is in situ. After initial deployment, significant aortic regurgitation was seen on the mitral valvular aspect of the valvular apparatrus. After re-balooning of the valve, the aortic regurgitation was reduced to mild. Another small jet was seen on the opposite side but this was only trace in severity.. The maximum gradient across the aortic valve was 6 mmHg with a mean of 3 mmHg. There was no pericardial effusion. ECHO ([**5-25**]) The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. An aortic CoreValve prosthesis is present. The transaortic gradient is normal for this prosthesis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2174-4-6**], a Corevalve prosthesis is in place. There is a normal transvalvular gradient and trivial aortic regurgitation. The severity of mitral regurgitation and pulmonary hypertension are reduced. ECHO ([**5-31**]) 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 normal (LVEF>55%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). An aortic CoreValve prosthesis is present and appears well-seated. The transaortic gradient is normal for this prosthesis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). The tricuspid valve leaflets are mildly thickened. There is borderline pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2174-5-25**], the estimated pulmonary artery systolic pressure is now higher (but may have been underestimated in the prior study). Brief Hospital Course: 89F with hx of critical AS, CAD, HTN with shortness of breath admitted for Corevalve procedure. ACTIVE ISSUES: #Aortic Stenosis Pt with SOB secondary to AS admitted for Corevale. Pt was continued on aggrenox and loaded with plavix. Corevalve on [**5-24**] without complications. Temporary pacer placed. On [**5-25**], pacer began pacing inappropriately and was removed. Post-procedure echo showed no gradient across aortic valve and only trace AR. Pt was transferred out of the CCU. Pt remained stable throughout hospital admission. During admission, she was also followed by geriatics given advanced age and PT for deconditioning associated with preop severe aortic stenosis. She was discharged with plan to continue dual antiplatelet therapy for 3 months with ASA 81 and plavix 75 mg daily. Aggrenox held. Follow up is scheduled with her PCP and cardiology. . CHRONIC ISSUES #CAD - stable. Pt was continued on home dose Imdur. Her beta blocker was intially held due to bradycardia but it was resumed once tolerated by heart rate. Continue on low dose aspirin and plavix. CK and MB fraction remained flat. . #HTN - BPs remained stable during admission. Home dose of metoprolol was initially held secondary to bradycardia in the 50-60s so she was started on amlodipine 2.5 mg po qd. Beta blocker held for majority of admission but restarted prior to discharge once heart rate could tolerate. Continued Imdur. . #CHF: stable Euvolemic throughout majority of admission. Treated with lasix x1 with good diuresis. . # HLD: stable Continued simvastatin . # HYPOTHYROID: stable. TSH normal Continued levothyroxine . # ANEMIA: Hct nl. on B12 and iron supplements Continued supplements . TRANSITIONAL ISSUES: Patient was full code. She will be discharged home to live with her son. [**Name (NI) **] has plans for repeat echocardiogram and cardiology appointment on [**2174-6-24**] with repeat labs prior to appointment. She was started on amlodipine for hypertension. Blood pressure regimen may need further adjustment once at home. Patient should continue to take ASA and Plavix for 3 months following procedure. Medications on Admission: Amoxicillin 500mg QID x 4 days (started [**2174-5-14**]) Diazepam 2.5mg PO BID PRN Anxiety Dipyridamole-Aspirin 25 mg-200 mg Cap, ER 12hr PO BID Ergocalciferol 50,000 unit q Sunday Isosorbide Mononitrate 30 mg ER 24 hr Metoprolol Succinate25 mg 0.5 tablets daily Levothyroxine 50 mcg po daily Simvastatin 40 mg daily Tramadol 50 mg po q6h prn for hip or back pain Vitamin B12 1000 mcg daily Ferrous sulfate 325mg daily Fish oil 1200/144mg ont tablet daily Discharge Medications: 1. diazepam 5 mg Tablet Sig: 0.5 Tablet PO twice a day as needed for anxiety. 2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*3* 3. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO 1X/WEEK ([**Doctor First Name **]). 4. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 5. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: 0.5 Tablet Extended Release 24 hr PO DAILY (Daily). 6. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. simvastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime. 8. tramadol 50 mg Tablet Sig: One (1) Tablet PO twice a day as needed for pain. 9. cyanocobalamin (vitamin B-12) 1,000 mcg Tablet Sig: One (1) Tablet PO once a day. 10. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 12. Fish Oil 1,200-144-216 mg Capsule Sig: One (1) Capsule PO once a day. 13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 14. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 15. Outpatient Lab Work Please check CBC and Chem-7 on Friday [**6-3**] with results to [**Last Name (LF) **],[**First Name3 (LF) **] F. Location: QUEEN CITY MEDICAL ASSOCIATES Address: [**Location (un) 89826**], [**Apartment Address(1) 4473**], [**Location (un) **],[**Numeric Identifier 84189**] Phone: [**Telephone/Fax (1) 89827**] Fax: [**Telephone/Fax (1) 89828**] Discharge Disposition: Home With Service Facility: [**Location (un) 5450**] VNA Discharge Diagnosis: Aortic Stenosis s/p CoreValve placement Hypertension Coronary Artery Disease Anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You had a percutaneous arotic valve replacement with a CoreValve device, the procedure went well and there were no complications. You were in the intensive care unit to monitor you closely and for a temporary pacing wire which has been removed. You are recovering from the procedure well and an echocardiogram shows that the valve is working well and the pressures inside your heart are lower which is beneficial to your heart. You will need to return in 1 month to see Dr. [**Last Name (STitle) **] and have another echocardiogram. . We made the following changes to your medicines: 1. Stop taking Aggrenox 2. Start taking Aspirin and Plavix to keep the valve free of blood clots. You will take these medicines for at least 2 months. 3. Start colace to avoid constipation on the iron 4. Start Amlodipine to lower your blood pressure. Followup Instructions: PCP: [**Name Initial (NameIs) 7274**]: [**Last Name (LF) **],[**First Name3 (LF) **] F. Location: QUEEN CITY MEDICAL ASSOCIATES Address: [**Location (un) 89826**], [**Apartment Address(1) 4473**], [**Location (un) **],[**Numeric Identifier 84189**] Phone: [**Telephone/Fax (1) 89827**] When: Wednesday, [**6-8**], 10AM . Department: CARDIAC SERVICES When: FRIDAY [**2174-6-24**] at 1 PM With: ECHOCARDIOGRAM [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: FRIDAY [**2174-6-24**] at 11:20 AM With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2174-6-3**]

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icd9cm

[ [ [] ] ]

[ "35.96", "88.53", "35.22", "37.23", "88.42" ]

icd9pcs

[ [ [] ] ]

12674, 12733

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252, 324

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3877, 3877

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11033, 12651

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193, 214

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352, 1651

3893, 4337

12876, 13020

1968, 2194

1673, 1739

2210, 2518

19,413

115,241

12687+12717

Discharge summary

report+report

Admission Date: [**2188-4-19**] Discharge Date: [**2188-4-21**] Service: TRAUMA SURGERY HISTORY OF PRESENT ILLNESS: This is a [**Age over 90 **] year-old woman status post fall at a nursing home from her bed to the floor transferred from outside facility with a question of a C3 fracture and questionable basilar skull fracture. The patient has a baseline dementia and was found down next to her bed after being seen approximately five minutes prior complaining of neck pain. The patient was initially seen at the [**Last Name (un) 4068**] Emergency Department and noted to have the above mentioned findings on CT and was transferred for further evaluation by the trauma team. During her initial evaluation and transfer the patient remained hemodynamically stable. PAST MEDICAL HISTORY: 1. Coronary artery disease. 2. Congestive heart failure. 3. Dementia. 4. Hypertension. 5. Degenerative joint disease. 6. Cerebrovascular disease. 7. History of gastrointestinal bleeds. 8. Depression. 9. Breast cancer. ALLERGIES: No known drug allergies. MEDICATIONS ON TRANSFER: 1. Protonix. 2. Imdur. 3. Lasix. 4. Aldactone. 5. Paxil. PHYSICAL EXAMINATION ON ADMISSION: Temperature 99.8. Blood pressure 124/64. Heart rate 88. Respiratory rate 24. Satting 100% on 2 liters nasal cannula. The patient was alert and in no acute distress. HEENT examination pupils are equal, round and reactive to light from 3 to 2 bilaterally. Extraocular movements intact. Tympanic membranes were clear. Oropharynx was clear. Cardiovascular regular rate and rhythm. Respiratory rate clear to auscultation bilaterally. Chest without deformities or tenderness. Abdomen soft, nontender. Pelvis stable. Back without deformities or tenderness. C spine without demonstrable tenderness. Rectal examination heme negative. Extremities left shoulder contusion with small skin tear. Neurological alert, not oriented, moving all extremities, but not following commands. INITIAL DIAGNOSTIC STUDIES: CBC white blood cell count 2.8, hematocrit 16.8, platelets 120. Chemistries sodium 147, potassium 3.8, chloride 118, bicarb 15, BUN 28, creatinine 1.2, glucose 84, lactate 0.7. Trauma portable chest x-ray and pelvis was negative. CT of head with contrast revealed fluid within the sphenoid sinus potentially concerning for occult skull base fracture without obvious fractures seen and a small asymmetric fossa of hyperdensity in the left basal ganglia potentially consistent with small focus of hemorrhage versus calcification. CT of the C spine with reconstruction without evidence of fracture. CT of the chest, abdomen and pelvis was without evidence of acute injury. TLS film was without evidence of fracture. HOSPITAL COURSE: 1. Closed head injury: Given the findings mentioned above on the initial head CT in the Emergency Department the patient was admitted to the CICU for q one hour neurological checks and neurosurgery was consulted. The patient was noted to be at baseline mental status and was without change during her hospitalization. Repeat head CT on the [**2-20**] indicated no change in the fluid seen in the sphenoid sinus or the potential with basal ganglia hemorrhage, however, a small to medium size subacute subdural hemorrhage was seen around the left frontal and temporal regions. The patient's mental status remained at baseline. Given this and the stability of findings on head CT, there was nor further need for intervention or imaging. 2. Neck injury: The patient was initially transferred for the concern of a potential fracture of C3 spinous process on initial imaging at [**Hospital 4068**] Hospital. These findings were not demonstrated on CT C spine with reconstruction here at the [**Hospital1 69**]. The patient initially complained of neck discomfort during her hospital stay. The patient was unable to cooperate with flexion and extension plain films to further evaluate the stability of her cervical spine. After discussion with Dr. [**First Name4 (NamePattern1) 518**] [**Last Name (NamePattern1) 519**] regarding the need for magnetic resonance imaging of the cervical spine to further evaluate potential injuries it was determined that given the nature of potential injuries and the limited interventions possible the patient was to be discharged to outpatient follow up with a soft collar. 3. Urinary tract infection: Urinalysis showed greater then 50 white blood cells per high powered field with many bacteria with urine cultures growing out E-coli. Sensitivities pending at the time of discharge. The patient received a three day course of Levofloxacin and remained afebrile throughout hospitalization. 4. Anemia: The patient has a history of chronic gastrointestinal bleeding and has a baseline hematocrit of approximately 26. Initially was noted to have a hematocrit of 16 upon presentation to this facility upon which value of the decision and to transfuse 1 unit of packed red blood cells was initiated. However, repeat laboratory draws revealed a CBC with a hematocrit of 26, which is at the patient's baseline. The patient remained guaiac negative throughout her hospital stay and hemodynamically stable. CONDITION ON DISCHARGE: Fair. DISCHARGE STATUS: To rehab. DISCHARGE DIAGNOSES: 1. Closed head injury. 2. Neck strain. 3. Anemia. 4. Urinary tract infection. 5. Coronary artery disease. 6. Congestive heart failure. 7. Dementia. 8. Hypertension. 9. Degenerative joint disease. 10. Cerebrovascular disease. 11. History of breast cancer. 12. Depression. DISCHARGE MEDICATIONS: 1. Protonix 40 mg po q.d. 2. Isosorbide mononitrate 10 mg po b.i.d. 3. Furosemide 40 mg po q.d. 4. Spironolactone 50 mg po q.d. 5. Fluoxetine 20 mg po q.d. FOLLOW UP PLANS: Outpatient follow up to be arranged with primary care physician [**Name9 (PRE) **] trauma clinic. Outpatient neurosurgical follow up to be arranged. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. [**MD Number(1) 521**] Dictated By:[**Name8 (MD) 28700**] MEDQUIST36 D: [**2188-4-21**] 09:21 T: [**2188-4-21**] 09:20 JOB#: [**Job Number 39179**] Admission Date: [**2188-4-19**] Discharge Date: [**2160-3-24**] Service: Trauma Surgery ADDENDUM: This Addendum is in regard to Neurosurgery recommendations. A repeat computed tomography of the head was reviewed with Radiology and Neurosurgery showing an unchanged left frontoparietal subdural hematoma. Neurosurgery recommendations included followup with Dr. [**First Name (STitle) **] in one month with a repeat head computed tomography. The patient was cleared by Neurosurgery to go back to nursing home. On discharge, the patient was stable. Afebrile with stable vital signs. Physical examination remarkable for ecchymosis of the left forehead which is stable. The patient was tolerating a regular diet and had good urine output; although incontinent at baseline. DISCHARGE DIAGNOSES: (Add to discharge diagnoses) 1. Status post fall. 2. Left frontoparietal subdural hematoma (stable). 3. Dementia. 4. Congestive heart failure. 5. Hypertension. 6. Degenerative joint disease. 7. History of cerebrovascular accident. 8. Depression. 9. History of breast cancer. 10. History of hiatal hernia. 11. Chronic anemia. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. [**MD Number(1) 521**] Dictated By:[**Last Name (NamePattern1) 27744**] MEDQUIST36 D: [**2188-4-22**] 09:59 T: [**2188-4-22**] 10:10 JOB#: [**Job Number 39244**]

[ "280.0", "E884.4", "852.20", "294.8", "599.0", "847.0", "311", "V10.3", "428.0" ]

icd9cm

[ [ [] ] ]

[ "99.04" ]

icd9pcs

[ [ [] ] ]

6992, 7617

5585, 6970

2746, 5195

129, 782

1194, 2728

1095, 1179

804, 1070

5220, 5257

42,583

107,613

24601

Discharge summary

report

Admission Date: [**2159-11-8**] Discharge Date: [**2159-12-6**] Date of Birth: [**2118-5-26**] Sex: M Service: CARDIOTHORACIC Allergies: Pollen/Hayfever Attending:[**Last Name (NamePattern1) 1561**] Chief Complaint: esophageal cancer and has received neoadjuvant chemoradiation. He presents now for surgical treatment. Major Surgical or Invasive Procedure: Minimally-invasive combined thoracoscopic and laparoscopic total esophagogastrectomy. 2. Laparoscopic-assisted/open jejunostomy tube placement. History of Present Illness: 41 y/o delightful,young gentleman who underwent CT scan evaluation of his chest for an ascending aortic aneurysm and was found to have distal thickening of his esophagus. Further evaluation confirmed the presence of a large distal esophageal cancer, stage T3, N1. He underwent neoadjuvant chemoradiotherapy and then restaging. He had a reasonable response and was, therefore, taken forward for a minimally-invasive esophagogastrectomy. Past Medical History: Diverticulitis w/ colovesicle fistula s/p repair, ventral hernia, dilated aortic root, s/p T&A Social History: lives with wife and 2 daughters. Employed by [**Company 33655**] Physical Exam: General: obese male in NAD HEENT: PERRL, EOMI, no cervical lymph adenopathy, neck supple. Resp-lungs CTA bilat Cor: RRR S1, S2 Abd: Obses w/ large incisional hernia-easily reduced. No hepatosplenomegally. Ext: no LE edema Neuro: A+OX3 Pertinent Results: [**2159-11-8**] 06:30PM GLUCOSE-128* UREA N-16 CREAT-1.0 SODIUM-139 POTASSIUM-4.9 CHLORIDE-108 TOTAL CO2-17* ANION GAP-19 [**2159-11-8**] 06:30PM CALCIUM-8.4 PHOSPHATE-3.9 MAGNESIUM-1.1* [**2159-11-8**] 06:30PM WBC-8.2 RBC-3.05* HGB-10.5* HCT-29.1* MCV-95 MCH-34.3* MCHC-36.0* RDW-15.0 [**2159-11-8**] 06:30PM PLT COUNT-231 [**2159-11-8**] 06:30PM PT-12.8 PTT-23.6 INR(PT)-1.1 [**2159-11-8**] 05:49PM LACTATE-6.5* Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2159-11-16**] 09:10AM 8.6 3.05* 10.2* 29.9* 98 33.3* 33.9 14.8 408 BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT) [**2159-11-16**] 09:10AM 408 Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2159-11-27**] 09:50AM 11.0 3.18* 10.1* 29.4* 92 31.7 34.4 15.6* 641* [**2159-11-26**] 06:15AM 9.5 3.14* 9.9* 29.2* 93 31.6 33.9 15.6* 670* [**2159-11-25**] 12:32AM 10.3 3.34* 10.5* 30.5* 92 31.3 34.3 15.8* 771* [**2159-11-24**] 04:40AM 10.3 3.20* 9.9* 29.1* 91 30.8 33.8 15.7* 648* [**2159-11-23**] 07:00AM 10.6 3.06* 9.3* 27.8* 91 30.4 33.5 16.1* 577* [**2159-11-22**] 07:24PM 9.9 3.22* 10.0* 28.9* 90 31.0 34.5 16.1* 558* [**2159-11-22**] 08:59AM 11.9* 2.88* 8.8* 25.4* 88 30.4 34.5 16.6* 553* Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2159-11-15**] 10:20AM 90 25* 0.8 145 4.0 104 321 13 1 NOTE UPDATED REFERENCE RANGE AS OF [**2159-6-1**] CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2159-11-15**] 10:20AM 8.7 4.2 2.1 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2159-11-27**] 09:50AM 128* 69* 4.0* 138 4.8 104 231 16 1 NOTE UPDATED REFERENCE RANGE AS OF [**2159-6-1**] [**2159-11-26**] 03:35PM 109* 70* 4.2* 139 5.0 103 241 17 1 NOTE UPDATED REFERENCE RANGE AS OF [**2159-6-1**] [**2159-11-26**] 06:15AM 105 70* 4.4* 141 5.1 104 241 18 1 NOTE UPDATED REFERENCE RANGE AS OF [**2159-6-1**] [**2159-11-25**] 01:50PM 119* 68* 4.9* 139 5.1 104 231 17 1 NOTE UPDATED REFERENCE RANGE AS OF [**2159-6-1**] [**2159-11-25**] 12:32AM 164* 71* 4.9* 137 4.7 104 221 16 1 NOTE UPDATED REFERENCE RANGE AS OF [**2159-6-1**] [**2159-11-24**] 07:35PM 69* 5.0* 5.3* [**2159-11-24**] 04:40AM 107* 68* 5.1* 139 4.4 102 231 18 1 NOTE UPDATED REFERENCE RANGE AS OF [**2159-6-1**] [**2159-11-23**] 07:00AM 110* 63* 5.2* 136 4.1 101 241 15 1 NOTE UPDATED REFERENCE RANGE AS OF [**2159-6-1**] [**2159-11-23**] 12:30AM 62* 5.0* [**2159-11-22**] 07:24PM 131* 60* 4.9* 134 4.8 99 231 17 1 NOTE UPDATED REFERENCE RANGE AS OF [**2159-6-1**] [**2159-11-22**] 08:59AM 146* 58* 4.7* 132* 4.7 98 251 14 1 NOTE UPDATED REFERENCE RANGE AS OF [**2159-6-1**] [**2159-11-21**] 10:18PM 113* 51* 4.4* 4.7 97 221 1 NOTE UPDATED REFERENCE RANGE AS OF [**2159-6-1**] [**2159-11-21**] 10:40AM 125* 45* 3.7* 132* 4.5 98 231 16 1 NOTE UPDATED REFERENCE RANGE AS OF [**2159-6-1**] [**2159-11-21**] 06:45AM 118* 42* 3.4*# 130* 4.8 97 241 14 RADIOLOGY Final Report BAS/UGI AIR/SBFT [**2159-11-15**] 10:34 AM Reason: THIN BARIUM contrast to look at anastomotic leak [**Hospital 93**] MEDICAL CONDITION: 41 year old man with esophagogastrectomy REASON FOR THIS EXAMINATION: THIN BARIUM contrast to look at anastomotic leak INDICATION: Status post esophagogastrectomy. PROCEDURE: Exam was performed with Conray, water soluble contrast followed by thin barium. Multiple obliquities of the esophagus were obtained following administration of oral contrast. Barium passes freely through the esophagus, through the esophagogastrectomy into the intrathoracic stomach. There is a less than 1 cm long, approximately 1 mm high outpouching of contrast from the GI tract at the upper thoracic level consistent with a small leak. No extravasation of contrast beyond this point is seen. Contrast passes through the stomach into the proximal small bowel in a delayed fashion. After approximately 5-10 minutes, contrast is still present within the stomach. IMPRESSION: Less than 1 cm x 1 mm thin outpouching of the GI tract at the upper thoracic level in the region of the presumed esophagogastrectomy that is consistent with a tiny leak. No free extravasation of contrast is seen beyond this finding. RADIOLOGY Preliminary Report UNILAT LOWER EXT VEINS LEFT [**2159-11-16**] 12:26 AM [**Hospital 93**] MEDICAL CONDITION: 41 year old man pod #7 s/p lap esophagogastrectomy now with unilateral L leg redness, pain REASON FOR THIS EXAMINATION: ?DVT INDICATION: 41-year-old man postop day 7 status post esophagogastrectomy, now with unilateral left leg redness. Evaluate. COMPARISON: None. IMPRESSION: Negative left lower extremity DVT study. Brief Hospital Course: Patiet admitted SDA for above procedure. Patient tolerated procedure well, transferred to PACU intubated, stable, right chest tube x1 to suction, neck JP drain to bulb suction, NGtube, J- tube. PACU course overnight significant for: intubation and sedation- propofol, IVF for low u/o;pain control Fentanyl gtt, electrolyte management; HR rate control w/ b blocker. POD#1-Pt in PACU all day; propofol weaned to off, vent weaned and extubated @10am w/o complication, followed by close resp management- IS, pulmonary toilet;Fentanyl gtt weaned to off, dilaudid IV PCA for pain control; hemodynamic/fluid managment; Patient transferred to floor late evening. B blocker increased. POD#2- Pain control w/ PCA; NGT> LCS; NPO; Jtube clamped; OOB> chair; course BS, CT > SC no leak to w/s at 12noon;IVHL> lasix iv x1 w/ good response; weaning O2; ST 104-114- b blocker increased to 37q6h. POD#3- Pain control w/Dilaudid PCA; right chest tube to water seal, no leak; NGT LCS,NPO, tube feedings via J- tube @10cc/hr;; Hct 24, tx 1U PRBC; lasix 20 mg IVx1 w/ goal 1.5L negative; Physical therapy consulted. POD#4- Pain control w/ PCA; CT to w/s; TF 10/hr and adv10cc q4 hr to goal 50/hr; lasix 20 mg IVx1 w/ goal 1.5L negative. Weaning O2 6L-94% chair. POD#5-1L negative overnight; NGT> LCS;J tube feedings tolerated well- Deliver 2.0 @50/hr=goal; OOB> chair and ambulation; weaning O2 3L-93%; 6L w/ ambulation POD#6- 94% RA> chair; LLE swelling, and erythema at ankle, hx gout, LENI- negative. POD#7-Toleratating tube feeds well, + BS; Swallow study passed, NGT d/c, no sips today; Character of CT drainage- yellow/milky- Triglyceride level=15, CT placed to suction; WBC-8.6. Pain control w/ Dilaudid PCA. POD#8-T 100.4, CT drainage ?concern for kylothorax- stable, no leak on suction; tolerating clears, + BS no stool; + peripheral edema>diuresis; POD#[**8-10**]-T-102, cx blood, urine, pleural fluid- gram + cocci, placed on Vanco and Zosyn;CT remains to suction- CXRY(new right apical pneumothorax) and Chest CT obtained- fluid collection right lower lung. Pt consented for CT placement/drainage for Right pleural effusion; WBC 17,Started Vanco/zosyn empirically; PO intake reversed to NPO. POD#11 ([**2159-11-18**])-To OR for VATs for evacuation right pleural effusion. MIld hypotension intra-op. IVF given w/ resolution. Fluid/tissue cx sent. POD#[**11-13**]- Pleural fluid-CX-coag + staph [**Last Name (un) 36**] to levo/clinda/ox; [**11-18**] tissue cx: rare coag + Staph. Creat- rising 4.4-4.7, Renal consult obtained. Vanco/Zosyn d/c per Renal consult, changed to Clinda per C&S results. Renal ultrasound normal. POD#15- CT to w/s w/ no leak, moderate drainage, murky quality. Cr 5.0, IVF [**Month (only) **]'d. Small amts po intake tolerated marginally. Episodes of nausea and vomitting 50-100/day. POD#16-17- Vomitting not improved; [**Doctor First Name 4663**] leak not improving. NPO and TPN started, cont. CR decreasing <5.0. CT & [**Doctor Last Name **] remains to w/s. WBC 10K; Clinda cont. POD#18-19-TPN advanced to goal, lipids added. clears only; Cr. 4.2, WBC 9.0; R angle CT clamped, +leakage around site> [**Doctor Last Name 406**] to waterseal. POD#20 CXR> no ptx, CT d/c'd, [**Doctor Last Name **] to bulb sx. Gastrographin swallow to eval anastamosis leak and gastric emptying shows no leak but persistant delayed emptying. TPN cont'd. POD#21 temp spike-pan cultured; all neg. Noted to have pericardial effusion- eval by cardiology but since effusion w/o change and no hemodynamic compromise will follow up as out pt. Creat returned to baseline. POD#21 taken to the OR for bronch, pylorus balloon dilation. POD#22-25 continued to progress w/ activity. decreased episodes of emesis. TPN weaning, clears restarted and tube feed 8pm-8am. [**Doctor Last Name 406**] drain d/c'd. POD#26 pt d/c'd to home w/ supportive services. Medications on Admission: atenolol 50' Discharge Medications: 1. tube feedings Tubefeeding: Fiber source HN Starting rate:90cc/hr from 8pm to 8am.Hold tube feeding for nausea/vomiting Flush w/200ccl water qid. Other instructions: do not check residuals 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed: crush and give via j-tube. Disp:*60 Tablet(s)* Refills:*1* 3. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours): crush and give via j-tube. Disp:*240 Tablet(s)* Refills:*2* 4. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). Disp:*900 ml* Refills:*2* 5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed. 6. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4-6H (every 4 to 6 hours) as needed. Disp:*600 ML(s)* Refills:*0* 7. Heparin Lock Flush (Porcine) 10 unit/mL Solution Sig: Five (5) ML Intravenous PRN (as needed): to by done by VNA . 8. Acetaminophen 500 mg/5 mL Liquid Sig: One (1) PO every [**3-6**] hours as needed. Disp:*600 ml* Refills:*1* Discharge Disposition: Home With Service Facility: Assisted Daily Living< Inc Discharge Diagnosis: Esophogeal cancer Diverticulitis w/ colovesicle fistula s/p repair, ventral hernia, dilated aortic root, s/p T&A Blood loss anemia- post-op Heart Failure Pericardial effusion acute renal failure pyloroplasty j-tube double lumen port a cath Discharge Condition: good Discharge Instructions: Call Dr.[**Name (NI) 1816**]/Thoracic surgery office for ([**Telephone/Fax (1) 170**]): fever, chills, shortness of breath, chest pain, persistant nausea, vomiting, diarrhea, or inability to take food orally. Also call for tan, foul smelling discharge from chest tube sites. Take all medications as directed. After showering on friday, remove your chest tube dressings and cover them daily with clean bandaids until healed. Take clear and full liquids as tolerated and you may trial soft foods as directed by Dr. [**Last Name (STitle) 952**]. No tub baths for 3-4 weeks Followup Instructions: Call Dr.[**Name (NI) 1816**]/ Thoracic Surgery office for an appointment in 3 weeks. [**Telephone/Fax (1) 170**]. Completed by:[**2159-12-10**]

[ "441.2", "510.9", "423.9", "151.0", "537.0", "511.0", "584.5", "457.8", "512.1", "553.21", "428.0", "285.1", "276.2", "998.2", "997.4", "424.1", "V15.3", "537.81" ]

icd9cm

[ [ [] ] ]

[ "34.99", "46.39", "44.22", "34.04", "40.3", "99.04", "33.24", "46.73", "96.6", "43.99", "99.15", "34.51" ]

icd9pcs

[ [ [] ] ]

11157, 11214

6204, 10045

394, 545

11498, 11505

1483, 4615

12123, 12269

10108, 11134

5861, 5952

11235, 11477

10071, 10085

11529, 12100

1228, 1464

251, 356

5981, 6181

574, 1012

1035, 1131

1147, 1213

31,195

190,209

33387

Discharge summary

report

Admission Date: [**2124-4-17**] Discharge Date: [**2124-4-24**] Date of Birth: [**2094-10-16**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1481**] Chief Complaint: Esophageal Cancer Major Surgical or Invasive Procedure: Minimally Invasive Esophagectomy History of Present Illness: 29 yo M with significant developmental delay found to have esophogeal cancer. He had been clearing his throat excessively and had dysphagia x1 year. [**2124-2-29**] Endoscopy/biopsy at OSH showed distal esophageal mass and acute inflammation suspicious for adenocarcinoma, subsequently confirmed by further workup PET, etc.) Oncology evaluated him but he was deemed not to be a good candidate for neoadjuvant chemotherapy and radiation. Thus he was scheduled for an operation [**2124-4-17**]. Past Medical History: Esophageal Cancer Peptic Ulcer Disease GERD Developmental Delay Down's Syndrome Selective Mutism s/p L Ear Mastoid Surgery s/p B hernia repair mitral valve prolapse Social History: Downs syndrome, developmental delay. no illicit substances Family History: non-contributory Physical Exam: VS: 100.1/96.2 101 108/64 16 96 RA Const: NAD HEENT: NC/AT Chest: CTAB Cardio: RRR Abd:soft NT/ND, +BS MS:5/5 strength diffusely EXT: no c/c/e Wound: c/d/i Pertinent Results: SPECIMEN SUBMITTED: Esophagectomy, paraesophageal node. Procedure date [**2124-4-17**] DIAGNOSIS: I. Esophagogastrectomy (A-N): 1. Adenocarcinoma of the distal esophagus, arising in a nodule of high grade glandular dysplasia, see synoptic report. 2. Small focus of intestinal metaplasia, consistent with Barrett's esophagus. 3. Stomach segment and proximal esophagus: Within normal limits. II. Paraesophageal node (O): Two lymph nodes: No tumor (0/2). [**2124-4-23**] 05:25AM BLOOD WBC-6.5 RBC-4.04* Hgb-12.5* Hct-36.6* MCV-91 MCH-30.9 MCHC-34.0 RDW-14.1 Plt Ct-243 [**2124-4-17**] 05:14PM BLOOD WBC-18.6* RBC-4.63 Hgb-14.5 Hct-41.3 MCV-89 MCH-31.2 MCHC-35.0 RDW-13.7 Plt Ct-221 [**2124-4-23**] 05:25AM BLOOD Glucose-115* UreaN-19 Creat-0.8 Na-143 K-3.7 Cl-103 HCO3-29 AnGap-15 [**2124-4-17**] 05:14PM BLOOD Glucose-111* UreaN-13 Creat-1.1 Na-142 K-4.1 Cl-110* HCO3-23 AnGap-13 Brief Hospital Course: 29 yo M admitted to the ICU s/p Minimally Invasive Esophagectomy on [**2124-4-17**]. In the ICU patient was extubated on [**2124-4-18**]. He was tachycardic during his ICU course, attributed to pain and volume depletion which were both addressed: Patient received IVF as necessary as well as medications for pain control. He received Tube Feeds via his J tube during his time in the ICU. Due to an inadequate cough reflex patient was started on pulmozyme on [**4-19**] to assist with clearing secretions. He had a swallow evaluation on [**4-20**] as well as a bronchoscopy to evaluate the vocal cords. He was found to have symmetric but inadequate vocal cord adduction, as well as diffuse edema. As his cough reflex returned and he began clearing his secretions. His diet was advanced to a soft diet and the patient was transferred to the floor, and is now ready for discharge home. Medications on Admission: fluoxetine 20mg/5ml daily lansoprazole 30mg [**Hospital1 **] lorazepam 1mg prn geodon 30mg daily Discharge Medications: 1. Fluoxetine 20 mg/5 mL Solution [**Hospital1 **]: One (1) tsp PO DAILY (Daily). 2. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] twice a day. 3. Lorazepam 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H (every 6 hours) as needed. 4. Ziprasidone HCl 20 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO DAILY (Daily). 5. Acetaminophen 650 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO every six (6) hours as needed for fever, pain. Discharge Disposition: Home with Service Discharge Diagnosis: Esophageal Cancer Discharge Condition: Good Discharge Instructions: You were in the hospital after having part of your esophagus removed due to esophageal cancer. Your post-operative course is now complete and you are being discharged home. You may take showers, allow water to run over your incisions but do not scrub them. Following the shower pat your incisions dry: do not rub. Please return to the hospital or call your surgeon if you experience any of the following: * Fever >101.4 * Nausea or vomiting with inability to tolerate food/liquids * Increasing/uncontrolled pain Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] in [**1-12**] weeks. He can be reached at [**Telephone/Fax (1) 25782**].

[ "530.81", "758.0", "427.89", "997.3", "151.0", "315.8" ]

icd9cm

[ [ [] ] ]

[ "96.6", "33.22", "42.41" ]

icd9pcs

[ [ [] ] ]

3911, 3930

2300, 3191

333, 368

3992, 3999

1388, 2277

4564, 4692

1174, 1192

3338, 3888

3951, 3971

3217, 3315

4023, 4541

1207, 1369

276, 295

396, 893

915, 1081

1097, 1158

20,124

196,628

49715

Discharge summary

report

Admission Date: [**2187-9-19**] Discharge Date: [**2187-10-13**] Date of Birth: [**2133-2-8**] Sex: M Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2181**] Chief Complaint: E.Coli sepsis and pneumonia Major Surgical or Invasive Procedure: intubation and mechanical ventilation PEG placement Tracheostomy History of Present Illness: 54 yo M with ESRD HD-dependent, HTN, DM, who p/w hypotension and bacteremia. Pt had N/V/D x6 days and decreased PO intake with fevers of 102 at home. He went for regularly scheduled HD 1 day PTA where his HD site was noted to be infected and cath had reportedly fallen out the previous day. Blood cultures were obtained and he continued his HD per NL protocol and was given 1 gm vancomycin empirically for the presumed infection. On the day of admission, the pt was called to come to the ED b/c [**2-5**] BCx noted to be growing out GNR--pt notified. On questioning in [**Name (NI) **], pt denied abd pain, but did admit to back pain (chronic). CXR showed large L pleural effusion with infiltrates.He received 3L NS, vanc, and gent. Labs were notable for Tbili 12.8 (Dir 9.7), lactate 7.4 (-->6.6-->5.8), and PLT 69. Several attempts were made at central line placement, but given pt's agitation, this was unsuccessful. He was transferred to the floor, LSC was attempted, but unsuccessful, so R femoral line was placed and pt was electively intubated b/c of AMS and sats dropping to the 80s. Pt transferred to the MICU for further managment. Past Medical History: ESRD on HD [**2-5**] anti GBM disease, on HD [**3-8**] DM2 x 10yrs peripheral neuropathy htn chronic LBP [**2-5**] herniated disks anemia, hx guaiac pos stools hx nepthrolithiasis s/p cervical laminectomy hx depression hx mssa bacteremia chf L AV graft [**7-8**] Social History: married to wife [**Name (NI) **] unemployed [**2-5**] disability tobacco 1ppd no etoh/ ivda Family History: h/o dm and renal failure Physical Exam: BP 86/49, 98.3, 95, 18, 100%RA Gen elderly, lying in bed, nad HEENT PERRLA, EOMI, dry MM CVS RR faint heart sounds, no jvd Pulm bibasilar crackles, R > L Abd: BS present, soft, nontender, no rebound or guarding Ext warm and dry, no edema Pertinent Results: [**2187-9-19**] 10:32PM TYPE-ART TEMP-36.9 RATES-14/19 TIDAL VOL-500 PEEP-5 O2-60 PO2-156* PCO2-47* PH-7.35 TOTAL CO2-27 BASE XS-0 INTUBATED-INTUBATED VENT-IMV [**2187-9-19**] 10:32PM LACTATE-5.0* [**2187-9-19**] 09:00PM GLUCOSE-114* UREA N-60* CREAT-9.8* SODIUM-142 POTASSIUM-4.5 CHLORIDE-97 TOTAL CO2-28 ANION GAP-22* [**2187-9-19**] 09:00PM ALT(SGPT)-114* AST(SGOT)-80* LD(LDH)-272* ALK PHOS-151* AMYLASE-28 TOT BILI-12.2* [**2187-9-19**] 09:00PM WBC-9.1 RBC-3.35* HGB-10.8* HCT-33.9* MCV-101* MCH-32.4* MCHC-32.0 RDW-15.7* [**2187-9-19**] 09:00PM NEUTS-66 BANDS-9* LYMPHS-7* MONOS-10 EOS-0 BASOS-0 ATYPS-0 METAS-8* MYELOS-0 [**2187-9-19**] 09:00PM PLT SMR-VERY LOW PLT COUNT-77* CHEST (PORTABLE AP) [**2187-9-19**] 9:08 PM CHEST (PORTABLE AP) Reason: Please eval ET tube placement [**Hospital 93**] MEDICAL CONDITION: 54 year old man with ESRD on HD, DM, who p/w GNR bacteremia, LLL Pna not intubated REASON FOR THIS EXAMINATION: Please eval ET tube placement INDICATIONS: For assessment of ET tube placement. PORTABLE AP CHEST: Comparison is made to the prior study from same day and also [**2187-3-8**]. FINDINGS: There has been dramatic interval change when compared to exam from [**3-8**]. The patient has a central cervical spine fusion in situ. The patient is now intubated and the ET tube is identified in good position with its tip 4 cm above the carina.. Evidence of extensive air space consolidation of the left side. Silhouetting of the left heart border in the lingula, and also some partial silhouetting of the left lower lobe.this has progressed over the course of the day. In the right lung, there is faint opacification in the right mid zone. The lungs appear otherwise normal. The bones are unremarkable without evidence of dystrophy. IMPRESSION: 1. Extensive left sided air space consolidation. This likely represents pneumonia. Other causes such as asymmetrical pulmonary edema,particularly given it's rapid progression, cannot be readily excluded, correlation with clinical history is recommended. 2. Patient now intubated Brief Hospital Course: Breifly: This is a 54 yo man with DM and ESRD due to anti-GBM disease who was admitted on [**9-19**] with ecoli sepsis and pneumonia. He was intubated for respiratory failure, was unable to be weaned off, and a tracheostomy was placed. He then developed a necrotizing left lung pnemonia. He was stabalized and transferred out of the ICU on [**10-8**] in good condition. 1) Bacteremia-- The patient presented with Ecoli pneumonia and bacteremia thought to ne due to an infected HD line. The patient was started on double coverage for gram nbegative rods with zosyn, levoquin, and vancomycin to cover gram positive cocci. On [**9-24**], the vanco and zosyn was stopped, as only etiology on culture was GNR, and the patient was continued on flagyl and levoquin for 21 day course. Blood cultures negative from [**9-19**] on. On [**9-27**] he was diagnosed with a necrotizing pnemonia. Then vanco and zosyn were restarted and the other were stopped. Vancomycin was stopped prior to his leaving the unit. He will need to coninue a total 4 week course of Zosyn, which will be until [**10-22**]. 2)Septic shock--The patient has a increased lactate and hypotension on admission. He was resuscitated with 6 L of IV fluids then levophed was used to keep his MAP above 65. A full course of stress dose steriods was completed on [**9-25**]. He remained normotensive or hypertensive off of pressors from [**9-22**] on. 3)Respiratory failure: Elective intubation in the setting of mental status change and decreasing O2 sats. However, the patient has a large Left lobe pneumonia and L pleural effusion contributing to hypoxemia. Thoracentesis was attempted, but not the effusion was not tappable as it was all consolidated LLL. CXR and Chest CT from [**9-21**] revealed nearly majority of left lung with solid consolidation, no evidence of empyema. His mental status and ventilation improved and he was weaned until [**9-24**] when developed increasing copious secretions, good cough but decreased MS again. Over [**Date range (1) 103957**], he continued with increasing secretions and worsening mental status, no longer with successful weaning of ventilator despite CXRs with no interval change (still with majority of lung solid consolidation). [**9-30**] CXR with small ?cystic lesions in L upper lobe consolidation, CT chest consistent with large confluent lucencies of left lung likely secondary to necrosis and Right lung base patchy infiltrates. Bronch [**9-30**] with large amount of grey purulent material from the left lung, BAL sent for fungal, bacterial, viral, and PCP [**Name Initial (PRE) 103958**]; all were negative. Pt had a tracheostomy on [**9-30**]. He came off of the vent on [**10-7**] and has been stable since. His O2 sats are 94 - 98 % on room air. However, he needs assistance managining with secretions - humidified TM, [**Hospital1 **] chest PT, guanefisin, head of the bed above 45 degrees, and avoiding dehydration. 4)Thrombocytopenia: On admission, concerning for DIC in setting of sepsis. However, with trending of DIC labs, pt never with full manifestation of DIC and thrombocytopenia resolved with d/c of zosyn. When Zosyn was started again for pnemonia, the patient did not have thrombocytopeina and in fact had a reactive thrombocytosis from infection. 5) R IJ clot [**9-24**] discovered after unsuccessful line placement, pt started on heparin gtt and transitioned to coumadin. Hos coumadin will need further titration in rehab. 6)ESRD [**2-5**] antiglomerular basement membrane disease: On HD since [**3-8**] Q T/th/Sat. Pt required QD or QOD dialysis since admission, which was helpful in maintaining patient's delicate fluid balance in the setting of sepsis. Now he is getting M,W,F dialysis during which at leadt 4 lbs is taken off. He gets dialysis through his fistula. 6)Anemia: Chronic anemia, guaiac +; likely [**2-5**] chronic dz and ESRD. He required several units of prbc transfusions early in MICU course but remained stable since. He recieved periodic transfusions during dialysis to keep his HCT above 30. He also recieved Epogen at dialysis. 7)Inc LFTs: Given his lab data on admission, ascending cholangitis was a concern and surgery was consulted to evaluate the need for emergent intervention. However, RUQ US was negative for obstruction or cholelithiasis/ cholecystitis. [**9-25**] bilirubin decreasing with improving clinical picture, likely jaundice of sepsis. 8) Diabetes: He was maintained on insulin gtt for first two weeks of MICU course, then transitioned successfully to glargine and sliding scale regular insulin with Insulin added to his total parenteral nutrition. The glargline was stopped after a few days because his AM BS were very low. How he is on [**Hospital1 **] NPH that will need to be titrated up as his tube feeds are increased. He is covered by a regular ISS as well. q6hour FS since his TF are continuous. 9) HTN: After trach and PEG placement, he had continued difficulty with hypertension with SPB in the 190-200 range. These episodes were controlled with dialysis and intermittent titration of captopril and lopressor. He is not on amlodipine, captopril, lopressor, and hydralizine with blood pressures still in the 150 - 160. His hydralizine will need to be continually titrated up for a goal of SBP 130 - 140. 10) Nutrition: He had a percutaneous enteral gastric tube placed on [**10-3**] with no complications. He has been recieving tube feeds at 40/hour. This rate is being increased currently to 45/hour. Once he tolerates this, add 40 of Promod. 11) Physical therpy: PT as been working with him extensively. Currently he is non weight bearing. He will need continuing PT to regain his pre hospital function. 12) Pain: The patient has chronic lower back pain secondary to herniated disk. He is no methadone and oxycodone for breakthrough. 13) Mental status: The patient has been confused for many weeks now, as expected after a prolonged ICU course. He is gradually clearing and is oriented to person and place, but not time. Continue frequent reorientation and have family being in familiar items. Avoid benzos and excessive short acting narcotics, as these measures have helped him during the past week. 14) Diarrhea: The patient developed diarrhea. Cdiff cultures are pending and metoclopromide was stopped. Medications on Admission: paxil 60 ad nifeipine ER 60 qd lisinopril 40 ad p metoprolol 50 [**Hospital1 **] n methadone 10 [**Hospital1 **] oxycodone prn Discharge Medications: 1. Paroxetine HCl 30 mg Tablet Sig: Two (2) Tablet PO QD (once a day). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO QD (once a day). 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO QD (once a day) as needed. 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 5. Chlorhexidine Gluconate 0.12 % Liquid Sig: 15 ml MLs Mucous membrane TID (3 times a day) as needed. 6. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day) as needed. 7. Captopril 25 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). 8. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO QD (once a day). 9. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO QD (once a day). 10. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 11. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours): per NG. 12. Warfarin Sodium 6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 13. Calcium Acetate 667 mg Tablet Sig: Four (4) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 14. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours). 15. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for back pain. 16. Methadone HCl 10 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 17. Piperacillin-Tazobactam 2-0.25 g Recon Soln Sig: One (1) Recon Soln Intravenous Q12H (every 12 hours) for 4 days. 18. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous QD (once a day) as needed. 19. Hydralazine HCl 50 mg Tablet Sig: 1.5 Tablets PO Q6H (every 6 hours). 20. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: One (1) injection Subcutaneous twice a day: 4 units NPH sc bid. humalog insulin sliding scale starting with 2 units at fingerstick of 150, 4 units at fingerstick 200. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: necrotizing ecoli pneumonia ecoli sepsis requiring pressors ESRD and HD DMII Discharge Condition: stable with persistent secretions. 97% on 40% TM. Tolerating Tube feeds at goal. Discharge Instructions: Call PCP if the patient developes fever, vomiting, or increased O2. [**Hospital1 **] will work on removing tracheostomy and PEG once your pneumonia has cleared Followup Instructions: WIll need to follow up with nephrologist and PCP.

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icd9cm

[ [ [] ] ]

[ "38.93", "96.6", "31.1", "99.04", "96.72", "96.04", "43.11", "33.22", "39.95" ]

icd9pcs

[ [ [] ] ]

12818, 12888

4384, 10232

338, 405

13009, 13091

2288, 3092

13301, 13354

1988, 2014

10879, 12795

3129, 3212

12909, 12988

10728, 10856

13115, 13277

2029, 2269

271, 300

3241, 4361

433, 1577

10247, 10702

1599, 1863

1879, 1972

50,906

166,760

39125

Discharge summary

report

Admission Date: [**2124-3-19**] Discharge Date: [**2124-3-22**] Date of Birth: [**2049-8-27**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1973**] Chief Complaint: Right Hip Fracture s/p Fall Out Of Scooter Major Surgical or Invasive Procedure: Intramedullary rod fixation of right peritrochanteric hip fracture. History of Present Illness: This is a 74 year-old woman who presents with a R intertrochanteric femur fracture after a mechanical fall from her scooter. She was initially admitted to the ICU in the setting of apneic/hypoxic episodes presumed to be from narcotics (she apparently received 3mg IV hydromorphone at OSH ED and 1mg additional at [**Hospital1 18**] ED). On [**3-19**], she was electively intubated and went to the OR for intramedullary rod fixation of the right hip fracture. She was kept intubated overnight and extubated this am without event. For hct drop, she was transfused 1 unit pRBCs this am, with subsequent stable hct. In the ICU, her SBP has been persistently in the 90s, although she remains asymptomatic with good UOP. On arrival to the floor, she noted [**6-24**] hip pain, but denied fever, chills, night sweats, chest pain, shortness of breath, cough, wheeze, abdominal pain, nausea, vomiting, diarrhea, constipation, dysuria, black or bloody stools, lightheadedness or dizziness. This morning she reports good control of her pain. Past Medical History: CAD s/p MI in [**2108**] CHF (normal EF) OSA (refuses BiPAP) Type 2 DM c/b neuropathy, ?nephropathy Benign Hypertension Hyperlipidemia Gout Anxiety "Psoriasis", c/b RLE ulcers. CKD baseline Cr 1.5 Social History: No tobacco (quit 15 years ago), no EtOH or drugs. Married x 53 years, lives at home with husband and son. Family History: Mother had MI in her sleep at age 35, father died of old age. Physical Exam: VITAL SIGNS: 99.2 105/43 96 24 93%2L GENERAL: Obese female in NAD HEENT: MMM CV: RRR, II/VI systolic murmur at LUSB LUNGS: Clear to auscultation bilaterally with mild crackles at bases, has wet cough ABD: Soft, obese, NT, ND, no masses or organomegaly, BS+ EXT: WWP, mild ankle edema. RLE wrapped with bandage. Wiggles toes bilaterally, <2 sec cap refill, sensation in toes intact to light touch. Has multiple lower extremity healing ulcerations. Pertinent Results: Admission Labs: [**2124-3-18**] 11:15PM WBC-15.0* RBC-3.98* HGB-11.5* HCT-36.1 MCV-91 MCH-28.8 MCHC-31.8 RDW-15.7* [**2124-3-18**] 11:15PM PLT COUNT-267 [**2124-3-18**] 11:15PM NEUTS-82* BANDS-0 LYMPHS-12* MONOS-4 EOS-2 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2124-3-18**] 11:15PM PT-11.5 PTT-23.0 INR(PT)-1.0 [**2124-3-18**] 11:15PM GLUCOSE-203* UREA N-43* CREAT-1.5* SODIUM-142 POTASSIUM-5.4* CHLORIDE-109* TOTAL CO2-25 ANION GAP-13 [**2124-3-18**] 11:15PM CALCIUM-8.8 PHOSPHATE-4.9* MAGNESIUM-1.5* [**2124-3-18**] 11:15PM CK-MB-3 [**2124-3-18**] 11:15PM cTropnT-0.01 Other Pertinent Labs: [**2124-3-19**] 12:17PM GLUCOSE-206* LACTATE-2.1* NA+-143 K+-6.3* CL--107 [**2124-3-19**] 02:23PM TYPE-ART PO2-65* PCO2-69* PH-7.13* TOTAL CO2-24 BASE XS--7 INTUBATED-NOT INTUBA Discharge Labs: [**2124-3-22**] 06:30AM BLOOD WBC-8.1 RBC-2.80* Hgb-7.9* Hct-25.4* MCV-91 MCH-28.3 MCHC-31.2 RDW-15.6* Plt Ct-242 [**2124-3-22**] 06:30AM BLOOD Glucose-137* UreaN-29* Creat-1.3* Na-144 K-4.2 Cl-110* HCO3-27 AnGap-11 [**2124-3-22**] 06:30AM BLOOD Calcium-7.4* Phos-2.3* Mg-2.2 Studies: [**2124-3-18**] ECG: Sinus rhythm. Non-specific ST-T wave changes in the lateral leads. No previous tracing available for comparison. [**2124-3-18**] Chest Xray: Single portable chest radiograph is reviewed. The lung volumes are low. Cardiac silhouette appears enlarged, though abundantly exaggerated by technique. There is increased opacity at the left base, increased from one day prior. This may reflect atelectasis, although evolving pneumonia is not excluded. It appears to be a mild degree of volume overload, without large effusion. There is no pneumothorax. Marked degenerative changes are identified in the visualized thoracic spine. [**2124-3-19**] Right femur xray: Eight intraoperative radiographs were performed in the operating room for operative assistance without a radiologist present. These demonstrate an intratrochanteric right proximal femoral fracture, which appears comminuted. There is evidence of placement of a gamma nail fixation with a long femoral intramedullary rod. Pre-existing right total knee arthroplasty is evident. For full details, please consult the operative report. [**2124-3-21**] Chest Xray (preliminary read): S/p removal of ET tube, no other significant change. Brief Hospital Course: 74 year old female with CAD s/p MI, chronic diastolic CHF and psoriasis who presented after a scooter accident with right hip fracture now s/p repair. #. Closed femur fracture with acute blood loss anemia: She presented with right hip fracture and underwent surgical repair on [**2124-3-19**] without complication. She was given 1 unit of packed red cells post-operatively for a small hematocrit drop and her hematocrit subsequently remained stable. She was started on SC heparin instead of Lovenox given her acute renal failure for DVT prophylaxis. She is weight bearing as tolerated on both lower extremities. She was seen by the physical therapy team who recommended rehab placement. Her pain was controlled post-operatively with standing Tylenol and oxycodone. #. Hypoxia: She was mildly hypoxic post-operatively felt to be due to a combination of CO2 retention in the setting of OSA, atelectasis, and narcotic use for pain. She refused to wear CPAP during this admission and her oxygen requirements decreased post-operatively. At discharge she was still requiring 2L O2. It is important for her to continue incentive spirometry after discharge. #. Acute on chronic kidney disease Stage III: Her creatinine increased to 1.9 during this admission from a presumed baseline of 1.3-1.5 of stage III CKD. We were unable to validate her baseline creatinine and her kidney function should be followed after discharge. Her creatinine improved to 1.3 with IV fluid hydration post-operatively and it was felt that she had prerenal azotemia in the setting of her hip fracture. Her outpatient [**Last Name (un) **] was restarted prior to discharge but held during most of her stay. #. Type 2 Diabetes Mellitus Uncontrolled with Complications: She was managed with her home insulin regimen post-operatively. Actos and glimeprimide were held during her stay but restarted at discharge. #. CAD s/p MI: She would likely benefit from aspirin treatment as an outpatient but this was deferred to her PCP. #. Chronic diastolic CHF: Her home Lasix dose was initially held due to acute renal failure but was restarted prior to discharge. She may need better heart rate control to optimize her CHF treatment. #. Benign Hypertension: Her blood pressure was slightly elevated on admission and post-operatively and her antihypertensives were restarted prior to discharge. #. Hyperlipidemia: She was continued on her statin and her fenofibrate was held during this admission. #. Gout: Continued on allopurinol. #. Psoriasis c/b RLE ulcers: She receives methotrexate weekly which she was not due for during this hospitalization. It should be resumed at discharge although her dose could not be confirmed during her stay as her primary care doctor's office was closed. #. Prior cellulitis: She reported recent antibiotic use on admission for a possible cellulitis although had no signs of cellulitis on physical exam. She was given antibiotics perioperatively and then was not continued on them Medications on Admission: Bactrim since 7 days ago (pt cannot confirm) Diflucan for leg infection (pt unsure if course still active) Allopurinol 300 qday Atacand 32mg ativan 0.5 mg TID Fenofibrate 150 qd tenoritic 50/25 mg methotrexate qW (6 pills on sunday) furosemide 20 mg folic acid humulog 75/25 --> 32 units [**Hospital1 **] actos 15 mg amaryl 4 mg [**Hospital1 **] lipitor 40 mg Discharge Medications: 1. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atacand 32 mg Tablet Sig: One (1) Tablet PO once a day. 3. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as needed for anxiety. 4. Fenofibrate 160 mg Tablet Sig: One (1) Tablet PO once a day. 5. Tenoretic 50 50-25 mg Tablet Sig: One (1) Tablet PO once a day. 6. Methotrexate Sodium 2.5 mg Tablet Sig: Unknown dose - please confirm with PCP who is open on Thursday, [**3-23**] Tablet PO once a week: On Sunday. 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 9. Humalog Mix 75-25 100 unit/mL (75-25) Suspension Sig: Thirty Two (32) units Subcutaneous twice a day. 10. Actos 15 mg Tablet Sig: One (1) Tablet PO once a day. 11. Amaryl 4 mg Tablet Sig: One (1) Tablet PO twice a day. 12. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day. 13. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six (6) hours. 14. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO three times a day. 15. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. 18. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for rash. 19. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital of [**Location (un) **] & Islands - [**Location (un) 6251**] Discharge Diagnosis: Primary Diagnosis: Right subtrochanteric femur fracture Secondary Diagnosis: Type 2 Diabetes Mellitus Obstructive Sleep Apnea Hypertension Discharge Condition: Mental Status: Clear and coherent, A&Ox3 but with transient periods of disorientation Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital after you fell from your scooter. You were found to have a fracture of your right hip and this was fixed in the operating room by Dr. [**Last Name (STitle) **]. Post-operatively, you required oxygen supplementation and experience transient confusion, which resolved. It was felt that these side effects were likely due to the pain medication that you were receiving. Your medications were unable to be confirmed with your primary care doctor because your primary care doctor's office was not open. It is important for your rehab facility to confirm your outpatient medications. Changes to your medications: Decreased Ativan to 0.5mg by mouth twice daily as needed for anxiety Added acetaminophen 650mg by mouth every 6 hours Added oxycodone 5mg by mouth every 6 hours as needed for pain Added subcutaneous heparin 5000units three times daily Added calcium carbonate 500mg by mouth three times daily Added vitamin D 800 units by mouth daily Added docusate sodium 100mg by mouth twice daily Added senna 1 tab by mouth daily as needed for constipation Added miconazole powder as needed for rash ** If your pain in uncontrolled, your rehab could consider starting gabapentin [**Doctor First Name **] help your pain control** Followup Instructions: You have the following appointments scheduled in follow-up: Department: Orthopedics Physician: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] Date/Time: Tuesday, [**4-4**], at 2:10pm Phone: [**Telephone/Fax (1) 1228**] Location: [**Hospital1 18**] [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Building, Floor 2 When you leave your rehab facility, you should call your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] a follow-up appointment.

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icd9cm

[ [ [] ] ]

[ "79.15" ]

icd9pcs

[ [ [] ] ]

9665, 9777

4723, 7718

358, 428

9961, 9961

2398, 2398

11479, 11975

1852, 1915

8128, 9642

9798, 9798

7744, 8105

10195, 10812

3202, 4700

1930, 2379

10841, 11456

276, 320

456, 1493

9876, 9940

2414, 2981

9817, 9855

3003, 3186

9976, 10171

1515, 1713

1729, 1836

23,754

152,454

52275

Discharge summary

report

Admission Date: [**2129-3-23**] Discharge Date: [**2129-4-5**] Date of Birth: [**2072-5-14**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1973**] Chief Complaint: ARF with electrolyte abnormalities Major Surgical or Invasive Procedure: None History of Present Illness: 56 male with PMH recently diagnosed small cell lung carcinoma with metastases to bone and liver, s/p chemo last week (cisplatin/etoposide) admitted to [**Hospital Unit Name 153**] for closer monitoring of electrolytes and fluid status in setting of ARF. Pt stated that he presented to [**Hospital 5871**] Hospital with worsening LBP and difficulty ambulating. On arrival to OSH was noted be by diaphoretic and hypoxic to 84%. There, found to have new ARF and severe neutropenia and transferred here for further management. . Pt states that he had increased back pain recently. Otherwise, denies fevers, chills, chest pain, n/v/abd pain/diarrhea, and dysuria. States chronic cough and some difficulty breathing at baseline - denies recent change. Has noted some decreased urinary output lately. . In our [**Name (NI) **], pt's VS on arrival were t98.2, p86, 165/64, rr20, 96% 6L (changed from NRB). He received 2L NS, cefepime 2gm IV x1, calcium gluconate 1gm. Our labs c/w OSH including ARF, hypocalcemia, severe neutropenia, hyperkalemia, hyperphosphatemia, as noted below. Past Medical History: 1. Small cell lung cancer -diagnosed 3 weeks ago -has liver and bone mets -followed by oncologist Dr. [**Last Name (STitle) 108087**] [**Name (STitle) **] on chemo 2 weeks ago (cisplatin/etoposide) Hx of tonsillectomy Anxiety, agoraphobia COPD HTN Hyperlipidemia Depression BPH Hypothyroidism CKD - doesn't know baseline creatinine Social History: He used to be a custodian. He smoked 2ppd for 20 years; quit drinking 15yrs ago; no IVDU Family History: One brother with PKD s/p renal transplant Physical Exam: VS: t99.3, p95, 145/60, rr17, 94% RA Gen: obese, flat affect, NAD HEENT: dry MM with white residue Neck: CVP 8mm CVS: RRR, nl s1 s2, no m/g/r Lungs: diffuse rhonchi with wheezing throughout lung fields Abd:obese, soft, NT, ND, +BS Ext: 1+ pitting edema bilaterally Neuro: A&O x 3, although appear sleepy. Pertinent Results: [**2129-3-23**] 08:20PM BLOOD WBC-0.2* RBC-3.44* Hgb-10.7* Hct-30.5* MCV-89 MCH-31.0 MCHC-34.9 RDW-13.6 Plt Ct-90* [**2129-3-23**] 08:20PM BLOOD Neuts-24* Bands-0 Lymphs-68* Monos-4 Eos-0 Baso-0 Atyps-4* Metas-0 Myelos-0 [**2129-3-23**] 08:20PM BLOOD PT-12.7 PTT-32.5 INR(PT)-1.1 [**2129-3-23**] 08:20PM BLOOD Glucose-80 UreaN-131* Creat-6.9* Na-118* K-5.5* Cl-83* HCO3-18* AnGap-23* [**2129-3-23**] 08:20PM BLOOD ALT-13 AST-14 LD(LDH)-281* CK(CPK)-142 AlkPhos-106 Amylase-19 TotBili-0.6 [**2129-3-23**] 08:20PM BLOOD Albumin-3.0* Calcium-5.6* Phos-8.8* Mg-2.4 [**2129-3-23**] 08:20PM BLOOD CK-MB-6 cTropnT-<0.01 [**2129-3-23**] 08:20PM BLOOD Lipase-12 [**2129-3-24**] 01:43AM BLOOD calTIBC-109* VitB12-705 Folate-8.7 Ferritn-848* TRF-84* [**2129-3-26**] 04:30AM BLOOD Vanco-12.2 [**2129-3-24**] 11:52AM BLOOD Type-ART Temp-37.4 pO2-56* pCO2-49* pH-7.27* calTCO2-23 Base XS--4 Intubat-NOT INTUBA [**2129-3-25**] 12:42AM BLOOD Type-ART O2 Flow-3 pO2-67* pCO2-47* pH-7.26* calTCO2-22 Base XS--5 Intubat-NOT INTUBA Comment-O2 DELIVER [**2129-3-25**] 12:42AM BLOOD freeCa-0.87* [**2129-3-25**] 04:35PM BLOOD freeCa-0.96* CXR: FINDINGS: There is no definite focal consolidation. No superimposed edema is evident. There is prominence in the aorticopulmonary window, which may relate to the patient's known lung cancer diagnosis. The cardiac silhouette is within normal limits accounting for the depth of inspiration and AP portable technique. There is blunting of the left costophrenic angle, which may be due to a small effusion. There is no definite right effusion. No pneumothorax is seen. A Port-A-Cath is evident with the tip projected over the superior vena cava. . IMPRESSION: No clear consolidation or superimposed edema. There is bibasilar atelectasis. . Head CT: FINDINGS: The extracalvarial soft tissues are unremarkable. The calvarium and skull base are intact. The paranasal sinuses and mastoid air cells are clear. The globes are intact with lenses in place. Intracranially, the ventricles are midline and normal in size and configuration. The cortical sulci and subarachnoid cisterns are likewise unremarkable. [**Doctor Last Name **] matter-white matter interface is well defined. There is no mass effect or CT evidence suggestive of underlying vasogenic edema. Additionally, no intracranial hemorrhage or CT evidence of acute cortical stroke is noted. . IMPRESSION: Unremarkable head CT examination. No secondary evidence to suggest underlying metastatic disease. . Renal U/S [**2129-3-24**] IMPRESSION: No evidence of hydronephrosis. Brief Hospital Course: 56 yo male with PMH newly diagnosed metastatic small cell cancer presents with severe neutropenia and ARF with electrolyte abnormalities. . 1. ARF: Most likely of multifactorial etiology including pre-renal, and intrinsic renal dysfunction (FeNa 8.5%). Intrinsic renal may be [**1-7**] cisplatin toxicity, tumor lysis syndrome, on top of CKD from HTN (baseline unknown). Post-renal etiology seems less likely, as pt is urinating and renal U/S with no evidence of hydronephrosis. The urinary output increased steadily and is 150 cc/hour today ([**2129-3-28**]). Creatinine slowly trending down, down to 8 today , as well as phosphate, down to 6 from >8. A renal consult was obtained early on which advised 3% saline for 20 cc/hour for 1 Liter, with which Na corrected to 127. The renal team did not feel that the patient had tumor lysis syndrome. The patient has been on a 1.5 L per day free water restriction. The patient does not wish to have hemodialysis, and the renal consult did not feel this was appropriate. He was given phos-binder, his medicines were renally dosed, and diovan and celebrex were held. In discussion with his oncologist his chemotherapy regimen is modified to no longer have platinums. . 2. Hypocalcemia: DDx includes precipitation into CaPo4 in setting of hyperphos, tumor lysis syndrome. Calcium was repleted in a conservative manner in view of his hyperphosphatemia. His cardiac status was closely monitored and he did not develop any cardiac symptoms. . 3. Hyponatremia: Likely [**1-7**] hypovolemia. Not sodium avid by lytes, but may be [**1-7**] concomitant intrinsic renal dz. . 4. Fever and Neutropenia: The patient was placed on neutropenic precautions. He had new infiltrates on CXR. He received vanc and cefepime, renally dosed. Vanc level was very high so he has not been given new dose yet. Sputum grew pan sensitive E Coli, and MSSA. He was switched to levaquin only. Respiratory symptoms improved. He was started on neupogen with good response and his neutropenia resolved. However his neupogen was stopped late, and he has a high level of leukocytosis. . 6.Thrombocytopenia: Most likely [**1-7**] chemo. Unlikely DIC (nl INR, fibrinogen 734). HIT negative. REsolved over first few days of admission. . 7. Lung cancer with bone metastasis: Resulting in diffuse bony pain. A pain consult was obtained. He is on oxycontin, dilaudid for breakthrough pain, and neurontin low dose qhs. This worked well and at rest he had no pain. But with walking he c/o left hip pain. He will resume chemotherapy with his primary oncologist. . 8. COPD: continued inhaler per home regimen; alb/atrov nebs standing every six hours. Discontinued propanolol, which the patient was probably taking for his social phobia, and started low dose metoprolol tid to avoid rebound tachycardia. Due to persistent wheezing, he was started on systemic steroids. now to taper . 9. Depression: Effexor was renally dosed and duloxetine was d/c'ed. QTc was monitored on EKGs. Social work worked with the patient. . 10. HTN: Diovan was held. BP remained stable. . 11. Hypothyroid: continue levothyroxine. . . DNR DNI: The patient decided on a meeting with medical team and his brother on 4/ 20 to be made DNR DNI. His brother is his health care proxy. Medications on Admission: Allopurinol 300mg qd Percocet prn Fentanyl 50 mcg q72h Diovan 80mg qd Protonix 40mg qd Flomax 0.8mg qd Crestor 5mg qd Synthroid 112mcg qd Abilify 15mg qd Cymbalta 60mg qd Inderal 60mg qd Effexor XR 375mg qd Valium 10mg tid Celebrex 200mg qd Spriva 1 qd Glycolax prn Advair 1 puff qd Androgel 10gmqd Albuterol 2 puffs q4h prn Discharge Medications: 1. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aripiprazole 15 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Diazepam 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed. 5. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). 6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: Two (2) Capsule, Sust. Release 24 hr PO HS (at bedtime). 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Three (3) Capsule, Sust. Release 24 hr PO DAILY (Daily). 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 11. Albuterol Sulfate 0.083 % Solution Sig: One (1) puff Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 12. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 13. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 14. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 17. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 18. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 19. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 20. Fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days. 21. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day for 5 days: taper as per PCP. 22. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation Q12H (every 12 hours). 23. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 24. Heparin Lock Flush (Porcine) 10 unit/mL Solution Sig: One (1) ML Intravenous DAILY (Daily) as needed. Discharge Disposition: Extended Care Facility: [**Hospital1 2670**] Care & Rehabilitation Discharge Diagnosis: PRIMARY: Acute renal failure Staph and ecoli pneumonia Neutropenia Discharge Condition: Good Discharge Instructions: Return to the hospital if you are unable to urinate, have palpitations, fever/chills, cough productive of sputum Followup Instructions: 1. You have an appointment scheduled with your oncologist, Dr. [**First Name (STitle) 82704**], on Wednesday [**2129-4-6**] at 11:45 ([**Telephone/Fax (1) 108088**]). You can discuss when to resume chemo at this appointment. 2. You have an appointment scheduled with your renal doctor, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], on [**2129-4-18**] at 2:00 ([**Telephone/Fax (1) 108089**]).

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10757, 10826

4914, 8172

349, 355

10936, 10942

2324, 4092

11103, 11526

1941, 1984

8548, 10734

10847, 10915

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10966, 11080

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275, 311

384, 1462

4101, 4891

1484, 1818

1834, 1925

8,940

113,806

27283

Discharge summary

report

Admission Date: [**2122-5-4**] Discharge Date: [**2122-5-6**] Date of Birth: [**2069-1-6**] Sex: M Service: MEDICINE Allergies: Flexeril Attending:[**First Name3 (LF) 3984**] Chief Complaint: liver failure Major Surgical or Invasive Procedure: attempted paracentesis History of Present Illness: 53 yo man with HCV, cirrhosis, distant alcoholism, s/p CABG, h/o AAA repair, CHF, admitted to ICU w/presumed SBP (elev peripheral WBC, abdominal pain, hypothermia) and hepatorenal syndrome. Serum Cr peaked at 4.6 now at 2.5 (baseline pta was around 1). Required vasopressors initially to maintain BP but was not intubated. CT scan [**4-20**] showed large amt of ascites new since [**Month (only) 216**]. Did not get paracentesis at that time, was treated empirically with Ceftriaxone. Stabilized and called out to floor. There, after 10 days of ceftriaxone, a paracentesis showed 14 wbc. Hospital course on the medical floor has been marked by ongoing hepatic failure as well as encephalopathy which is said to be relatively new to this patient. He has reportedly been hemodynamically stable. He is being transferred to [**Hospital1 18**] for further hepatology evaluation. Upon arrival to [**Hospital1 18**], pt is confused and unable to give additional history. ROS unable to obtain. Past Medical History: Known esophageal varices with h/o GI bleeding from ??????erosive gastritis?????? HCV ?????? unclear whether ever treated Anemia [**1-29**] GIB and renal failure Colonoscopy with polypectomy GI AV malformation DM II CAD s/p cabg CHF EF 45% Hep C HTN Hyperlipidemia AFib b/l avascular necrosis of hips (new on admission) MRSA Social History: Married, lives w/wife [**First Name8 (NamePattern2) **] [**Name (NI) 22226**] [**Telephone/Fax (1) 66908**]) who is also seriously ill (? cognitive impairment) [**First Name8 (NamePattern2) **] [**Known lastname 22226**] = brother # [**Telephone/Fax (1) 66909**]. The patient has three childre. One son lives in [**Name (NI) 108**]. Family History: Pt. unable to provide due to encephalopathy. Physical Exam: On transfer - Afebrile, Tc 96.6, HR 95 BP 136/60, 95% on RA VITALS on admit:T 96.9 BP 117/51 HR 80 RR 18 93%RA wt 116kg GEN Confused , appears old than stated age, poorly groomed SKIN Yellow, multiple petchia on arms HEENT PERRL, sclera yellow, OP clear NECK JVD, no lad LUNGS CTAB CV RRR no m/r/g ABD distended, non-tender, BS+, shifting dullness EXT 3+edema up to abdomen NEURO Confused, positive asterixis Pertinent Results: labs on admission: [**2122-5-4**] 07:30PM BLOOD WBC-13.8* RBC-3.74* Hgb-11.3* Hct-33.6* MCV-90 MCH-30.2 MCHC-33.7 RDW-19.2* Plt Ct-63* [**2122-5-4**] 07:30PM BLOOD Neuts-86.9* Lymphs-8.7* Monos-3.7 Eos-0.6 Baso-0.1 [**2122-5-4**] 07:30PM BLOOD PT-31.8* PTT-57.7* INR(PT)-3.4* [**2122-5-5**] 04:34PM BLOOD Fibrino-80* [**2122-5-4**] 07:30PM BLOOD Glucose-97 UreaN-98* Creat-3.6* Na-133 K-5.4* Cl-98 HCO3-23 AnGap-17 [**2122-5-4**] 07:30PM BLOOD ALT-123* AST-215* LD(LDH)-257* AlkPhos-75 Amylase-56 TotBili-25.7* [**2122-5-5**] 04:34PM BLOOD proBNP-3220* [**2122-5-4**] 07:30PM BLOOD Lipase-100* [**2122-5-4**] 07:30PM BLOOD Albumin-2.9* Calcium-9.7 Phos-5.3* Mg-2.6 [**2122-5-5**] 04:34PM BLOOD Cryoglb-NO CRYOGLO [**2122-5-6**] 12:30PM BLOOD AFP-3.3 [**2122-5-4**] 07:30PM BLOOD C3-48* C4-5* Labs prior to death: [**2122-5-6**] 03:18AM BLOOD WBC-9.8 RBC-3.06* Hgb-9.6* Hct-27.6* MCV-90 MCH-31.3 MCHC-34.8 RDW-19.4* Plt Ct-47* [**2122-5-6**] 12:30PM BLOOD PT-23.3* PTT-44.4* INR(PT)-2.3* [**2122-5-6**] 03:18AM BLOOD Calcium-9.9 Phos-6.8* Mg-2.8* [**2122-5-6**] 11:13AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.005 [**2122-5-6**] 11:13AM URINE Blood-LG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2122-5-6**] 11:13AM URINE RBC->50 WBC-0-2 Bacteri-FEW Yeast-NONE Epi-0-2 [**2122-5-6**] 11:13AM URINE Hours-RANDOM UreaN-2 Creat-3 Na-121 [**2122-5-6**] 11:13AM URINE Osmolal-217 HCV viral load: not detected. ABDOMINAL US: 1. Echogenic liver consistent with fatty infiltration. Advanced liver disease, including hepatic cirrhosis/fibrosis cannot be excluded. Marked ascites. The patient was marked for tap. 2. Reversal of the normal portal venous flow. The portal veins, hepatic veins, and hepatic arteries are patent. 3. Gallbladder sludge without evidence of cholecystitis. RENAL US: The right kidney measures 11.4 cm in length, and the left kidney measures 9.4 cm in length. There is no hydronephrosis. The cortical thickness and echogenicity are normal. No shadowing stones are present. The urinary bladder is poorly evaluated secondary to the presence of a large amount of ascites in the pelvis. KUB: Multiple dilated loops of small bowel are identified, the largest measuring approximately 3.6 cm in diameter. There is also prominence of the ascending and transverse colon, the latter measures 6.8 cm in widest diameter. There is no evidence of free intraperitoneal air on these images. The patient is status post median sternotomy as well as aortic bypass graft. There is a hazy appearance to the abdomen consistent with known ascites. CXR: 1. Discoid atelectases. 2. No evidence of congestive heart failure or pulmonary infiltration. ECHO: Technically difficult study. Limited views obtained. 1.The left atrium is mildly dilated. 2.The left ventricular cavity size is normal. Overall left ventricular systolic function is hard to assess given the limited views but the basal portion of the inferior wall appears dyskinetic. 3. Right ventricular systolic function is hard to assess but is probably normal. 4.The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No aortic regurgitation seen. 5.The mitral valve leaflets are mildly thickened. Very mild (TR- 1+) mitral regurgitation is seen. 6. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. 7.There is no pericardial effusion. Brief Hospital Course: 1. Liver failure/Decompnesated cirrhosis. The reason for fairly rapid decompensation was not clear. Per history, there was no recent alcohol use. The history regarding patient's previous management of Hep C was not clear. MELD score on presentation was 45. Hepatology service was involved and the possibility of liver transplant was enterntained. The patient was encephalopathic. He was managed with Lactulose 45 ml qid. Rifamaxin 400 mg tid. Repeat HepC viral load came back non-detectable. Abd US showed cirrhosis, marked ascites, GB sludge, and patent vessels. Diagnostic paracentesis was attempted on the floor but was unsuccessful ("dry tap"). The patient was treated empirically with Vancomycin and Zosyn for presumed peritonitis. The patient was transfered to the ICU and the arrangements were made for large volume paracentesis to be done by IR given compromised respiratory status. Per IR request, patient was to receive 4 units of FFP to reverse coagulopathy and to lower INR to <2 prior to the procedure. After two units of FFP the patient developed respiratory distress and required 100% NRB to keep Os sats in high 90%. The family meeting led by Dr. [**Last Name (STitle) 497**] in the presence of the patients brother, [**Name (NI) **], as well as the renal fellow and ICU team was held. Given the patient's poor prognosis and multiple comorbidities, the decision was to change the goals of care from DNR/DNI to comfort measures. The patient was started on Morphine drip and passed away in a few hours. The family consented to autopsy. . Renal failure. Presumed to be secondary to hepatorenal syndrome vs. ATN vs. increased compartment syndrome vs. other. Patient was anuric. Renal US showed no evidence of obstruction. Patient has been treated with midodrine and octreotide for presumed hepatorenal syndrome. . Coagulopathy/thrombocytopenia. Coags, cryoglubulin, fibrinogen were monitored. There was no evidence of DIC. Patient received Vit K. FFP/cryo were administered as needed given tenuous respiratory status. . Abdominal pain. The patient was septic on presentation to the OSH and treated empirically for SBP w/o paracentesis. On admission to the ICU, the patient had positive peritoneal signs on exam. WBC was 13.8 on transfer to [**Hospital1 **] and then normalized. The patient was treated empirically with Zosyn and Vancomycin. KUB showed ileus. US showed patent vasculature. NG tube was placed but patient then self-removed the NG tube. Medications on Admission: Home meds lisonpril 5 mg qd pantoprazole 40mg [**Hospital1 **] oxazepam 15mg qd percocet 5mg q8h lasix 40 mg po bid amiodarone 200 mg po qd glipizide 10 mg qam 5mg qpm atorvastatin 40 mg qd viagra prn Meds on transfer ceftriaxone x 10 days, now complete Insulin SS NPH 38/24 Protonix Lactulose 45 qid MVI Folate Thiamine Aldactone 50 Lasix 80 daily Flagyl 250 tid (added for encephalopathy) Oxycodone 10 q4 hours for ??????abdominal pain?????? Zofran 8 mg po prn Miconazole cream for ? fungal infection around paracentesis site. Genatmicin for ??????pus?????? around his Foley. Foley was d/c??????ed, U/A and Urine culture negative completed 5 days of vancomycin, for a Rash on abdomen, ? cellulitis ?????? but thought was more fungal, so changed to miconazole cream Discharge Disposition: Expired Discharge Diagnosis: Peritonitis Liver cirrhosis, decompensated Coagulopathy Ileus Discharge Condition: Expired [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**] Completed by:[**2122-5-11**]

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

9275, 9284

5993, 8457

280, 304

9390, 9554

2528, 2533

2037, 2083

9305, 9369

8483, 9252

2098, 2509

227, 242

332, 1321

2547, 5970

1343, 1669

1685, 2021

51,027

142,090

2949

Discharge summary

report

Admission Date: [**2162-5-7**] Discharge Date: [**2162-5-20**] Date of Birth: [**2094-11-26**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1781**] Chief Complaint: Left foot pain Major Surgical or Invasive Procedure: [**2162-5-7**] Left guillotine below-the-knee amputation. [**2162-5-13**] Closure of left below knee amputation after left guillotine amputation History of Present Illness: A patient is a 66-year-old male who was transferred to the [**Hospital1 **] MC emergency room with left foot wet gangrene extending up to the forefoot and plantar aspect of the foot with fevers. Past Medical History: DM2, peripheral neuropathy, HTN, CRI (BL cr 3.4), sp CVA, blind Social History: Patient lives at home with his two sons. Denies [**Name2 (NI) **], Etoh or Drugs. Moved here from [**Location (un) 4708**] 31 years ago. Family History: Both parents had DM. Physical Exam: ON DISCHARGE: 98.2 77 152/80 18 99% room air Blind, HOH NAD RRR CTAB soft, ND, NT Left BKA incision clean, dry, intact with staples Right dopplerable DP and PT pulses. Pertinent Results: ON ADMISSION: [**2162-5-7**] 01:00PM BLOOD WBC-21.8*# RBC-3.84* Hgb-9.9* Hct-28.9* MCV-75* MCH-25.7* MCHC-34.2 RDW-16.2* Plt Ct-673* [**2162-5-7**] 01:00PM BLOOD PT-13.2* PTT-31.8 INR(PT)-1.2* [**2162-5-7**] 01:00PM BLOOD Glucose-234* UreaN-50* Creat-3.7* Na-132* K-4.6 Cl-95* HCO3-25 AnGap-17 [**2162-5-7**] 05:23PM BLOOD CK(CPK)-38 [**2162-5-7**] 05:23PM BLOOD CK-MB-NotDone cTropnT-0.38* [**2162-5-7**] 05:23PM BLOOD Calcium-8.3* Phos-4.1 Mg-2.7* . ON DISCHARGE: [**2162-5-18**] 05:05AM BLOOD WBC-11.1* RBC-3.78* Hgb-9.9* Hct-29.6* MCV-78* MCH-26.2* MCHC-33.4 RDW-18.2* Plt Ct-560* [**2162-5-16**] 06:20AM BLOOD Neuts-83.3* Lymphs-11.8* Monos-3.7 Eos-1.0 Baso-0.1 [**2162-5-14**] 05:00AM BLOOD PT-13.7* PTT-34.7 INR(PT)-1.2* [**2162-5-18**] 05:05AM BLOOD Glucose-72 UreaN-59* Creat-4.4* Na-135 K-4.1 Cl-96 HCO3-28 AnGap-15 [**2162-5-12**] 05:10AM BLOOD CK(CPK)-25* [**2162-5-12**] 05:10AM BLOOD CK-MB-NotDone cTropnT-0.24* [**2162-5-18**] 05:05AM BLOOD Calcium-8.3* Phos-4.6* Mg-2.4 . RADIOLOGY Final Report CT HEAD W/O CONTRAST [**2162-5-7**] 7:25 PM CT HEAD W/O CONTRAST Reason: eval SDH, SAH [**Hospital 93**] MEDICAL CONDITION: 67 year old man s/p L guillotine amp [**5-7**] with unilateral weakness in PACU REASON FOR THIS EXAMINATION: eval SDH, SAH CONTRAINDICATIONS for IV CONTRAST: elev creat INDICATION: Unilateral weakness. COMPARISON: None. TECHNIQUE: Non-contrast axial CT images of the head were obtained at 5 mm section thickness. NON-CONTRAST CT HEAD: No intracranial hemorrhage, shift of normally midline structures, or evidence of acute major vascular territorial infarction is observed. Mild periventricular and subcortical white matter hypodensity is likely the sequelae of chronic small vessel ischemia. Ventricular and focal prominence likely the sequelae of global atrophy, perhaps slightly advanced for age. Post-surgical changes of the right orbit are partially imaged. Surrounding osseous structures are unremarkable. IMPRESSION: No intracranial hemorrhage or edema. . RADIOLOGY Final Report CHEST (PRE-OP PA & LAT) [**2162-5-7**] 1:45 PM CHEST (PRE-OP PA & LAT) Reason: need for [**Hospital **] [**Hospital 93**] MEDICAL CONDITION: 67 year old man with left foot gangrene REASON FOR THIS EXAMINATION: need for pre-op REASON FOR EXAMINATION: Pre-operative evaluation in a patient with left foot gangrene. PA and lateral upright chest radiograph compared to [**2162-3-2**]. The heart size is normal. Marked tortuosity of the aorta is noted with no evidence of focal dilatation. The trachea is deviated to the right most likely due to multinodular goiter. The lungs are clear. Pleural surfaces are smooth and there is no pleural effusion. Mild lung hyperinflation is noted. IMPRESSION: 1. Tortuous aorta. 2. Thyroid enlargement most likely due to multinodular goiter. No evidence of pneumonia. . RADIOLOGY Final Report PERSANTINE MIBI [**2162-5-11**] PERSANTINE MIBI Reason: ST ELEVATION PLEASE EVALUATE RADIOPHARMECEUTICAL DATA: 10.2 mCi Tc-[**Age over 90 **]m Sestamibi Rest ([**2162-5-11**]); 30.1 mCi Tc-99m Sestamibi Stress ([**2162-5-11**]); HISTORY:DM, ESRD, PVD, abnormal EKG SUMMARY OF DATA FROM THE EXERCISE LAB: Dipyridamole was infused intravenously for 4 minutes at a dose of 0.142 mg/kg/min. METHOD: Resting perfusion images were obtained with Tc-99m sestamibi. Tracer was injected approximately one hour prior to obtaining the resting images. Two minutes after the cessation of infusion of dipyridamole, approximately three times the resting dose of Tc99m sestamibi was administered IV. Stress images were obtained approximately one hour following tracer injection. Imaging protocol: Gated SPECT. This study was interpreted using the 17-segment myocardial perfusion model. INTERPRETATION: The image quality is adequate Left ventricular cavity size is normal Rest and stress perfusion images reveal uniform tracer uptake throughout the left ventricular myocardium. Gated images reveal global hypokinesis. The calculated left ventricular ejection fraction is 37 %, compared with 48% from [**2161-11-18**]. IMPRESSION: Global hypokinesis of unknown cause. No myocardial perfusion defects. Normal sized heart. . Cardiology Report STRESS Study Date of [**2162-5-11**] INTERPRETATION: This 67 year old type 2 IDDM man with ESRD and PVD was referred to the lab for evaluation. The patient was infused with 0.142 mg/kg/min of dipyridamole over 4 minutes. No arm, neck, back or chest discomfort was reported by the patient throughout the study. There were no additional ST segment changes from baseline during the infusion of in recovery. The rhythm was sinus with several isolated apbs. The patient was hypertensive at baseline with an appropriate response to the infusion. Heart rate response was flat. The dipyridamole was reversed with 125 mg of aminophylline IV. IMPRESSION: No anginal type symptoms or ischemic EKG changes. Nuclear report sent separately. . Cardiology Report ECHO Study Date of [**2162-5-11**] INTERPRETATION: Findings: This study was compared to the prior study of [**2161-11-16**]. LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal IVC diameter with >50% decrease during respiration (estimated RAP 5-10 mmHg). LEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. Low normal LVEF. No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Indeterminate PA systolic pressure. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - poor apical views. Conclusions: The left atrium is normal in size. The estimated right atrial pressure is [**4-29**] mmHg. 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%). Right ventricular chamber size is normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2161-11-16**], mild aortic regurgitation is now identified and left ventricular systolic function is less vigorous. In the absence of a history of systemic hypertension, an infiltrative process (e.g., amyloid) should be considered. CLINICAL IMPLICATIONS: Based on [**2161**] AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. Brief Hospital Course: The patient was admitted to Dr.[**Name (NI) 7257**] Vascular Surgery Service at [**Hospital1 18**]. He was found to have a septic left foot and underwent a left guillotine BKA. Placed on antibiotics and plan for completion BKA next week. Wound and blood cultures obtained. BC negative. Stump with periodic breakthrough bleeding, CBC closely followed. Afebrile. Pain controlled with Percocet. Amputation support group and social work in to see patient. Dr [**Last Name (STitle) **], cardiology consulted for preop clearance. Patient had recent, nl echo and PMIBI. cleared for surgery. [**5-10**]: In preop holding area, patient slightly diaphoretic with questionable ST elevation on rhythm strips. 12 lead ECG unchanged. Surgery cancelled and Dr. [**Last Name (STitle) **] [**Name (STitle) 14168**]. [**5-11**]: Repeat ??????[**Doctor Last Name **] and PMIBI obtained. Cardiac enzymes, troponin decreasing. Cleared for surgery. [**5-13**]: Underwent uneventful closure of left below knee amputation after left guillotine amputation. No complications. patient extubated an transferred to PACU. POD 1- Doing well, VSS. Continued on ABX (vanco/Levo/Flagyl) and bedrest. Bowel regime and pain control. Transferred from VICU to floor. Physical therapy consulted for rehab placement. POD 2- No events, VSS. Dressing C/D/I. SR on tele monitor. POD 3- No events, VSS. Post op dressing changed. Vanco held (Cr 2.1). OOB with assist. POD 4- No events. Cr remains elevated. Physical exam unchanged. Pain controlled. POD [**4-25**]- No events. VSS, afebrile. Incision C/D/I. No infection. ABX discontinued. Plan rehab when bed available. Social work and amputee support group following patient. Renal consulted for elevated Cr. Recommendations are to hold Lasix and renally dose medication. ARF secondary to lasix. po intake encouraged. No need for dialysis [**2162-5-20**]: Discharged to rehab. VSS. Will need continued monitoring of electrolytes (cr). To f/u with Dr. [**Last Name (STitle) **] in [**1-23**] weeks. Cleared for discharge by renal. Will follow up with Dr. [**Last Name (STitle) 118**] (renal) in 1 week with repeat labs. Will hold Lasix and Lisinopril until evaluation by renal surgery. Medications on Admission: ASA 325', toprol 200', diflucan 50', lantus, lisinopril 10', lasix 40', MVI, lipitor 20' Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL Injection TID (3 times a day). Disp:*qs mL* Refills:*0* 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*qs Tablet(s)* Refills:*0* 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*qs Tablet(s)* Refills:*0* 4. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*qs Tablet Sustained Release 24 hr(s)* Refills:*0* 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed. Disp:*qs Tablet, Delayed Release (E.C.)(s)* Refills:*0* 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*qs Capsule(s)* Refills:*0* 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*qs Tablet(s)* Refills:*0* 8. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 9. Morphine Sulfate 2-4 mg IV Q4-6H:PRN breakthrough 10. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 11. INSULIN SLIDING SCALE Insulin SC Fixed Dose Orders: Breakfast lantus 15 Units . Insulin SC Sliding Scale: Breakfast Lunch Dinner Bedtime Regular insulin Glucose Insulin Dose 0-50 mg/dL 4 oz. Juice 51-150 mg/dL 0 Units 151-200 mg/dL 2 Units 201-250 mg/dL 4 Units 251-300 mg/dL 6 Units 301-350 mg/dL 8 Units 351-400 mg/dL 10 Units > 400 mg/dL Notify M.D. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Location (un) 38**] Discharge Diagnosis: Left septic foot Discharge Condition: Stable Discharge Instructions: Please call your doctor or return to the emergency room for the followin: - Chest pain - Shortness-of-breath - Temperature > 101.5 - Inability to tolerate food - Increased redness or fould drainage from incisions - Or other concerns . Please take your medications as prescribed. . Please follow-up as directed. . Please leave the staples in for four weeks from his date of surgery ([**2162-4-21**]). DO NOT PLACE STUMP SHRINKERS ON THE LEFT BKA. . Please d/c foley at rehab when ambulatory. DISCHARGE INSTRUCTIONS FOLLOWING AMPUTATION This information is designed as a guideline to assist you in a speedy recovery from your surgery. Please follow these guidelines unless your physician has specifically instructed you otherwise. Please call our office nurse if you have any questions. Dial 911 if you have any medical emergency. ACTIVITY: There are restrictions on activity. On the side of your amputation you are non weight bearing for 4-6 weeks. You should keep this amputation site elevated with knee straight when ever possible. No driving until cleared by your Surgeon. PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS: Redness in or drainage from your leg wound(s). New pain, numbness or discoloration of your foot or toes. Watch for signs and symptoms of infection. These are: a fever greater than 101 degrees, chills, increased redness, or pus draining from the incision site. If you experience any of these or bleeding at the incision site, CALL THE DOCTOR. BATHING/SHOWERING: You may shower immediately upon coming home. No bathing. Followup Instructions: Please call Dr. [**Last Name (STitle) **] at ([**Telephone/Fax (1) 1798**] to schedule a follow-up appointment to be seen in [**1-23**] weeks. Completed by:[**2162-5-20**]

[ "369.4", "585.9", "443.9", "V58.67", "250.60", "V12.59", "357.2", "250.70", "785.4", "584.9", "403.90" ]

icd9cm

[ [ [] ] ]

[ "84.15", "84.3" ]

icd9pcs

[ [ [] ] ]

12275, 12356

8378, 10573

329, 476

12417, 12426

1188, 1188

14039, 14213

959, 981

10712, 12252

3353, 3393

12377, 12396

10599, 10689

12450, 14016

996, 996

8119, 8355

1654, 2288

275, 291

3422, 8096

504, 700

2660, 3316

1202, 1640

722, 788

804, 943

7,528

112,853

53454+53455

Discharge summary

report+report

Admission Date: [**2112-1-19**] Discharge Date: [**2112-2-3**] Date of Birth: [**2050-3-12**] Sex: M Service: MEDICINE CHIEF COMPLAINT: Shortness of breath and chest pain HISTORY OF PRESENT ILLNESS: The patient, Mr. [**Known firstname 449**] [**Known lastname 109917**], is a 61-year-old white male with a history of anxiety, coronary artery disease status post coronary artery bypass graft x2, end stage renal disease on dialysis, type II diabetes, ischemic cardiomyopathy with one patent vessel and ejection fraction of 15%, was presented to [**Hospital6 1760**] after complaint of shortness of breath and chest pain. The patient reported shortness of breath for about a month in which sitting around the house would cause breathing difficulties. The patient reported that his breathing is relieved by breathing from a paper bag, as recommended by her friend. It initially occurred in less frequency, but now patient reported symptoms approximately eight times daily. Furthermore, the patient reported episodic nonradiating, sharp, chest pain lasting a few seconds. On the day of admission, the patient called his primary care physician and was advised to come to the Emergency Department for evaluation/treatment. While in the Emergency Department, the patient's symptoms of chest pain and shortness of breath were improved with oxygen supplement. At interview, the patient denied chest pain, shortness of breath, fever, chills, nausea, vomiting, diaphoresis. The patient reported similar episodes in [**2111-11-24**] with the same symptoms of shortness of breath and chest pain. The patient was admitted for two days that subsequently ruled myocardial infarction. A Persantine MIBI stress test was performed which showed superior and inferior wall fixed defect/moderate lateral wall defect and ejection fraction of 15%. There was no acute electrocardiogram change at that time. The working diagnosis at that time was that the patient was under dialyzed as a result of lower dry weight. The patient was dialyzed again during admission and the symptoms improved. The patient reported increased anxiety, in which he thinks that he is about to die because of all these medical problems. The patient lives alone with only one friend that he can really talk to and has been separated from his wife and [**Name2 (NI) 8526**]. The patient has been out of work since the age of 46 due to renal and cardiac problems. PAST MEDICAL HISTORY: 1. Diabetes 2. End stage renal disease 3. Coronary artery disease, status post coronary artery bypass graft x2 in [**2089**] and [**2097**] 4. Gastritis 5. Anemia 6. High cholesterol status post right cerebrovascular accident 7. Cardiomyopathy 8. Hypertension 9. Anxiety ALLERGIES: The patient has no known drug allergies. INITIAL MEDICATIONS: 1. Zestril 25 qd 2. Imdur 60 mg 1 tablet qd 3. Nitroglycerin prn 4. Neurontin 100 mg 1 tablet qd 5. Nephrocaps 1 tablet qd 6. Prilosec 40 mg qd 7. Lopressor 50 mg [**Hospital1 **] 8. Pravachol 40 mg qd 9. Xanax 0.25 mg [**Hospital1 **] 10. Reglan 10 mg tid 11. Glyburide 2.5 mg qd 12. ASA 325 mg qd SOCIAL HISTORY: The patient admits to smoking half pack a day for the past 20 years. Denies use of alcohol and intravenous drugs. The patient is separated from his wife, lives alone, has a [**Hospital1 8526**]. FAMILY HISTORY: Both the father and the brother have type II diabetes and also coronary artery disease. ADMISSION VITALS: Blood pressure 97/60, pulse 89, respiration 20, O2 saturation 100% on 2 liters. PHYSICAL EXAMINATION: GENERAL: The patient is a 61-year-old male who appeared older than stated age, no apparent distress, awake, alert and oriented to time, place and person, was unhappy that he has returned to the hospital for his symptoms. HEAD, EARS, EYES, NOSE AND THROAT: Normocephalic, atraumatic. Pupils equal, round and reactive to light. Extraocular eye movements intact bilaterally. Mucous membranes moist. Oropharynx benign. No lymphadenopathy bilaterally. CARDIOVASCULAR: The patient has regular rate and rhythm with 3/6 holosystolic ejection murmur appearing loudest at the left upper sternal border. Jugular venous distention was normal at 8 cm. PULMONARY: The patient's lung fields are clear to auscultation bilaterally without wheezing or crackles. ABDOMEN: Soft and nontender with active bowel sounds in all quadrants. There was no mass, no bruit, no rebound tenderness or guarding. EXTREMITIES: There is 1+ bilateral lower extremity edema. There was no upper extremity edema. Overall, there is no clubbing or cyanosis. There is an AV shunt on the left arm. NEUROLOGIC: Cranial nerves II through XII are intact bilaterally. The motor exam was [**2-26**] for all muscle groups and deep tendon reflex was 2+ at all points. MINI MENTAL EXAM: The patient feels lonely from living by himself and has been agitated and very unhappy with the fact that he has to come to the hospital quite often. The patient has no suicidal or homicidal ideation. ADMISSION LABS: CBC: White count 8.0, hematocrit 41.6, hemoglobin 13.9, platelets 140. Chemistries: Sodium 136, potassium 4.1, chloride 92, bicarbonate 27, BUN 41, creatinine 7.1 with glucose of 188. PT 15.1, PTT 29.4, INR 1.6. Electrocardiogram showed no acute changes, has the evidence of old left bundle branch block. IMAGING STUDIES: The patient had a chest x-ray which showed mild chronic failure and bilateral basilar atelectasis. HOSPITAL COURSE: In summary, this is a 61-year-old white male with a history of coronary artery disease, status post coronary artery bypass graft x2, diabetes, end stage renal failure on hemodialysis, severe ischemic cardiomyopathy with one patent vessel and an ejection fraction of 10% who was admitted with shortness of breath and chest pain. The pertinent issues are as follows: 1. CARDIOVASCULAR: The patient ruled out for myocardial infarction with the cycled enzyme of CK and also troponin, all of which are within normal limits. The patient was also initially placed on telemetry but was subsequently discontinued since there were no events recorded. The patient's cardiac medication of Zestril, Imdur and nitroglycerin were held because the blood pressure was in the 80s and the patient was asymptomatic. On hospital day #3, the patient was seen by the congestive heart failure service for evaluation in hopes to provide better treatment plan for his cardiac status. The patient was found to be an ideal candidate for the placement of a ventricular pacemaker and on [**2112-1-25**], the patient was brought to the Operating Room and the pacemaker was successfully placed. The patient's blood pressure has been in the 80s to 90s during the earlier part of the admission and after the cardiac medications were discontinued, the pressure was hovering in the 70s on the day before pacemaker placement. After the pacemaker was placed on [**1-25**], the blood pressure remained low in the 60s and 70s and four boluses of 250 cc normal saline were given to boost up the blood pressure. On the next hospital day, the patient did not tolerate the increase in fluid well and had obtunded and complained of discomfort. A stat echocardiogram was ordered which showed ejection fraction to be less than 10%. However, there was no pleural effusion. At this point, the patient was given dopamine to increase his blood pressure, but was subsequently discontinued after about 10 minutes or so because the patient was complaining of [**6-1**] chest pain with radiation to the left arm. The patient was brought to the coronary cardiac care unit for monitoring of these episodes of hypertension and the patient did well in the unit with no improvement in the blood pressure, but asymptomatic with the patient able to function both physically and mentally. After the patient was returned to the floor, the patient was given cardiac rehabilitation by ambulating with nurse 3x a day. The patient was also given a trial of Midodrine which increased his blood pressure and at the same time caused no symptoms. The EP service and the congestive heart failure service has followed the patient throughout. 2. PULMONARY: The patient has been doing well after the initial complaint of shortness of breath in the Emergency Room. The patient's oxygen saturation has been between 97% and 100% on room air and lung auscultation has been essentially clear without evidence of crackles or wheezing. The patient will be discharged with instructions that if he gets short of breath again, do not exhale into the paper bag like he did before. The patient's symptoms of shortness of breath is most likely contributed by his anxiety of his medical conditions and this can be hopefully alleviated by placing the patient on Celexa. 3. RENAL: The patient has been getting hemodialysis on a Monday, Wednesday, [**Date Range 2974**] schedule and has been doing well with that. It was found that if more fluids were taken out, the patient's blood pressure actually responds better and the patient's subjectively feels better. The amount of fluid that has been taken out during this admission has been between 2 kg to 3 kg. 4. DIABETES: During this admission, the patient was given Glyburide 2.5 mg qd as well as the regular insulin sliding scale. The patient's fingerstick glucose check 4x a day has been fairly stable. 5. GASTROINTESTINAL: The patient with history of gastritis was placed on Reglan and also on Protonix on admission. The patient's Reglan was discontinued because it was suspected that it was one of the causes for hypotension. The patient has been doing well just on Protonix without gastrointestinal complaints. 6. PSYCHIATRY: The patient has been emotionally up and down throughout admission, but more stable towards the end. The patient was very distressed about having to go to dialysis 3x a day and that is essentially his whole life and he really cannot do anything else. After hospital day 10, the patient has been emotionally more stable. The patient has not had any episodes of crying. This is unclear as to whether this is from the effect of Celexa or because the patient has become accustomed to the medical team and has built trust in the care. A psychiatric hospital was obtained initially in the beginning of the admission. The recommendation was that the patient is baseline and could obtain help from SSRI. DISCHARGE CONDITION: Stable DISCHARGE DIAGNOSES: 1. Diabetes 2. End stage renal disease on dialysis 3. Coronary artery disease 4. Gastritis 5. Anemia 6. High cholesterol 7. Status post right cerebrovascular accident 8. Cardiomyopathy 9. Hypertension 10. Anxiety 11. Ischemic cardiomyopathy DISCHARGE MEDICATIONS: 1. Midodrine 10 mg po tid while awake, with the last dose given before 6 p.m. to prevent hypertension 2. Glyburide 2.5 mg 1 tablet po qd 3. Nephrocaps 1 tablet po qd 4. ASA 325 mg qd 5. Pravachol 40 mg qd 6. Protonix 40 mg 1 tablet po qd 7. Tylenol 650 mg 1 tablet po q 4 to 6 hours prn pain/fever 8. Celexa 20 mg 1 tablet po qd FOLLOW UP APPOINTMENTS: The patient is to follow up with: 1. The electrophysiology team which right now, he has an appointment on [**Last Name (LF) 2974**], [**2112-3-21**] at 11 a.m. This is a six week follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] who has already done a follow up 10 days after the placement of the pacemaker. 2. The patient is also to follow up with the congestive heart failure service with Dr. [**Last Name (STitle) **] at the [**Hospital1 **] Hospital Cardiology Department. 3. The patient should also follow up with his primary care doctor. DR.[**Last Name (STitle) 313**],[**First Name3 (LF) 312**] 12-766 Dictated By:[**Doctor Last Name 109918**] MEDQUIST36 D: [**2112-2-3**] 13:33 T: [**2112-2-3**] 13:49 JOB#: [**Job Number 32990**] Admission Date: [**2112-1-19**] Discharge Date: [**2112-2-3**] Date of Birth: [**2050-3-12**] Sex: M Service: MEDICINE ADDENDUM: 1. Attending of record is Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. 2. The patient should also follow up with his outside primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 20670**]. 3. After discharge, the patient was discharged to rehabilitation, [**Hospital **] Rehabilitation, in [**Location (un) 538**], MA. [**First Name11 (Name Pattern1) 312**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 313**], M.D. [**MD Number(1) 314**] Dictated By:[**Doctor Last Name 109918**] MEDQUIST36 D: [**2112-2-4**] 11:06 T: [**2112-2-4**] 11:14 JOB#: [**Job Number **]

[ "403.91", "285.21", "425.4", "414.01", "300.00", "428.0", "458.2", "E937.8", "250.40" ]

icd9cm

[ [ [] ] ]

[ "37.72", "89.64", "37.83", "37.27", "37.26" ]

icd9pcs

[ [ [] ] ]

10453, 10461

3369, 3558

10482, 10733

10756, 11094

5500, 10431

3580, 5036

158, 194

11119, 12762

223, 2450

5053, 5364

2472, 3137

3154, 3352

5382, 5482

73,043

193,749

1175

Discharge summary

report

Admission Date: [**2152-5-26**] Discharge Date: [**2152-6-2**] Date of Birth: [**2070-10-18**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2195**] Chief Complaint: Post-operative Observation s/p Subtotal Parathyroidectomy Major Surgical or Invasive Procedure: Subtotaled parathyroidectomy right thyroid lobectomy. History of Present Illness: This is an 81 year old male with PMH of non-ischemic cardiomyopathy with an EF=25% on his last ECHO [**9-21**], ESRD on HD with related anemia, HTN, h/o of prostate cancer s/p radical prostatectomy in 2/94, and secondary/tertiary hyperparathyroidism who presented for an elective subtotal parathyroidectomy in the setting of remarkably elevated PTH levels documented since [**2138**], failure of medical management due to patient compliance issues, and development of renal osteodystrophy. His peak PTH level was 1498 (normal 15-65) in [**2-23**] and his PTH on admission was 999. He also has renal osteodystrophy with imaging notable for a Rugger-Jersey spine. He has been on HD for the last 14 years through an AV fistula in his left arm. On arrival to the ICU, his initial vitals were T: 95.3, BP: 228/95, P: 104, R: 10, and O2: 100% on 2L NC. The patient was extremely lethargic, but was able to relay that he had a headache and central chest pain. The surgery team transferred the patient for closer monitoring given his multiple medical comorbidities s/p a subtotal parathyroidectomy of his right thyroid lobe with no significant blood loss. He arrived extubated and fatigued with a PIV in place from the OR for IVF administration as well as a femoral A-line for BP monitoring. HE received about 1 Liter of fluid intra/post-op. It was also recommended that he recieve no blood thinners given his recent surgery to a hypervascular area. Review of sytems: Patient endorses headache and chest pain, the remainder of ROS was limited by lethargy and inattentiveness. Past Medical History: 1. ESRD - [**2-15**] prolonged obstructive uropathy in setting of prostate CA - hemodialysis M/W/F - thrombectomy of avg [**12-19**] 2. Secondary/tertiary hyperparathyroidism with renal osteodystrophy noted in [**2-23**] with imaging notable for Rugger-Jersey spine 3. Anemia related to ESRD with baseline HCT in hte mid 30s on Epogen 4. HTN 5. Non-ischemic Cardiomyopathy of unclear etiology-last echo [**9-21**] with EF=25%, global hypokinesis - cardiac catheterization in [**2145**]: minor coronary irregularities 6. NSVT first noted in [**2151**] 7. Prostate CA s/p radical prostatectomy & LN dissection in 2/94 Social History: He grew up in a [**Doctor Last Name **] family and worked in maintenance at the Rat Cellar night club for 22 years. Prior to his last admission in [**Month (only) 958**], he was living in senior housing and getting his meals from the cafeteria there. He was otherwise independent in his ADLs and walking without assistance. After his last discharge he has been staying at [**Hospital **] Healthcare Center. Denied tobacco, alcohol, and recreational drug use in the past. Family History: unknown, grew up in [**Doctor Last Name **] home Physical Exam: POST-OP EXAM: Vitals: T: 95.3, BP: 228/95, P: 104, R: 10, O2: 100% on 2L NC General: Lethargic, oriented to time and person, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, surgical towel wrapped around neck, JVP difficult to assess with bandage in place Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Tachycardic, 2/6 SEM radiating to axilla Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding GU: Foley in place Ext: warm, well perfused, no clubbing and cyanosis, trace-1+ edema bilaterally DISCHARGE EXAM: Pertinent Results: ON ADMISSION: [**2152-5-26**] 02:28PM BLOOD WBC-5.0 RBC-4.10* Hgb-11.3* Hct-36.9* MCV-90 MCH-27.7 MCHC-30.8* RDW-17.1* Plt Ct-172 [**2152-5-26**] 02:28PM BLOOD Glucose-88 UreaN-42* Creat-6.9*# Na-141 K-4.4 Cl-99 HCO3-30 AnGap-16 [**2152-5-26**] 02:28PM BLOOD CK(CPK)-75 CK-MB-2 cTropnT-0.11* [**2152-5-26**] 02:28PM BLOOD Calcium-8.5 Phos-3.2 Mg-1.8 PTH PRE-POST OP [**2152-5-26**] 10:55AM BLOOD PTH-999* [**2152-5-26**] 03:10PM BLOOD PTH-68* POST OPERATIVE CALCIUM TREND [**2152-5-26**] 02:28PM BLOOD Calcium-8.5 [**2152-5-26**] 10:59PM BLOOD Calcium-8.3* [**2152-5-27**] 04:52AM BLOOD Calcium-7.8* Brief Hospital Course: This is an 81 year old male with PMH of non-ischemic cardiomyopathy with an EF=25% on his last ECHO [**9-21**], ESRD on HD with related anemia, HTN, h/o of prostate cancer s/p radical prostatectomy in 2/94, and secondary hyperparathyroidism underwent an elective subtotal parathyroidectomy [**2152-5-26**] (see operative note for details) who was admitted to the ICU post-operatively in the setting of remarkably elevated PTH levels documented since [**2138**], failure of medical management due to patient compliance, and development of renal osteodystrophy admitted to the ICU post-op for closer monitoring given his multiple medical comorbities. # Hypertensive Urgency/Emergency: The patient arrived to the ICU with a BP=228/95 and a HR=104 complaining of headache and chest pain. Metoprolol IV did not appreciably effect BP/HR. Therefore, a labetalol drip was started. EKG obtained which was not significantly changed from baseline. The labetalol drip was ultimately weaned down and stopped once the patient's BP was better controlled. The patient was also noted to be due for HD on the day of admission. He underwent HD while in the ICU, which also helped with his hypertension. On the floor, the patient was still hypertensive, which was poorly controlled with metoprolol 10mg IV Q6H. He was transitioned to PO tartrate then eventually Metoprolol XL 100mg PO daily. Valsartan 20mg PO daily was added, then was increased to 40mg PO daily. His pressures had improved control. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] is to follow his pressures at HD and make adjustments accordingly. Pt to hold antihypertensives until after HD session on HD days and to hold for SBP>120. # Hyperparathyroidism: The patient has had known hyperparathyroidism since [**2138**] secondary to ESRD. He has failed medical management likely due to poor compliance with his meds. He was admitted for an elective subtotal parathyroidectomy and his PTH level was 999 prior to surgery. [**Name (NI) **] PTH was significantly improved. However, pt's post-operative course was characterized by persistently low calcium levels, requiring repeated IV calcium repletion. His post-operative course was also complicated by throat pain with difficulty tolerating PO intake. This resolved on its own. # ESRD on HD: Renal was consulted. HD was performed post-op with increased zemplar dosing and increased calcium bath. The patient's home sensipar was discontinued, and his home renvela was decreased. Was continued on novasource renal supplements with each meal. # Hypocalcemia: Patient, with total calcium nadir of 7.2. Patient's calcium normalized after several days of intensive calcium repletion with calcium carbonate 1000mg PO TID plus calcium gluconate IV. He should have his calcium checked at hemodialysis (he is also scheduled to have calcium baths in his diasylate there) and have his blood calcium levels checked at each dialysis and repleted with calcium gluconate as needed. # Nonischemic cardiomyopathy/NSVT. The patient has an EF=25% on his most recent ECHO [**9-21**]. Volume management per HD, with goal of negative 2L during most sessions. Held aspirin given recent surgery, restarted on POD 5. # Hip Pain - Restart home regimen of acetaminophen and Lidoderm patches if symptomatic, otherwise current dosing of morphine/oxycodone should be sufficient. His hip pain seemed to disappear, seeming to suggest that it may have been bony pain secondary to his tertiary hyperparathyroidism leading to renal osteodystrophy. # GERD. Continue home PPI and H2 blocker. Medications on Admission: -Nephrocaps PO daily -Sensipar 120mg PO daily -Docusate 200mg PO daily -MS Contin 15mg PO q12h -Metoprolol tartrate 50mg PO BID -Renvela 1600mg PO TID with meals -Acetaminophen 650mg PO q6h -Ranitidine 150mg PO HS -Senna 17.2mg PO HS -Nepro renal supplement [**Hospital1 **] -Bisacodyl 10mg PR daily PRN constipation -Fleet's enema PR daily PRN constipation -Miralax 17 grams PO PRN constipation -Zofran ODT 4mg q8h PRN nausea -Mylanta 30cc PO q6h PRN GI upset -Oxycodone 5mg PO q6h PRN breakthrough pain -Prilosec OTC 20mg PO daily -Lidoderm 5% patch topically daily to left hip (12hrs on, 12hrs off) -Aspirin 81mg PO daily Discharge Medications: 1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 4. Ranitidine HCl 15 mg/mL Syrup Sig: One (1) PO HS (at bedtime). 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 6. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. Valsartan 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for Constipation. 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for Constipation. 12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for Pain/fever. 13. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO TID (3 times a day): Please take between meals. 14. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 15. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Primary Diagnosis: Tertiary Hyperparathyroidism Hypertensive urgency Hypocalcemia Tetany Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital for removal of your parathyroid gland and partof your thyroid gland. The surgery went well. After the surgery, you had very high blood pressures that were treated with blood pressure medicines and your pressures improved. You also had low calcium levels which were treated with calcium by mouth and intravenously. You are now ready to go to a rehab center to complete your recovery. It is very important for you to take you calcium pills three times a day and between meals. We have made the following changes to your medications: -Stop taking Renvela -Change metoprolol from 25mg by mouth twice daily to metoprolol XL 100mg by mouth daily -Start taking calcium carbonate (tums) 1000mg by mouth three times daily between meals Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Department: CARDIAC SERVICES When: FRIDAY [**2152-6-23**] at 3:40 PM With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 677**], M.D. [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage You will be seen by a PCP at your rehab facility. After you are discharged, you should follow up with your own PCP. Completed by:[**2152-6-8**]

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icd9cm

[ [ [] ] ]

[ "06.2", "39.95", "06.89" ]

icd9pcs

[ [ [] ] ]

10270, 10340

4505, 8089

373, 429

10473, 10473

3878, 3878

11532, 11984

3179, 3229

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10361, 10361

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1925, 2034

457, 1907

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12,676

121,526

45545

Discharge summary

report

Admission Date: [**2176-9-20**] Discharge Date: [**2176-9-25**] Date of Birth: [**2107-2-5**] Sex: M Service: CARDIOTHOR REASON FOR ADMISSION: This patient is a postoperative admission for coronary artery bypass grafting. HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 3315**] has a history of a non-Q wave myocardial infarction in [**2159**] and [**2160**]. He had a cardiac catheterization revealing left anterior descending and left circumflex disease. There is also 20% left main disease. At that time, he had an angioplasty of the left anterior descending and circumflex with a 30% stenosis residual in both at that time. He reports that he has done well for the past 15 years from a cardiac standpoint. He is status post cervical spine surgery in [**2175-9-25**], which was complicated by postoperative dysphagia. This dysphagia has persisted over the past year resulting in a 30 pound weight loss, weakness and activity intolerance. He denies chest pain but does report that over the past several weeks he has been getting dyspnea on exertion. He had a routine stress test on [**8-29**] of [**2175**]. He was able to exercise for seven minutes on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] protocol. During exercise, there was 1 mm horizontal downsloping with ST depressions and T wave inversion in leads I and V2. In addition, there was 0.5 to 1.0 mm upsloping and ST elevation inferiorly and in the lateral precordial leads. Echocardiogram showed basilar inferior hypokinesis at rest. With exercise there was severe hypokinesis at the distal septum apex and inferior wall. Ejection fraction was estimated at 50%. The patient was referred for cardiac catheterization to evaluate coronary artery disease. The patient underwent a cardiac catheterization which showed significant left main disease of 70% and diffuse three vessel disease with an ejection fraction of 51%. Please see catheterization report for full details. PAST MEDICAL HISTORY: 1. Cervical spine surgery. 2. Peripheral vascular disease. 3. Coronary artery disease. 4. Hypertension. 5. Diabetes mellitus. 6. Left lower extremity vascular surgery. MEDICATIONS PRIOR TO ADMISSION: 1. Aspirin 325 mg q. day. 2. Atenolol 25 q. day. 3. Zestril 40 q. day. 4. Glyburide 10 q. a.m. and 5 q. p.m. 5. Metformin 500 twice a day. 6. Folic acid one three times a day. 7. B6 100 mg q. day. 8. B12 1 mg q. day. 9. Multivitamin one q. day. 10. Vitamin E 400 International Units q. day. 11. Calcium, no amount quantified. ALLERGIES: He is allergic to codeine which causes nausea. LABORATORY: White blood cell count 7.1, hematocrit 31. Sodium 140, potassium 4.7, chloride 105, CO2 26, BUN 37, creatinine 1.0, INR 1.1. SOCIAL HISTORY: Retired, married; lives with his wife. HOSPITAL COURSE: On [**9-20**], the patient was admitted to the Operating Room where he underwent coronary artery bypass grafting. Please see Operating Room report for full details. In summary, the patient had a coronary artery bypass graft times four with a left internal mammary artery to the left anterior descending, saphenous vein graft to the diagonal and to obtuse marginal 3 sequentially and saphenous vein graft to the PDA. He tolerated the operation well and was transferred from the Operating Room to the Cardiothoracic Intensive Care Unit. At the time of transfer, the patient had a mean arterial pressure of 70; he was in sinus rhythm at 76 beats per minute. CVP was 5 and his PAD was 10. He had Levophed at 0.02 mics per kilogram per minute and Propofol at 30 micrograms per kilogram per minute. The patient did well in the immediate postoperative period. During the course of his surgical day, he was weaned from his cardiac active medications, his anesthesia was reversed and he was weaned from the ventilator and successfully extubated on postoperative day two. His Swan-Ganz line, his arterial line and his chest tubes were removed. He was started on beta blockade and diuretics and transferred to the floor for continuing postoperative care. Once on the floor, with the assistance of Physical Therapy and the nursing staff, the patient's activity level was gradually increased. His medications were adjusted and on postoperative day five, it was decided that the patient was stable and ready for discharge to home. The patient's postoperative course was complicated by two issues. 1. Atrial fibrillation for which the patient was treated with Lopressor following which he converted to normal sinus rhythm. 2. Right sided hand numbness: Which was noted following awakening from surgery and persisted throughout postoperative day five. The patient was seen by Neurology and will have follow-up with Neurology in the future. He was also seen by Occupational Therapy and was provided with exercises to increase in strength and functioning of his right hand. At the time of discharge, the patient's physical examination is as follows: Vital signs were temperature 98.1 F.; heart rate 73 and sinus rhythm; blood pressure 127/51; respiratory rate 16; O2 saturation 100% on room air. Weight preoperatively 172 pounds; at discharge 176.5 pounds. Laboratory data was white blood cell count of 7.4, hematocrit 29.9, platelets 146. Sodium 140, potassium 3.8, chloride 100, CO2 27, BUN 29, creatinine 1.0, glucose 116. On physical examination he was alert and oriented times three. He moves all extremities. He continues to complain of right hand numbness; strength in the right hand is four over five; left hand is five over five. Respiratory: Clear to auscultation bilaterally. Cardiovascular: Regular rate and rhythm, S1, S2, no murmurs, rubs or gallops. Sternum was stable. Incision with Steri-Strips, open to air, clean and dry. Abdomen soft, nontender, nondistended, with normoactive bowel sounds. Extremities are warm and well perfused with no cyanosis, clubbing or edema. Right leg saphenous vein graft incision site with Steri-Strips open to air, clean and dry. DISCHARGE MEDICATIONS: 1. Metoprolol 75 mg twice a day. 2. Lasix 20 mg q. day times ten days. 3. Potassium chloride 20 mEq q. day times ten days. 4. Aspirin 325 mg q. day. 5. Glyburide 10 mg q. a.m. and 5 mg q. p.m. 6. Metformin 500 mg twice a day. 7. Percocet 5/325 one to two tablets p.o. q. four hours p.r.n. DISPOSITION: The patient is to be discharged to home. DISCHARGE INSTRUCTIONS: 1. To follow-up in the [**Hospital 409**] Clinic in two weeks. 2. Follow-up with Dr. [**Last Name (STitle) 1537**] in four weeks. 3. Follow-up with his primary care provider in three to four weeks. 4. Follow-up with Neurology as prescribed by the Neurology Service. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Name8 (MD) 415**] MEDQUIST36 D: [**2176-9-25**] 13:49 T: [**2176-9-25**] 15:27 JOB#: [**Job Number 97150**]

[ "V15.82", "787.2", "997.1", "V45.82", "250.00", "414.01", "401.9", "782.0", "427.31" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

6050, 6404

2831, 6027

6428, 6964

2220, 2756

273, 1991

2013, 2188

2773, 2813

70,150

156,140

54

Discharge summary

report

Admission Date: [**2191-5-9**] Discharge Date: [**2191-5-14**] Date of Birth: [**2108-6-9**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 603**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: 82 year old male with HTN, chronic CHF, and COPD BIBA after developing SOB. Pt has noted increasing SOB on exertion over the past week. Has also noted occasional episodes of diarrhea and rare short bouts of chest pain. Increasing DOE on exertion yesterday. Today walked to his car and was so short of breath he leaned on the [**Doctor Last Name 534**] to attract attention for help. A neighbor came and found him and called an ambulance. . Of note pt was also admitted [**2190-1-30**] for SOB, c/w CHF exacerbation, responded to lasix. . When EMS arrived they noted his BP to be 200/100. . In the ED inital vitals were HR: 100 BP: 134/109 Resp: 34 O(2)Sat: 92 (CPAP)low. Labs showed CBC 8.2>35.0<202 (bl hct around 36). 7.8% eos 56% pmns. chem panel 141/4.6;103/23;21/1.3<243. lactate 5.4 --> 1.6. trop <0.01. BNP 4453 (down from >10K). UA positive for lg blood, 100 pro, TR glu, RBC>182 WBC 133, few bact. pt was immediately placed on BiPAP. In the emergency department he was given BiPAP and nitroglycerin drip in addition to 40 of Lasix IV. Pt was admitted to the [**Hospital Unit Name 153**] for respiratory distress. . On arrival to the ICU, pt sates he feels improved but remains wheezy on exam. Is able to speak in full sentences comfortably and satting high 90s. Is talking to his wife on the phone. Children at bedside. Past Medical History: # CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension # Diastolic CHF -- Echo in [**2180**] with EF 60% # Mitral regurgitation # Chronic LE edema -- worse in the summer and after walking # DOE -- Stress test [**10/2179**] with mild inferior wall fixed defect, mild LVH; repeat stress echo [**1-30**] no ischemic changes, mild MR #[**Medical Record Number **]Carotid ultrasound [**2183**] -- less than 40% occlusion # Hyperlipidemia # COPD -- on inhalers # Prostate cancer (presumptive diagnosis) -- refused Urology workup for elevated PSA ([**2189-9-16**]: PSA 30.9) # Primary hyperparathyroidism -- s/p resection in [**10/2179**] for right superior adenoma -- parathyroid tissue implanted into left forarm -- hypocalcemia on Ca and Vit D supplementation # Depression # Anxiety -- Sertraline and tapering Lorazepam # Anemia -- declines colonoscopy # Gout # Obesity # H/o MVC [**2188**] Social History: # Home: Lives at home with wife, married in [**2127**]. # Work: Retired punch press operator, lost distal left index finger in work accident many year ago. # Exercise: Works around house and yard # Tobacco: Smokes cigars [**1-31**]/day. # Alcohol: No alcohol for 8 months. Previously drank brandy [**3-4**]/day. # Drugs: None Family History: No known family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. # Mother -- died at age 68, patient unsure of cause # Father -- died at age 75, patient unsure of cause # Siblings -- One sibling deceased of unknown type cancer. Physical Exam: Vitals: T:97.9 BP:132/85 P:91 R: 18 O2: 99% 2L NC General: Alert, oriented, can speak in full sentences although externally audible wheezing on expiration. Obese male. HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD but thick neck Lungs: Diffuse wheezing throughout all lung fields 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 with blood tinged sero-sanguinous colored fluid Ext: cold lower extremities but palpable pedal pulses, no clubbing, cyanosis or edema neuro: 5/5 strength throughout Pertinent Results: ADMISSION LABS: [**2191-5-9**] 01:45PM BLOOD WBC-8.2 RBC-3.80* Hgb-10.8* Hct-35.0* MCV-92 MCH-28.5 MCHC-31.0 RDW-14.0 Plt Ct-231 [**2191-5-9**] 01:45PM BLOOD Neuts-56.5 Lymphs-32.0 Monos-3.3 Eos-7.8* Baso-0.5 [**2191-5-9**] 01:45PM BLOOD PT-11.8 PTT-23.0* INR(PT)-1.1 [**2191-5-9**] 01:45PM BLOOD Glucose-243* UreaN-21* Creat-1.3* Na-141 K-4.6 Cl-103 HCO3-23 AnGap-20 . CARDIAC ENZYMES: [**2191-5-9**] 01:45PM BLOOD CK-MB-3 proBNP-4453* [**2191-5-9**] 01:45PM BLOOD cTropnT-<0.01 [**2191-5-9**] 08:47PM BLOOD CK-MB-3 cTropnT-<0.01 [**2191-5-9**] 01:45PM BLOOD CK(CPK)-224 . OTHER PERTINENT LABS OF HOSPITAL COURSE: [**2191-5-9**] 01:45PM BLOOD Albumin-4.1 [**2191-5-9**] 02:01PM BLOOD Lactate-5.4* [**2191-5-9**] 03:41PM BLOOD Lactate-1.6 [**2191-5-9**] 08:58PM BLOOD freeCa-1.10* . URINE STUDIES: [**2191-5-9**] 03:26PM URINE Blood-LG Nitrite-NEG Protein-100 Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR [**2191-5-9**] 03:26PM URINE RBC->182* WBC-133* Bacteri-FEW Yeast-NONE Epi-0 . Urine culture [**2191-5-9**]: NO GROWTH. Blood cultures [**2191-5-9**]: no growth. . EKG [**2191-5-9**]: Atrial fibrillation with rapid ventricular response. compared to the previous tracing of [**2190-2-5**] atrial fibrillation is now recorded. Otherwise, no diagnostic interim change. . CXR (portable AP) [**2191-5-10**]: Findings compatible with mild congestive heart failure. Recommend followup after treatment to evaluate for underlying infection. . CXR (portable AP) [**2191-5-10**]: There is mild increase of mild pulmonary edema. Mild cardiomegaly is stable. There are persistent low lung volumes. There is no pneumothorax. There is mild increase in left lower atelectasis. . TTE [**2191-5-10**]: The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. The mitral valve leaflets are elongated. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild symmetric LVH with normal global and regional biventricular systolic function. Moderate aortic regurgitation. At least mild mitral regurgitation. Moderate pulmonary hypertension. Compared with the prior study (images reviewed) of [**2190-2-5**], the findings are similar. Brief Hospital Course: 82 y/o M history of HTN found with respiratory distress requiring bipap, hypertension, and newly noted to be in new atrial fibrillation. . #Respiratory distress/SOB: The patient's shortness of breath was felt to be due to a combination of heart failure and COPD exacerbation, discussed separately below. There was also concern for possible pneumonia on initial CXR, but the patient remained afebrile, and follow-up CXR showed no infiltrate. At the time of discharge, the patient was able to maintain good oxygenation saturations with ambulation on room air. . #Acute on chronic diastolic heart failure: The patient presented with shortness of breath. Cardiac enzymes were negative. He was initially treated with lasix, bipap, and nitro gtt, although he did not appear grossly volume overloaded. As his respiratory status improved, he was transitioned to oral furosemide. TTE showed preserved systolic function, and was unchanged from prior study. . #COPD exacerbation: The patient presented with shortness of breath and diffuse wheezing in the setting of a smoking history. He was noted to have symbicort on his medication list but was not taking this currently. He was given azithromycin x 5 days, nebulizers, and was started on a prednisone taper. The plan for the remainder of the taper is as follows: 20 mg daily [**Date range (1) 604**], 10 mg daily [**Date range (1) 605**], 5 mg daily [**Date range (1) 606**]. Symbicort and Spiriva were started. The patient was urged to stop smoking. . #Atrial fibrillation, with rapid ventricular response: The patient was found to be in atrial fibrillation, which is a new diagnosis for him. He had rapid ventricular response, treated with metoprolol, with improvement in heart rate. Metoprolol was uptitrated to 300 mg daily. The patient's CHADS score is 3. Anticoagulation was recommended to the patient and his family, and the patient elected to defer this decision for now and discuss with his primary care doctor. . #Hypertension: The patient was noted to have BP of 200/100 by EMS. It is unclear if his marked hypertension was a cause of his shortness of breath (flash pulmonary edema), or a consequence of his respiratory distress. The patient's blood pressure rapidly improved. The patient's home amlodipine, hydralazine, and isosorbide monotitrate were continued. Furosemide was initially given IV, then convered back the patient's home dose. Metoprolol was increased to metoprolol succinate 300 mg dialy in the setting of Afib with rapid vemtricular response. Clonidine was changed to twice daily dosing (0.1 mg [**Hospital1 **]). . #Elevated lactate: The patient had lactate 5.4 on presentation. This rapidly downtrended to 1.6. There was no evidence of hypoperfusion. The elevated lactate may have been related to increased work of breathing in the setting of respiratory distress, although the rapidity of the resolution (normalizing in <2 hours) also raises the possibility that the initial lactate was a spurious laboratory value. . #Eosinophilia: Patient with 7.8% eosinophils out of WBC 8.2. On review of past laboratory date, it is apparent that this is a chronic process. . #Chronic kidney disease, stage II: Creatinine was 1.3 on admission, which is the patient's baseline. Creatinine increased slightly to 1.6 with diuresis and subsequently remained stable at 1.5-1.6. . #Transitional issue: The patient will complete his prednisone taper and follow up in primary care and pulmonology for further management of his dyspnea. Visiting nursing was arranged to assist the patient with medications. Medications on Admission: with the exception of symbicort which he may or maynot be taking albuterol sulfate 2.5 mg/3 mL (0.083 %) Solution for Nebulization 3 ml(s) inhaled every four (4) hours [**2190-7-7**] albuterol sulfate [Ventolin HFA] 90 mcg HFA Aerosol Inhaler 1-2 puffs inhaled four times a day as needed for cough, congestion, shortness of breath or wheezing [**2190-7-7**] amlodipine 10 mg Tablet 1 Tablet(s) by mouth once a day [**2191-5-3**] budesonide-formoterol [Symbicort] 160 mcg-4.5 mcg/Actuation HFA Aerosol Inhaler 2 puffs inhaled twice a day [**2190-7-7**] calcitriol 0.25 mcg Capsule 1 Capsule(s) by mouth twice a day [**2191-5-3**] clonidine 0.3 mg Tablet 1 Tablet(s) by mouth once a day furosemide 20 mg Tablet 1 Tablet(s) by mouth twice a day [**2191-5-3**] hydralazine 50 mg Tablet 1 Tablet(s) by mouth three times a day [**2191-3-30**] ibuprofen 600 mg Tablet 1 Tablet(s) by mouth three times a day as needed for pain [**2190-4-20**] isosorbide mononitrate 30 mg Tablet Extended Release 24 hr metoprolol tartrate 50 mg Tablet 1 (One) Tablet(s) by mouth twice a day Take 1 tab po qam and 1 tab po at 11:00am [**2191-5-3**] sertraline 50 mg Tablet 1.5 Tablet(s) by mouth once a day [**2191-5-3**] simvastatin 20 mg Tablet 1 Tablet(s) by mouth DAILY (Daily) [**2191-3-30**] * OTCs * aspirin 81 mg Tablet, Delayed Release (E.C.) 1 Tablet(s) by mouth once a day [**2190-10-28**] nr calcium carbonate [Tums] dosage uncertain Discharge Medications: 1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation every four (4) hours as needed for shortness of breath or wheezing. Disp:*1 vial* Refills:*2* 2. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. 3. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 4. budesonide-formoterol 160-4.5 mcg/actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation twice a day. Disp:*1 inhaler* Refills:*2* 5. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO twice a day. 6. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 9. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 10. simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 12. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: Three (3) Tablet Extended Release 24 hr PO once a day. Disp:*90 Tablet Extended Release 24 hr(s)* Refills:*2* 13. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) inhalation Inhalation once a day. Disp:*1 device* Refills:*2* 14. metoprolol tartrate 100 mg Tablet Sig: One (1) Tablet PO once: Take evening of [**2191-5-14**]. 15. prednisone 10 mg Tablet Sig: as directed Tablet PO as directed: Take 2 tablets daily for 3 days, then 1 tablet daily for 3 days, then half tablet daily for 3 days. Disp:*11 Tablet(s)* Refills:*0* 16. sertraline 25 mg Tablet Sig: Three (3) Tablet PO once a day. 17. calcium carbonate Oral Discharge Disposition: Home With Service Facility: Art of Care VNA Discharge Diagnosis: Primary: 1. COPD exacerbation 2. Acute on chronic diastolic heart failure 3. Atrial fibrillation, new onset, with rapid ventricular response 4. Shortness of breath . Secondary: 1. Hypertension 2. Chronic kidney disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You came to the hospital with difficulty breathing. You were initially admitted to the intensive care unit. You were treated with steroids and inhalers, with improvement in your breathing. You were also treated with diuretics for heart failure. . You were found to have an irregular heart rhythm called atrial fibrillation. You had some rapid heart rates. Due to this, your metoprolol was increased, with some improvement in your heart rate. . Atrial fibrillation places you at an increased risk for stroke. You can decrease this risk by taking blood thinning medications. We discussed the risks and benefits of blood thinning medications, and you decided that you wanted to defer this decision for now and speak with your primary care doctor. . We have arranged follow-up with your primary care doctor and with a lung doctor (pulmonologist). See below for details. . You need to stop smoking. It is making your lung disease worse. . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. . There are some changes to your medications: 1. CHANGE clonidine to 0.1 mg twice daily. 2. START metoprolol succinate 300 mg daily. This is a more long-acting form of metoprolol that you will take daily instead of metoprolol tartrate (short-acting form). You will start metoprolol succinate tomorrow morning [**2191-5-15**]. For tonight [**2191-5-14**], you will take one metoprolol tartrate 100 mg pill (given to you by the hospital to take home). 3. STOP ibuprofen as this can cause kidney problems in patients with high blood pressure. 4. START Symbicort (budesonide-formoterol) inhaler. 5. START Spiriva (tiotropium) inhaler 6. START prednisone taper, as follows: 20 mg (2 tablets) daily [**Date range (1) 604**] 10 mg (1 tablet) daily [**Date range (1) 605**] 5 mg (half tablet) daily [**Date range (1) 606**] Followup Instructions: Department: BIDHC [**Location (un) **] When: THURSDAY [**2191-5-19**] at 10:45 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 607**], MD [**Telephone/Fax (1) 608**] Building: 545A Centre St. ([**Location (un) 538**], MA) None Campus: OFF CAMPUS Best Parking: Department: PULMONARY FUNCTION LAB When: THURSDAY [**2191-5-19**] at 2:40 PM With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: MEDICAL SPECIALTIES When: THURSDAY [**2191-5-19**] at 3:00 PM With: [**Name6 (MD) 610**] [**Name8 (MD) **] RN/DR. [**Last Name (STitle) 611**] [**Telephone/Fax (1) 612**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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Discharge summary

report+report

Admission Date: [**2112-10-30**] Discharge Date: [**2112-11-24**] Date of Birth: [**2049-7-1**] Sex: M Service: NEUROSURGERY Allergies: Dilantin Attending:[**First Name3 (LF) 78**] Chief Complaint: SAH Major Surgical or Invasive Procedure: [**2112-10-31**] external ventricular drain placement [**2112-10-31**] diagnostic cerebral angiogram with coiling of acomm aneurysm [**2112-11-3**] IVC filter for lower extremity DVT [**2112-11-4**] Diagnostic Cerebral Angiogram [**2112-11-7**] Diagnostic Cerebral Angiogram with intra-arterial Verapamil [**2112-11-11**] ventriculo peritoneal shunt palcement [**2112-11-19**] Trach/PEG History of Present Illness: This is a 63 year old man with a history of well controlled HTN who had the sudden onset of the worst headache of his life on [**2112-10-30**] between 11am and 1pm today. He was working on his pool but this type of yard work is not abnormal for him. He exercises 5 times a week in a gym. He had neck pain as well. LOC is unclear. [**Name2 (NI) **] drove to [**Hospital **] hospital but felt awkward driving. He has nausea and emesis. He denies vision loss, motor or sensory deficit. He has a h/o SDH but no aneurysm history. He was loaded with fosphenytoin at [**Hospital1 **]. Past Medical History: HTN Hypercholesterol Foot surgery acute on chronic sdh evacuation in [**2107**] Social History: [**11-28**] ETOH per day, no tobacco, unemployed Family History: no h/o aneurysm Physical Exam: On Admission: Gen: WD/WN, comfortable, NAD. HEENT: Pupils: 25.-2mm EOMsintact Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 2.5 to 2.0 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 full power [**3-30**] throughout. No pronator drift Sensation: Intact to light touch Toes downgoing bilaterally Coordination: normal on finger-nose-finger. Impaired short term memory ***************ON DISCHARGE*************** Pt is awake and alert. He makes eye contact. [**Name (NI) **] is oriented x 3 with very minimal prompting. His speech is clear. His naming is intact. PERRL 4-2 mm bilaterally, no facial droop, tongue is midline, he MAE's and is antigravity x 4 but is generally deconditioned. His incision to his scalp and abdomen are well healed. Pertinent Results: [**2112-10-30**] CTA Head: IMPRESSION: 1. Irregular triangular-shaped ACOM aneurysm measuring 5 mm at its dome with a narrow neck, likely the source of the subarachnoid hemorrhage. Small amount of intraventricular hemorrhage layering in the occipital horns, likely from redistribution. 2. Multifocal areas of intracranial arterial narrowing including the left ACA A1 segment, both MCAs, the right posterior communicating artery, and the right PCA. 3. Enlarged ventricles relative to the [**2107**] baseline, though stable from the recent prior study, compatible with communicating hydrocephalus. This was subsequently decompressed with an EVD. [**2112-10-31**]: CT Head: Similar distribution of the known subarachnoid hemorrhage, but with evidence of interval increase of intraventricular hemorrhagic extension and ventricular dilatation. [**2112-11-1**]: CTA Head: Stable, resolving SAH; Improving Hydrocephalus, EVD within ventricle, no evidence of spasm. [**2112-11-3**]: CT Head: Stable. [**2112-11-3**]: CT Torso: 1. Conventional anatomy of the IVC and renal veins. 2. Known right common femoral DVT with surrounding fat stranding at the right groin. 3. Likely additional thrombosis in the right common and external iliac vein, evaluation is limited due to poor venous contrast opacification. 4. Pancreatic head and pancreatic tail hypoattenuating lesions likely represent IPMTs. 5. Right kidney lower pole enhancing lesion. MRI is recommended for further workup. [**2112-11-3**]: BLE LENIS: Deep venous thrombosis of the right common femoral, deep femoral, proximal and middle superficial femoral veins. [**2112-11-4**]: EEG R temporal slowing which can be consistent with vasospasm. No epileptiform activity. [**2112-11-4**] Cerebral Angiogram: Negative for vasopasm [**2112-11-7**]: Cerebral Angiogram: Mild vasospasm; Intraarterial Verapamil administered [**2112-11-11**] CT HEAD IMPRESSION: 1. Stable appearance of intracranial hemorrhage and ventriculostomy, with gliosis along the catheter tract. 2. Unchanged degree of intracranial hemorrhage. CHEST (PORTABLE AP) Study Date of [**2112-11-12**] 4:20 AM IMPRESSION: No definite change. EEG Study Date of [**2112-11-13**]: No seizures noted CHEST (PORTABLE AP) Study Date of [**2112-11-14**] 3:54 AM IMPRESSION: Overall no significant change except improvement in right basilar atelectasis. CT HEAD W/O CONTRAST Study Date of [**2112-11-14**] 7:43 AM IMPRESSION: 1. Stable ventriculomegaly. 2. Slight decrease in residual hyperdense subarachnoid and intraventricular blood. Chest Xray [**2112-11-15**]: FINDINGS: As compared to the previous radiograph, the patient has been re-intubated. The tip of the endotracheal tube projects 4.2 cm above the carina. There is no evidence of complications. Newly appeared right basal atelectasis of moderate severity. No other lung parenchymal opacities. Unchanged size of the cardiac silhouette. No pulmonary edema. No complications Head CT [**11-17**]: IMPRESSION: 1. No CT evidence for new infarct or hemorrhage. 2. Stable ventricular size with VP shunt catheter in similar position. 3. Slightly decreased hyperdense blood layering within the occipital horns bilaterally and slightly decreased density of the focus of subarachnoid hemorrhage near the vertex. Radiology Report CHEST (PORTABLE AP) Study Date of [**2112-11-18**] 12:42 PM FINDINGS: As compared to the previous radiograph, the patient is still intubated. The left and right central venous access lines are unchanged. The pre-existing opacity at the right lung base is slightly less severe than on the previous examination, no parenchymal opacities have newly occurred. Unchanged moderate cardiomegaly and calcified mediastinal and left hilar lymph nodes. BILAT LOWER EXT VEINS PORT Study Date of [**2112-11-20**] 10:31 AM IMPRESSION: 1. DVT extending from the right superficial femoral (occlusive), to the popliteal (non-occlusive), and posterior tibial veins (occlusive). The right peroneal veins were not visualized, so an underlying clot in this region cannot be excluded. 2. The right common femoral vein is patent 3. No DVT within the left lower extremity. The study and the report were reviewed by the staff radiologist. COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2112-11-23**] 06:20 7.1 2.75* 8.8* 26.0* 94 31.8 33.8 14.0 212 DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas Myelos [**2112-11-14**] 03:56 75* 2 8* 7 5* 0 0 2* 1* Source: Line-aline RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy Polychr Envelop [**2112-11-14**] 03:56 NORMAL 1+ OCCASIONAL 1+ NORMAL OCCASIONAL OCCASIONAL Source: Line-aline BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct INR(PT) [**2112-11-23**] 06:20 212 [**2112-11-23**] 06:20 13.2 27.0 1.1 LAB USE ONLY [**2112-11-23**] 06:20 RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2112-11-23**] 06:20 108*1 27* 0.8 141 3.6 107 30 8 [**2112-11-22**] 02:10 111*1 28* 0.8 143 3.9 111* 29 7* Source: Line-CVL [**2112-11-21**] 14:44 109*1 27* 0.8 144 3.8 110* 26 12 [**2112-11-21**] 02:10 1001 25* 0.9 144 3.3 109* 28 10 [**2112-11-20**] 03:47 971 38* 1.0 144 4.0 111* 26 11 [**2112-11-19**] 02:13 951 49* 1.1 138 4.0 106 26 10 Source: Line-central [**2112-11-18**] 04:08 112*1 51* 1.3* 140 4.1 108 26 10 ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili [**2112-11-18**] 04:08 136* 76* 561* 0.5 Source: Line- CVL OTHER ENZYMES & BILIRUBINS Lipase [**2112-11-5**] 01:53 132* ADDON @ 929 CPK ISOENZYMES cTropnT [**2112-10-30**] 13:49 <0.011 LIGHT GREEN <0.01 CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2112-11-23**] 06:20 8.9 3.2 1.9 HEMATOLOGIC VitB12 Folate [**2112-11-8**] 00:17 968* 14.0 Source: Line-a-line PITUITARY TSH [**2112-11-8**] 00:17 5.1* Source: Line-a-line ANTIBIOTICS Vanco [**2112-11-22**] 06:03 11.7 Source: Line-CVL; Vancomycin @ Trough NEUROPSYCHIATRIC Phenyto [**2112-11-6**] 01:46 10.6 Brief Hospital Course: 63yo Male admitted to the ICU with SAH from ruptured Anterior communicating artery aneurysm for Q1 hour neurochecks, systolic blood pressure control and aggressive fluid management. He was loaded with Dilantin and started on dilantin 100mg TID. On [**2112-10-30**] after the initial dilantin load the patient had a focal motor seizure. He was given 1mg of ativan and a second dilantin load with resolution of seizure activity. The patient had persistent lethargy after 2 hours and STAT head CT demonstrated interval increase in ventricular size. Subsequently the patient was intubated for airway protection and underwent placement of right frontal external ventricular drain for hydrocephalus. EVD was leveled at 20cm above the tragus but it was dropped to 15cm as it did not drain. On [**2112-10-31**] the patient underwent diagnostic cerebral angiogram with coil embolization of anterior communicating artery aneurysm under general anesthesia. The patient tolerated the procedure well. There were no complications, the patient was transfered to the ICU and extubated early the next morning. Postangiogram the patient remained with stable neurological exam. [**2112-11-3**] patient had persistant fevers. Dopplers of the lower extremities revealed right lower extremity DVT for which he had an IVC filter placed as he was not a candidate for anticoagulation due to SAH and EVD. On [**11-4**] his EEG showed R temporal slowing which could be consistent with vasospasm; and on exam the patient was noted to be weaker on the LUE. He underwent a repeat cerebral angiogram on [**11-4**] which showed no evidence of vasospasm. EVD stopped draining on [**11-5**] and again on [**11-7**]. Both times the drain was flushed with tPA with return of function and waveform. On [**11-4**] and [**11-7**], pt experienced right UE shaking/tremors and Neurology was consulted for recommendations on antiseizure medications in the setting of possible seizures with a therapeutic dilantin level. EEG however showed no seizure activity. At neurology's recommendation he was transitioned to Keppra for seizure prophylaxis. Upper extremity tremors could potentially be attributed to alcohol withdrawal. CSF was sent for culture on [**11-7**] for fever to 103. Central line was exchanged on [**11-7**] for persistent fevers. Pt underwent Cerebral angiogram on [**2112-11-8**] for worsening mental status and left leg weakness. Angiogram showed only mild vasospasm and intra-arterial verapamil was injected to bilateral ICAs and the left vertebral artery. [**11-11**] Patient was taken to the OR for internalization of his EVD, via placement of a VPS. Patient remained intubated postoperatively because of increased secreations. He continued to improve and he was extubated on [**2112-11-14**]. He received one unit of packed cells for a HCT of 24. On [**11-15**] he was started on Zosyn and Vancomycin for suspected aspiration pneumonia noted on his CXR. [**11-15**] eve his exam worsened, he exhibited increased respiratory effort and he was intubated and underwent a bronch. A BAL was sent, his Tmax was 104.7 and he was placed back on the cooling blanket. On [**11-16**] his WBC spiked up to 17.2 from 9.9 the day prior. On [**2114-11-18**] he remained neurologically stable but much poorer then previous exams. He was again febrile overnight. General Surgery was consulted for trach and peg placement which was placed on [**2112-11-19**]. His exam remained stable post- Trach/PEG. He had dopplers of the lower extremities on the 26th for enlarged RLE c/w LLE. He continued on the vent and was eventually weaned off of the vent onto trach mask on [**11-21**]. He maintained on the trach mask and was transferred to the SDU on [**11-22**]. On [**11-23**] his exam was remarkable and a Speech evaluation was ordered for PMV placement. PMV was initiated on [**11-23**]. It was noted that his LFT's had trended up from the 11th to the 24th. This will require follow up. Medications on Admission: simvastatin 80QD, Amlodipine 5QD, allopurinol 300QD, Lisinopril 10QD, ASA 81QD Discharge Medications: 1. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/ha. 4. erythromycin 5 mg/gram (0.5 %) Ointment Sig: One (1) Ophthalmic QID (4 times a day). 5. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for BM. 6. ibuprofen 100 mg/5 mL Suspension Sig: [**9-14**] ml PO Q8H (every 8 hours) as needed for fever. 7. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 8. Pantoprazole 40 mg IV Q24H 9. HYDROmorphone (Dilaudid) 0.5 mg IV Q4H:PRN pain 10. Ondansetron 4 mg IV Q8H:PRN nausea 11. levetiracetam 500 mg/5 mL Solution Sig: 1000 (1000) mg Intravenous [**Hospital1 **] (2 times a day). 12. Piperacillin-Tazobactam 4.5 g IV Q8H 13. Vancomycin 750 mg IV Q 12H 14. HydrALAzine 10 mg IV Q6H:PRN SBP>160 15. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: Seizure SAH Anterior communicating artery aneurysm rupture Obstructive hydrocephalus DVT Fever Mild cerebral artery vasospasm Drug reaction : dilantin / rash Anemia requiring transfusion 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: 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, or Ibuprofen etc. ?????? You have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. Followup Instructions: Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in four weeks with an MRI/ MRA of the brain Please call [**Telephone/Fax (1) 4296**] to make this appointment. Completed by:[**2112-11-24**] Admission Date: [**2112-11-28**] Discharge Date: [**2112-12-2**] Date of Birth: [**2049-7-1**] Sex: M Service: MEDICINE Allergies: Dilantin Attending:[**First Name3 (LF) 3705**] Chief Complaint: HTN after neurosurgical procedure, agitation Major Surgical or Invasive Procedure: None History of Present Illness: Of note, Mr. [**Known lastname **] is alert and oriented times person only and thus is a poor historian. History obtained from records. Mr. [**Known lastname **] is a 63-year-old gentleman recently admitted from [**2112-10-30**] to [**2112-11-24**] to the neurosurgical service due to rupture of an anterior communicating artery aneurysm requiring coiling, complicated by hydrocephalus, seizures, and aspiration PNA, now with trach collar and PEG. On [**2112-11-24**], he had been transferred to [**Hospital6 **] and presented to [**Hospital1 18**] from there overnight due to headache, agitation, and hypertension. . Patient was discharged from neurosurgical service on [**11-24**] to an extended care facility. According to notes from facility, patient was progressively HTN with BPs in the 170s/100s and complained of persistent headache. He was given dilaudid for headache and hydralazine for HTN. Transfer to [**Hospital1 18**] apparently for concern for acute pathology in context of recent neurosurgical intervention. . Upon arrival to ED, initial vitals were: 97.8 64 150/92 22 100% 15L trach mask. Patient was found to be agitated, A&O x1. He was given zyprexa 2.5mg and hyralazine 10mg IV x1 for an elevated blood pressure. Per report, CT head was unchanged from post-VP shunt images. Neurosurgery was consulted, who felt that patient's issues did not necessitate neurosurgical intervention. Thus, patient was was admitted to medicine for delirium/agitation work-up. Upon transfer, vitals were: 159/84, 65, 18, 96% on RA. Past Medical History: [**2112-10-31**]: SAH from ACOMM rupture complicated by hydrocephalus, seizure [**2112-11-3**] IVC filter for lower extremity DVT [**2112-11-11**] ventriculo peritoneal shunt palcement [**2112-11-19**] Trach/PEG Aspiration PNA treated with vanc/zosyn HTN Hypercholesterol Foot surgery Acute on chronic SDH evacuation in [**2107**] Social History: [**11-27**] ETOH per day, no tobacco, unemployed Family History: no h/o aneurysm Physical Exam: O: T: 97.5, BP: 185/108 HR:88 RR 22 O2Sats 94% RA General: deconditioned, comfortable, NAD. HEENT: VP shunt site c/d/i. MM are dry. Pupils: PERRLA EOMs full Neck: Supple, no meningismus, trach collar is c/d/i with minimal secretions Cardiovascular: RRR, Soft midsystolic murmur at the RUSB, non-radiating. Abd: Nondistended, Soft, NTTP, normoactive bowel sounds, subumbilical shunt c/d/i, no erythema or masses. Neuro: Mental status: Alert and oriented times one, to person only. His speech is altered due to his trach collar, which does not have passe muir valve. CN: EOMI, PERRL, facial sensation is in tact, Motor: decreased bulk bilaterally. No abnormal movements, tremors. No pronator drift. Grips are full strength. Lower Extremities are antigravity and symmetric. Cooperative, follows commands. Hand grip is [**3-30**] bilaterally. He is able to lift both feet of the bed bilaterally when flexing at the hip. He is moving all of his extremities. He was sleeping, but awakened easily when I called his name. Unable to assess coordination, gait because he was uncooperative. Babinski is negative bilaterally. Pertinent Results: Admission: [**2112-11-28**] 12:10AM GLUCOSE-86 UREA N-25* CREAT-0.8 SODIUM-141 POTASSIUM-3.9 CHLORIDE-107 TOTAL CO2-31 ANION GAP-7* [**2112-11-28**] 12:10AM ALT(SGPT)-45* AST(SGOT)-30 ALK PHOS-285* TOT BILI-0.4 [**2112-11-28**] 12:10AM LIPASE-88* [**2112-11-28**] 12:10AM VIT B12-1423* FOLATE-16.0 [**2112-11-28**] 12:10AM TSH-5.4* [**2112-11-28**] 12:10AM WBC-7.2 RBC-2.72* HGB-8.8* HCT-25.6* MCV-94 MCH-32.2* MCHC-34.2 RDW-15.1 [**2112-11-28**] 12:10AM NEUTS-65.0 LYMPHS-25.1 MONOS-5.9 EOS-3.1 BASOS-1.0 [**2112-11-28**] 12:10AM PLT COUNT-228 [**2112-11-28**] 12:10AM PT-12.8 PTT-37.8* INR(PT)-1.1 [**2112-11-28**] 12:10AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.011 [**2112-11-28**] 12:10AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2112-11-28**] 12:10AM URINE RBC-0 WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-<1 . Discharge: [**2112-12-1**] 08:03AM BLOOD WBC-5.7 RBC-2.94* Hgb-9.4* Hct-28.4* MCV-97 MCH-32.1* MCHC-33.3 RDW-15.7* Plt Ct-228 [**2112-12-1**] 08:03AM BLOOD Glucose-103* UreaN-28* Creat-1.0 Na-146* K-3.8 Cl-107 HCO3-34* AnGap-9 . Imaging: MRA Head [**2112-12-1**]: . CT head no contrast [**2112-11-28**]: FINDINGS: Previously seen subarachnoid hemorrhage at the vertex and intraventricular hemorrhage in the occipital horns has resolved. A right frontal approach intraventricular shunt catheter is seen, ending in unchanged position at the right foramen of [**Last Name (un) 2044**]. The ventricles are only minimally dilated and unchanged from [**2112-11-17**]. No large acute territorial infarction. The [**Doctor Last Name 352**]-white matter differentiation is well preserved. There is a hypoattenuating lesion at the right globus pallidus, likely lacunar infarct. The paranasal sinuses are clear and well aerated. Mild opacification of the right mastoid air cells. Left mastoid air cells are clear. No fracture. IMPRESSION: Resolved intracranial hemorrhage. . CXR PA Lat [**2112-11-28**]: FINDINGS: Re-demonstrated are calcified mediastinal and hilar lymph nodes, stable since [**2107**] as well as a left mid lung zone granuloma. There are right lower lobe opacities, new compared to [**2107**] and [**2112-11-18**], representing atelectasis or pneumonia. Large aortic arch and descending aorta, unchanged. No large pleural effusion and no pneumothorax. A left subclavian line ends at the mid SVC. Tracheostomy tube ends 4.3 cm above the carina. A ventriculoperitoneal shunt and G tube are seen. IMPRESSION: Slightly worsened right lower lobe opacities might likely represents pneumonia, much less likely atelectasis. . CXR Port [**2112-11-30**]: AP chest compared to [**11-15**] through [**11-28**], there has been no appreciable change since [**11-28**]. Given elevation of the right lung base, opacification in the right lower lobe is as likely to be atelectasis as pneumonia. Left lower lobe and the remainder of the lungs clear. Moderate-to-severe cardiomegaly stable, but increased since [**Month (only) 1096**]. Tracheostomy tube in standard placement. The VP shunt catheter is traceable over the upper chest, but indistinct in the abdomen. Tracheostomy tube in standard placement. No pneumothorax. . Microbiology: CVC Tip Cx [**2112-11-28**] Negative Blood Cx [**2112-11-28**] negative to date Blood Cx [**2112-11-30**] negative to date Brief Hospital Course: ASSESSMENT/PLAN: Mr. [**Known lastname **] is a 63-year-old gentleman with a pmhx significant for recent ACOMM aneurysmal rupture ([**2113-10-30**]) s/p neurosurgical intervention with multiple complications including VP shunt placement, aspiration pneumonia, and failure to wean from vent (now with trach collar and PEG) admitted from rehab with headache, hypertension, and agitation. . . # Hyperactive Delirium: Mr. [**Known lastname **] continued to sun-down and become agitated in the evenings. He was confused with wax and [**Doctor Last Name 688**]. He was usually alert and oriented to person only, but was able to say the year occasionally. He has no recollection of the events during the last month (i.e. ICH). The etiology of the delirium was thought secondarily to ICH, resolving pneumonia and possibly benzodiacepine use. Infection was ruled out with CT of the head, neurosurgery evaluation of the VP shunt, serial blood cultures, UA, Chest x-ray and urine culture. Electrolytes were within normal range and normal renal function. Patient was moving bowels approximately every other day and had good urine output. Patient was admitted with a right subclavian line, which was erythematous in the insertion site in the skin. It was removed and culture was negative. Patient was afebrile during the stay. A geriatrics consultation was obtained for management of delirium. His medications were minimized. His tethers were minimized. A one on one sitter was maintained at all times. Olanzapine was initiated and titrated to a dose of 5mg qAM and qHS given at 8pm. For acute agitation he recieved olanzapine 2.5mg po q6hrs prn and haldol 1mg iv daily prn for refractory agitation. He was reoriented. His lab draws were minimized. A bowel regimen was maintained. Soft restraints were utilized when indicated. We are trying to minimize waking him up at night try to normalize his day-night cycle. . #h/o Right Lower Ext and Bilateral Upper Ext DVT diagnosed on [**2112-11-3**]: An MRA Brain was done on the evening of [**2112-12-1**], which ensured that the anterior communicating artery aneurism was obliterated by coiling given that we were considering full anticoagualtion. The final read is pending and will have to be followed up. The decision was made to anticoagulate with coumadin 5mg daily for a therapeutic INR of [**12-29**]. Anticoagulation will have to continue for at least 3 months (without a bridge) from the date that he becomes therapeutic. We will contact the rehab facility to relay any changes in this plan. . # HYPERTENSION: On admission, Mr. [**Known lastname 64545**] systolic blood pressures were in the 160-170 range. Hydralazine was given in spot doses during hospital days one and two. His metoprolol was uptitrated. Amlodipine and captopril were added to his regimen. His systolic blood pressures on discharged were in 130 range. Captopril can be increased as needed. Target BP <140/90 mmHg. . # h/o PNEUMONIA: During his last admission ending on [**2113-11-19**], Mr. [**Known lastname **] was discharged on vanc/zosyn. Appears as though antibiotics were started on [**11-15**]. A 10-day course would have finished on [**11-24**]. Since Mr. [**Known lastname **] remained afebrile, asymptomatic, and without leukocytosis, antibiotics were not administered during this admission. . # HEADACHE: Resolved on hospital day 2 without intervention. A neurosurgical consult was obtained upon admission. As per neurosurgical consult, there was no change from prior physical exam and no concern for urgent neurosurgical intervention. A CT head showed no acute process and resolution of his previous SAH. The patient remained afebrile and without leukocytosis and a lumbar puncture was not done. The VP shunt was functioning properly per neurosurgery. . # FEN: No IVF, replete electrolytes, tube feeds per nutrition consultation included: Tubefeeding: Fibersource HN Full strength; Starting rate: 70 ml/hr; Do not advance rate Goal rate: 70 ml/hr Residual Check: q4h Hold feeding for residual >= : 200 ml Flush w/ 100 ml water q4h Other instructions: please bolus free water 250cc q 6hrs. thankyou . # Prophylaxis: Subcutaneous heparin, no indication for ppi, bowel regimen. . # Access: peripherals # Code: FULL CODE # Communication: HCP [**Name (NI) **] [**Known lastname **] (wife) [**Telephone/Fax (1) 64546**] Medications on Admission: colace 100mg [**Hospital1 **] erythromycin opt ont .5% ou qid heparin 5000 sq tid lansoprazole 30mg ngt daily levetiracetam 1000mg pgt [**Hospital1 **] metoprolol 37.5mg pgt [**Hospital1 **] senna [**Hospital1 **] prn trazodone 50mg qhs at 2100 multi-vitamin acetaminophen 650 q6hr prn bisacodyl 10mg prn hydralazine 10mg pgt q6hrs prn sbp>160 hydromorphone 2mg pgt q6hrs prn lorazepam .5mg pgt qid prn ondansetron 4mg iv q8hrs prn trazodone 50mg q4hrs prn at night only for insomnia zyprexa 2.5mg po prn agitation (spot dosing) Discharge Medications: 1. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 2. levetiracetam 500 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID (2 times a day). 3. docusate sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One (1) PO BID (2 times a day). 4. captopril 12.5 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO TID (3 times a day). 5. amlodipine 5 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily). 6. metoprolol tartrate 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). 7. olanzapine 5 mg Tablet, Rapid Dissolve [**Last Name (STitle) **]: 0.5 Tablet, Rapid Dissolve PO Q6H (every 6 hours) as needed for agitation. 8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Last Name (STitle) **]: One (1) Inhalation Q6H (every 6 hours) as needed for wheeze, sob. 9. olanzapine 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at bedtime). 10. senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 11. acetaminophen 650 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times a day). 12. bisacodyl 10 mg Suppository [**Last Name (STitle) **]: One (1) Suppository Rectal HS (at bedtime). 13. olanzapine 5 mg Tablet, Rapid Dissolve [**Last Name (STitle) **]: One (1) Tablet, Rapid Dissolve PO QAM (once a day (in the morning)). 14. Ondansetron 4 mg IV Q8H:PRN nausea/vomiting 15. Coumadin 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day: Continue for therapeutic INR of [**12-29**]. Will need at least 3 months of treatment after that date or as directed by a doctor. 16. Haldol Decanoate 100 mg/mL Solution [**Date Range **]: One (1) mg Intramuscular q1hr prn as needed for agitation refractory to zyprexa: Maximum of 3mg per 24 hour period. . 17. Labs Please check INR on sunday [**2112-12-4**]. Target INR [**12-29**] for DVTs. Patient on Coumadin. Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: Hyperactive Delerium Hypertension Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [**Known lastname **]: It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted to the hospital because you had a headache, hyperactive delerium, and high blood pressure. Your headache resolved and a CT scan of your head did not show anything concerning. Your high blood pressure was treated with two new medications (see below), which worked well. The geriatricians helped us in treating your delerium with medications, including olanzapine, and other ergonomic and practical measures. A MRA of your brain was done, which showed your aneurysm has healed well. You were started on coumadin 5 mg daily for anticoagulation for your clots. You will need to follow up for your INR until therapeutic and to be anticoagulated for 3 months. Please make these changes to your home medications: -STOP erythromycin eye drops -INCREASE metoprolol tartrate to 50mg [**Hospital1 **] -START tylenol 650mg TID around the clock -STOP Trazodone -STOP hydralazine -Start amlodipine 10mg daily -Start Captopril 25mg TID -Start Zyprexa 5mg in the morning, 5mg in the evening at 8pm, and 2.5mg q6hrs prn agitation -Start haldol 1mg iv daily prn agitation -STOP lorazepam -START bisacodyl suppository daily -STOP subcutaneous heparin -START Coumadin 5mg Daily until you reach a therapeutic INR between [**12-29**] and continue coumadin for at least 3 months from that date. -STOP Dilaudid Followup Instructions: Please make an appointment to follow-up with your PCP immediately after your stay at Rehab. In addition, you have the following appointment: Department: NEUROSURGERY When: THURSDAY [**2113-1-12**] at 9:15 AM With: [**Name6 (MD) **] [**Last Name (NamePattern4) 7746**], MD [**Telephone/Fax (1) 3666**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Completed by:[**2112-12-2**]

[ "272.0", "693.0", "331.4", "780.60", "263.9", "780.39", "276.0", "401.0", "E936.1", "285.9", "453.41", "348.30", "430", "784.0", "453.40", "435.9", "518.81" ]

icd9cm

[ [ [] ] ]

[ "88.41", "31.1", "33.24", "96.72", "38.91", "39.72", "33.21", "02.39", "43.11", "02.34", "38.7", "96.04" ]

icd9pcs

[ [ [] ] ]

29454, 29526

22487, 26825

15909, 15916

29604, 29604

19084, 22464

31205, 31662

17914, 17932

27405, 29431

29547, 29583

26851, 27382

29782, 30582

17947, 18368

30600, 31182

15824, 15871

15944, 17477

1838, 2950

3956, 9061

1507, 1586

29619, 29758

17499, 17831

17847, 17898

60,679

137,094

40108

Discharge summary

report

Admission Date: [**2148-3-12**] Discharge Date: [**2148-3-21**] Date of Birth: [**2080-9-12**] Sex: F Service: SURGERY Allergies: Clonidine / Hypaque-Iodine/Iodine-containing Attending:[**First Name3 (LF) 158**] Chief Complaint: Rectal and renal mass Major Surgical or Invasive Procedure: Abdominal perineal resection, placement of fiducial- Dr. [**Last Name (STitle) **] Laparoscopic left radical nephrectomy with removal of renal vein thrombus.- Dr. [**Last Name (STitle) 3748**] History of Present Illness: Patient is a 67 yo female who presented for evaluation of rectal pain in 7/[**2146**]. Patient was treated for hemorrhoids and eventually [**Year (4 digits) 1834**] a colonoscopy where a rectal mass was discovered and biopsy was consistent with adenocarcinoma. Patient [**Year (4 digits) 1834**] full course of chemoradiation and full staging workup, during which an incidental left renal mass was discovered. Mass biopsy was consistent with renal cell carcinoma with growth from 6-8 cm over the several months of surveillance. Patient presents for elective [**Month (only) **] and radical nephrectomy. Past Medical History: -Diabetes type 2, nine years; -breast cancer in [**2126**], status post right mastectomy and TRAM flap, -hypothyroidism -hypercholesterolemia -rectal cancer s/p neoadjuvant chemo - staging scan showed L renal mass -HTN Social History: She is a retired corporate. She is married, five children. No tobacco, alcohol, or drug use. Family History: Negative for renal or bladder cancer Physical Exam: Vitals: T: afebrile BP: 138/63 P: 63 R: 14 O2: 100% General: Intubated, sedated HEENT: PERRL, sclera anicteric, ET tube in place Neck: supple, JVP not elevated, no LAD Lungs: Roncherous sounds anteriorly bilaterally, unable to assess posterior fields CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: multiple dressings in place with JP drain exiting RLQ, hypoactive and soft BS, non-distended, unable to assess TTP GU: foley in place Ext: warm, well perfused, 2+ pulses; no clubbing, cyanosis or edema Pertinent Results: [**2148-3-12**] 09:33PM BLOOD WBC-12.2* RBC-3.81* Hgb-11.7* Hct-35.9* MCV-94 MCH-30.8 MCHC-32.7 RDW-15.8* Plt Ct-258 [**2148-3-12**] 09:33PM BLOOD Neuts-63 Bands-25* Lymphs-9* Monos-2 Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0 [**2148-3-12**] 09:33PM BLOOD Glucose-184* UreaN-14 Creat-1.5* Na-136 K-4.6 Cl-106 HCO3-21* AnGap-14 Brief Hospital Course: Ms. [**Known lastname **] [**Last Name (Titles) 1834**] laparoscopic left radical nephrectomy with removal of renal vein thrombus and abdominoperineal resection of rectal cancer on [**2148-3-12**] without complications. Due to the length of the case (11-12 hours)and hypotension in the OR, patient was transferred to the ICU postoperatively intubated. Her course is detailed below by system: 1. Neuro: Patient was kept on propofol and fentanyl for sedation and pain control while on ventilator. Once extubated, her epidural was removed on POD#4 and she was transitioned from IV pain medication to po as she tolerated po intake. Her neurologic status was at baseline throughout. 2. CV: Patient was hypotensive with SBP in low 80s to 90s on POD#1 and #2. Her CVP and low urine output reflected underresuscitation, and she was repleted with crystalloid and colloid until normotensive. She was kept on neosinephrine for the first two days postop for hypotension which was weaned by POD#3. Her BP was within normal limits for the remainder of her stay and her home medications were restarted on POD#5. She had no EKG changes or signs of ischemia throughout her stay. 3. Respiratory: Patient was extubated on POD#1 without difficulty. Her O2 was gradually weaned and she had sats >95% on room air at the time of discharge. 4. GI: Patient's NGT was dced on POD#3. Patient's ostomy was pink and protuberant throughout her course. She was kept NPO until gas was noted in the ostomy bag when she was gradually advanced from clears to regular diet. She required laxatives to assist in bowel movements via ostomy but was passing gas into bag without difficulty. At the time of discharge, she was having normal ostomy output. 5. GU/Renal: Foley was dced on POD#4 once urine output was normal. Her Cr was initially elevated at 1.5, reflecting prerenal ARF from low volume statyus, but function was returned to baseline at 1 by discharge. 6. Heme/ID: She was kept on heparin SC and venodyne boots for DVT prophylaxis. Hct was appropriate throughout. Perioperative antibiotics were given. Portacath was used for access and required TPA for draw backs. Dispo: Patient was seen by physical therapy and recommendation was made for short term rehab. Medications on Admission: -Amlodipine 5mg qday -Humalog ISS -Lantus insulin 55units qHS -levothyroxine 125mcg qday -lisinopril 40mg qday -metoprolol 25mg qday -morphine -simvastatin 20mg qday -MVI Discharge Medications: 1. insulin glargine 100 unit/mL Solution Sig: Forty (40) units Subcutaneous at bedtime: Please follow home regimen. 2. Humalog 100 unit/mL Solution Sig: please resume home sliding scale units Subcutaneous per sliding scale: Please resume home sliding scale, continue to check blood sugars prior to administration. 3. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*60 Tablet(s)* Refills:*0* 6. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain for 5 days: Do not drink alcohol or drive a car while taking this medication. Use caution when taking this medication and long acting narcotics. . Disp:*30 Tablet(s)* Refills:*0* 10. morphine 15 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO Q12H (every 12 hours). 11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 12. Miralax 17 gram Powder in Packet Sig: One (1) packet PO once a day as needed for constipation: Please take if constipation develops. Disp:*30 * Refills:*0* Discharge Disposition: Home with Service Facility: [**Hospital 66**] Rehab & Nursing Center - [**Hospital1 392**] Discharge Diagnosis: Left renal cell carcinoma, and rectal cancer. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital after a laparoscopic left radical nephrectomy with removal of renal vein thrombus and Abdominal perineal resection, placement of fiducial to treat your rectal cancer and left renal cell cancinoma. Your hospitalization was complicated by low blood pressure which required you to stay in the intensive care unit, when your blood pressure was stabilizad you were transferred to the inpatient unit. You have been stable on the floor, your condition has improved, and you are now ready to be discharged home. Please monitor your bowel function closely. You have had a bowel movement prior to your discharge. If you have any of the following symptoms please call the office for advice or go to the emergency room if severe: increasing abdominal distension, increasing abdominal pain, nausea, vomiting, inability to tolerate food or liquids, prolonges loose stool, or constipation. You have a new colostomy. It is important to monitor the output from this stoma. It is expected that the stool from this ostomy will be solid and formed like regular stool. You should have [**11-19**] bowel movements daily. If you notice that you have not had [**First Name8 (NamePattern2) 691**] [**Doctor Last Name 3945**] from your stoma in [**11-19**] days, please call the office. You may take an over the counter stool softener such as colace if you find that you are becoming constipated from narcotic pain medications. Please watch the appearance of the stoma, it should be beefy red/pink, if you notice that the stoma is turning darker blue or purple, or dark red please call the office for advice. The stoma (intestine that protrudes outside of your abdomen) should be beefy red or pink, it may ooze small amounts of blood at times when touched and this should subside with time. The skin around the ostomy site should be kept clean and intact. Monitor the skin around the stoma for buldging or signs of infection listed above. Please care for the ostomy as you have been instructed by the wound/ostomy nurses. You will be able to make an appointment with the ostomy nurse in the clinic 7 days after surgery, You will have a visiting nurse at home for the next few weeks helping to monitor your ostomy until you are comfortable caring for it on your own. You have a long vertical incision on your abdomen that is closed with staples as well as small laparoscopic incisions also closed with staples. These incisions can be left open to air or covered with a dry sterile gauze dressing if the staples become irritated from clothing. The staples will stay in place until your first post-operative visit at which time they can be removed in the clinic, most likely by the office nurse. You also have an incision where your rectum once was, it is important thta you avoid sittin in one position on this area for more than 20-30 minutes. Please periodically look at this incision with a mirror to be sure you have not developed any signs of infection. Please monitor the incisions for signs and symptoms of infection including: increasing redness at the incision, opening of the incision, increased pain at the incision line, draining of white/green/yellow/foul smelling drainage, or if you develop a fever. Please call the office if you develop these symptoms or go to the emergency room if the symptoms are severe. You may shower, let the warm water run over the incision lines and pat the area dry with a towel, do not rub. Please keep the incision where your rectum once was as clean and dry as possible. No heavy lifting for at least 6 weeks after surgery unless instructed otherwise by Dr. [**Last Name (STitle) **]. You may gradually increase your activity as tolerated but clear heavy excersise with Dr. [**Last Name (STitle) **]. You will be prescribed a small amount of the pain medication dilaudid. Please take this medication exactly as prescribed. You also take morphiene sustained release at home, and we have continued that while you have been in the hospital, please be aware that this is a strong medication and combined with additional medication could cause sedation. Please take the dilaudid only as needed and monitor yourself closely. If you do not need additional pain medications, we recommend against taking these two medications together. You may take Tylenol as recommended for pain. Please do not take more than 4000mg of Tylenol daily. Do not drink alcohol while taking Followup Instructions: Please make an appointment for your first post-operative check with Dr. [**Last Name (STitle) **] in [**5-30**] days, please call [**Telephone/Fax (1) 160**]. Please make an appointment with Dr. [**Last Name (STitle) 3748**] for your first post-operative check with Dr. [**Last Name (STitle) 3748**], please call [**Telephone/Fax (1) 3752**]. Completed by:[**2148-3-21**]

[ "244.9", "E878.6", "V58.67", "198.89", "V45.71", "189.1", "250.00", "154.8", "276.52", "584.9", "V10.3", "220", "V45.3", "276.69", "V87.41", "272.0", "197.6", "458.29" ]

icd9cm

[ [ [] ] ]

[ "38.07", "92.27", "48.52", "55.51", "54.21" ]

icd9pcs

[ [ [] ] ]

6407, 6500

2477, 4715

325, 520

6590, 6590

2129, 2454

11181, 11556

1522, 1560

4936, 6384

6521, 6569

4741, 4913

6741, 11158

1575, 2110

264, 287

548, 1152

6605, 6717

1174, 1394

1410, 1506

27,212

110,793

31204

Discharge summary

report

Admission Date: [**2168-7-23**] Discharge Date: [**2168-8-4**] Date of Birth: [**2101-10-22**] Sex: M Service: MEDICINE Allergies: Iodine Attending:[**First Name3 (LF) 106**] Chief Complaint: s/p brady arrest Major Surgical or Invasive Procedure: endotracheal intubation History of Present Illness: Mr. [**Known lastname 73649**] was a 66 year old male with h/o CAD s/p CABG (atatomy not known) as well as PCI with stent in [**12/2167**] in [**Location (un) 7349**] who was in his USOH until 4 pm on [**7-22**] when the patient collapsed after lifting heavy boxes. By report, CPR was initiated immediately and 911 called with rapid EMS response. Per report, EMS found pt in WCT likely VT and pulseless. Pt received a total of 9 shocks and lidocaine push during the transport to OSH ED. On arrival in the ED the patient was unreponsive and without a pulse, s/p two more shocks and intubated for airway protection. EKG with WCT and he was given amio bolus x 2 and started on a drip. The patient also was given epi and atropine during the code. The patient remained hypotensive and was started on dopamine/levophed for pressure support. The patient was then transferred to [**Hospital1 **] for ongoing care. Echo at OSH by report demonstrated an EF of 40% with global hypokinesis, no focal wall motion abnormalities, but was a limited study. CT of the head showed no acute changes. Meds on transfer included amio gtt and plavix. Past Medical History: - CABG [**76**] yrs ago, ANATOMY: LIMA to LAD, SVG to High Lateral - PCI [**2167-12-2**] w/two DES to mid and distal RCA - PCI [**2167-12-16**] w/DES to SVG . Cardiac Risk Factors: Dyslipidemia, Hypertension Social History: Lives in [**Location 7349**], was here in the [**Name (NI) 73650**], [**First Name3 (LF) **] in area. Family History: not obtained Physical Exam: per Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]: VS: T 99 BP 118/63 HR 70 RR 20 O2 100% on AC 500/15 Gen: Intubated and sedated. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Bleeding gums. Neck: Supple with JVP flat CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: Intubated, b/l coarse crackles, ?rib fracture Abd: Soft, NTND. No HSM or tenderness. Ext: No c/c/e. No femoral bruits. Pertinent Results: admission labs: 145 112 38 --------------< 174 4.0 19 1.5 CK: 9097 MB: >500 Trop-T: 9.87 Ca: 10.1 Mg: 2.8 P: 4.0 . 15 20.1 >----< 319 44.2 [**2168-7-24**] 09:29AM BLOOD WBC-11.7* RBC-3.11* Hgb-10.0* Hct-28.4* MCV-91 MCH-32.1* MCHC-35.1* RDW-14.6 Plt Ct-189 [**2168-7-25**] 04:21PM BLOOD WBC-10.1 RBC-3.10* Hgb-10.1* Hct-28.2* MCV-91 MCH-32.7* MCHC-35.9* RDW-14.5 Plt Ct-135* [**2168-8-3**] 05:39AM BLOOD WBC-17.8* RBC-1.47*# Hgb-4.6*# Hct-14.9*# MCV-101* MCH-31.6 MCHC-31.1 RDW-14.4 Plt Ct-269 [**2168-7-25**] 04:45AM BLOOD Fibrino-822* [**2168-7-25**] 04:21PM BLOOD Glucose-126* UreaN-26* Creat-0.9 Na-143 K-3.7 Cl-114* HCO3-23 AnGap-10 [**2168-8-2**] 05:56AM BLOOD Glucose-112* UreaN-27* Creat-0.9 Na-150* K-3.2* Cl-112* HCO3-26 AnGap-15 [**2168-7-24**] 08:02AM BLOOD ALT-143* AST-216* LD(LDH)-839* AlkPhos-39 TotBili-0.6 [**2168-7-25**] 04:45AM BLOOD ALT-111* AST-165* LD(LDH)-799* AlkPhos-36* TotBili-0.7 [**2168-7-27**] 05:44AM BLOOD ALT-74* AST-96* CK(CPK)-694* AlkPhos-40 TotBili-0.6 [**2168-7-23**] 01:40AM BLOOD CK-MB-GREATER TH cTropnT-9.87* [**2168-7-23**] 02:25PM BLOOD CK-MB-282* MB Indx-3.1 [**2168-7-25**] 09:14AM BLOOD CK-MB-13* MB Indx-0.6 [**2168-7-26**] 05:31AM BLOOD CK-MB-13* MB Indx-0.8 [**2168-7-27**] 05:44AM BLOOD CK-MB-5 [**2168-7-25**] 09:14AM BLOOD Hapto-143 [**2168-7-23**] 02:29AM BLOOD Type-ART pO2-445* pCO2-39 pH-7.39 calTCO2-24 Base XS-0 [**2168-7-23**] 01:53PM BLOOD Type-ART pO2-72* pCO2-30* pH-7.48* calTCO2-23 Base XS-0 [**2168-7-30**] 05:27AM BLOOD Type-ART Temp-38.7 Tidal V-500 PEEP-5 pO2-138* pCO2-35 pH-7.46* calTCO2-26 Base XS-2 Intubat-INTUBATED [**2168-7-23**] 12:43PM BLOOD Lactate-1.6 . [**2168-8-1**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-neg [**2168-7-31**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-neg [**2168-7-30**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-neg [**2168-7-28**] URINE URINE CULTURE-NG [**2168-7-28**] URINE URINE CULTURE-NG [**2168-7-28**] SPUTUM GRAM STAIN (Final [**2168-7-28**]): >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2168-8-3**]): RARE GROWTH OROPHARYNGEAL FLORA. KLEBSIELLA PNEUMONIAE. RARE GROWTH. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # 232-0962F ([**2168-7-27**]). [**2168-7-28**] BLOOD CULTURE NG [**2168-7-28**] BLOOD CULTURE NG [**2168-7-27**] SPUTUM GRAM STAIN (Final [**2168-7-27**]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [**2168-7-29**]): OROPHARYNGEAL FLORA ABSENT. KLEBSIELLA PNEUMONIAE. SPARSE GROWTH. Trimethoprim/Sulfa sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 2 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S [**2168-7-26**] CATHETER TIP-IV NG [**2168-7-26**] URINE URINE CULTURE-NG [**2168-7-26**] BLOOD CULTURE NG [**2168-7-26**] BLOOD CULTURE NG [**2168-7-25**] SPUTUM GRAM STAIN (Final [**2168-7-25**]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. RESPIRATORY CULTURE (Final [**2168-7-27**]): SPARSE GROWTH OROPHARYNGEAL FLORA. KLEBSIELLA PNEUMONIAE. SPARSE GROWTH. Trimethoprim/Sulfa sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S [**2168-7-25**] BLOOD CULTURE NG [**2168-7-25**] URINE URINE CULTURE-NG [**2168-7-25**] BLOOD CULTURE NG [**2168-7-24**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL {KLEBSIELLA PNEUMONIAE} INPATIENT [**2168-7-23**] BLOOD CULTURE NG [**2168-7-23**] BLOOD CULTURE NG [**2168-7-23**] URINE NG . CHEST (PORTABLE AP) [**2168-7-23**] 11:10 AM TWO PORTABLE VIEWS. Comparison with the previous study done earlier the same day. There is streaky density at the lung bases consistent with subsegmental atelectasis as before. The patient is status post median sternotomy and CABG. Mediastinal structures are unchanged. An endotracheal tube and nasogastric tube remain in place. IMPRESSION: Subsegmental atelectasis. . PORTABLE SEMI-UPRIGHT CHEST 7:56 A.M. [**8-3**] Compared with [**2168-8-2**] at 10:44 p.m., no obvious interval change in the pulmonary vascular engorgement centrally. The patchy streaky opacities at the right lung base are slightly more prominent and confluent suggesting pneumonia. . Cardiology Report ECG Study Date of [**2168-7-23**] 1:59:54 AM Sinus rhythm, rate 76. Technical artifacts are seen. An indeterminate axis is noted. Right bundle-branch block pattern is seen. Ther is likely an anteroseptal myocardial infarction of undetermined age. No previous tracing available for comparison. . ECHO [**8-22**] MEASUREMENTS: Left Atrium - Long Axis Dimension: *4.8 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: *5.5 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: *5.9 cm (nl <= 5.0 cm) Left Ventricle - Septal Wall Thickness: 0.8 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: 0.8 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: *6.5 cm (nl <= 5.6 cm) Left Ventricle - Ejection Fraction: 20% (nl >=55%) Aorta - Valve Level: *4.0 cm (nl <= 3.6 cm) Aorta - Ascending: *3.5 cm (nl <= 3.4 cm) Aortic Valve - Peak Velocity: 1.4 m/sec (nl <= 2.0 m/sec) Mitral Valve - E Wave: 0.7 m/sec Mitral Valve - A Wave: 0.7 m/sec Mitral Valve - E/A Ratio: 1.00 Mitral Valve - E Wave Deceleration Time: 174 msec Pulmonic Valve - Peak Velocity: 1.0 m/sec (nl <= 1.0 m/s) INTERPRETATION: Findings: LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum. No ASD by 2D or color Doppler. Dilated IVC (>2.5cm) with <50% decrease during respiration (estimated RAP 16-20 mmHg). LEFT VENTRICLE: Normal LV wall thickness. Moderately dilated LV cavity. No LV mass/thrombus. Severely depressed LVEF. No resting LVOT gradient. No VSD. RIGHT VENTRICLE: Focal apical hypokinesis of RV free wall. Paradoxic septal motion consistent with conduction abnormality/ventricular pacing. AORTA: Moderately dilated aortic sinus. Mildly dilated ascending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets. No MVP. Trivial MR. TRICUSPID VALVE: Tricuspid valve not well visualized. Indeterminate PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: No PS. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Echocardiographic results were reviewed by telephone with the MD caring for the patient. Conclusions: The left atrium is mildly dilated. There is an echodensity associated with the left atrial of the posterior mitral annulus ([**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 2966**] vs artifact/tissue?). No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 16-20 mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. No masses or thrombi are seen in the left ventricle. Overall left ventricular systolic function is severely depressed with severe global hypokinesis and akinesis (thinned) of the basal inferior and lateral walls. There is very apical dyskinesis. There is no ventricular septal defect. There is focal hypokinesis of the apical free wall of the right ventricle. The aortic root is moderately dilated at the sinus level. 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 structurally normal. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Severely depressed LVEF with regionality c/w CAD. Possible [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 2966**] vs artifact. If clinically indicated, a TEE may better characterize [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 73651**]. . MR HEAD W/O CONTRAST [**2168-7-25**] 9:33 PM MR HEAD W/O CONTRAST Reason: Please assess for bleed, please asses for thromboembolic cva [**Hospital 93**] MEDICAL CONDITION: 66 year old man with brady arrest requiring 11 shocks by DC-cardioversion. REASON FOR THIS EXAMINATION: Please assess for bleed, please asses for thromboembolic cva, please assess neck for cord compression and soft tissue injury. INDICATION: Cardiac arrest, requiring shocks by cardiac conversion. TECHNIQUE: Multiplanar T1- and T2-weighted sequences were obtained through the brain with diffusion-weighted imaging. FINDINGS: Evaluation of the ADC map demonstrates diffuse cortical low signal. This corresponds to increased signal on the diffusion-weighted sequence within the cortex. These findings represent diffuse cortical slow diffusion. This would represent diffuse cortical injury from anoxia. There is a tiny focus of abnormal magnetic susceptibility at the [**Doctor Last Name 352**]-white matter junction in the posterior right frontal lobe consistent with petechial hemorrhage. There is no midline shift, mass effect, or hydrocephalus. The normal vascular flow voids are present. There is paranasal sinus disease due to the patient's intubated status. IMPRESSION: Findings are consistent with diffuse anoxic brain injury. . MR CERVICAL SPINE W/O CONTRAST [**2168-7-25**] 9:33 PM MR CERVICAL SPINE W/O CONTRAST Reason: Now patient with c-collar needs to be cleared. [**Hospital 93**] MEDICAL CONDITION: 66 year old man s/p brady arrest and fall. REASON FOR THIS EXAMINATION: Now patient with c-collar needs to be cleared. INDICATION: Brady arrest and fall. The patient with C collar needs to be cleared. TECHNIQUE: Multiplanar T1- and T2-weighted sequences were obtained through the cervical spine with sagittal STIR sequence. FINDINGS: The alignment of the cervical spine appears normal. There is no abnormal bone marrow edema. The intrinsic cord signal appears generally normal although it is poorly evaluated due to some motion. At the level of [**6-12**], there is a small focus of abnormal magnetic susceptibility within the left-sided cord. This is suspicious for an intramedullary hemorrhage. There are multilevel posterior osteophytes causing mild spinal canal narrowing. There are areas of moderate bilateral neural foraminal narrowing associated with these osteophytes. Given the patient's history and the presence of abnormal susceptibility within the cord, the concern is for a cord injury. IMPRESSION: Small area of abnormal magnetic susceptibility within the cord at the level of C5-6 is concerning for a petechial hemorrhage. This could be a secondary finding associated with cord injury. The intrinsic cord signal is poorly evaluated due to patient motion artifact on the STIR sequence. There however is no bone marrow edema. . OBJECT: BEDSIDE SIDE EEG WITH VIEDO, [**Date range (1) 73652**]. THE HEART WAS MONITORED BECAUSE DISORDERS OF HEART RHYTHMS [**Month (only) **] PRODUCE NEUROLOGICAL COMPLAINTS AS DESCRIBED ABOVE OR NEUROLOGICAL DISORDERS SUCH AS SEIZURES, WHEN SYMPTOMATIC, [**Month (only) **] PRODUCE CARDIAC ARRHYTHMIAS. REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] FINDINGS: ROUTINE SAMPLING: A low voltage [**3-12**] Hz disorganized posterior background rhythm is seen with frequent electrode artifacts seen at the bilateral temporal leads with a very rhythmic alpha frequency quality that is limited to these leads; however, at other times, it is also seen in the right central region. There was also electrode artifact seen in the left central leads. When these artifacts were at their lowest, a very slow [**4-10**] Hz low voltage rhythm was noted with no clear regions of focal slowing and no clear epileptiform discharges noted. SLEEP: There were no normal sleep/wake transitions seen. CARDIAC MONITOR: A generally regular rhythm was noted with an average rate of 96 bpm. However, frequent premature ventricular contractions were seen. AUTOMATIC SPIKE DETECTION FILES: There were 259. These consisted primarily of electrode artifact, particularly at the bilateral temporal leads. There also seemed to be superimposed electrical artifact of low voltage and high frequency. No true epileptiform features were noted. AUTOMATIC SEIZURE DETECTION FILES: There were 43. These consisted of the above-noted electrode or electrical artifact seen in the bilateral temporal leads as well as multiple other leads. No true electrographic seizures were recorded, however. PUSHBUTTON ACTIVATIONS: There were none. IMPRESSION: This is an abnormal 24-hour video EEG telemetry in the waking and sleeping states due to the low voltage suppressed slow and disorganized background rhythm with much superimposed electrical artifact. Nonetheless, no true electrographic seizures or epileptiform features were noted. There were no pushbutton activations. This slow low voltage and disorganized background is suggestive of a severe encephalopathy which may be seen with medication effect, toxic metabolic abnormalities, or infections as well as global ischemic disease. Of note, there were frequent premature ventricular contractions noted throughout the tracing. . Neurophysiology Report EP Study Date of [**2168-7-28**] OBJECT: CARDIAC ARREST. ASSESS NEUROLOGIC FUNCTION. REFERRING DOCTOR: DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 489**] FINDINGS: BRAIN STEM AUDITORY EVOKED POTENTIAL (07-085): After stimulation of the right ear there was no discernible evoked potential at any position. This can often come from lesions in the VIIIth cranial nerve. The patient was reported to have an earlier and severe hearing loss on the right. After stimulation of the left ear there was a very poorly formed and faint peak at position I and another poorly formed peak at position V with a normal latency. This suggests some conduction from the periphery to the mid-brain, and with a normal latency. MEDIAN NERVE SOMATOSENSORY EVOKED POTENTIAL (07-086): After stimulation of the right median nerve there was an evoked potential peak at Erb's point with a normal latency. Subsequent peaks were not discernible. This suggests a defect in the large fiber somatosensory conducting system after right median stimulation, with the defect proximal to the brachialplexus. This can be at the root level or centrally. After left median nerve stimulation there were no discernible evoked potential peaks at any position. There was no peak at Erb's point. This suggests a defect in the large fiber somatosensory conducting system peripherally. This can be due to peripheral neuropathies, body habitus, and sometimes to technical factors. Brief Hospital Course: 66 M with h/o CAD s/p CABG and PCI who presented from OSH s/p cardiac arrest, reportedly down for ~10 hrs, pulseless, s/p multiple shocks, intubated & sedated on amiodarone and heparin gtt's. Hospital course by problem: . #) CAD: Pt was s/p CABG with unknown anatomy (done in [**Location (un) 7349**]), also with recent PCI in [**12-13**]. AMI per EKG. Due to an unkown etiology for his arrest, thought seconsary to scar rather than acute MI, in combination with his tenuous clinical status and questionable nuerologic recovery - an acute cardiac catheterization was not performed. . #) Rhythm: His amiodarone drip was continued for several days. He had only small runs of NSVT and a malignant arhythmia did not return. His amiodarone drip was discontinued. He remained in sinus rhythym while monitored on telemetry. . #) Pump: EF was reportedly 40% at OSH with global HK. A repeat echo here showed an EF of 20%. . #) Resp: He remained intubated up until the point he was made comfort measures only at which point he was taken off the ventilator. . #) Neuro: Neurology was involved in this patient's care and an MRI was obtained. The MRI showed diffuse cortical injury. He did not recover meaningful cortical activity. He developed epileptiform partialis continuium is his right arm and was initially started on a dilantin load. This was discontinued after EEG showed no epileptiform activity. A family meeting was held to discuss the neurologic prognosis and ultimately the family decided that given his poor prognosis, they would change his care to comfort measures only. . #) Febrile Illness - unclear source. Infectious vs. central fever. The patient appeared septic early in the course of his hospitalization and was broadly covered with Vanc and Zosyn. This was changed to levoquin for 2 days, but high spiking fevers to 102 returned and he was re-started on Vanc/Zosyn. Sputum cultures were not initially definitive for a source, though eventually grew klebsiella (cukture data above. . #) Dispo: The patient was made comfort measures only and expired on [**2168-8-4**]. Medications on Admission: Diovan 120 mg daily ASA 325 Plavix 75 Lipitor 30 Folic Acid Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: Anoxic brain injury following cardiac arrest. Discharge Condition: expired. Discharge Instructions: not applicable Followup Instructions: not applicable Completed by:[**2168-9-23**]

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Discharge summary

report

Admission Date: [**2193-8-30**] Discharge Date: [**2193-9-4**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 348**] Chief Complaint: s/p fall Major Surgical or Invasive Procedure: none History of Present Illness: [**Age over 90 **] y/o F wtih hx of HTN, afib on coumadin, dementia and CHF presents s/p unwitnessed fall at home ([**Location (un) 52925**]). Was seen at [**Hospital 4199**] Hospital and had CT scan showing IPH and transferred here for further neuro eval. Per the patient, she was washing her bathroom floor, when she felt a little unsteady and just fell. Doesn't remember chest pain, shortness of breath, dizziness or any other precipitating factors. After talking with staff at her residence, she apparently was found in the bathroom bleeding this morning. She had not pressed her life button. It was unclear what time she had fallen or for how long she was down. She is demented at baseline and has been getting worse over the last year, having increasing angry spells. She is unsteady and supposed to use a walker, but she does not use it in her apartment. She has not had any signs of infection or change in her health recently. . Initial vitals in the ED were T 98.2, HR 70, BP 144/76, pox 100%. At the OSH, she had received 10 mg Vit K and a tetanus shot. In our ED, he received activated factor 9 (Profilnine 1800 u) and 1u FFP. . On the floor, she denies any pain. She is alert and pleasant but oriented only x1 (to self). She seems to remember what happened today, but tries to change the subject when she can't answer questions. She denies fevers, chills, chest pain, shortness of breath, palpitations, weakness, headaches, vision changes, abdominal pain, nausea, vomitting, dysuria or bowel changes. Past Medical History: HTN A-Fib Dementia CHF Pacemaker for bradycardia Anxiety Hyperlipidemia Chronic Renal Insufficiency Social History: Unknown, lives in [**Location (un) 52925**] in the dementia unit, per records has no smoking or etoh history; no children and has a nephew who lives in [**Name (NI) 86**] as next of [**Doctor First Name **]. Family History: Unknown Physical Exam: Vitals - T , HR 70, BP 138/110, R 19, 98% on RA Gen - thin, elderly woman in NAD HEENT - large L ecchymosis over eye, tender to palpation, EOMI, R pupil pinpoint and reactive, L pupil irregular and nonreactive, supple neck, no LAD, no JVD CV - RRR, no m,r,g Lungs - CTA B, no wheezes, rhonchi or rales Abd - soft, NT, ND, no hsm or masses, normoactive BS Buttock - mild bruising over L buttock, no abrasionas Neuro - CN intact (except III - see HEENT exam), strength 5/5 equal and bilateral in all extremities, reflexes 2+ Ext - warm, thin, no edema, dry skin, no bruising or abrasions Pertinent Results: [**2193-8-30**] 10:54PM WBC-8.0 RBC-3.58* HGB-10.3* HCT-31.3* MCV-88 MCH-28.7 MCHC-32.8 RDW-14.0 [**2193-8-30**] 10:54PM PT-15.5* PTT-32.2 INR(PT)-1.4* [**2193-8-30**] 10:54PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-7.5 LEUK-TR [**2193-8-30**] 03:50PM CK(CPK)-112 [**2193-8-30**] 03:50PM cTropnT-0.06* [**2193-8-30**] 03:50PM CK-MB-4 [**2193-8-30**] 03:50PM DIGOXIN-0.5* [**2193-8-30**] 03:50PM CALCIUM-9.5 PHOSPHATE-2.0* MAGNESIUM-2.4 [**2193-8-30**] 03:50PM WBC-6.6 RBC-4.08* HGB-11.6* HCT-35.9* MCV-88 MCH-28.6 MCHC-32.4 RDW-14.1 [**2193-8-30**] 03:50PM PT-25.9* PTT-35.4* INR(PT)-2.5* [**2193-9-1**] 06:00AM BLOOD Glucose-87 UreaN-50* Creat-1.7* Na-145 K-4.1 Cl-107 HCO3-28 AnGap-14 [**2193-8-31**] 04:07AM BLOOD CK(CPK)-114 [**2193-8-31**] 04:07AM BLOOD CK-MB-3 cTropnT-0.07* CT Head [**2193-8-30**] 1. Stable right frontal and left temporal intraparenchymal hemorrhages. These findings are most comptible with amyloid angiopathy though underlying lesions cannot be excluded. Recommend MRI to further assess. 2. No new areas of hemorrhage. No midline shift. No change in the size of the ventricles. 3. Parenchymal atrophy and chronic small vessel white matter changes. Hip X-ray [**2193-8-30**]: IMPRESSION: No fractures. Left hip fixation without hardware failure. CXR [**2193-8-30**]: IMPRESSION: Mild cardiomegaly, but no acute cardiopulmonary process. Brief Hospital Course: [**Age over 90 **] y/o F with hx of dementia, afib on coumadin, HTN and CHF who presented after unwitnessed fall at home now w/IPH. . # IPH - Patient had one CT scan at the OSH and one in ED that showed stable IPH in the R frontal lobe and L temporal lobe. She also received a CXR and hip x-ray at that time that ruled out additional fractures. She has dementia at baseline and is oriented only to person, but was otherwise neurologically intact. Neurosurgery was consulted and recommended reversal of anticoagulation, SQ Heparin, and q4 hr neuro checks. She received Vitamin K, Profilnine, and 2u FFP. Her INR's were followed throughout her stay, her coumadin and ASA were held and she did not require additional coagulation intervention. Her SC Heparin was eventually decreased from TID to [**Hospital1 **] dosing without incident. As the ED felt that she required more frequent neuro checks than the original recommendation, she was admitted to the MICU overnight to receive q2 hour neuro checks. After a full day of frequent checks, she was transferred to the medicine floor for continued care. -She will follow-up with Neurosurgery in 1 month for repeat head imaging and will hold her Coumadin until then. . # Fall - Patient's fall was of unclear etiology. The patient is a poor historian given her dementia, but per her recollection she was cleaning the bathroom floor when she fell. She has no memory following the fall. If this is accurate, her fall was most likely mechanical as she has no history of seizure, was not orthostatic, and demonstrated no evidence of infection as assessed by vitals signs, CXR, UA, and WBC. EP evaluated her pacemaker and found no evidence that she had a cardiac event to explain her fall. She was monitored on telemetry throughout her hospitalization and did not demonstrate concerning morphology or clinical symptoms. 2 sets of cardiac enzymes were negative. She had an ECHO in [**4-28**] that demonstrated an EF of 60% without AS and a CXR showed no abnormalities. She was assessed by PT and cleared for dispo to her [**Hospital3 **] facility, but given the extent of her dementia, she is being to rehab before transitioning to a long-term facility with 24 hour monitoring. . # Afib - Patient is atrial paced since [**2189**]. She had normal vital signs throughout her hospitalization. She was continued on her home dose of Sotalol 80mg [**Hospital1 **] and her anticoagulative regimen of Coumadin and ASA were held throughout her stay with plan to restart after follow-up with Neurosurgery. Her pacemaker was evaluated as above. -hold coumadin until neurosurgery follow up . # Chronic Systolic Heart Failure - Patient demonstrated no signs of fluid overload on exam, so home lasix was held. A Digoxin level was obtained based on a Cr of 1.8, but it was not elevated, so she was continued on her home dose of Digoxin. PO intake was appropriate, but as she demonstrated no need for Lasix by clinical exam, it was held throughout her stay. On review of records, it appears that the patient has not seen a cardiologist in approximately 3 years, so she should follow up with PCP. [**Name10 (NameIs) **] lasix until patient follows up with PCP or until clinically indicated. . # Dementia - Patient is pleasant and agreeable, although per [**Location (un) **] her dementia has been worsening over the last year. She was continued on her home dose of Namenda, Aricept, Mirtazapine and Citalopram per home doses. . # Chronic kidney disease - Pt. with a creatinine of 1.8 on admission, decreased to 1.7 by day 3 of her hospitalization. A baseline Cr in [**2189**] was 1.2, but she has no record of a physician appointment since [**2190**], so it is unclear the progression of her [**Name (NI) 2091**]. Her Digoxin level was assessed and found to be appropriate, so it was continued. Her Lasix dose was held as it did not appear to be clinically indicated and out of concern for worsening renal function. . # HTN - Pt's bp's stable since admission. Continued on home dose of Losartan and Sotalol. . Patient remained DNR/DNI, without invasive procedures throughout this hospitalization. Medications on Admission: Aricept 5 mg daily ASA 325 mg daily Citalopram 40 mg daily Cozaar 50 mg daily Digoxin 0.125 mg daily Colace 100 mg [**Hospital1 **] Lasix 40 mg daily Lovastatin 20 mg daily Mirtazapine 7.5 mg daily Namenda 10 mg [**Hospital1 **] Nexium 40 mg daily Sotalol 80 mg [**Hospital1 **] Coumadin 4 mg daily Vitamin E 400 u daily Discharge Medications: 1. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Lovastatin 20 mg Tablet Sig: One (1) Tablet PO daily (). 5. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 6. Memantine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Sotalol 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Extended Care Facility: Masconomet [**Hospital1 1501**] Discharge Diagnosis: intraparenchymal hemorrhage Discharge Condition: Improved. Stable. Residual ecchymoses over the left eye and zygoma. Discharge Instructions: You were admitted to the hosptial after falling. We saw some bleeding inside of your brain. The neurosurgeons evaluated you but did not think you needed any surgery. We reversed the blood thinning effects of coumadin with some medications. Your neurological exam stayed normal. We do not think that the cause of your fall was your heart as your pacemaker did not show any evidence of arrythmia. . Medications: The following changes have been made to your medications, 1. Coumadin: Please stop taking Coumadin until you see a Neurosurgeon in approximately 1 month. The details of the appointment are below. 2. Lasix: Please do not take Lasix until you see your primary care physician. [**Name10 (NameIs) **] details of your appointment are below. 3. Aspirin: Your dose of aspirin was decreased from 325mg a day to 81mg a day. Please continue to take this lower dose. . If you have any chest pain or pressure, shortness of breath, or have ongoing dizziness or lightheadedness, please call your physician or go the emergency room. Followup Instructions: You have a CT scan scheduled for [**2193-10-2**] at 11:45AM at the [**Hospital3 **] [**Hospital 1225**] Medical Center. Please follow-up the CT scan with Dr. [**Last Name (STitle) **], MD [**First Name (Titles) **] [**2193-10-2**] at 1:00PM also at the [**Hospital3 **] [**Hospital 1225**] Medical Center. To reschedule, please call [**Telephone/Fax (1) 1669**]. . Please follow-up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 65991**], within the next 2-3 weeks. You can call [**Telephone/Fax (1) 48524**] to schedule.

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9641, 9699

4274, 8392

269, 275

9770, 9839

2814, 4251

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Discharge summary

report

Admission Date: [**2189-9-1**] Discharge Date: [**2189-9-7**] Date of Birth: [**2137-2-8**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 783**] Chief Complaint: 1. Acute mental status changes 2. Emergency HTN Major Surgical or Invasive Procedure: 1. Resection of brachial artery aneurysm with vein graft repair of artery 2. Placement of a double lumen 14.5 French tunneled hemodialysis catheter History of Present Illness: Pt sedated and intubated. Information taken from chart. 52 yo M with Alport's syndrome, ESRD on HD, renal transplant x 2, diastolic CHF, HTN who presents with agitation and altered mental status. He was at hemodialysis today when he became agitated. HD was stopped midway and he was brought to the ED. Per the renal attg note, he has been combative through the last several HD sessions, but this time he was even more so. Per the note, he was acting intoxicated but did not smell of ETOH. In the ED, his vitals showed HR in the low 100s and BP 220's/130's. He was given hydral. He was noted to have a very large aneurysmal AV fistula. Vascular surgery was called. He was started on an esmolol gtt before coming up to the floor. Of note, the renal attg note states that he has a hx of cocaine abuse in the past. MICU COURSE: HTN emergency with AMS in setting of initial BP 220/130 while at HD appeared confused, combative. Admitted to MICU, started labetolol gtt, intubated for airway protection, tox screen negative, head MRI-neg, underwent surgical repair of RUE fistula aneurysm which was actively expanding w/HTN emergency, HD catheter placed, extubated Friday. Infection w/u negative, Walking, mentating as baseline, titrating BP meds, standing hydral added, toprol, lisinopril Baseline SBP 160s. While on floor, pt mentating well, denies any complaints, no HA/Visual changes, no confusion. No CP/Palp, no SOB. Comfortable. States he's now getting some sensation in his RUE p surgical repair of expanding fistula aneurysm. He has no further complaints. Past Medical History: 1. Alport's Syndrome: c/b ESRD on HD and deafness 2. ESRD: s/p failed renal transplant x 2 ([**2152**] and [**2168**]), now on HD M/W/F 3. Malignant hypertension 4. h/o CHF w/ dilated cardiomyopathy: now w/ recovered fxn, ECHO [**3-21**] w/ EF>55%, 1+ MR 5. SVT s/p ablation [**3-21**] 6. h/o seizures: likely metabolic etiology per notes 7. Restless legs syndrome 8. Anemia of chronic disease 9. h/o respiratory failure secondary to pulmonary edema 10. Pruritis: treated w/ prednisone, mirapex Social History: Divorced w/2 children, and he lives with his son and daughter. 3 pack yr hx. Occ EtOH. hx marijuana and cocaine, none x 2 yrs. No IVDU. Family History: Mother with alport's syndrome, father with CAD and CABG at age 60, brother died at 16 yrs old from ESRD Physical Exam: VS: 99 BP 148/90 HR 82 18 99%RA GEN: NAD, Pleasant, cooperative HEENT: MMM RESP: CTABL, no crackles, no wheezing CV: Reg Nml, S1, S2, II/VI SEM ABD: Soft ND/NT +BS EXT: RUE-Dressing in place with JP drain-~10cc serosang fluid, HD cath in R chest-non-tender, no drainage, No peripheral edema, warm 2+DP pulses b/l NEURO: A&Ox3, no focal deficits, appropriate, following commands, strength 5/5 throughout Pertinent Results: [**2189-9-1**] 02:30PM BLOOD WBC-7.5 RBC-3.20* Hgb-9.4* Hct-29.1* MCV-91 MCH-29.3 MCHC-32.2 RDW-19.2* Plt Ct-192 [**2189-9-2**] 07:31AM BLOOD WBC-6.4 RBC-3.26* Hgb-9.4* Hct-29.3* MCV-90 MCH-28.8 MCHC-32.1 RDW-19.4* Plt Ct-171 [**2189-9-3**] 02:35AM BLOOD WBC-9.0 RBC-3.32* Hgb-9.9* Hct-31.3* MCV-94 MCH-29.7 MCHC-31.5 RDW-19.3* Plt Ct-155 [**2189-9-4**] 04:20AM BLOOD WBC-9.9 RBC-3.12* Hgb-9.0* Hct-28.5* MCV-91 MCH-29.0 MCHC-31.7 RDW-19.1* Plt Ct-167 [**2189-9-6**] 07:15AM BLOOD WBC-6.0 RBC-2.94* Hgb-8.7* Hct-27.5* MCV-94 MCH-29.6 MCHC-31.7 RDW-19.5* Plt Ct-205 [**2189-9-7**] 05:40AM BLOOD WBC-8.1 RBC-2.80* Hgb-8.3* Hct-25.4* MCV-91 MCH-29.7 MCHC-32.7 RDW-18.9* Plt Ct-237 [**2189-9-7**] 08:00AM BLOOD WBC-8.3 RBC-2.97* Hgb-8.7* Hct-27.8* MCV-93 MCH-29.2 MCHC-31.3 RDW-19.4* Plt Ct-249 [**2189-9-1**] 11:49PM BLOOD PT-12.1 PTT-30.3 INR(PT)-1.0 [**2189-9-1**] 02:30PM BLOOD Glucose-85 UreaN-88* Creat-19.1*# Na-136 K-7.1* Cl-98 HCO3-18* AnGap-27* [**2189-9-6**] 07:15AM BLOOD Glucose-147* UreaN-27* Creat-10.3*# Na-138 K-4.6 Cl-98 HCO3-28 AnGap-17 [**2189-9-7**] 08:00AM BLOOD Glucose-102 UreaN-42* Creat-14.3* Na-137 K-4.8 Cl-96 HCO3-24 AnGap-22* [**2189-9-1**] 11:49PM BLOOD CK(CPK)-4391* [**2189-9-1**] 07:05PM BLOOD ALT-16 AST-24 AlkPhos-110 Amylase-499* TotBili-0.3 [**2189-9-1**] 07:05PM BLOOD Lipase-105* [**2189-9-1**] 11:49PM BLOOD cTropnT-0.10* [**2189-9-1**] 11:49PM BLOOD CK-MB-12* MB Indx-0.3 [**2189-9-1**] 02:30PM BLOOD Calcium-8.6 Phos-8.4*# Mg-2.9* [**2189-9-7**] 08:00AM BLOOD Calcium-9.5 Phos-5.4* Mg-2.1 [**2189-9-1**] 11:49PM BLOOD VitB12-647 Folate-13.0 [**2189-9-1**] 11:49PM BLOOD Osmolal-304 [**2189-9-1**] 11:49PM BLOOD TSH-3.8 [**2189-9-1**] 07:05PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Non-contrast CT of the head. FINDINGS: There is no evidence of intracranial hemorrhage, mass effect, or shift of normally midline structures. [**Doctor Last Name **]-white matter differentiation is preserved. The ventricles are normal in size and symmetric. There is moderate cavernous carotid athersclerotic calcifications. The visualized paranasal sinuses and mastoid air cells are clear. There is congenital nonfusion of the C1 vertebral body. IMPRESSION: No evidence of intracranial hemorrhage. TECHNIQUE: Multiplanar T1- and T2-weighted images of the brain were performed. An MR angiogram of the circle of [**Location (un) 431**] was also obtained with 3D time-of-flight images, including reconstruction of multiplanar maximum intensity projection reconstructions. MRI OF THE BRAIN: Faint foci of hyperintensity in the vertex parietal sulci on the FLAIR images show a bilateral symmetric distribution. These may be artifactual or could be explained by propofol administration or hyperoxygenation. No signal abnormalities are demonstrated within the basal cisterns. There is no mass effect, hydrocephalus, or shift of the normally midline structures. A mild extent of scattered punctate foci of T2 hyperintensity in the deep, subcortical, and periventricular white matter of the cerebral hemispheres is most suggestive of chronic small vessel infarcts. However, there is no area of restricted diffusion to suggest a recent infarct. No susceptibility artifacts are present. A small amount of fluid and/or mucosal thickening is present in the sphenoid sinus, as well as mucosal thickening in the ethmoid sinuses, an appearance that can be seen in intubation. The frontal and maxillary sinuses, as well as mastoid air cells are clear, aside from a tiny area of mucosal thickening along the medial wall of the left maxillary sinus, likely inflammatory in origin. MR ANGIOGRAM: A 4-mm aneurysm is present along the anterior communicating artery without a well-defined neck. The A1 segment of the left anterior cerebral artery is small. Blood supply to each anterior cerebral artery predominantly stems from the right A1 segment. The right posterior communicating artery is either very small or absent. There is no evidence of stenosis or arteriovascular malformation. IMPRESSION: 1. Evidence of chronic small vessel infarction in the cerebral white matter, but no evidence of recent infarction, encephalitis, or other acute intracranial process. 2. Small anterior communicating artery aneurysm of 4 mm in diameter. Neurosurgical evaluation is recommended. The findings were discussed with Dr. [**Last Name (STitle) 14393**] on [**2189-9-3**]. SPECIMEN SUBMITTED: BRACHIAL ARTERY ANEURYSM. Procedure date Tissue received Report Date Diagnosed by [**2189-9-2**] [**2189-9-2**] [**2189-9-7**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/tk?????? Previous biopsies: [**Numeric Identifier 102896**] SKIN RT ZYGOMA EXC. [**Numeric Identifier 102897**] RENAL BX DIAGNOSIS: Artery, right brachial aneurysm, resection: A. Atherosclerosis with thrombus. B. Blood vessel with changes consistent with aneurysm. EEG: FINDINGS: ABNORMALITY #1: The background is low voltage, slow, and disorganized, typically in the [**4-23**] Hz range with a superimposed faster beta frequency rhythm. The background is punctuated by frequent and prolonged bursts of high amplitude polymorphic delta slowing in a generalized distribution and persisting for 5-10 seconds at a time. BACKGROUND: As above. HYPERVENTILATION: Could not be performed as this was a portable study. INTERMITTENT PHOTIC STIMULATION: Could not be performed as this was a portable study. SLEEP: No normal waking or sleeping morphologies were noted. CARDIAC MONITOR: Showed a generally regular rhythm with an average rate of 66 beats per minute. IMPRESSION: This is an abnormal portable EEG due to the low voltage, slow, and disorganized background which was frequently admixed with prolonged bursts of high amplitude generalized delta frequency slowing. Findings are consistent with a moderate global encephalopathy, suggestive of bilateral subcortical or deep midline dysfunction. Medications, metabolic disturbances, and infection are among the common causes of encephalopathy. No clearly focal or epileptiform findings were noted, although encephalopathic patterns may obscure focal EEG abnormalities. No electrographic seizures were seen Brief Hospital Course: This is a 52 yo M with Alport's syndrome, ESRD on HD, renal transplant x 2, diastolic CHF, HTN who presented on [**2189-9-1**] with agitation and altered mental status while he was at hemodialysis. HD was stopped midway and he was brought to the ED. Per the renal attg note, he has been combative through the last several HD sessions, but this time he was even more so. He was acting intoxicated but did not smell of ETOH. In the ED, his vitals showed HR in the low 100s and BP 220's/130's. He was given hydralazine. He was started on an esmolol gtt. He was noted to have a very large aneurysmal AV fistula which was actively expanding. Transplant surgery was called who resected the right brachial artery aneurysm. He had then a placement of a double lumen 14.5 French tunneled hemodialysis catheter. MICU COURSE: Patient was admitted to the MICU with HTN emergency with AMS in setting of initial BP 220/130 while at HD appeared confused and combative. He was started on labetolol gtt and intubated for airway protection. His tox screen was negative, head MRI was negative. He was extubated on [**2189-9-4**]. His infection work-up was negative. He started to walk and mental status was at baseline. The change in mental status may be attributed to eleveated blood pressures as well as his kidney failure and missed [**Date Range 2286**]. On [**2189-9-6**] he was then admitted to the medicine service. While on floor, pt was mentating well, denied any complaints, no HA/Visual changes, no confusion. No CP/Palp, no SOB. He was on lisinopril, toprol, and hydralazine and his systolic blood pressures were in the range of 140-150. Because of potential compliance difficulties, hydralazine was discontinued and amolodipine 5mg daily was started in addition to troprol 100mg daily and lisinopril 40mg daily. He will followup with a new PCP one day after discharge. Pt refused to stay one more day for BP monitoring. On the MRA scan which was done for the work-up of his mental status changes, a 4mm anterior communiting aneurysm was incidentally found. Neurosurgery was consulted who recommended an outpatient follow-up with Dr. [**First Name (STitle) **] ([**Telephone/Fax (1) 1669**]) in 1 week. He will follow-up in transplant clinic on [**9-17**] for removal of his staples and evaluation of his aneurysmal fistula. He will receive HD via a portacath and will continue on Mon-Wed-Friday HD at his regular [**Hospital 3782**] clinic. He also has chronic anemia likely [**12-19**] to his renal disease. Per renal recommendation, iron studies were sent and he will follow-up with his PMD to investigate other causes for his anemia. His Hct was stable throughout this admission but was lowest on discharge at 25. Pt refused to stay for further evaluation. He will receive epo at outpt HD as indicated, though this may continue to exacerbate his HTN. Medications on Admission: 1. Lisinopril 40mg daily 2. Prednisone 5mg daily 3. PhosLo 1334mg tid with meals 4. Metoprolol XL 100mg daily - STOPPED 3MONTHS PTA Discharge Medications: 1. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 2. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO three times a day: to help decrease phosphorous. Disp:*180 Tablet(s)* Refills:*2* 4. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 5. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: 1. Emergency HTN 2. Acute mental status changes 3. Right brachial artery aneurysm 4. ESRD 5. Alport's syndrome 6. 4mm anterior communicating artery aneurysm 7. Anemia Discharge Condition: Improved VS: T99 BP148/90 HR82 RR18 O2Sat99%RA Discharge Instructions: You were admitted to the hospital for acute mental status changes and high blood pressure. You received antihypertensive medications and your blood pressure improved. You aneurysm in your right arm was expanding during your hospital stay and you had vascular surgery to remove the aneurysm. A new hemodialysis catheter was placed in your right chest. You need to follow-up with vascular surgery for removal of your staples. An anterior communicating artery aneurysm was incidentally found on a MRA scan while you were in the hospital. You need to follow-up with neurosurgery for further care. Please contact your PCP or come directly to the ED if you experience fever, unresolved headaches, blurry vision, changes in your mental status, or shortness of breath. Followup Instructions: 1. You have a follow-up appoitment with your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], on Tuesday, [**9-8**], at 3PM. Location is [**Location (un) **] of [**Hospital Ward Name 23**] Building. If you have any questions, please call [**Telephone/Fax (1) 250**]. 2. You have a follow-up appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**], Transplant surgery, on Thursday, [**9-17**], at 10:45AM. If you have any questions, please call [**Telephone/Fax (1) 673**]. 3. Neurosurgery follow-up with Dr. [**First Name (STitle) **] in 1 week. [**Telephone/Fax (1) 102898**]. [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]

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icd9cm

[ [ [] ] ]

[ "96.71", "96.04", "38.43", "39.95" ]

icd9pcs

[ [ [] ] ]

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33831

Discharge summary

report

Admission Date: [**2124-1-31**] Discharge Date: [**2124-2-2**] Date of Birth: [**2078-8-7**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 949**] Chief Complaint: Variceal Bleed Major Surgical or Invasive Procedure: Endoscopic banding History of Present Illness: 5 yo M w/ ETOH hepatitis & cirrhosis (last drink 11pm night PTA [**1-30**]) c/b ascites, PSE, portal HTN, esophageal varices, PUD, subacute pancreatitis, and HTN who was admitted [**1-31**] from [**Hospital3 **] where he p/w melena & BRBPR. Per report, patient had melena for the past few days. Last night he was sleeping and woke up in a "pool of bright red blood". He went to the bathroom, had LOC and awoke again in a pool of blood. EMS was called and he was taken to [**Hospital3 **]. At [**Hospital1 46**], patient was tachycardic and had HCT of 20, given 1u PRBC, started on octreotide gtt and x-fer to [**Hospital1 18**] where protonix gtt was added and pt received 2u PRBC before x-fer to MICU. Denies hx DTs/ w/d seizures. Still actively drinking. Had EGD in MICU on [**1-31**] which showed 3 cords of grade II varices, which were banded x2. He also had a hiatal hernia and findings c/w portal HTN-ive gastropathy and blood in the stomach body. He continued on octreotide and protonix ggts and was x-fer to [**Doctor Last Name 3271**]-[**Doctor Last Name 679**] in stable condition. Past Medical History: PAST MEDICAL HISTORY: - ETOH hepatitis/cirrhosis, portal hypertension, esophageal varices - Subacute pancreatitis - Hypertension PAST SURGICAL HISTORY: Appendectomy Repeated surgeries for facial trauma Unknown surgery on bilateral shoulders Social History: Heavy ETOH abuse with binge drinking episodes. He is single with no children, past smoker. Last drink was one week ago, previously drank one 6 pack per day, +/- whiskey. Now drinks 2 beers before bed, +/- shot. Livers with his mother. [**Name (NI) 1403**] as a grocery clerk. Family History: CAD, father deceased at 64, grandfather deceased at 61, both from MI Physical Exam: Vitals: T:100.4 BP:150/77 P:93-102 R: 15 O2:100% RA General: A & O x3. Mild tremor with outstreatched hands. HEENT: Sclera anicteric, dry mm, oropharynx clear. Lips slightly assymmetric but pt reports had severe accident to face previously. Nystagmus with poor accomodation of right eye. Neck: supple, no LAD Lungs: Clear to auscultation bilaterally anteriorly CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: + bs, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly, ? very fluid shift <2cm on exam Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CN exam notable for Lips slightly assymmetric but pt reports had severe accident to face previously. Nystagmus with poor accomodation of right eye. Otherwise CN II-XII intact (did not check pupil reaction). UE reflexes +2. Sensation grossly intact. LE strength 5/5. . Pertinent Results: ADMISSION [**2124-1-31**] 07:40AM BLOOD WBC-2.1*# RBC-2.34* Hgb-6.1* Hct-19.6* MCV-84 MCH-26.0* MCHC-31.0 RDW-18.5* Plt Ct-69* [**2124-1-31**] 07:40AM BLOOD Neuts-75.8* Lymphs-14.1* Monos-8.1 Eos-1.3 Baso-0.7 [**2124-1-31**] 07:40AM BLOOD PT-18.3* PTT-35.0 INR(PT)-1.7* [**2124-1-31**] 07:40AM BLOOD Glucose-90 UreaN-14 Creat-0.6 Na-143 K-4.3 Cl-110* HCO3-20* AnGap-17 [**2124-1-31**] 07:40AM BLOOD ALT-17 AST-56* LD(LDH)-184 CK(CPK)-187* AlkPhos-106 TotBili-3.0* [**2124-1-31**] 07:40AM BLOOD CK-MB-4 cTropnT-<0.01 [**2124-1-31**] 07:40AM BLOOD Albumin-2.8* Calcium-7.4* Phos-3.5 Mg-1.7 [**2124-1-31**] 07:40AM BLOOD ASA-NEG Ethanol-29* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG DC labs [**2124-2-2**] 12:18PM BLOOD Hct-27.2* [**2124-2-2**] 05:00AM BLOOD WBC-3.0* RBC-3.29* Hgb-8.9* Hct-27.6* MCV-84 MCH-27.1 MCHC-32.2 RDW-17.8* Plt Ct-60* [**2124-2-2**] 05:00AM BLOOD PT-16.9* PTT-35.2* INR(PT)-1.5* [**2124-2-2**] 05:00AM BLOOD ALT-15 AST-44* AlkPhos-82 TotBili-4.9* [**2124-2-2**] 05:00AM BLOOD Calcium-7.8* Phos-3.3 Mg-1.9 EGD [**2124-1-31**]: -Varices at the lower third of the esophagus (ligation) -Hiatal hernia -Friability, erythema, congestion and mosaic appearance in the fundus and stomach body compatible with portal hypertensive gastropathy -Blood in the stomach body -Otherwise normal EGD to third part of the duodenum Brief Hospital Course: 45 yo M w/ active EtOH-ism, ETOH hepatitis/cirrhosis, portal HTN, cirrhosis is c/b esophageal w/ multiple banding in past, PUD, HTN, p/w melena and BRB (hematemesis). Pt treated with EGD w/ variceal banding x2 and octreotide drip x 3 days. Discharged with counselling (meds and etoh abstinence), ppi and cipro ppx . 1. Upper GI Bleed- This was caused by varices. He was not taking his nadolol in a strict fashion. He was hemodynamically stable with stable hematocrit for 48 hours prior to discharge. He was discharged on nadolol, ppi [**Hospital1 **] and cipro for post-GI bleed ppx 2. ETOH hepatitis, cirrhosis: MELD 17, Meld-Na 19; [**Last Name (un) 26460**] 29 on discharge. SW consulted, patient aware of resources for help. Discharged on home nadolol, spironolactone, and lactulose. Also MVI, thiamine, folate - IVF if not taking adequate PO TO BE FOLLOWED Patient requires repeat banding in mid [**Month (only) **]. reassess the need for ppi [**Hospital1 **] Medications on Admission: lactulose 30ml TID nadolol 20mg daily omeprazole 40mg once daily spironolactone 50mg daily sucralfate 10ml [**Hospital1 **] Discharge Medications: 1. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 3 days. Disp:*6 Tablet(s)* Refills:*0* 7. Spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a day. 8. Lactulose 10 gram/15 mL Solution Sig: Thirty (30) mL PO three times a day: titrate to [**4-14**] loose BM's daily. 9. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary Variceal Bleed Etoh hepatitis and cirrhosis EtOH abuse Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: You were admitted with a bleed from your esophagus. You were banded. This is a procedure that MUST be repeated in [**Month (only) **]. You must take antibiotics and your nadolol as prescribed. The reason for your admission was directly related to alcohol; we all wish you strength to overcome it, but if you need help, you come in, call the social worker or Dr.[**Name (NI) 948**] office. We are there for you. . CONTINUE Nadolol NEW MEDICATION Ciprofloxacin - take as directed for the full course HOLD Spironolactone . You should hold the spironolactone and check your weight daily. If your weight has gone up 3 or more pounds from your current weight on discharge, please call Dr.[**Name (NI) 948**] or [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 78204**] office at [**Telephone/Fax (1) 2422**]. Followup Instructions: Provider: [**Name10 (NameIs) **] [**Apartment Address(1) **] (ST-3) GI ROOMS Date/Time:[**2124-2-22**] 7:30 [**Location (un) **] of [**Hospital Ward Name 1950**] building [**Location (un) **] [**Location (un) 86**], MA Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2124-2-22**] 7:30 Provider: [**First Name11 (Name Pattern1) 674**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 13146**] Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2124-2-24**] 3:00 Completed by:[**2124-2-2**]

[ "537.89", "571.1", "456.20", "401.9", "789.59", "305.1", "571.2", "303.01", "572.3", "572.2", "285.1", "577.0", "531.90" ]

icd9cm

[ [ [] ] ]

[ "94.62", "42.33" ]

icd9pcs

[ [ [] ] ]

6512, 6518

4446, 5416

327, 348

6628, 6628

3080, 4423

7616, 8201

2045, 2116

5590, 6489

6539, 6607

5442, 5567

6773, 7593

1644, 1735

2131, 3061

273, 289

376, 1469

6642, 6749

1513, 1621

1751, 2029

75,808

181,444

7248

Discharge summary

report

Admission Date: [**2126-4-30**] Discharge Date: [**2126-5-6**] Date of Birth: [**2062-10-24**] Sex: F Service: CARDIOTHORACIC Allergies: Ampicillin / Bactrim / Demerol / atenolol / Latex Attending:[**First Name3 (LF) 1505**] Chief Complaint: Fatigue/Dyspnea/Chest pain Major Surgical or Invasive Procedure: [**2126-4-30**] - Redo Sternotomy with AVR(19mm St. [**Male First Name (un) 923**] Mechanical valve), aortic endarterectomy. History of Present Illness: 63 year female status post CABGx3 in [**2113**] now with severe aortic stenosis. She has been followed by serial echocardiograms which now show that her aortic stenosis is critical. A cardiac catheterization was performed in anticipation of surgery which showed native three vessel disease and an 80% lesion in the vein graft to her obtuse marginal artery. She is symptomatic with dyspnea on exertion and fatigue. Given the progression of her disease, she has now been referred for surgical management. Seen originally in early [**Month (only) 547**], she presents today for PATs/consent. Past Medical History: Coronary artery disease Aortic stenosis Hyperlipidemia Tobacco abuse Hypertension Diabetes Mellitus type 2 Abdominal Aortic Aneurysm 4.9cm neuropathy spinal stenosis/disc dz/chr. back pain obesity PNA (this winter) GERD Past Surgical History: CABGx3 [**2113**] TAH/BSO appendectomy cholecystectomy tonsillectomy Social History: Last Dental Exam:[**11-9**] Lives with:alone Occupation:retired RN Tobacco: Continues to smoke 1 ppd-- quit [**2126-4-2**] ETOH:none Family History: father with CHF/MI at 40 Physical Exam: Pulse:96 Resp: 18 O2 sat: 96% B/P Right: 145/83 Left: 156/86 Height: 5'3 [**12-2**] " Weight:216 General: obese, anxious/tearful Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x]anicteric sclera;OP unremarkable Neck: Supple [x] Full ROM [x]no JVD Chest: Lungs clear bilaterally [x]well-healed sternotomy Heart: RRR [x] Irregular [] Murmur- 3/6 SEM radiates to carotids Abdomen: Soft [x] non-distended [x] non-tender [x] obese; healed scars, bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema: 1+ bilaterally Varicosities: None [x- spider veins]; well healed saphenect. incision right ankle to top thigh Neuro: Grossly intact; MAE [**4-4**] strengths; nonfocal exam Pulses: Femoral Right: 2+ Left:1+ DP Right: 1+ Left: NP PT [**Name (NI) 167**]: 1+ Left: 1+ Radial Right: 2+ Left: 2+ Carotid Bruit murmur radiates to B carotids Pertinent Results: [**2126-4-30**] ECHO PRE-BYPASS: The left atrium is dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). The basal inferior and inferoseptal are severely hypokinetic. Right ventricular chamber size and free wall motion are normal. There is critical aortic valve stenosis (valve area <0.8cm2). The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. Minimal TR or PI. There is no pericardial effusion. Dr. [**Last Name (STitle) **]/[**Doctor First Name **] was notified in person of the results before surgical incision. POST-BYPASS: Preserved biventricular sytolic function. Intact thoracic aorta. The aortic mechanical prosthesis is in place and is functioing well, residual mean gradient of 20mm of Hg with usual washour jets. No perivalvular leaks seen. [**2126-5-6**] 05:19AM BLOOD WBC-12.0* RBC-3.09* Hgb-9.7* Hct-27.7* MCV-90 MCH-31.2 MCHC-34.8 RDW-15.6* Plt Ct-234 [**2126-5-5**] 05:53AM BLOOD WBC-10.8 RBC-2.92* Hgb-9.0* Hct-26.4* MCV-90 MCH-30.7 MCHC-34.0 RDW-15.4 Plt Ct-204 [**2126-5-6**] 05:19AM BLOOD PT-27.8* INR(PT)-2.7* [**2126-5-5**] 05:53AM BLOOD PT-34.6* PTT-28.3 INR(PT)-3.5* [**2126-5-4**] 05:03AM BLOOD PT-45.1* INR(PT)-4.7* [**2126-5-3**] 09:49PM BLOOD PT-38.4* INR(PT)-3.9* [**2126-5-3**] 04:16AM BLOOD PT-23.4* PTT-25.0 INR(PT)-2.2* [**2126-5-2**] 05:30AM BLOOD PT-14.8* PTT-22.2 INR(PT)-1.3* [**2126-5-1**] 12:27AM BLOOD PT-13.5* PTT-23.2 INR(PT)-1.1 [**2126-4-30**] 04:08PM BLOOD PT-14.1* PTT-25.5 INR(PT)-1.2* [**2126-4-30**] 02:27PM BLOOD PT-14.5* PTT-26.2 INR(PT)-1.2* [**2126-5-6**] 05:19AM BLOOD Glucose-122* UreaN-34* Creat-1.1 Na-135 K-4.2 Cl-96 HCO3-30 AnGap-13 [**2126-5-5**] 05:53AM BLOOD UreaN-38* Creat-1.2* Na-137 K-4.3 Cl-98 HCO3-32 AnGap-11 [**2126-5-4**] 05:03AM BLOOD Glucose-115* UreaN-38* Creat-1.3* Na-134 K-4.3 Cl-96 HCO3-28 AnGap-14 [**2126-5-6**] 05:19AM BLOOD Mg-2.0 [**2126-5-4**] 05:03AM BLOOD Calcium-8.4 Phos-2.8 Mg-2.2 Brief Hospital Course: Ms. [**Known lastname 26812**] was admitted to the [**Hospital1 18**] on [**2126-4-30**] for surgical management of her valvular disease. She was taken directly to the operating room where she underwent a redo sternotomy with replacement (Mechanical valve) of her aortic valve and an aortic endarterectomy. Please see operative note for details. Postoperatively she was taken to the intensive care unit for monitoring. Over the next 24 hours, she awoke neurologically intact and was extubated. Coumadin was initiated for her mechanical valve. She was transferred to the step down unit for further recovery. She was gently diuresed towards her preoperative weight. The physical therapy service was consulted for assistance with her postoperative strength and mobility. By the time of discharge on POD 6 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to home with VNA in good condition with appropriate follow up instructions. Dr. [**First Name (STitle) **] will follow INR/coumadin dosing. Medications on Admission: CONJUGATED ESTROGENS [PREMARIN] - (Prescribed by Other Provider) - 0.625 mg Tablet - 1 Tablet(s) by mouth three time weekly mon wed fri GLIPIZIDE - (Prescribed by Other Provider) - 5 mg Tablet - 1 Tablet(s) by mouth once a day HYDROCHLOROTHIAZIDE - (Prescribed by Other Provider) - 25 mg Tablet - 1 Tablet(s) by mouth once a day LISINOPRIL - (Prescribed by Other Provider) - 20 mg Tablet - 1 Tablet(s) by mouth once a day METFORMIN - (Prescribed by Other Provider) - 1,000 mg Tablet - 1 Tablet(s) by mouth twice a day MORPHINE [MS CONTIN] - (Prescribed by Other Provider) - 30 mg Tablet Extended Release - 1 Tablet(s) by mouth three times a day ROSUVASTATIN [CRESTOR] - (Prescribed by Other Provider) - 40 mg Tablet - 1 Tablet(s) by mouth once a day TOLTERODINE [DETROL] - (Prescribed by Other Provider) - 2 mg Tablet - 1 Tablet(s) by mouth twice a day Medications - OTC ASPIRIN - (Prescribed by Other Provider) - 325 mg Tablet - 1 Tablet(s) by mouth once a day ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - (Prescribed by Other Provider) - 2,000 unit Capsule - 1 Capsule(s) by mouth twice a day MULTIVITAMIN-MINERALS-LUTEIN [CENTRUM SILVER] - (Prescribed by Other Provider) - Tablet - 1 Tablet(s) by mouth once a day Discharge Medications: 1. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*0* 2. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 3. morphine 30 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO Q8H (every 8 hours). Disp:*60 Tablet Extended Release(s)* Refills:*0* 4. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*120 Tablet(s)* Refills:*0* 5. tolterodine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 6. rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* 7. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 12. 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* 13. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 14. glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 15. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 1 weeks. Disp:*7 Tablet(s)* Refills:*0* 16. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO once a day for 1 weeks. Disp:*14 Tablet Extended Release(s)* Refills:*0* 17. warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: Dose may change, Dr. [**First Name (STitle) **] to manage for goal INR 2.5-3.0. Disp:*30 Tablet(s)* Refills:*2* 18. Outpatient Lab Work Labs: PT/INR Coumadin for mechanical AVR Goal INR 2.5-3.0 First draw [**2126-5-7**] Results to Dr. [**First Name (STitle) **], phone: [**Telephone/Fax (1) 13553**] (fax- [**Telephone/Fax (1) 26813**]) Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: Coronary artery disease Aortic stenosis Hyperlipidemia Tobacco abuse Hypertension Diabetes Mellitus type 2 Abdominal Aortic Aneurysm 4.9cm neuropathy spinal stenosis/disc dz/chr. back pain obesity PNA (this winter) GERD 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 +1 Discharge Instructions: 1) Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage. 2) Please NO lotions, cream, powder, or ointments to incisions. 3) Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart provided. 4) No driving for approximately one month and while taking narcotics. Driving will be discussed at follow up appointment with surgeon when you will likely be cleared to drive. 5) No lifting more than 10 pounds for 10 weeks 6) Please call with any questions or concerns [**Telephone/Fax (1) 170**] *Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 1504**], [**2126-5-30**] 1:00 Cardiologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4455**], [**6-4**] at 10:45am WOUND CARE NURSE Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2126-5-14**] 10:15 During pre-op eval chest CT obtained revealed Sub 4mm pulmonary nodule. PT has recently quit smoking. Radiology reccomended f/u chest CT in 12 months if continues to be high risk. Please call to schedule appointments with your Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 13553**] in [**3-5**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Labs: PT/INR Coumadin for mechanical AVR Goal INR 2.5-3.0 First draw [**2126-5-7**] Results to Dr. [**First Name (STitle) **], phone: [**Telephone/Fax (1) 13553**] (fax- [**Telephone/Fax (1) 26813**]) Plan confirmed with [**Doctor First Name 7019**] [**5-2**] Completed by:[**2126-5-6**]

[ "272.4", "305.1", "414.00", "424.1", "441.4", "278.00", "356.9", "401.9", "V45.81", "458.29", "530.81", "285.9", "250.00" ]

icd9cm

[ [ [] ] ]

[ "00.40", "35.22", "38.14", "39.61" ]

icd9pcs

[ [ [] ] ]

9386, 9461

4852, 5928

343, 470

9725, 9938

2549, 4829

10912, 12060

1591, 1618

7207, 9363

9482, 9704

5954, 7184

9962, 10889

1354, 1424

1633, 2530

277, 305

498, 1089

1111, 1331

1440, 1575

25,049

185,904

10615

Discharge summary

report

Admission Date: [**2145-11-2**] Discharge Date: [**2145-11-7**] Date of Birth: [**2078-1-6**] Sex: M Service: ORTHOPAEDICS Allergies: Vicodin / Ms Contin / Gabapentin Attending:[**First Name3 (LF) 64**] Chief Complaint: On presentation to ICU: Hypotension after right THA Major Surgical or Invasive Procedure: Right total hip arthroplasty History of Present Illness: 67 yo M with complicated past medical history who had an elective total right hip arthroplasty earlier today. During the surgery he received 3500 mL of crystalloid and had 965 mL of UOP. He was reported to have an EBL of 600 mL. He was noted to be hypotensive in the PACU following the operation and was given a single unit of PRBC with little effect on blood pressure. His HCT was measured as 30.4 after that unit of blood (down from baseline HCT of 33.8 pre-op). Additionally, patient had very low urine output of < 5 mL/hr. He was placed on phenylephrine peripherally to support his blood pressure and a transfer to the ICU was requested. The PACU anesthesia attending was concerned about fluid status and possibility of volume overload given that patient is an extremely difficult intubation and has required fiberoptic intubation in the past. ROS: (+)ve: fatigue, right groin pain, dry mouth, hunger (-)ve: fever, chills, sweats, chest pain, palpitations, orthopnea, paroxysmal nocturnal dyspnea, constipation, diarrhea, sore throat, myalgias, nausea, vomiting Past Medical History: 1) Diabetes mellitus II c/b neuropathy, nephropathy, retinopathy 2) Chronic diastolic CHF 3) Chronic kidney disease (baseline Cr 2.4 - 2.8) 4) OSA (Mask Choice: Swift II NV, DME Ordered: BiPAP 14/11; EERS 100, 4L O2) 5) Polyneuropathy (hand and feet) 6) Spinal stenosis 7) Severe degenerative arthritis 8) Anemia of chronic disease 9) Chronic restrictive ventilatory disease secondary to a bile duct 10) Leak with pulmonary fibrosis requiring decortication 11) PVD w/ ower extremity claudication 12) Benign prostatic hyperplasia 13) Glaucoma; on carbonic anhydrase inhibitor 14) Bilateral cataracts s/p surgical removal 15) Depression 16) Erectile dysfunction s/p penile implant [**11-6**] . PAST SURGICAL HISTORY: 1) [**2138**] Roux-en-y reconstruction after laparoscopic cholecystectomy c/b damage to CBD 2) [**2139**] Decortication for fibrothorax complicated by respiratory failure requiring tracheostomy. 3) Appendectomy. 4) Left knee/hip replacement 5) L shoulder AC recection Social History: Patient is a retired manager from the Polaroid companyx26 years, referee in four sportsx40yrs (recently had to give up due to health issues), lives in [**Hospital1 **] with wife. [**Name (NI) **] 3 children, in good health, 4 grandchildren. EtOH use: occasional beer, no smoking, no illicit drug use. Patient uses walker to get around or electronic wheelchair. Family History: Brother-[**Name (NI) 2320**], h/o several strokes. Mother-dead in 70's from breast cancer. Father-dead at 61 from complications of emphysema, CHF. All children in good health. Physical Exam: Exam on presentation to ICU: VS: T 97.8, HR 87, BP 91/56, RR 12, O2Sat 100% 2L NC GENERAL: NAD aside from occasional right groin pain HEENT: PERRL, EOMI, no conjunctival pallor, no scleral icterus, oral mucosa and lips extremely dry NECK: Supple, No LAD, No thyromegaly, no JVP elevation CARDIAC: RR, distant heart sounds, nl S1, nl S2, no M/R/G LUNGS: attenuated and decreased anterior breath sounds with basilar crackles noted at midaxillary line bilaterally and anterior, unable to obtain posterior exam due to patient positioning ABDOMEN: Obese, BS+, soft, NT, distended, tympanitic EXTREMITIES: Trace bipedal edema, compression stockings and pneumoboots in place, right hip with large C/D/I bandage overlying, right thigh soft though tender in right groin area, bilateral radial pulses and hand cap refill preserved SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: [**2145-11-2**] 01:22PM WBC-18.4*# RBC-3.40* HGB-10.7* HCT-30.4* MCV-89 MCH-31.4 MCHC-35.2* RDW-13.7 [**2145-11-2**] 01:22PM PLT COUNT-220 [**2145-11-2**] 01:22PM GLUCOSE-230* UREA N-92* CREAT-2.8* SODIUM-138 POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-28 ANION GAP-14 [**2145-11-2**] 01:22PM CALCIUM-8.2* PHOSPHATE-5.4*# MAGNESIUM-2.2 [**2145-11-2**] 10:36PM HCT-28.9* [**2145-11-2**]: Right hip film: Since the study of [**2145-3-10**], the patient has undergone a total hip arthroplasty. The current films are somewhat limited by exposure. The metallic components are in expected position. There is a cerclage wire at the level of the lesser trochanter. The penile prosthesis is partially visualized. IMPRESSION: There has been a total hip arthroplasty. [**2145-11-5**] 07:00AM BLOOD Hct-26.2* [**2145-11-4**] 12:35PM BLOOD Hct-28.5* [**2145-11-3**] 11:43AM BLOOD Hct-28.3* [**2145-11-3**] 03:50AM BLOOD WBC-23.0* RBC-3.00* Hgb-9.4* Hct-27.0* MCV-90 MCH-31.3 MCHC-34.8 RDW-14.3 Plt Ct-199 [**2145-11-2**] 10:36PM BLOOD Hct-28.9* Brief Hospital Course: MICU course: 67 year old male with complicated past medical history who had an elective total right hip arthroplasty on [**2145-11-2**]. #. Post Operative Hypotension: He had post-operative hypotension requiring phenylephrine to keep mean blood pressure in the 60s. His hypotension was associated with urine output less than 5 mL/hr. He was felt to be hypovolemic and was fluid resuscitated with approximately 2 liters of LR. It was felt that he was likely third spacing after his hip surgery. Post-operatively his hematocrit dropped slightly and he was also given 1 unit of blood. #. Hip fracture: His pain was relatively well-controlled, initially with a Dilaudid PCA and then with oral Dilaudid prn. He was also given Valium for anxiety and muscle spasms. He was given two doses of Vancomycin post-operatively. His JP drain was pulled on POD 1. #. Acute on chronic renal failure: His creatinine increased slightly from baseline (2.8 to 3.5) after admission, most likely of prerenal etiology due to volume depletion. It trended down with IV fluids. #. Code Status: Full Code Floor course The patient was initially treated with a PCA followed by PO pain medications on POD#1. The patient received IV antibiotics for 24 hours postoperatively, as well as lovenox for DVT prophylaxis starting on the morning of POD#1. The drain was removed without incident on POD#1. The Foley catheter was removed without incident on POD 4 after a voiding trial. The surgical dressing was removed on POD#2 and the surgical incision was found to be clean, dry, and intact without erythema or purulent drainage. While in the hospital, the patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was stable, and the patient's pain was adequately controlled on a PO regimen. The operative extremity was neurovascularly intact and the wound was benign. The patient was discharged to home with services or rehabilitation in a stable condition. The patient's weight-bearing status was weight bearing as tolerated with posterior precautions. Medications on Admission: 1) Calcitriol 0.5 mg 2) Cozaar 50 mg daily 3) Finasteride 5 mg daily 4) Tamsulosin 0.8 mg at supper daily 5) Furosemide 80 mg TID 6) Lamotrigine 225 mg daily 7) Metolazone 2.5 mg PRN 8) Pantoprazole 40 mg daily 9) Simvastatin 10 mg QHS 10) Pramipexole 0.125 mg QHS 11) Oxycodone 5/325 1-2 tabs Q8H:PRN pain 12) Insulin glargine 18 units QHS 13) Insulin lispro sliding scale 14) Ipratropium bromide 1 spray each nostril TID:PRN rhinorrea 15) Ketoconazole 2% cream 16) Lactulose 1 tsp [**Hospital1 **]:PRN constipation 17) Aspirin 325 daily 18) Iron 65 mg daily 19) Omega 3 1200 mg TID 20) Miralax 1 tsp PRN constipation Allergies: Vicodin/MSContin/Gabapentin Discharge Medications: 1. Lovenox 40 mg/0.4 mL Syringe Sig: One (1) vial Subcutaneous once a day for 21 days. Disp:*21 vials* Refills:*0* 2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for Pain. 3. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q 8H (Every 8 Hours). 4. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal [**Hospital1 **] (2 times a day). 5. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for spasm. 6. Pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO QD () for 5 days. 7. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for edema. 8. Lamotrigine Oral 9. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for dyspnea or wheezing. 10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for for pain. Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: Right hip OA Discharge Condition: good Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. experience severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers >101.5, shaking chills, redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your PCP regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not operate heavy machinery or drink alcohol when taking these medications. As your pain improves, please decrease the amount of pain medication. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (e.g., colace) as needed to prevent this side effect. 5. You may not drive a car until cleared to do so by your surgeon or your primary physician. 6. Please keep your wounds clean. You may get the wound wet or take a shower starting 5 days after surgery, but no baths or swimming for at least 4 weeks. No dressing is needed if wound continues to be non-draining. Any stitches or staples that need to be removed will be taken out by a visiting nurse at 2 weeks after your surgery. 7. Please call your surgeon's office to schedule or confirm your follow-up appointment at 4 weeks. 8. Please DO NOT take any NSAIDs (i.e. celebrex, ibuprofen, advil, motrin, etc). 9. ANTICOAGULATION: Please continue your lovenox for 3 weeks to prevent deep vein thrombosis (blood clots). Thrn take aspirin 325mg teice a day for 3 weeks. 10. WOUND CARE: Please keep your incision clean and dry. It is okay to shower after POD#5 but do not take a tub-bath or submerge your incision until 4 weeks after surgery. Please place a dry sterile dressing on the wound each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed by VNA in 2 weeks. If you are going to rehab, the rehab facility can remove the staples at 2 weeks. 11. VNA (once at home): Home PT/OT, dressing changes as instructed, wound checks, and staple removal at 2 weeks after surgery. 12. ACTIVITY: Weight bearing as tolerated on the operative leg. No strenuous exercise or heavy lifting until follow up appointment. Physical Therapy: weight bearing as tolerated with posterior precautions Treatments Frequency: WOUND CARE: Please keep your incision clean and dry. It is okay to shower after POD#5 but do not take a tub-bath or submerge your incision until 4 weeks after surgery. Please place a dry sterile dressing on the wound each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed by VNA in 2 weeks. If you are going to rehab, the rehab facility can remove the staples at 2 weeks. VNA (once at home): Home PT/OT, dressing changes as instructed, wound checks, and staple removal at 2 weeks after surgery. Followup Instructions: Provider: [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3260**], [**MD Number(3) 3261**]:[**Telephone/Fax (1) 1228**] Date/Time:[**2145-12-10**] 12:00 Completed by:[**2145-11-7**]

[ "428.0", "440.4", "250.40", "428.32", "250.50", "285.1", "362.01", "998.0", "715.95", "583.81", "585.9", "250.60", "285.29", "357.2", "458.29", "311", "584.9", "327.23", "440.21", "E878.1" ]

icd9cm

[ [ [] ] ]

[ "81.51" ]

icd9pcs

[ [ [] ] ]

9089, 9161

5184, 7442

346, 376

9218, 9225

4122, 5161

12368, 12601

2877, 3054

8151, 9066

9182, 9197

7468, 8128

9249, 10883

2211, 2482

3069, 4103

11652, 11707

11729, 11729

255, 308

11741, 12345

404, 1472

1494, 2188

2498, 2861

5,698

134,480

49853

Discharge summary

report

Admission Date: [**2105-10-8**] Discharge Date: [**2105-10-27**] Date of Birth: [**2043-11-8**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7591**] Chief Complaint: Hypoxia Major Surgical or Invasive Procedure: Tracheostomy Central venous line placement History of Present Illness: 61 y.o. f w/ NHL who was admitted to [**Hospital1 18**] on [**10-7**] after presenting with worsening SOB. Rec'd chemotherapy on day of admission, adriamycin, vinblastine, and dacarbazine- bleomycin being held [**2-11**] decreased pfts and concern for bleomycin induced lung toxicity. Tolerated chemotx well by notes but continued to have increasing SOB, progressive since one week PTA. Denied cp/cough/fever at that time. . Pt was dc'd from [**Hospital1 18**] on [**9-10**] after she had presented w/ 3wk of gradually worsening SOB. underwent bronchoscopy which was negative for PCP. [**Name Initial (NameIs) **] [**2-11**] bleomycin-induced lung injury. Prednisone was initiated at 60mg daily w/ improvement. f/u pfts on [**9-16**] showed improved dlco (inc from 63% to 80%). pred was tapered down to 20mg, which is the dose the patient was on when he presented. No PCP [**Name Initial (PRE) 1102**]. . In [**Name (NI) **], pt noted to be more hypoxic than at baseline, in the mid 90s on 3-5L NC. by report, pt was comfortable at rest but w/ signficant DOE. rec'd levofloxacin. CT performed, felt c/w exacerbation of bleomycin associated lung injury and prednisone increased to 60mg qday. By report (no note available), nf evaluated for fever and dyspnea. CXR obtained, ABG. Called to see patient w/ respiratory distress. On 100% nrb, sao2 75%, transferred to ICU. . .. NKDA .. medications on transfer: 1. Colace 2. Verapamil SR 250 mg po q12h 3. Allopurinol 100 mg po qd 4. HCTZ 25 mg po qd 5. Lorazepam 0.5 mg po q4h PRN nausea 6. Prednisone 60mg daily. 7. Reglan prn 8. Protonix 40mg qday 9. Heparin SC Past Medical History: 1) Iron deficiency anemia, dx [**2105-3-17**] after ER visit for weakness 2) Cervical cancer status post a total vaginal hysterectomy without oophorectomy about [**2088**]. No chemo/xrt. noted on routine pap, no symptoms. 3) HTN 4) Osteoarthritis s/p L knee replacement. 5) Hypercholesterolemia but pt reports her medications were stopped 6) H. pylori found on endoscopy, status post treatment Onc history: interfollicular variant non-Hodgkin's lymphoma with bulky retroperitoneal lymphadenopathy and B symptoms diagnosed in [**4-14**] finished day 15 cycle 4 of ABVD on [**9-2**] . Social History: Lives at home with her two grandsons and has a homemaker help her once per week. In the past worked for [**Hospital1 18**] Home Care. Denies tobacco, etoh, drugs. The patient has not been sexually active for many years. She denies any history of illicit drug abuse. She has never had a blood transfusion. Family History: Father died of MI in 50s Brother with DM and PVD Sister with PVD and heart failure Physical Exam: T98.2; hr 120 ; bp 115/75; rr 45; 83% on 100% nrb Elderly female in obvious resp distress, utilizing acc mm, paradoxical respiration. Alert and oriented. PERRL OP clr JVP not appreciable, [**2-11**] elev resp rate. b/l coarse basilar rales +bs. soft. nt. nd. no le edema no clubbing/cyanosis. Pertinent Results: 136 98 15 / 129 AGap=14 ------------ 3.5 28 0.7 Ca: 9.1 Mg: 2.0 P: 3.0 5.8 \ 9.9 / 135 ------ 28.8 PT: 12.6 PTT: 23.1 INR: 1.1 pH 7.50 pCO2 36 pO2 59 HCO3 29 BaseXS 4 Comments: Verified Provider Notified [**Name9 (PRE) **] [**Name9 (PRE) **] Lab Policy Type:Art Lactate:3.1 ALT: 36 AP: 64 Tbili: 0.5 Alb: 3.6 AST: 48 LDH: 437 Dbili: 0.2 TProt: Gran-Ct: 4010 Brief Hospital Course: 61 yo F w/ NHL, bleomycin induced lung toxicity, admitted w/ SOB in setting of tapering prednisone dose, now w/ hypoxic resp failure. 1) Hypoxic respiratory failure: Differential diagnosis was originally exacerbation of bleomycin induced lung injury, pneumocystis carinii pneumonia, chronic eosinophilic pneumonia, as well as atypical pneumoniaa. Patient was originally placed on steroids, broad-spectrum antibiotics, and a BAL was performed, which was negative for eosinophils or PCP. [**Name10 (NameIs) **] scan showed diffuse alveolar filling and interstitial fibrosis consistent with bleomycin toxicity. Over the course of several hospital days, patient developed several acute episodes of worsening hypoxia, mostly with agitation and with movement. A further workup was performed, which revealed pneumomediastinum seen on CXR, with subcutaneous emphysema and pneumomediastinum on CT with no abdominal perforation or pneumothorax. The pneumomediastinum was likely secondary to barotrauma, and resolved with serial CXRs. CTA done at the time was negative for a PE. She was placed on high dose steroids, then switched to a prednisone taper, for treatment of bleomycin toxicity. Patient also had an antibiotic course of ceftriaxone and azithromycin, which was stopped once cultures were negative. She was also on prophylactic doses of TMP-SMX for PCP [**Name Initial (PRE) 1102**]. An echo was performed to rule out a shunt as cause of hypoxia, and was found to be negative. A decompression needle was kept at the bedside for acute pneumothorax. Efforts were made to adjust patient's vent settings and to wean her oxygen to minimize bleomycin lung toxicity, but patient was unable to tolerate weaning with acute desaturations and episodes of hypoxia. Patient had a surgical tracheostomy placed, with efforts to wean oxygen and perhaps go to rehabilitation. However, she continued to have high oxygen requirements, and no improvement in her clinical status. The decision was made to withdraw care. 2) Neutropenic fever. Patient originally had a fever to 105 after the initial BAL, which was thought to be transient bacteremia. Cultures were all negative, and patient was originally placed on antibiotics, with blood glucose control and steroids. This was then later d/c'd when her clinical status improved. She continued to have fevers intermittently, with persistently negative cultures. Due to her functional neutropenia, she was placed on vancomycin and cefepime. She was then taken off her antibiotics, during which time she became hypotensive and tachycardic, requiring fluid boluses. She then was placed back on antibiotics, improved initially, but then continued to have hypotension and tachycardia. At that time, patient was made DNR/DNI, and she passed away several hours later. 3) NHL- Patient was on cycle [**5-15**] ABVD (without bleo). There were no acute/active issues regarding her lymphoma. Her LDH was followed. She was followed by hematology-oncology. 4) Anemia/thrombocytopenia/leukopenia: Her pancyopenia was thought to be secondary to recent chemotherapy vs marrow suppression from drugs or from her NHL. Her hematocrit was maintained above 25 with transfusions. She had no active source of bleeding. She was taken off her heparin when she developed thrombocytopenia, and a HIT antibody was checked, and was negative. She was then placed back on her heparin. She was given a course of neupogen as well, and remained on neutropenic precautions. 4) Htn: Her verapamil and HCTZ were held. 5) Glucose. Patient was placed on an ISS, and was placed on an insulin drip for better glucose control. Her blood sugars improved with decrease in steroid dose. . 6) F/E/N: Patient received tube feeds. She had an attempted PEG tube placement but had decreased oxygen saturations during the procedure, and it was aborted. She then had air under the diaphragm, and tube feeds were held for several days. Her electrolytes were repleted. . 7) Ppx: Heparin sc. PPI since on high-dose steroids . 8) ACCESS: Port a cath, peripheral. Subclavian and arterial line placed. The subclavian line was changed to an IJ. . 9) CODE: Patient was initially full code. She was then made DNR/DNI, and then comfort measures only. . 10) Comm: son, [**Name (NI) **] [**Telephone/Fax (1) 104163**] 11) Pain/sedation: Patient was on a fentanyl and versed drip. She was made comfortable. 12) Dispo: Patient expired in the hospital. Medications on Admission: HCTZ Verapamil Bactrim Prednisone Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Bleomycin lung toxicity Neutropenic fever Sepsis of unknown etiology Barotrauma with pneumomediastinum and subcutaneous emphysema Diarrhea Non-Hodgkin's lymphoma Thrombocytopenia Anemia Discharge Condition: Expired Discharge Instructions: None Followup Instructions: None

[ "518.84", "V43.65", "038.9", "998.81", "515", "250.00", "E930.7", "288.0", "V10.41", "202.80", "284.8", "401.9", "995.92" ]

icd9cm

[ [ [] ] ]

[ "45.13", "33.24", "96.72", "38.91", "38.93", "96.6", "31.1", "86.05", "96.04", "99.04" ]

icd9pcs

[ [ [] ] ]

8325, 8334

3791, 8212

324, 369

8563, 8572

3382, 3768

8625, 8632

2968, 3053

8296, 8302

8355, 8542

8238, 8273

8596, 8602

3068, 3363

277, 286

397, 1790

1815, 2020

2042, 2629

2645, 2952

43,337

161,880

5315

Discharge summary

report

Admission Date: [**2126-12-9**] Discharge Date: [**2126-12-13**] Date of Birth: [**2071-11-28**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Shortness of breath. Major Surgical or Invasive Procedure: s/p Aortic valve replacement(19mm tissue valve) [**2126-12-9**] History of Present Illness: 54 yo female with past medical history significant for bicuspid aortic valve and aortic valve stenosis. She has had worsening chest/jaw pain radiating to right arm with walking short distances/stairs. Low dose beta blockers has not helped. Pain is relieved with rest. She feels the severity has been worsening over the last 6 months. Patient denies SOB, dizziness, PND, edema or syncope. She is now admitted for elective aortic valve replacement. Past Medical History: Bicuspid aortic valve AS Hyperthyroidism-History of [**Doctor Last Name 933**] disease tonsillecotmy as a child right knee surgery 4 years ago hyperlipidemia-prescribed medication by PCP but [**Name9 (PRE) 15598**]'t take Laparoscopy Social History: Lives with: Husband, [**Name (NI) **] Occupation: IT specialist Tobacco: never ETOH: none Family History: coronary artery disease Physical Exam: Pulse: 80 reg Resp:20 O2 sat: 100% RA B/P Right: 144/49 Left: 138/62 Height: 4"11" Weight:61.2 kg General: WDWN female in NAD Skin: Warm [x] Dry [x] intact [x] HEENT: NCAT, PERRLA, EOMI, sclera anicteric, OP benign. Neck: Supple [x] Full ROM [x] No JVD Chest: Lungs clear bilaterally [x] Heart: RRR [x], Nl S1-S2, IV/VI SEM radiating to carotids Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] trace Edema Varicosities: None [x] Neuro: Grossly intact [X] Pulses: Femoral Right: +2 Left: +2 DP Right: +2 Left: +2 PT [**Name (NI) 167**]: +2 Left: +2 Radial Right: +2 Left: +2 Carotid Bruit Right: transmitted murmur Left: transmitted murmur Pertinent Results: [**2126-12-12**] 06:35AM BLOOD WBC-10.8 RBC-3.35* Hgb-9.8* Hct-30.5* MCV-91 MCH-29.4 MCHC-32.3 RDW-13.6 Plt Ct-173# [**2126-12-10**] 11:10PM BLOOD PT-13.4 PTT-34.0 INR(PT)-1.1 [**2126-12-12**] 06:35AM BLOOD Glucose-108* UreaN-8 Creat-0.5 Na-140 K-4.5 Cl-105 HCO3-29 AnGap-11 [**Known lastname 21672**],[**Known firstname **] [**Medical Record Number 21673**] F 55 [**2071-11-28**] Radiology Report CHEST (PORTABLE AP) Study Date of [**2126-12-10**] 11:14 PM [**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG CSRU [**2126-12-10**] 11:14 PM CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 21674**] Reason: s/p AVR w/hypotension r/o PTX/effusion [**Hospital 93**] MEDICAL CONDITION: 55 year old woman with as above REASON FOR THIS EXAMINATION: s/p AVR w/hypotension r/o PTX/effusion Final Report HISTORY: Hypotension status post AVR. FINDINGS: In comparison with study of earlier in this date, there is increasing opacification at both bases consistent with increasing atelectasis and effusion. DR. [**First Name11 (Name Pattern1) 1569**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 11006**] Approved: WED [**2126-12-11**] 10:25 AM [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 21672**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 21675**] (Complete) Done [**2126-12-9**] at 2:34:43 PM FINAL 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: [**2071-11-28**] Age (years): 55 F Hgt (in): 59 BP (mm Hg): 123/67 Wgt (lb): 135 HR (bpm): 82 BSA (m2): 1.56 m2 Indication: Intraoperative TEE for AVR. Aortic valve disease. Chest pain. Left ventricular function. Preoperative assessment. Right ventricular function. Valvular heart disease. ICD-9 Codes: 786.05, 424.1 Test Information Date/Time: [**2126-12-9**] at 14:34 Interpret MD: [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1510**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2010AW1-: Machine: AW1 Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm Left Ventricle - Ejection Fraction: 55% >= 55% Aorta - Ascending: *3.6 cm <= 3.4 cm Aortic Valve - Peak Velocity: *4.2 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: *72 mm Hg < 20 mm Hg Aortic Valve - Valve Area: *0.5 cm2 >= 3.0 cm2 Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. No ASD by 2D or color Doppler. LEFT VENTRICLE: Mild symmetric LVH. Normal regional LV systolic function. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Mildly dilated ascending aorta. Normal aortic arch diameter. Normal descending aorta diameter. AORTIC VALVE: Bicuspid aortic valve. Critical AS (area <0.8cm2). Trace AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was 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. Conclusions Prebypass No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve is bicuspid. There is critical aortic valve stenosis (valve area <0.8cm2). Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results on [**2126-12-9**] at 1400 hrs. Post bypass Patient is AV paced and receiving an infusion of phenylephrine. Biventricular systolic function is unchanged. Bioprosthetic valve seen in the aortic position. The valve appears well seated and the leaflets move well. The peak gradient across the valve is 18 mm Hg. The aorta is intact post decannulation. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2126-12-9**] 16:49 Brief Hospital Course: The patient was admitted on [**2126-12-9**] and underwent elective aortic valve replacement with a 19mm pericardial tissue valve. She tolerated the procedure well and was transferred to the CVICU in stable condition on neo and propofol. She was extubated that night and her chest tubes were discontinued on POD#1. She was transferred to the floor on POD#1 and that night she received some Lasix and her SBP dropped to the 70's. She received a bolus which had a slight response and was transferred back to the CVIVU. She improved and was transferred back to the floor on POD#2 and continued to progress. She had an episode of rapid atrial fibrillation on POD#2 and was treated with Digoxin and Loressor and converted to sinus rhythm. Her epicardial pacing wires were discontinued on POD#3 and she was discharged to home in stable condition on POD#4. Medications on Admission: ASA 81mg po daily Metoprolol 12.5mg [**Hospital1 **] Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. 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. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 5. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days. Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 6. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). Discharge Disposition: Home With Service Facility: [**Location (un) 932**] Area VNA Discharge Diagnosis: aortic stenosis hyperthyroidism-h/o [**Doctor Last Name 933**] disease hyperlipidemia Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with percocet prn Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: Please call to schedule appointments Surgeon Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**] Primary Care Dr. [**Last Name (STitle) 11487**] ([**Telephone/Fax (1) **]) in [**11-30**] weeks Cardiologist Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 21676**]) in [**11-30**] weeks Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse will schedule Completed by:[**2126-12-13**]

[ "997.1", "242.90", "746.4", "427.31", "424.1", "458.29", "272.4" ]

icd9cm

[ [ [] ] ]

[ "39.61", "35.21" ]

icd9pcs

[ [ [] ] ]

8825, 8888

7086, 7942

344, 410

9018, 9114

2087, 2751

9739, 10192

1269, 1294

8046, 8802

2791, 2823

8909, 8997

7968, 8023

9138, 9716

1309, 2068

284, 306

2855, 7063

438, 887

909, 1145

1161, 1253

6,954

186,800

48626

Discharge summary

report

Admission Date: [**2117-7-18**] Discharge Date: [**2117-7-23**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 21990**] Chief Complaint: anemia, upper GI bleed Major Surgical or Invasive Procedure: EGD Left IG line placement History of Present Illness: [**Age over 90 **] yr old female with past medical hx of bladder cancer, rectal cancer s/p resection and colostomy and B12 deficiency who was recently admitted for upper GIB. Pt was admitted to the MICU for monitoring during active GI bleed. GI was prepared to scope during that admission but the POA could not be reached. When hct stabilized and there was no further evidence of bleed, pt was called out to the floor. On the floor, pt's POA was [**Name (NI) 653**] and he agreed to endoscopy. However, due to a stable hct, the decision was made to send pt back to rehab with daily hcts and scope as an outpatient. On day of admission ([**7-18**]), pt's hct was checked and found to be 23 (hct 30 on discharge from [**Hospital1 18**] on [**7-13**]) so she was sent back to [**Hospital1 18**]. In the [**Name (NI) **], pts hct was 22 and fell to 19.8. GI was consulted again but due to inability to again contact the POA, scope was deferred. She was given a total of 5U of PRBCs overnight and her hct remained 23. She was transferred to the MICU for active UGIB and GI made aware. Past Medical History: Bladder cancer Rectal cancer s/p chemo/XRT and resection with colostomy in [**2103**] Depression B12 deficiency Cataracts Social History: Lives alone in [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] Family History: unable to obtain Physical Exam: temp 99, BP 118/70, HR 99 (95-110), R 18, O2 96% on 3L Gen: NAD, resting comfortably, complains of thirst HEENT: MM dry, EOMI Neck: supple, JVD flat CV: regular, tachy, no murmurs Chest: clear bilaterally with min crackles at bases Abd: +BS, soft, NTND, colostomy bag in place with black, tarry stool Ext: trace edema (L>R), warm, 2+ DP; pain on palpation of right hip with decreased ROM Neuro: grossly intact, moves all ext Pertinent Results: Admission labs: [**2117-7-17**] 09:00PM BLOOD WBC-10.1# RBC-2.52*# Hgb-7.3*# Hct-22.2*# MCV-88 MCH-29.1 MCHC-33.1 RDW-13.7 Plt Ct-533* [**2117-7-17**] 09:00PM BLOOD Neuts-79.6* Lymphs-16.0* Monos-2.6 Eos-1.4 Baso-0.3 [**2117-7-17**] 09:00PM BLOOD PT-15.4* PTT-27.0 INR(PT)-1.6 [**2117-7-18**] 02:25AM BLOOD Ret Aut-2.1 [**2117-7-17**] 09:00PM BLOOD Glucose-81 UreaN-50* Creat-1.1 Na-133 K-4.8 Cl-101 HCO3-20* AnGap-17 [**2117-7-17**] 09:00PM BLOOD ALT-37 AST-80* LD(LDH)-452* AlkPhos-218* Amylase-113* TotBili-0.3 [**2117-7-17**] 09:00PM BLOOD Lipase-158* GGT-122* [**2117-7-17**] 09:00PM BLOOD Albumin-2.8* Calcium-8.9 Phos-2.6* Mg-1.8 [**2117-7-17**] 09:00PM BLOOD Hapto-426* . [**7-19**] EGD: actively bleeding Dieulafoy’s lesion in the duodenal bulb, which resolved after injection with epinephrine and bicapped . Urine culture: Enterococcus sensitive to Ampicillin . Urine cytology: Neg for malignant cells . Discharge labs: [**2117-7-23**] 03:39AM BLOOD WBC-6.0 RBC-3.71* Hgb-11.2* Hct-32.1* MCV-87 MCH-30.1 MCHC-34.8 RDW-15.6* Plt Ct-359 [**2117-7-23**] 03:39AM BLOOD Plt Ct-359 [**2117-7-23**] 03:39AM BLOOD Glucose-83 UreaN-12 Creat-0.8 Na-141 K-3.3 Cl-109* HCO3-25 AnGap-10 Brief Hospital Course: [**Age over 90 **] yr old female with past medical hx of bladder cancer, rectal cancer s/p resection and colostomy and B12 deficiency who was recently admitted for upper GIB discharged to nursing home with close follow up for serial hematocrits, who was admitted on [**2117-7-18**] for progressively dropping hematocrits. Hospital course by problem: . Upper GI Bleed: On day of admission ([**7-18**]), pt's hct was checked and found to be 23 (hct 30 on discharge from [**Hospital1 18**] on [**7-13**]) so she was sent back to [**Hospital1 18**]. In the [**Name (NI) **], pts hct was 22 and fell to 19.8. Patient was tachycardic in the ED, despite bolus of 1L NS, and was transfused. GI was consulted again but due to inability to again contact the POA, scope was deferred. She was given a total of 5U of PRBCs overnight and her hematocrit remained 23, as well as having black tarry stools in the colostomy bag and hematuria in her Foley. She was transferred to the MICU for management of UGIB that was unresponsive to transfusion. In the MICU, patient was more closely monitored for signs of continued GIB. Patient was transfused 2u pRBC for continuously dropping hematocrit. A cordis was placed for IV access and transfusion of pRBCs, and an emergent endoscopy was performed on [**7-19**] which showed an actively bleeding Dieulafoy’s lesion in the duodenal bulb, which resolved after injection with epinephrine and bicapped. Hematocrits were checked q4 and remained stable, with a goal of transfusion for Hct<25. Patient was also initiated on IV PPI [**Hospital1 **]. Patient remained hemodynamically stable, and Hct checks were gradually decresed to [**Hospital1 **]. On discharge, the patient's hct had been stable at about 32 for 2 days. PPI was changed to PO per GI team. Patient was tolerating a PO diet. Was discharged to [**Hospital3 **] for careful monitoring of hcts qd x 1 week. . UTI: Patient recently treated for a UTI with a 5 day course of DS bactrim, completed on the day of admission. She still had a UTI on admission, with cx pos for enterococcus (Levaquin resistant, amp sensitive). Patient was started on a 7 day course of Ampicillin to be completed at [**Last Name (un) 1188**] house. . Hematuria: Patient continued to have some hematuria, as she did on her prior admission when she was seen by the urology service. Urine cytologies were sent and were negative for malignant cells (had been positive for atypical cells last admission). Given her history of bladder cancer, she should consider following up with urology clinic as an outpatient, for the cystoscopy and CT urogram that was recommended by them on the last admission. . Hip pain: The patient is s/p right hemiarthroplasty. Had a fall at nursing home earlier this month. All imaging has been negative for fracture. Patient should receive PT at [**Hospital3 **]. Medications on Admission: B12 1000mcg SC q month ASA 325mg qd MVI with iron, 1 tab qd Tylenol prn s/p Bactrim DS [**Hospital1 **] x 5d course, finished yesterday Discharge Medications: 1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 2. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Ampicillin Sodium 2 g Recon Soln Sig: One (1) Recon Soln Injection Q6H (every 6 hours): Until [**2117-7-26**] for a total of 7 days. 5. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. 6. vit B12 Sig: 1000 (1000) mcg Subcutaneous once a month. 7. Ferrous Sulfate 325 (65) mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 1186**] - [**Location (un) 538**] Discharge Diagnosis: Upper GI bleed (actively bleeding Delafoy's lesion in duadenal bulb) UTI Hematuria Dementia Discharge Condition: Good Discharge Instructions: NOTE TO [**Hospital3 **] STAFF: Please check Hct once a day for 7 days. Please inform Dr. [**First Name (STitle) **] if the value drops below 30 Please continue Ampicillin to finish a 7 day course Please restart ASA 325 qd in one week Please consider making an outpatient appointment for the patient with urology clinic: ([**Telephone/Fax (1) 772**] for an outpatient cystoscopy and CT urogram. They saw her when she was in the hospital. Followup Instructions: With Dr. [**First Name (STitle) **] ([**Telephone/Fax (1) 30577**] Please consider making an outpatient appointment for the patient with urology clinic: ([**Telephone/Fax (1) 772**] for an outpatient cystoscopy and CT urogram. They saw her when she was in the hospital. Completed by:[**2117-7-23**]

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icd9cm

[ [ [] ] ]

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31,993

146,282

33149

Discharge summary

report

Admission Date: [**2120-12-17**] Discharge Date: [**2120-12-19**] Service: NEUROLOGY Allergies: No Drug Allergy Information on File Attending:[**First Name3 (LF) 2569**] Chief Complaint: Presented to OSH and transferred after CT demonstrated left sided intracerebral hemorrhage. Major Surgical or Invasive Procedure: Intubation History of Present Illness: The pt is a 89year old man with a past medical history significant for HTN, afib on coumadin, carotid stenosis s/p endarterectomy x3 who presented to [**Hospital **] Hospital after a friend, who had been trying to reach the patient all day, called EMS and they found him sitting in a chair with right sided paralysis and eyes looking to the left. Blood sugar was 101. The duration of the patient's symptoms are unknown. At [**Hospital1 **] a head CT was noted to show a left subinsular acute hemorrhage 5cm by 2cm with early mass effect. At the OSH the patient's INR was noted to be 3.31 ad he got Vit K. Blood pressure was in the 180s. Here getting 2 units FFP. The patient was intubated for declining mental status and difficulty maintaining his airway. He was apparently answering questions when he arrived but then lost the ability to do so. ROS Unable to obtain in intubated patient. Past Medical History: HTN Afib CEA x3 Social History: Per the family the patient hasn't smoked in 30 years. He drinks alcohol regularly but they don't know how much he drinks. Family History: NC Physical Exam: Vitals: T:afebrile P:120-140s R:18 BP:150-190s/100s SaO2:96%3L General: Inutbaged sedated. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: tachy, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: -Mental Status: on propofol to maintain airway. Not awakening to voice or deep noxious stimuli. Not following commands. [**Name8 (MD) **] RN reached for ETT while in the CT scanner. They insisist that this was purposeful movment. I saw no such purposeful movment despite releasing the patient's restraints. -Cranial Nerves: Pupils reactive. -Motor: withdrew left upper and lower extremity to noxious stimuli. Right upper extremity internally rotated slightly to noxious stim. The Right lower extremity triple flexed. -Sensory: As above. -Coordination: Untested -DTRs: [**Name2 (NI) **] 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: Untestable. Pertinent Results: [**2120-12-16**] 09:15PM BLOOD WBC-14.6* RBC-5.23 Hgb-16.3 Hct-48.5 MCV-93 MCH-31.1 MCHC-33.5 RDW-14.1 Plt Ct-188 [**2120-12-17**] 02:38AM BLOOD WBC-15.5* RBC-4.71 Hgb-15.2 Hct-44.0 MCV-93 MCH-32.2* MCHC-34.5 RDW-14.1 Plt Ct-130* [**2120-12-16**] 09:15PM BLOOD PT-21.0* PTT-35.4* INR(PT)-2.0* [**2120-12-17**] 02:38AM BLOOD PT-13.7* PTT-29.9 INR(PT)-1.2* [**2120-12-16**] 09:15PM BLOOD Glucose-145* UreaN-19 Creat-1.1 Na-141 K-4.0 Cl-102 HCO3-22 AnGap-21* [**2120-12-16**] 09:15PM BLOOD CK-MB-4 cTropnT-<0.01 [**2120-12-17**] 02:38AM BLOOD Calcium-8.8 Phos-3.3 Mg-1.9 [**2120-12-16**] 09:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Head CT: There is a large parenchymal hemorrhage centered in the left basal ganglia measuring approximately 9.2 x 3.8 cm, almost doubled in size in comparison to the outside hospital images. There is significant adjacent mass effect with effacement of the left convexity sulci and approximately 1-cm rightward subfalcine herniation. Surrounding low-density is consistent with edema. Hemorrhage extends to the ventricles with moderate amount of blood products seen within the posterior horns of the lateral ventricles, third and fourth ventricles. Mild prominence of the ventricles likely reflects evolving hydrocephalus. A small focus of mid left convexity subdural hematoma is noted. Bilateral dense atherosclerotic calcifications are noted in the carotids siphons and vertebral arteries. No fractures are identified. The imaged paranasal sinuses and mastoid air cells are well aerated. There is a left hearing aid in place. Brief Hospital Course: Mr. [**Known lastname **] INR was reversed with FFP successfully from 2.0 to 1.2. He was admitted to the ICU for further management. His blood pressure was kept between 120-160 with a MAP of less than 130. Given the extent of his injury, the poor prognosis was discussed with the family. They stated that the patient had made his wishes clear that he would not want to be maintained on life support. The following morning a goals of care meeting was held with the family including his daughter and HCP, [**Name (NI) **] [**Name (NI) 17437**]. She stated clearly that her father would not want to be maintained on life support and would not want to live with the deficits he would sustain from his stroke. He was therefore made CMO and extubated. He was started on a morphine drip. Medications on Admission: Lasix Coumadin Lisinopril Metoprolol Simvastatin Discharge Medications: NA Discharge Disposition: Expired Discharge Diagnosis: Hemmorhagic Stroke Atrial fibrillation Hypertension Discharge Condition: Expired Discharge Instructions: Not Applicable Followup Instructions: Not Applicable [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]

[ "427.31", "348.4", "V58.61", "431", "401.9", "V10.05" ]

icd9cm

[ [ [] ] ]

[ "99.07", "96.71", "96.04" ]

icd9pcs

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5267, 5276

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338, 350

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174,721

33258

Discharge summary

report

Admission Date: [**2162-10-16**] Discharge Date: [**2162-10-19**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2009**] Chief Complaint: Nausea, vomiting, diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: 87 year-old gentleman with history of ESRD on HD, CAD, CHF, presents with 3 day history of epigastric pain, nausea, vomiting, and diarrhea. He has not had much of an appetite in the last two days and has been spending a lot of time in the bathroom. He notes an uncomfortable feeling in his epigastrum, though is unable to further clarify the character of the pain. Patient notes that he has additionally had two days of cough, though denies fevers, sweats headache, dyspnea, sore throat, or myalgias. He has had some mild chills. He has had no known sick contacts. [**Name (NI) **] was recently discharged from the hospital on [**2162-9-20**] after a 3 day stay for new onset dysarthria and worsening LUE weakness. At that time his neurologic symptoms were attributed to poor PO intake prior to presentation and representation of prior CVA symptoms. Vital signs upon presentation to the ED were T 97.6, HR 80, BP 173/65, O2Sat 100% 2L. Initial labs showed serum potassium of 6.3. Did not have peaked T waves on EKG at presentation, though had a QRS prolongation to 120 ms [**First Name (Titles) 767**] [**Last Name (Titles) 5348**] of 100 ms. Additionally had new TWI in leads V1 and V2. Received calcium gluconate, insulin and dextrose, 1 amp bicarb, and aspirin. Due to concern for intra-abdominal process, was started on zosyn and vancomycin. Received a CT abdomen and RUQ U/S that both showed gallstone at gallbladder neck, though no definitive evidence of acute cholecystitis per ultrasound. Surgery consulted and felt that empiric antibiotics were appropriate. Was given an aspirin due to concern for cardiac process and had a set of cardiac enzymes sent. Prior to transfer to the floor vitals were: T 97, HR 81, BP 154/70, RR 20, O2Sat 99% 2L NC. ROS: (+)ve: nausea, vomiting, epigastric pain, diarrhea, chills, cough, loss of appetite, weight loss, LUE weakness (-)ve: fever, sweats, hemoptysis, dyspnea, orthopnea, PND, constipation, lower extremity edema, myalgias, arthralgias Past Medical History: 1) ESRD on HD (M/W/F) s/p AVF placement 2) Coronary artery disease s/p balloon angioplasty > 5 years ago 3) CVA >10 years ago w/ residual left-sided weakness and left facial droop 4) Hypertension 5) Congestive heart failure (TTE [**2162-4-22**]: LVEF 35-40%) 6) BPH w/ elevated PSA 7) Nephrolithiasis 8) Thrombocytopenia of unclear etiology, stable 9) s/p abdominal surgery for unclear reasons, believed by patient to be gastric cancer resection 10) h/o Bell's palsy Social History: Lives with daughter in [**Name (NI) 669**], MA. Tobacco: Quit smoking [**1-20**] month ago and used to smoke [**12-22**] cigarretes per day for 60 years. EtOH: Prior use with 3-4 beers per day, but quit >20 years ago not remembering exact date. Illicits: Denies Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Father died of cirrhosis, mother of cancer (unknown site). Physical Exam: VITAL SIGNS: T 97.5, HR 85, BP 158/66, RR 30, O2Sat 100% 2L NC GENERAL: NAD, thin elderly gentleman HEENT: PERRL (3 to 2 mm bilaterally), EOMI, bilaterally equal arcus senilis, visual acuity intact with ability to read small text at a distance, NECK: no [**Doctor First Name **], CARDIAC: RR, nl S1, nl S2, no M/R/G LUNGS: Basilar crackles clearing partially with cough ABDOMEN: Thin, BS+, soft, tender epigastrum and RUQ to deep palpation, non-distended, no rebound or guarding EXTREMITIES: No LE edema SKIN: No rashes NEURO: Oriented to date, day, place, person. Strength 5/5 at hips, knee flexion and extension, ankle dorsiflexion and plantarflexion, Strength 5/5 along RUE and [**2-21**] along LUE, LUE with palpable thrill over AV fistula PSYCH: Mood and affect appropriate Pertinent Results: Admission Labs: [**2162-10-16**] 10:18AM WBC-5.4 RBC-4.22* HGB-11.3* HCT-36.3* MCV-86# MCH-26.8* MCHC-31.1 RDW-16.8* [**2162-10-16**] 10:18AM PLT SMR-VERY LOW PLT COUNT-69*# [**2162-10-16**] 10:18AM NEUTS-81.3* LYMPHS-12.3* MONOS-6.0 EOS-0.2 BASOS-0.2 [**2162-10-16**] 10:18AM CK-MB-NotDone cTropnT-0.18* [**2162-10-16**] 10:18AM GLUCOSE-122* UREA N-57* CREAT-8.7*# SODIUM-146* POTASSIUM-6.3* CHLORIDE-99 TOTAL CO2-20* ANION GAP-33* [**2162-10-16**] 10:49AM LACTATE-7.2* [**2162-10-16**] 10:18AM CK-MB-NotDone cTropnT-0.18* [**2162-10-16**] 10:18AM ALT(SGPT)-33 AST(SGOT)-47* CK(CPK)-83 ALK PHOS-123* TOT BILI-0.7 [**2162-10-16**] 10:18AM LIPASE-10 Discharge Labs: [**10-19**]: WBC-4.8 RBC-4.03* Hgb-11.0* Hct-33.9* MCV-84 MCH-27.2 MCHC-32.4 RDW-16.8* Plt Ct-80* [**10-19**]: Glucose-129* UreaN-24* Creat-5.4*# Na-143 K-3.6 Cl-98 HCO3-32 AnGap-17 [**10-18**]: CK(CPK)-78 [**10-19**]: Calcium-8.6 Phos-4.0# Mg-2.1 [**10-19**]: Lactate-2.2* [**2162-10-16**] Chest Xray: Cardiomegaly, pulmonary edema, and small effusions suggest mild cardiac failure. Recommend repeat PA and lateral after diuresis to evaluate for coexistent infection. [**2162-10-16**] CT Abdomen/Pelvis: IMPRESSIONS: Small bilateral pleural effusions, right greater than left. Distended gallbladder with multiple gallstones, including one in the gallbladder neck. Trace pericholecystic fluid and gallbladder wall edema, although without definite gallbladder free wall thickening. Cholecystitis is a concern. This can be further evaluated via ultrasound or hepatobiliary scan. Extensive atherosclerotic calcifications throughout the aorta and major mesenteric branches, although mesenteric arteries are without stenosis or thrombosis evident. Due to suboptimal contrast administration, venous structures are not opacified. However, there are no secondary signs of venous thrombus. There is no evidence of bowel ischemia. Very high grade stenosis of the proximal right superficial femoral artery. Stable appearance of simple and hyperdense renal cysts. Diffusely enlarged prostate gland with prominent median lobe, with multiple proteinaceous/hemorrhagic nodules. This is consistent with BPH, although tumor is not definitively excluded. [**2162-10-16**] Liver or Gallbladder Ultrasound 1. Enlarged but compressible gallbladder with gallstones; stone in the gallbladder neck was not definitely impacted. Asymmetric perihepatic gallbladder wall edema. Findings are not typical for acute cholecystitis, and are likely because of hepatic dysfunction, possibly from vascular congestion. 2. Patent portal vein. SMV not well visualized due to overlying bowel gas. Brief Hospital Course: 87 year-old gentleman with history of ESRD on HD, CAD, CHF, who presented with 3 day history of epigastric pain, nausea, vomiting, and diarrhea. #. Gastroenteritis and cholelithiasis: He presented with 3 days of nausea, vomiting, diarrhea, and loss of appetite. It was felt to most likely be a gastroenteritis. CT did not show obvious source of infection and no evidence of bowel ischemia. However, the gall bladder had an atypical appearance. Follow-up RUQ ultrasound did not show acute cholecystitis. Surgery was consulted as the clinical picture could suggest an intermittently obstructing stone and biliary colic. He underwent bowel rest, serial lactates, and empiric treatment with Unasyn. He was also ruled out for MI and his lactate downtrended. Symptoms resolved and patient tolerated a normal diet at discharge. #. Hyperkalemia: Upon presentation to the ED, his serum potassium was 6.3 and EKG was noted to have QRS prolongation to 120 with recent [**Month/Day/Year 5348**] QRS of 100 on EKG dated [**2162-9-18**]. He was given calcium gluconate, bicarb, insulin and D50. Repeat potassium in ED was 4.6 prior to transfer to the ICU. He underwent hemodialysis overnight and his serum potassium returned to [**Location 213**]. #. CAD: He was ruled out for MI and was continued on isosorbide mononitrate, lisinopril, aspirin, metoprolol, and simvastatin. # Chronic Renal Disease on HD: Pt received HD while hosptalized. #. Congestive heart failure, systolic: He appeared clinically euvolemic to dry upon examination on discharge, and through admission without evidence of JVP elevation. #. Prophylaxis: He was given SC heparin for DVT prophylaxis. #. Code Status: He was full code during this hospitalization. #. Contact: With [**First Name8 (NamePattern2) 77233**] [**Name (NI) **] (Daughter) [**Telephone/Fax (1) 77234**] Key Follow up: On abdominal CT the following were found: 1. Very high grade stenosis of the proximal right superficial femoral artery. 2. Diffusely enlarged prostate gland with prominent median lobe, with multiple proteinaceous/hemorrhagic nodules. This is consistent with BPH, although tumor is not definitively excluded. Medications on Admission: 1) Isosorbide Mononitrate 30 mg Tablet SR 24 hr 1 PO daily 2) Lisinopril 5 mg PO daily 3) Metoprolol Tartrate 12.5 mg [**Hospital1 **] PO daily 4) Nitroglycerin 0.3mg Tablet, SL 5) Omeprazole 40 mg DAILY 6) Simvastatin 40 mg PO at bedtime 7) Trazodone 50 mg Tablet PO at bedtime 8) Acetaminophen 650 mg PO q6hrs as needed for fever or pain 9) Aspirin 325 mg PO once a day 10) Iron AspGl & PS Cm-Vit C-Ca-SA 150 mg-50 mg-50 mg 1 Capsule PO daily 11) Multivitamin Tablet 1 PO daily 12) Acetaminophen-Codeine 300 mg-30 mg 1 Tablet PO at bedtime PRN pain 13) Docusate Sodium 100 mg PO BID PRN constipation Discharge Medications: 1. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 7. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Acetaminophen-Codeine 300-30 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for pain: Do not take this medication and consume alcohol. Do not take this mediation and drive. . 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 11. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Sublingual once a day as needed for chest pain: Call doctor if you develop chest pain. . 12. Multivitamin Capsule Sig: One (1) Capsule PO once a day. 13. Iron AspGl & PS Cm-Vit C-Ca-SA [**Medical Record Number 77235**] mg Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary: Gallstones (Symptomatic Cholelithiasis) Discharge Condition: Mental Status:Clear and coherent Activity Status:Ambulatory - requires assistance or aid (walker or cane) Discharge Instructions: Dear Mr. [**Known lastname **], It was a pleasure caring for you while you were hospitalized with abdominal pain, nausea, vomiting, and diarrhea. During your stay evaluation showed that you had a gallstone that was thought to be contributing to this pain. Your gallbladder was further evaluated and you were found to not have a gallbladder infection. Further, during your hospitalization you received hemodialysis in keeping with your outpatient schedule. At discharge you should follow up with your primary care physician to further discuss the abdominal pain which brought you to the hospital and your other chronic medical problems. [**Name (NI) **] will also need to follow up with general surgery regarding these gallstones and the need to have your gallbladder removed. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. No changes were made to your medication regimen. Please return to the hospital or contact your physician if your abdominal pain recurrs, you develop chest pain, shortness of breath, blood in your bowel movements, dark black bowel movements, major changes in your bowel or bladder habits, or other changes that concern you. Followup Instructions: General Surgery; [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. Phone:[**Telephone/Fax (1) 6554**] Date/Time:[**2162-11-1**] 12:30 Primary Care: [**Name6 (MD) 21154**] [**Last Name (NamePattern4) 21155**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2162-11-1**] 3:50 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2162-11-30**] 10:00

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icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

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291, 297

11028, 11028

4091, 4091

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71,006

168,993

42084

Discharge summary

report

Admission Date: [**2111-5-25**] Discharge Date: [**2111-6-1**] Date of Birth: [**2024-9-23**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Codeine / IV Dye, Iodine Containing Contrast Media / Hexabrix Attending:[**First Name3 (LF) 1505**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: [**2111-5-26**] - Left Heart Catheterization Catheter Placement, Right Femoral Artery Temporary Pacemaker Placment, Right Femoral Vein Aortography, Ascending Aorta Balloon Aortic Valvuloplasty Percutaneous Aortic Valve Replacement History of Present Illness: 86 year old female referred for severe aortic stenosis. She had presented to a hospital in Fla. with abdominal pain r/o SBO. She was treated medically including volume resuscitation and CHF. Workup revealed severe aortic stenosis. She was discharged after a month to a local rehab. She had a recurrence of abdominal pain, r/o ileitis and was transferred from an OSH to [**Hospital1 18**] for tertiary care for her AS. She admits to shortness of breath after 100ft, chest pressure after extended activity, inability to climb more than a flight of stairs. Echo reveals [**Location (un) 109**] 0.6cm2, mean gradient 64, peak gradient 5.2, asc. aorta normal diameter by echo. She was referred here for aortic valve treatment options. Recommendations were made for GI and [**Location (un) 1106**] input regarding abdominal issues to better quantify surgical risk for aortic valve replacement. Patient was seen by [**Location (un) 1106**] surgery. Findings included mild SMA stenosis though unlikely related to her hospitilization for cecitis/ileitis. Celiac patent without stenosis. SMA borderline hemodynamically significant stenosis with no recommendations for mesenteric stenting at this time. She has been cleared by the GI team and presents for admission prior to CoreValve. Past Medical History: aortic stenosis - CHF - hypertension - PVD - s/p right CEA - ileitis vs. ischemic colitis - SBO x 2 - exploratory lap [**2-12**] abdominal infection 50yrs ago - cataracts Social History: Lives at home with cat, tob hx 2ppd x35y, quit 25y ago, no etoh, no illicits. Family History: Lung cancer Physical Exam: Pulse: 84 B/P: 142/77 Resp: 18 O2 Sat: 96 Temp: 97.7 Height: 64 inches Weight: 100 lbs General: Alert, pleasant thin female in NAD at rest Skin: color pink, skin warm and dry, no lesions HEENT: Normocephalic, anicteric, oropharynx moist Well healed surgical scar rt neck. Bilat bruits vs referred murmur Neck: supple, trachea midline, (-)JVD. Chest: no obvious deformities, no scars Heart: murmur throughout Abdomen: soft, flat, non-tender, non-distended, (+)BS, well healed lower abdominal midline incision. Extremities: no obvious deformities. 1+ pedal edema rt. Neuro: alert and oriented. Gross FROM. Ambulating indep. Pulses: weakly palp peripheral pulses Pertinent Results: [**2111-5-28**] ECHO The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Left ventricular systolic function is hyperdynamic (EF 80%). The right ventricular free wall is hypertrophied. Right ventricular chamber size is normal. with borderline normal free wall function. An aortic CoreValve prosthesis is present. Mild paravalvular (1+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is severe mitral annular calcification. There is moderate thickening of the mitral valve chordae. There is moderate functional mitral stenosis (mean gradient 8 mmHg) due to mitral annular calcification. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] There is no pericardial effusion. . [**2111-6-1**] 04:32AM BLOOD WBC-9.5 RBC-3.43* Hgb-10.6* Hct-33.3* MCV-97 MCH-31.0 MCHC-31.9 RDW-14.7 Plt Ct-223 [**2111-5-31**] 06:40AM BLOOD WBC-10.3 RBC-3.17* Hgb-10.0* Hct-30.4* MCV-96 MCH-31.4 MCHC-32.7 RDW-14.5 Plt Ct-186 [**2111-5-29**] 04:07AM BLOOD PT-12.3 PTT-25.7 INR(PT)-1.1 [**2111-6-1**] 04:32AM BLOOD Glucose-92 UreaN-22* Creat-0.7 Na-136 K-4.5 Cl-105 HCO3-20* AnGap-16 [**2111-5-31**] 06:40AM BLOOD UreaN-22* Creat-0.7 Na-140 K-4.3 Cl-106 [**2111-5-29**] 04:07AM BLOOD Glucose-117* UreaN-21* Creat-0.8 Na-135 K-3.9 Cl-103 HCO3-22 AnGap-14 Brief Hospital Course: Ms. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2111-5-25**] for surgical management of her aortic valve disease. She was worked-up in the usual preoperative manner. On [**2111-5-26**] she was taken to the operating room where she underwent a direct aortic percutaneous aortic valve replacement via a hemisternotmy. Please see operative note for details. Postoperatively she was taken to the intensive care unit for monitoring. Later on postoperative day one, she awoke and was extubated. Some postoperative delerium was noted which responded to haldol and cleared over time. On postoperative day two, she was transferred to the step down unit for further recovery. Physical therapy was consulted for assistance with her postoperative strength and mobility. Diuresis was initiated. Coreg and lisinopril were resumed. Plavix was initiated in accordance with the CoreValve protocol. She continued to make steady progress and was discharged to [**Location (un) **] House on postoperative day 6. All follow-up appointments were scheduled for the patient. Medications on Admission: ATORVASTATIN - (Prescribed by Other Provider) - 20 mg Tablet - 1 Tablet(s) by mouth once a day CARVEDILOL - (Prescribed by Other Provider) - 3.125 mg Tablet - 1 Tablet(s) by mouth twice a day LISINOPRIL - (Prescribed by Other Provider) - 5 mg Tablet - 1 Tablet(s) by mouth once a day Medications - OTC ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day CHOLECALCIFEROL (VITAMIN D3) - (Prescribed by Other Provider) - 1,000 unit Capsule - 1 (One) Capsule(s) by mouth once a day CYANOCOBALAMIN (VITAMIN B-12) - (Prescribed by Other Provider) - 1,000 mcg Tablet - 1 (One) Tablet(s) by mouth once a day MULTIVITAMIN - (Prescribed by Other Provider) - Tablet - 1 Tablet(s) by mouth once a day Discharge Medications: 1. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO every [**4-17**] hours as needed for pain. 6. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. lisinopril 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Location (un) **] House Nursing Home - [**Location 9583**] Discharge Diagnosis: - aortic stenosis - CHF - hypertension - PVD - s/p right CEA - ileitis vs. ischemic colitis - SBO x 2 - exploratory lap [**2-12**] abdominal infection 50yrs ago - cataracts Discharge Condition: Alert and oriented x3 nonfocal Ambulating, deconditioned Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Edema: no lower extremity. left upper extremity swelling 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 and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please see attached CoreValve discharge instructions** Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2111-6-10**] 3:20 Provider: [**Name10 (NameIs) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2111-7-1**] 1:30 in the [**Hospital **] medical office building, 110 [**Doctor First Name **] [**Hospital Unit Name **] Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2111-9-2**] 9:30 Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] (office will call you with appt.) Completed by:[**2111-6-1**]

[ "780.09", "424.1", "428.0", "401.9", "428.32" ]

icd9cm

[ [ [] ] ]

[ "37.78", "37.22", "35.05" ]

icd9pcs

[ [ [] ] ]

7110, 7198

4670, 5746

349, 582

7416, 7631

2911, 4647

8561, 9167

2201, 2214

6558, 7087

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5772, 6535

7655, 8538

2229, 2892

302, 311

610, 1893

1916, 2089

2105, 2185

29,035

152,710

17989

Discharge summary

report

Admission Date: [**2154-2-1**] Discharge Date: [**2154-2-11**] Date of Birth: [**2089-12-13**] Sex: F Service: MEDICINE Allergies: Erythromycin Base / Indomethacin / Actonel / Reglan / linezolid / meropenem Attending:[**First Name3 (LF) 1711**] Chief Complaint: High degree AV block Major Surgical or Invasive Procedure: -Pacemaker placement History of Present Illness: 64 yo F with a-fib on coumadin, dCHF, mod-severe MR improved to mild MR [**First Name (Titles) **] [**Last Name (Titles) **] [**12-17**], IDDM, HTN, hyperlipidemia, NASH & ESRD s/p liver and kidney [**7-/2153**] presented to [**Hospital1 **] with high degree AV block. The patient was last admitted [**Date range (1) 49798**] for dyspnea and lower ext edema. She was diuresed and sent home on 100mg lasix [**Hospital1 **] and 5mg metolazone. The patient reports lower abdominal pain, loose stools and nausea/vomiting over the last 2 days. Pt also reports some chills, but no frank fevers. Today, the patient was visiting her family and felt weak. She was unable to get out of her chair and look extremely fatigued per the family. They called EMS and she was found to have HR 20-30's and they were unable to palpate a pulse. There is also a report of several seconds of VT, but no stripes available and no reported shocks. There was no reported loss of conciousness. She was transcutaneously paced and taken to [**Hospital 5871**] Hospital. The tracing showed high degree AV block 2:1. The patient was also found to be in acute renal failure with a creatinine of 3.3 and hyperkalemic to 5.6. She was given calcium, insulin and D50. She was given 3.3L of IVF. She reportly underwent non-contrast CT abdomen that was negative, but no report or images. Her WBC count was 12.4, lactate 3.3 and given 1 dose of Zosyn & Imipenem. A transvenous pacer was placed, paced at 70 and transferred here for further evaluation. . In the ED, initial vitals were 98.6 71 148/51 21 98% 6L. The patients labs were significant for Cr 2.8, BUN 107, WBC: 11.3, lactate 2.2, INR: 3.9. Cardiac enzymes were trop 0.08, CK 41. UA was negative and CXR did not show infiltrate or extensive edema. Pt received renal U/S prior to transport to the CCU. . On arrive the patient states she has continued lower abdominal pain. She states that she has had a chronic cough and some SOB. She has nausea, but no vomiting. She states she feels cold and reports shakes. She reports some mild chest discomfort. On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, joint pains, cough, hemoptysis, black stools or red stools. She denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of paroxysmal nocturnal dyspnea, stable 2 pillow orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: * AFib on coumadin * Diastolic heart failure NYHA II-III with EF of 70% * Calcific aortic stenosis * Moderate-to-severe mitral regurgitation --> improved to Mild MR [**First Name (Titles) **] [**Last Name (Titles) **] [**12-17**] * Severe mitral annular calcification * Mild tricuspid regurgitation * Moderate pulmonary hypertension 3. OTHER PAST MEDICAL HISTORY: * Diabetes Mellitus Type 2 on Insulinn complicated by retinopathy, nephropathy, and neuropathy. * HTN * Hyperlipidemia * End-stage renal disease secondarely to DM and contrast-induced s/p transplant from cadaveric donor on [**2153-7-21**] * Non-alcoholis steato-hepatitis Liver bx [**2152-9-6**] = Stage IV cirrhosis, Grade 2 inflammation, complicated by portal HTN, ascities and encephalopathy. Now s/p transplant on [**2153-7-21**] * Esophageal varices (grade I and II, s/p banding), s/p TIPS [**8-15**] * s/p VATS decortication [**11-16**] * Splenic vein thrombosis on coumadin * Anemia * Thrombocytopenia * H/o C Diff * H/o Seizures * Meningioma, small in L frontal lobe * GERD * OSA * Cervical DJD * Dermoid cyst * R adrenal mass * Recurrent MDR UTI (ESBL Klebsiella) * Status post cholecystectomy followed by tubal ligation * Status post left oopherectomy * Status post appendectomy Social History: Widowed, lives in [**Hospital3 **] in [**Hospital1 6930**] MA. Has 4 children, several in MA. Smoking: None; EtOH: Never; Illicits: None Family History: Mother and Father with CAD. Father with stroke at 90 No other family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: VS: T=100.0...BP=138/64...HR=77...RR=24...O2 sat= 98% 3L GENERAL: Pt toxic appearing, slight rigors in upper ext. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Dry MM, No xanthalesma. NECK: Supple with JVP unable to assess given cordis on RIJ. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. III/VI SEM no /r/g. No thrills, lifts. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: well healed surgical scars, soft, + tenderness periumbilical and lower abdomen, no RUQ tenderness and no tenderness over implant site. EXTREMITIES: No c/c/ trace edema. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: ADMISSION LABS: [**2154-2-1**] 08:14PM BLOOD WBC-11.3* RBC-3.37* Hgb-10.4* Hct-31.4* MCV-93 MCH-31.0 MCHC-33.3 RDW-17.6* Plt Ct-466* [**2154-2-1**] 08:14PM BLOOD Neuts-91.5* Lymphs-4.1* Monos-3.6 Eos-0.5 Baso-0.2 [**2154-2-1**] 08:14PM BLOOD PT-38.0* PTT-39.9* INR(PT)-3.9* [**2154-2-1**] 08:14PM BLOOD Glucose-223* UreaN-107* Creat-2.8*# Na-133 K-3.9 Cl-93* HCO3-22 AnGap-22* [**2154-2-1**] 08:14PM BLOOD ALT-16 AST-21 CK(CPK)-41 AlkPhos-155* TotBili-0.7 [**2154-2-1**] 08:14PM BLOOD cTropnT-0.08* [**2154-2-1**] 08:14PM BLOOD Albumin-3.7 Calcium-9.2 Phos-5.0* Mg-2.2 [**2154-2-1**] 08:33PM BLOOD tacroFK-8.3 [**2154-2-1**] 08:23PM BLOOD Lactate-2.2* . IMAGING: RENAL U/S: IMPRESSION: At least no diastolic flow with suggestion of reversal of diastolic flow within an arterial branch within the renal hilum. Stable elevated resistive indices seen in more peripheral branches involving the upper pole, interpolar region, and lower pole. Rejection or ATN are of concern. Patent renal vein. . ECHOCARDIOGRAM: Conclusions 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%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. There is moderate aortic valve stenosis (valve area 1.2 cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is borderline pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [**2153-12-7**], the severity of aortic stenosis has slightly progressed. The severity of mitral regurgitation and the estimated pulmonary artery systolic pressure are slightly lower. Brief Hospital Course: 64 yo F with a-fib on coumadin, dCHF, mod-severe MR improved to mild MR [**First Name (Titles) **] [**Last Name (Titles) **] [**12-17**], IDDM, HTN, hyperlipidemia, NASH & ESRD s/p liver and kidney [**7-/2153**] presented to [**Hospital1 **] with high degree 2:1 AV block and acute renal failure. . # High Degree AV block/syncope: Pt with syncopal episode and found to have HR 20-30's at OSH. Likely high degree 2:1 AV block as p waves appear to be conducted on the OSH. The patient had a transvenous pacer placed at the OSH and was hemodynamically stable when being paced at 70. However, when the pacer was stopped briefly to check her underlying rhythm her blood pressure dropped to the 70s. The cause of her heart block was most likely electrolyte abnormalities and renal failure in a patient who is predisposed to heart block given her history calcified aortic stenosis and mitral annular calcification. She did not have any evidence of acute MI on ECG or by cardiac enzymes or myocarditis. Her coreg was held. Her lyme titers were negative. She had a [**Company 1543**] dual chamber pacemaker placed on [**2-5**] without complications. # Acute on Chronic Renal Failure: Pt s/p kidney transplant 6/[**2153**]. Baseline creatinine function following transplant was 0.8-1.2. However, was trending up to 1.5 in [**1-16**]. Her [**Last Name (un) **] was thought to be secondary to hypoperfusion and diuresis in the setting of heart block. Her renal function improved quickly with the initiation of pacing. Her diuretics and ACEi were initially held but restarted once creatinine improved to 1.0. The renal and transplant teams followed the patient and adjusted her immunosuppressive agents. They did not feel that rejection was contributing to her symptoms. Renal ultrasound of the transplant was within normal limits. . #. Leukocytosis/Fever: Pt with WBC count of 11.3 that rose as high as 15.3 during her hospital stay. Lactate 2.2 and fever to 101.6. Patient was covered broadly with vancomycin, meropenum and flagyl given her immunocompromised state and history of infections with resistant organisms. The patient had a CT of the abdomen and pelvis given her abdominal pain and nausea. She did not have any cause of infection visualized on CT scan. Her urine culture from the OSH grew ESBL klebsiella, blood cultures negative. Antibiotics were narrowed to meropenem for a total 14 day course. CMV and BK virus were ****. . # Bladder: The patient had significant blood clots passed through her foley catheter. She occasionally complained of severe pain in her suprapubic area, generally relieved with continuous bladder irrigation. Her pain recurred while on CBI, on [**2-6**]. The CBI was stopped, and urology came to see the patient. Her foley was irrigated vigorously with manual flushes. . # CAD: The patient had a history of 3 vessel CAD, but no evidence of ACS. CE trop 0.08, CK 41. She was monitored with serial EKGs and continued on an aspirin and a statin. . # Chronic diastolic heart failure: The patient has a history of dCHF (EF >55). Pt appears dry on exam. She was given fluids without respiratory compromise. . # History of splenic vein thrombosis: Her INR was initally elevated at 3.9 Her coumdadin was held prior to pacemaker placement, and INR trended down to 1.4. . # NASH s/p liver transplant: Her LFT remained stable without evidence of acute rejection. Tranplant team followed and advised regarding immunosuppressive medications. They felt her abdominal pain was at her baseline. . # DM: The patient was continued on her home regimen of NPH 28U qam with an insulin sliding scale. . # HTN: Pt BP was SBP 140-130's on admission with a paced rhythm. She was continued on amlodipine. Her betablocker and ACEi were held. Medications on Admission: AMLODIPINE 10 mg daily ATORVASTATIN 10 mg daily CARVEDILOL 25mg [**Hospital1 **] FUROSEMIDE 100mg [**Hospital1 **] METOLAZONE 5 mg daily LISINOPRIL 5 mg daily MYCOPHENOLATE MOFETIL 500 mg [**Hospital1 **] PREDNISONE 5 mg daily TACROLIMUS 2mg [**Hospital1 **] TRIMETHOPRIM-SULFAMETHOXAZOLE - 400 mg-80 mg Tablet daily WARFARIN 4mg daily OMEPRAZOLE 40 mg daily INSULIN REGULAR HUMAN Sliding Scale NPH Insulin 28 units qam CITALOPRAM 60 mg daily LEVETIRACETAM 500 mg [**Hospital1 **] COLACE 100mg [**Hospital1 **] . Discharge Disposition: Home With Service Facility: [**First Name5 (NamePattern1) 5871**] [**Last Name (NamePattern1) 269**] Discharge Diagnosis: 1. Bradycardia s/p pacer placement 2. Hematuria secondary to foley trauma 3. Acute on chronic renal failure Discharge Condition: Stable for discharge. On room air. Requires walker for ambulation. Discharge Instructions: You were admitted because of weakness. We found that your heart was beating too slowly (rates in the 20s to 30s). To correct this, we placed a pacemaker to keep your heart beating regularly. Once the pacemaker was placed, your heart rates return to their normal rates in the 60s. . While you were in the hospital we also noted that you had a urinary tract infection. To treat this, you need to continue to take a medicine called [**Last Name (NamePattern1) 49799**] once a day, administered through your IV. You will need to continue to take this until [**2-15**] (listed below). . We had initially stopped your blood thinning medicine (coumadin) but restarted it once the pacer was placed. Following this, you developed blood in your urine, which was probably because of the blood thinning medication in combination with the Foley catheter. Over several days, the bleeding slowed and then stopped. We removed the foley catheter and you were able to urinate on your own without any blood. . We made the following medication changes during your hospitalization: (1) Started [**Last Name (LF) 49799**], [**First Name3 (LF) **] antibiotic for your urinary tract infection. You should continue to get 1 dose of this intravenously every day with the last day of dosing being [**2154-2-15**]. (2) You should take aspirin 325 mg daily by mouth. (3) You should take a medicine called sevelamer 800 mg three times a day. This keeps phosphate levels from building up too high in your blood. (4) You should take simethicone for gassy or abdominal pain. This can help relieve your pain. You can take 40 mg and up to 80 mg four times a day as needed. (5) You can take oxycodone 5 mg every four hours as needed for pain until your spasms improve. (6) We changed your lasix dose from 100 mg twice a day to 40 mg twice a day. . You need to keep your follow up appointments with cardiology and urology as listed below. Followup Instructions: 1. You have an appointment with the [**Hospital **] Clinic (device clinic) on [**2-12**] at 1 PM. If you have any questions or want to reschedule this appointment, please call [**Telephone/Fax (1) 62**]. . 2. You have an appointment with Dr [**Last Name (STitle) 2357**], a cardiologist who specializes in pacemakers, on [**3-1**] at 120 PM. His office is on the [**Location (un) 436**] of the [**Hospital Ward Name 23**] Building. If you have questions, you can call [**Telephone/Fax (1) 62**]. . 3. You have an appointment with your urologist Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3748**] on [**2154-2-28**] at 230 PM. If you want to reschedule or have any questions, please call [**Telephone/Fax (1) 3752**]. . 4. You have a follow up with the transplant infectious disease office on Monday [**2-18**] at 230 PM: its on [**Hospital Unit Name **] on the [**Location (un) 436**]. If you have any questions, please call [**Telephone/Fax (1) 49800**] . 5. You have an appointment with Dr. [**Last Name (STitle) **] (transplant kidney doctor) on Friday [**3-1**] at 940 AM on [**Hospital Ward Name **] [**Location (un) 436**]. If you have questions [**Telephone/Fax (1) 11086**].

[ "996.81", "250.50", "041.3", "428.32", "867.0", "584.9", "V42.7", "250.60", "272.4", "426.0", "427.31", "E879.6", "E878.0", "564.09", "327.23", "276.52", "428.0", "362.01", "530.81", "401.9", "357.2", "250.40" ]

icd9cm

[ [ [] ] ]

[ "37.83", "37.72", "38.93" ]

icd9pcs

[ [ [] ] ]

12111, 12214

7782, 11548

357, 380

12366, 12437

5667, 5667

14399, 15616

4473, 4648

12235, 12345

11574, 12088

12461, 14376

4663, 5648

3045, 3378

297, 319

408, 2937

5683, 7759

3409, 4302

2959, 3025

4318, 4457

5,281

155,601

26484

Discharge summary

report

Admission Date: [**2170-12-30**] Discharge Date: [**2171-1-14**] Service: SURGERY Allergies: Ivp Dye, Iodine Containing Attending:[**Doctor First Name 5188**] Chief Complaint: respiratory failure, renal failure Major Surgical or Invasive Procedure: none History of Present Illness: Pt is an 84 femaile who presented to St. [**Hospital 9231**] Hospital ER in [**Hospital1 65437**]on [**2170-12-27**] with a 36hr history of upper abdominal pain rediating to the pack. Her work-up revealed distended gallbladder with stones and minilaml elevation of liver function tests. She was transfered to Mid [**Hospital **] Hospital for definitive treatment. On [**2170-12-28**] she underwent a laparoscopic cholecystecomy. Intraoperativly she developed atrial fibrillation. A cardiology consult was obtained and she was placed on lovenox and procainamide. Her rhytm converted and the procainamide was discontinued. She became hypotensice without evidence of active bleeding. She was emperically given 2units FFP, IV fluid bolus and was placed on dopamine for a short period of time. Vasopressors were discontinued however her urine output remained less than 30cc hr. A swan ganz cathether was attempted to be placed however she developed mild hemoptysis. She was subsequently intubated for progressive respiratory distress. Per the family's wishes the patient was transfered to the [**Hospital1 18**] SICU on [**2170-12-30**] for treatment of her renal and respiratory failures Past Medical History: 1. Hypertension 2. Restless leg syndrome 3. s/p B/L knee replacement 4. s/p hysterectomy 5. s/p parotid tumor excision 6. s/p Left nephrectomy for renal stones 7. s/p appendectomy Social History: lives alone in [**First Name9 (NamePattern2) **] [**Hospital1 **]. Former smoker (30pk history). No EtOH Physical Exam: On admission: 99.7 64SR, 81/35, 42/26, open eyes, moves feet RRR no crackles/rhonchi, but decreased BS B/L especially on right side Abd soft, NT, ND, wounds C/D/I ext cool, ppor distal pulses. Pertinent Results: From Mid [**Hospital **] Hospital: [**2170-12-30**] Blood Cultures 2 of 3 bottles. E Coli resisant to Amicillin, intermediate resistance to Amp/Sulbactam, otherwise sensitive [**2171-1-11**] 06:25AM BLOOD WBC-9.7 RBC-2.63* Hgb-8.3* Hct-23.7* MCV-90 MCH-31.3 MCHC-34.8 RDW-14.8 Plt Ct-339 [**2171-1-10**] 12:00PM BLOOD WBC-12.5* RBC-2.60* Hgb-8.1* Hct-23.3* MCV-90 MCH-31.2 MCHC-34.8 RDW-15.0 Plt Ct-348 [**2170-12-31**] 01:19AM BLOOD WBC-8.0 RBC-2.74* Hgb-8.6* Hct-24.5* MCV-89 MCH-31.4 MCHC-35.1* RDW-14.2 Plt Ct-83* [**2170-12-30**] 06:43PM BLOOD WBC-7.9 RBC-2.73* Hgb-8.6* Hct-25.4* MCV-93 MCH-31.5 MCHC-33.9 RDW-13.9 Plt Ct-82* [**2171-1-11**] 06:25AM BLOOD Plt Ct-339 [**2171-1-10**] 12:00PM BLOOD Plt Ct-348 [**2171-1-9**] 02:55AM BLOOD PT-13.1 PTT-26.2 INR(PT)-1.2 [**2170-12-30**] 06:43PM BLOOD Plt Smr-LOW Plt Ct-82* [**2170-12-30**] 06:43PM BLOOD PT-15.1* PTT-37.4* INR(PT)-1.6 [**2170-12-30**] 06:43PM BLOOD Fibrino-599* [**2171-1-14**] 05:55AM BLOOD Glucose-96 UreaN-24* Creat-1.0 Na-143 K-4.2 Cl-110* HCO3-26 AnGap-11 [**2171-1-13**] 05:55AM BLOOD Glucose-107* UreaN-33* Creat-1.1 Na-141 K-4.3 Cl-109* HCO3-26 AnGap-10 [**2170-12-30**] 10:47PM BLOOD K-3.5 [**2170-12-30**] 06:43PM BLOOD Glucose-82 UreaN-41* Creat-3.5* Na-137 K-3.1* Cl-102 HCO3-21* AnGap-17 [**2171-1-12**] 05:38AM BLOOD Amylase-355* [**2171-1-11**] 06:25AM BLOOD Amylase-318* [**2171-1-9**] 02:55AM BLOOD ALT-10 AST-15 CK(CPK)-17* AlkPhos-165* Amylase-603* TotBili-1.0 [**2170-12-31**] 12:54PM BLOOD ALT-70* AST-41* CK(CPK)-20* AlkPhos-154* Amylase-149* TotBili-2.5* DirBili-1.9* IndBili-0.6 [**2170-12-31**] 01:19AM BLOOD ALT-81* AST-54* CK(CPK)-31 AlkPhos-162* TotBili-3.1* [**2170-12-30**] 06:43PM BLOOD ALT-87* AST-62* LD(LDH)-183 CK(CPK)-43 AlkPhos-162* Amylase-265* TotBili-3.5* [**2171-1-12**] 05:38AM BLOOD Lipase-233* [**2171-1-11**] 06:25AM BLOOD Lipase-122* [**2171-1-9**] 02:55AM BLOOD Lipase-360* [**2170-12-31**] 12:54PM BLOOD Lipase-27 [**2170-12-30**] 06:43PM BLOOD Lipase-28 [**2171-1-14**] 05:55AM BLOOD Calcium-7.8* Phos-4.0 Mg-1.7 [**2171-1-13**] 05:55AM BLOOD Calcium-7.8* Phos-4.0 Mg-2.1 [**2170-12-31**] 01:19AM BLOOD Calcium-8.3* Phos-2.8 Mg-2.2 [**2170-12-30**] 06:43PM BLOOD Albumin-2.6* Calcium-7.0* Phos-2.6* Mg-1.4* [**2171-1-2**] 09:15PM BLOOD Triglyc-87 [**2171-1-2**] 11:03PM BLOOD Cortsol-51.9* [**2171-1-2**] 10:05PM BLOOD Cortsol-45.0* [**2171-1-2**] 09:15PM BLOOD Cortsol-35.8* Brief Hospital Course: The patient was admited to the [**Hospital1 18**] SICU under Dr.[**Name (NI) 6045**] service. The patient was kept intubated with pressors to maintain blood pressure. On [**1-6**] the patient was transfered to the floor. . 1. Renal Failure: A nephrology consult was obtained for non-oliguric renal failure secondary to post-op hypotension and ATN. Cr slowly began to fall and the patient auto-diuresed well. Her water loses were replaced with D5W while her sodium and BUN normalized. Cr was normal at 1.0 upon discharge. . 2. Sepsis: IV antibiotics were started (Levofloxacin, ampicillin, flagyl) and were dosed renally. Pressors were weaned [**2171-1-1**]. Ampicillin d/c'd [**1-2**]. Flagyl d/c'd [**1-3**] once ID & Sensitivies returned from the outside hospital. Levofloxacin continued. On [**2171-1-4**] the patient had a temp spike and cultures were again sent. No further cultures were positive and levofloxacin was discontinued after a 14-day course. . 3. Increased liver function tests/?Underlying cholangitis/continued abdominal pain: Abd ultrasound showed no evidence of dilated bile ducts, [**Last Name (un) 26186**] leaks, or retained stones. A GI consult was obtained and emergent ERCP was held given the U/S results. CT scan was obtained [**2171-1-2**] which revealed no reason for abdominal pain. Abdominal pain resolved. Pancreatic enzymes rose, though the patient was asymptomatic. . 4. Nutrition: TPN was started on [**2171-1-1**]. A bed-side swallow evaluation was performed [**2171-1-4**] and showed no s/s of apiration with thin liquids and purees. Diet was started on [**1-10**]. TPN was stopped [**1-12**] when the patient was tolerating a regular diet. . 5. Atrial Fibrillation: The patient was again in AFib on [**1-1**] and started on IV Amiodorone. DC cardioversion was successful. PO Amiodorone started [**1-3**] . 6. Respiratory failure: weaned and extubated [**2171-1-3**] During the remaining last few days of [**Hospital **] hospital stay, her diet was advanced to regular and her pain was controlled. PT was consulted and recommended a short rehabilitation stay. Pt agreed with plan and was discharged to rehab on [**2171-1-14**] in stable condition. Medications on Admission: Home medications: HCTZ 25mg daily Nadolol 40mg daily KCL Mirapex 0.5 mg daily Neurontin 600mg daily Hydrocodone prn Discharge Medications: 1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 3. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO twice a day as needed for constipation. Disp:*420 ml* Refills:*0* 4. Nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Pramipexole 0.25 mg Tablet Sig: One (1) Tablet PO daily (). 6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN (as needed). 8. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q4H (every 4 hours) as needed. 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 10. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: sepsis, acute renal failure, acute respiratory failure Discharge Condition: good Discharge Instructions: Restart you home medications as usual, except your HCTZ (do not take HCTZ). We have started you on a new medication called amiodarone. Please fill and take as directed. Regular diet. You may resume activity as tolerated. You may shower, then pat-dry incision. Do not rub incision. No tub baths or swimming for 3-4 weeks. You may leave the incision uncovered or use a light dressing for comfort. * Increasing pain * Fever (>101.5 F) or Vomiting * Inability to eat or drink * Inability to pass gas or stool * Pain/redness/swelling of incision * Other symptoms concerning to you Followup Instructions: Call Dr.[**Name (NI) 6045**] clinic at ([**Telephone/Fax (1) 15350**] to schedule a follow-up appointment in [**2-11**] weeks. Follow-up with your PCP [**Last Name (NamePattern4) **] [**2-11**] weeks for management of you BP meds (HCTZ, nadolol) and afib medication amiodarone. [**Name6 (MD) **] [**Last Name (NamePattern4) **] MD, [**MD Number(3) 5190**] Completed by:[**2171-1-14**]

[ "038.9", "719.41", "V13.01", "576.1", "427.31", "998.59", "401.9", "518.81", "V43.65", "584.5", "995.92", "790.4" ]

icd9cm

[ [ [] ] ]

[ "38.91", "00.17", "96.72", "96.6", "99.15", "38.93", "99.04" ]

icd9pcs

[ [ [] ] ]

7773, 7852

4475, 6678

270, 276

7950, 7956

2056, 4452

8586, 9002

6844, 7750

7873, 7929

6704, 6704

7980, 8563

1843, 1843

6722, 6821

196, 232

304, 1502

1857, 2037

1524, 1705

1721, 1828

32,453

100,661

32315

Discharge summary

report

Admission Date: [**2130-3-24**] Discharge Date: [**2130-3-29**] Date of Birth: [**2089-3-19**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 30**] Chief Complaint: hematemesis Major Surgical or Invasive Procedure: EGD History of Present Illness: 41 y/o male with EtOH cirrhosis, chronic pancreatitis, who presented to an OSH with hematemesis. He was recently discharged from [**Location (un) 3320**] Corrections three days PTA. On the morning of admission, he spoke with his mother who reported that he sounded well. Later that day, he felt sick and had several episodes of hematemesis (approx 900 cc with 8+ episodes). He then went to [**Hospital3 3583**] for further care. At the OSH, his VS were stable as was his Hct. He reportedly had a transfusion reaction when getting 1 U PRBCs (chest redness and tremors). He was subsequently intubated and transferred to [**Hospital1 18**]. Past Medical History: 1. ETOH cirrhosis 2. Chronic pleural effusions Social History: He is currently homeless. His kids live with his sister, who is his HCP. [**Name (NI) **] denies smoking, admits ETOH in the past, which he can stop when he wants to. Family History: Non-contributory Physical Exam: VS: Tc 98.2, 98.0, BP 118/62, HR 107, RR 16, SaO2 97%/RA General: Middle-aged male in NAD, AO x 3 HEENT: NC/AT, PERRL, EOMI. Anicteric sclerae. MMM, OP clear Neck: supple, no LAD or JVD Chest: CTA-B, no w/r/r CV: RRR s1 s2 normal, no m/g/r Abd: soft, distended, +TTP over the epigastrum without rebound or guarding, quiet BS Ext: no c/c/e, wwp Neuro: AO x 3, +tremulous, no asterixis Skin: + few spider angiomas and palmar erythema Pertinent Results: [**2130-3-24**] 04:05PM BLOOD WBC-5.3 RBC-3.31* Hgb-9.4* Hct-26.8* MCV-81*# MCH-28.3 MCHC-35.0 RDW-16.0* Plt Ct-107*# [**2130-3-24**] 04:05PM BLOOD Neuts-82.1* Lymphs-14.1* Monos-2.2 Eos-1.3 Baso-0.2 [**2130-3-24**] 04:05PM BLOOD PT-16.6* PTT-34.8 INR(PT)-1.5* [**2130-3-24**] 04:05PM BLOOD Glucose-138* UreaN-15 Creat-0.5 Na-142 K-3.5 Cl-105 HCO3-22 AnGap-19 [**2130-3-24**] 04:05PM BLOOD ALT-18 AST-36 TotBili-1.3 [**2130-3-24**] 04:05PM BLOOD Lipase-110* [**2130-3-24**] 04:05PM BLOOD TotProt-6.0* Albumin-3.7 Globuln-2.3 Calcium-8.1* Phos-3.8 Mg-1.3* [**2130-3-26**] 06:35AM BLOOD Hapto-69 [**3-24**] Blood cultures-pending EGD Esophagus: Mucosa: Abnormal mucosa was noted in the distal esophagus with erythema and friability consistant with moderate esophagitis. Stomach: Mucosa: Two blood clots were noted below the GE junction with no evidence of active bleeding. One hemostatic clip was placed and 4 ml of epinephrine were injected into the mucosa underneath one of the clots. Duodenum: Mucosa: Normal mucosa was noted. Impression: Abnormal mucosa in the esophagus Abnormal mucosa in the stomach Normal mucosa in the duodenum Otherwise normal EGD to third part of the duodenum Brief Hospital Course: 41 y/o male with EtOH cirrhosis, chronic pancreatitis, who presented to an OSH with hematemesis. He was recently discharged from [**Location (un) 3320**] Corrections three days PTA. On the morning of admission, he spoke with his mother who reported that he sounded well. Later that day, he felt sick and had several episodes of hematemesis (approx 900 cc with 8+ episodes). He then went to [**Hospital3 3583**] for further care. At the OSH, his VS were stable as was his Hct. He reportedly had a transfusion reaction when getting 1 U PRBCs (chest redness and tremors). He was subsequently intubated and transferred to [**Hospital1 18**]. . Of note, patient was admitted to [**Hospital1 18**] in [**2129-10-20**] with an upper GI bleed. At that time an upper endoscopy revealed severe esophagitis, probably portal hypertensive gastropathy but no evidence of varices. Patient reports that he had an admission at [**Hospital3 3583**] 1-2 months ago for hematemesis and at the time the EGD revealed varices. . In the ED, initial VS were significant for tachycardia into the 110's. He was given 1 L NS, started on an octreotide gtt, and given 1 gm CTX IV. . MICU course: He was extubated on arrival successfully. His VS remained stable although HR was in the 110's. He was continued on an octreotide gtt overnight and kept NPO. He had an EGD [**2130-3-25**] which revealed 2 clots at the GE junction (no active bleeding); epi was injected and clips were placed. The octreotide gtt was stopped and the patient was continued on IV PPI only. His Hct remained stable and he required no further transfusions. During his course he has had persistent abdominal pain, c/w pancreatitis, and was kept NPO with sips only and given dilaudid for pain. He has required ativan per CIWA for withdrawal approx q3 hours. . # Hematemesis - His hematemesis was most likely due to esophagitis and portal gastropathy, with abnormal mucosa at the GE junction. There was no evidence of varices on EGD. His Hct remained stable while on the medical floor and patient had been hemodynamically stable. Initially after his endoscopy his had further episodes of hematemesis and there was a question of re-scoping but as his Hct stabilized this was not felt to be indicated. He was on a PPI IV bid, and he had antiemetics prn. He started tolerating a clear liquid diet which was slowly advanced and he was felt to be stable for discharge. . # Abdominal pain - His pain was consistent with a prior history of pancreatitis, patient reports flares 1-2x/month. Lipase/amylase not elevated, possibly [**1-21**] chronic pancreatitis. His diet was slowly advanced and his pain was controlled with IV dilaudid initially then po dilaudid. . # Cirrhosis - Secondary to EtOH, patient with ongoing EtOH abuse. INR mildly elevated but albumin normal, suggesting intact synthetic function. His coags/platelets and albumin were followed and platelets were maintained above 50, with FFP given for INR>1.5. He also received lasix and aldactone but they commonly had to be held due to borderline blood pressure (systolic 100's). The liver service followed him while he was hospitalized but he is not currently adherent to therapy. . # Thrombocytopenia - His baseline platelets normal around 200 back in [**10-27**], now down to 80's. This is likely due to worsening cirrhosis and possible marrow suppression from EtOH. There is no evidence of hemolysis as Hct has been stable. Hemolysis labs were negative and platelets were kept above 50 given his active bleeding on admission. . # EtOH abuse -He was maintained on an ativan CIWA (avoiding valium given cirrhosis) as patient high-risk to withdraw. He continued thiamine/folate/MVI; and switched to po's once taking po's. SW was consulted and assisted the medical team in obtaining a shelter for him to be discharged to. . # ?Adrenal insufficiency - The patient was unsure of history, noted to be on hydrocortisone, which was confirmed with his pharmacy. On contacting his PCP (Dr. [**MD Number(4) 75518**] last saw him in [**Month (only) 359**]), the diagnosis began on a prolonged ICU stay at [**Hospital3 **] a year ago. At times he does not take the steroids and his blood pressure maintains SBP 100's. He initially had been on hydrocortisone but upon learning this a prednisone taper was initiated. . # Communication - Mother [**First Name8 (NamePattern2) 1439**] [**Name (NI) 53917**]) home - [**Telephone/Fax (1) 75519**]; cell - [**Telephone/Fax (1) 75520**] . Medications on Admission: Pantoprazole 40 mg IV bid Ondansetron 4 mg IV q8 hrs prn Lorazepam 2 mg IV Q2H PRN CIWA>10 Thiamine 100 mg IV daily FoLIC Acid 1 mg IV daily HYDROmorphone (Dilaudid) 1-2 mg IV q4 hrs prn Insulin SC Trazadone 75 mg qhs Seroquel 200 mg [**Hospital1 **] Hydrocortisone 10 mg q8 Discharge Medications: 1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 5. Lamotrigine 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 7. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule, Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*120 Cap(s)* Refills:*2* 8. Prednisone 2.5 mg Tablet Sig: Four (4) Tablet PO once a day for 5 days: please take 4 tablets a day for 5 days, then take 3 tablets a day for the next 7 days, take two tablets a day for the next 7 days and then one tablet a day for 7 days. Disp:*65 Tablet(s)* Refills:*0* 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 10. Quetiapine 200 mg Tablet Sig: 0.5 Tablet PO QHS PRN (). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: gastric ulcer, esophagitis ----------------- alcohol cirrhosis chronic pleural effusions Discharge Condition: stable, afebrile, ambulatory Discharge Instructions: You were admitted to the hospital with hematemesis (vomiting blood). You had an EGD (scope) to evaluate your esophagus and stomach, where an ulcer was found. You received medications to treat this and your symptoms improved. You should take your medications as prescribed. You will be taking prednisone 10mg a day and the dose will be decreased over time. Followup Instructions: Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] [**Telephone/Fax (1) 26647**] Thursday [**4-13**] at 1:15pm Completed by:[**2130-4-5**]

[ "530.10", "303.91", "577.1", "531.40", "285.1", "287.5", "571.2", "511.9" ]

icd9cm

[ [ [] ] ]

[ "96.71", "45.13", "99.04" ]

icd9pcs

[ [ [] ] ]

9107, 9113

2971, 7445

325, 331

9247, 9278

1756, 2948

9686, 9857

1271, 1289

7770, 9084

9134, 9226

7471, 7747

9302, 9663

1304, 1737

274, 287

359, 998

1020, 1068

1084, 1255

82,939

104,094

38658

Discharge summary

report

Admission Date: [**2180-3-7**] Discharge Date: [**2180-3-15**] Date of Birth: [**2153-12-22**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5378**] Chief Complaint: OSH transfer for AMS, seizures Major Surgical or Invasive Procedure: extubation, Lumbar puncture History of Present Illness: Per admitting resident: 26 year old RH man with an unremakable PMH who was last seen in his USOH in the early am (prior to going to work) and then at noon (normal conversation with his wife over the phone) p/w confusion and question of seizure. Today at around 13:00 he was found confused by his peers. The report says he could not maintain a conversation and was thrashing and moving his arms and legs bl and symmetrically. He did not have a facial droop. He was not bumping into objects per wife. [**Name (NI) **] was not seen seizing. There was no documented LOC. While taken by EMS to OSH, there is the question of a seizure episode. Unfortunately, I see no documentation in this regard. EMS took the pt to [**Hospital **] hospital. The pt was noted to have a fever 101.9F with 139/ 68 and 155 bpm and 24 RR with So2 100% in RA. Pt received a CT CNS w/o contrast that showed LEF Ttemporo-parietal hypodense wedge shaped lesion. No fractures or bleed. No hydrocephalus or herniation data. His Chem showed a normal Na and Ca. His Glu was 177. He did have an AG of 22. He was tapped: LP showed: Pr 58, glu 92 BRCs 50, 2 WBC (100% L) RBCs 48, 2 WBCs. (100% L) His EKG showed a sinus tachycardia w/o repol abnormalities. His C-spine scan was negative. He received ceftriaxone 2 g iv and vancomycin 1 g iv. He received 1 g PHT iv and was ETT'd at 14:45 after sedation with sucinylcholine and vecuronium and placed on a versed drip. Once at [**Hospital1 18**], he was started on propofol drip and bolussed with versed (agitated). He also received acyclovir 800 mg iv. ROS is negative otherwise. NO sick contacts. [**Name (NI) **] ID symptoms. No headaches. NO seizure hx. NO aneurisms hx. Baseline: IADLS. Additional hx obtained from witness: Per discussion with witness, patient was working on a boat engine. Last seen normal at noon time. Owner heard back from him when calling his name at 1pm on another part of the boat. ~ 30 minutes later, owner heard loud banging, ran to see pt. and oted that him laying on floor, arms and legs stiffened, head shaking and banging on the back of the metal wall. This lasted nearly 1-2 minutes. Once banging stopped, patient appeared to be unconscious with heavy breathing. EMS arrived and by this time (10 mins) he "came to" crawled out of area on his own, could not say his name to EMS, did not know where he was, "glassy eyed" and dazed. Few minutes later had another episode: eyes opened wide, clenched his teath, foam coming out of his mouth, body straightened/rigid. This lasted 2 minutes and then became loose again and confused. Patient was at that time transported to OSH. Past Medical History: none Social History: Lives with wife and daughter Exercises (-) Tobacco occasional cigarrettes. ETOH two beers per night Drugs (-) He works as an electrician. Family History: Hx of early strokes (-) Seizures (-) CNS tumors (+) - granmother. Demyelinating conditions (-) Autoimmune conditions (-) Procoagulant conditions (-) CAD (-) Aneurysm (+) grandfather. Physical Exam: Exam on admission: 176/ 76, 136 bpm: agitated. When sedated: 130/ 80s. On vent, CMV mode breathing at 22 RR (overbreathing the vent). Sedated on Propofol at 50 mcg/ kg/ min which was stopped 15 minutes prior to my examination. Gen: Lying in bed, fighting the tube. HEENT: NC/AT, moist oral mucosa Neck: supple, no carotid or vertebral bruit Back: No point tenderness or erythema CV: Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally Abd: Soft, nontender, non-distended. No masses or megalies. Percussion within normal limits. +BS. Ext: no edema, no DVT data. Pulses ++ and symmetric. Neurologic examination: MS: He is responsive to noxious stimuli in all limbs. He does withdraw to pain symmetrically and localizes well. CN: Brain stem reflexes : preserved: Corneals + bl. Pupils 3.5 to 2.5 bl and symmetrically. resisting my pupillary exam. Closes his eyes symmetrically. No gaze deviation. No bobbing or Robbing. No nystagmus. No facial asymmetries. Gag +. Tone: normal. DTR: 2+. Toes : would not allow exam (withdraws and quicks) Labs: reviewed. U Tox and serum tox: negative, except for tylenol level (7.5: given at [**Hospital1 18**] and at OSH). Pertinent Results: Labs on admission: [**2180-3-7**] 07:25PM BLOOD WBC-16.1* RBC-4.77 Hgb-14.4 Hct-41.8 MCV-88 MCH-30.1 MCHC-34.3 RDW-12.4 Plt Ct-232 [**2180-3-9**] 03:17AM BLOOD WBC-8.8 RBC-4.45* Hgb-13.5* Hct-38.9* MCV-87 MCH-30.3 MCHC-34.6 RDW-12.7 Plt Ct-190 [**2180-3-7**] 07:25PM BLOOD Neuts-92.3* Lymphs-4.0* Monos-3.4 Eos-0.1 Baso-0.2 [**2180-3-7**] 07:25PM BLOOD PT-12.5 PTT-22.5 INR(PT)-1.1 [**2180-3-7**] 07:25PM BLOOD Glucose-148* UreaN-13 Creat-1.7* Na-139 K-3.8 Cl-106 HCO3-24 AnGap-13 [**2180-3-8**] 01:55PM BLOOD UreaN-11 Creat-1.6* Na-142 K-3.7 Cl-111* HCO3-25 AnGap-10 [**2180-3-9**] 12:36PM BLOOD Glucose-121* UreaN-7 Creat-1.3* Na-141 K-3.3 Cl-105 HCO3-28 AnGap-11 [**2180-3-8**] 12:02AM BLOOD ALT-61* AST-193* CK(CPK)-[**Numeric Identifier 85885**]* AlkPhos-43 TotBili-0.7 [**2180-3-8**] 01:55PM BLOOD CK(CPK)-[**Numeric Identifier **]* [**2180-3-8**] 10:32PM BLOOD CK(CPK)-[**Numeric Identifier 85886**]* [**2180-3-9**] 03:17AM BLOOD ALT-141* AST-622* LD(LDH)-1687* CK(CPK)-[**Numeric Identifier 85887**]* AlkPhos-32* TotBili-0.4 DirBili-0.2 IndBili-0.2 [**2180-3-9**] 12:36PM BLOOD CK(CPK)-[**Numeric Identifier 85888**]* [**2180-3-7**] 07:25PM BLOOD Albumin-4.4 Calcium-8.3* Phos-2.9 Mg-2.8* [**2180-3-8**] 12:02AM BLOOD Triglyc-101 HDL-48 CHOL/HD-3.7 LDLcalc-108 [**2180-3-8**] 01:55PM BLOOD ANCA-NEGATIVE B [**2180-3-7**] 07:25PM BLOOD CRP-8.7* [**2180-3-7**] 07:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-7.6* Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Labs during hospital stay CBC [**2180-3-14**] 04:20AM BLOOD WBC-5.9 RBC-4.67 Hgb-13.8* Hct-39.5* MCV-85 MCH-29.6 MCHC-35.0 RDW-12.4 Plt Ct-227 [**2180-3-13**] 05:15AM BLOOD WBC-5.3 RBC-4.31* Hgb-13.2* Hct-36.5* MCV-85 MCH-30.7 MCHC-36.2* RDW-12.3 Plt Ct-174 [**2180-3-12**] 05:50AM BLOOD WBC-4.1 RBC-4.09* Hgb-12.5* Hct-35.0* MCV-85 MCH-30.5 MCHC-35.7* RDW-12.2 Plt Ct-171 [**2180-3-11**] 04:17AM BLOOD WBC-5.6 RBC-4.06* Hgb-12.8* Hct-35.5* MCV-88 MCH-31.6 MCHC-36.1* RDW-12.1 Plt Ct-182 [**2180-3-10**] 03:17AM BLOOD WBC-6.8 RBC-4.39* Hgb-13.3* Hct-38.8* MCV-89 MCH-30.4 MCHC-34.4 RDW-12.2 Plt Ct-191 [**2180-3-9**] 03:17AM BLOOD WBC-8.8 RBC-4.45* Hgb-13.5* Hct-38.9* MCV-87 MCH-30.3 MCHC-34.6 RDW-12.7 Plt Ct-190 [**2180-3-8**] 01:55PM BLOOD Hct-36.8*# [**2180-3-8**] 12:02AM BLOOD WBC-14.0* RBC-5.27 Hgb-16.0 Hct-47.0 MCV-89 MCH-30.4 MCHC-34.0 RDW-12.3 Plt Ct-262 [**2180-3-13**] 05:15AM BLOOD Neuts-66.0 Lymphs-29.4 Monos-3.1 Eos-1.1 Baso-0.3 [**2180-3-9**] 03:17AM BLOOD Neuts-80.4* Lymphs-14.2* Monos-4.8 Eos-0.2 Baso-0.4 [**2180-3-14**] 04:20AM BLOOD Plt Ct-227 [**2180-3-13**] 05:15AM BLOOD Plt Ct-174 [**2180-3-12**] 05:50AM BLOOD Plt Ct-171 [**2180-3-11**] 04:17AM BLOOD Plt Ct-182 [**2180-3-10**] 03:17AM BLOOD Plt Ct-191 [**2180-3-9**] 03:17AM BLOOD Plt Ct-190 [**2180-3-8**] 01:55PM BLOOD ESR-1 Chem 7 [**2180-3-14**] 04:20AM BLOOD Glucose-94 UreaN-15 Creat-1.0 Na-140 K-3.8 Cl-100 HCO3-30 AnGap-14 [**2180-3-13**] 05:35PM BLOOD Glucose-110* UreaN-13 Creat-1.0 Na-140 K-4.2 Cl-103 HCO3-30 AnGap-11 [**2180-3-13**] 05:15AM BLOOD Glucose-110* UreaN-11 Creat-1.2 Na-139 K-3.7 Cl-102 HCO3-30 AnGap-11 [**2180-3-12**] 03:22PM BLOOD Glucose-120* UreaN-10 Creat-1.0 Na-140 K-3.6 Cl-102 HCO3-30 AnGap-12 [**2180-3-12**] 05:50AM BLOOD Glucose-112* UreaN-9 Creat-1.1 Na-138 K-3.5 Cl-102 HCO3-30 AnGap-10 [**2180-3-11**] 03:24PM BLOOD Glucose-105* UreaN-8 Creat-1.2 Na-139 K-3.1* Cl-98 HCO3-35* AnGap-9 [**2180-3-11**] 04:17AM BLOOD Glucose-170* UreaN-7 Creat-1.1 Na-140 K-3.3 Cl-100 HCO3-34* AnGap-9 [**2180-3-10**] 02:37PM BLOOD Glucose-118* UreaN-6 Creat-1.1 Na-140 K-3.6 Cl-103 HCO3-34* AnGap-7* [**2180-3-10**] 03:17AM BLOOD Glucose-167* UreaN-5* Creat-1.1 Na-140 K-3.4 Cl-103 HCO3-33* AnGap-7* [**2180-3-9**] 07:50PM BLOOD Glucose-131* UreaN-6 Creat-1.3* Na-140 K-3.8 Cl-103 HCO3-32 AnGap-9 [**2180-3-9**] 12:36PM BLOOD Glucose-121* UreaN-7 Creat-1.3* Na-141 K-3.3 Cl-105 HCO3-28 AnGap-11 [**2180-3-8**] 01:55PM BLOOD UreaN-11 Creat-1.6* Na-142 K-3.7 Cl-111* HCO3-25 AnGap-10 Muscle enzymes [**2180-3-14**] 04:20AM BLOOD ALT-436* AST-448* LD(LDH)-484* CK(CPK)-[**Numeric Identifier 85889**]* [**2180-3-13**] 05:35PM BLOOD CK(CPK)-[**Numeric Identifier 85890**]* [**2180-3-13**] 05:15AM BLOOD ALT-487* AST-803* CK(CPK)-[**Numeric Identifier 85891**]* AlkPhos-57 TotBili-0.4 [**2180-3-12**] 05:50AM BLOOD ALT-377* AST-994* LD(LDH)-2039* CK(CPK)-[**Numeric Identifier **]* AlkPhos-46 TotBili-0.4 [**2180-3-11**] 04:17AM BLOOD ALT-299* AST-1062* CK(CPK)-[**Numeric Identifier 85892**]* AlkPhos-34* TotBili-0.3 [**2180-3-10**] 02:37PM BLOOD CK(CPK)-[**Numeric Identifier 85893**]* [**2180-3-10**] 03:17AM BLOOD ALT-224* AST-890* LD(LDH)-3034* CK(CPK)-[**Numeric Identifier 85894**]* AlkPhos-29* TotBili-0.2 [**2180-3-9**] 07:50PM BLOOD CK(CPK)-[**Numeric Identifier 85895**]* [**2180-3-9**] 12:36PM BLOOD CK(CPK)-[**Numeric Identifier 85888**]* LFTs [**2180-3-9**] 03:17AM BLOOD ALT-141* AST-622* LD(LDH)-1687* CK(CPK)-[**Numeric Identifier 85887**]* AlkPhos-32* TotBili-0.4 DirBili-0.2 IndBili-0.2 [**2180-3-8**] 10:32PM BLOOD CK(CPK)-[**Numeric Identifier 85886**]* Ca/Mg/P [**2180-3-14**] 04:20AM BLOOD Calcium-8.6 Phos-3.7 Mg-1.9 [**2180-3-13**] 05:35PM BLOOD Calcium-8.6 Phos-3.6 Mg-2.0 Iron-67 [**2180-3-13**] 05:15AM BLOOD Albumin-3.4* Calcium-8.7 Phos-2.7 Mg-1.8 [**2180-3-12**] 03:22PM BLOOD Calcium-7.9* Phos-2.4* Mg-1.8 [**2180-3-12**] 05:50AM BLOOD Albumin-3.2* Calcium-7.7* Phos-2.1* Mg-1.8 [**2180-3-11**] 03:24PM BLOOD Calcium-7.8* Phos-2.5* Mg-1.8 [**2180-3-10**] 02:37PM BLOOD Calcium-7.7* Phos-2.0* Mg-1.9 [**2180-3-10**] 03:17AM BLOOD Calcium-7.4* Phos-2.2* Mg-1.8 Other tests [**2180-3-10**] 03:17AM BLOOD TSH-1.8 [**2180-3-8**] 12:02AM BLOOD TSH-1.5 [**2180-3-8**] 01:55PM BLOOD ANCA-NEGATIVE B [**2180-3-8**] 01:55PM BLOOD [**Doctor First Name **]-NEGATIVE [**2180-3-10**] 02:37PM BLOOD HIV Ab-NEGATIVE [**2180-3-7**] 07:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-7.6* Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Urine [**2180-3-11**] 12:58PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.015 [**2180-3-11**] 12:58PM URINE Blood-LG Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-9.0* Leuks-NEG CSF [**2180-3-9**] 10:33AM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-22* Polys-33 Lymphs-49 Monos-18 [**2180-3-9**] 10:33AM CEREBROSPINAL FLUID (CSF) WBC-5 RBC-125* Polys-13 Lymphs-80 Monos-7 [**2180-3-9**] 10:33AM CEREBROSPINAL FLUID (CSF) TotProt-24 Glucose-81 CSF other tests HSV, EBV, HHV 6, CMV - negative Lyme, MS profile- pending Microbiology HIV-1 Viral Load/Ultrasensitive (Final [**2180-3-13**]): HIV-1 RNA is not detected. Performed using the Cobas Ampliprep / Cobas Taqman HIV-1 Test. Detection range: 48 - 10,000,000 copies/ml. This test is approved for monitoring HIV-1 viral load in known HIV-positive patients. It is not approved for diagnosis of acute HIV infection. In symptomatic acute HIV infection (acute retroviral syndrome), the viral load is usually very high (>>1000 copies/mL). If acute HIV infection is clinically suspected and there is a detectable but low viral load, please contact the laboratory for interpretation. It is recommended that any NEW positive HIV-1 viral load result, in the absence of positive serology, be confirmed by submitting a new sample FOR HIV-1 PCR, in addition to serological testing. RAPID PLASMA REAGIN TEST (Final [**2180-3-13**]): NONREACTIVE. Reference Range: Non-Reactive. [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB (Final [**2180-3-13**]): POSITIVE BY EIA. [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB (Final [**2180-3-13**]): POSITIVE BY EIA. [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM AB (Final [**2180-3-13**]): NEGATIVE <1:10 BY IFA. INTERPRETATION: RESULTS INDICATIVE OF PAST EBV INFECTION. In most populations, 90% of adults have been infected at sometime with EBV and will have measurable VCA IgG and EBNA antibodies. Antibodies to EBNA develop 6-8 weeks after primary infection and remain present for life. Presence of VCA IgM antibodies indicates recent primary infection. CMV IgG ANTIBODY (Final [**2180-3-10**]): POSITIVE FOR CMV IgG ANTIBODY BY EIA. 23 AU/ML. Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml. CMV IgM ANTIBODY (Final [**2180-3-10**]): NEGATIVE FOR CMV IgM ANTIBODY BY EIA. INTERPRETATION: INFECTION AT UNDETERMINED TIME. A positive IgG result generally indicates past exposure. Infection with CMV once contracted remains latent and may reactivate when immunity is compromised. If current infection is suspected, submit follow-up serum in [**2-16**] weeks. Greatly elevated serum protein with IgG levels >[**2170**] mg/dl may cause interference with CMV IgM results. DIRECT INFLUENZA A ANTIGEN TEST (Final [**2180-3-9**]): Negative for Influenza A. DIRECT INFLUENZA B ANTIGEN TEST (Final [**2180-3-9**]): Negative for Influenza B. TOXOPLASMA IgG ANTIBODY (Final [**2180-3-10**]): NEGATIVE FOR TOXOPLASMA IgG ANTIBODY BY EIA. 0.0 IU/ML. Reference Range: Negative < 4 IU/ml, Positive >= 8 IU/ml. LYME SEROLOGY (Final [**2180-3-9**]): NO ANTIBODY TO B. BURGDORFERI DETECTED BY EIA. Reference Range: No antibody detected. Negative results do not rule out B. burgdorferi infection. Patients in early stages of infection or on antibiotic therapy may not produce detectable levels of antibody. Patients with clinical history and/or symptoms suggestive of lyme disease should be retested in [**2-16**] weeks. ASO Screen (Final [**2180-3-9**]): POSITIVE by Latex Agglutination. Reference Range: < 200 IU/ml (Adults and children > 6 years old). ASO TITER (Final [**2180-3-9**]): POSITIVE 200-400 IU/ml. Performed by latex agglutination. Reference Range: < 200 IU/ml (Adults and children > 6 years old). TOXOPLASMA IgM ANTIBODY (Final [**2180-3-10**]): NEGATIVE FOR TOXOPLASMA IgM ANTIBODY BY EIA. INTERPRETATION: NO ANTIBODY DETECTED. Blood Culture, Routine (Preliminary): STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE SET ONLY. SENSITIVITIES PERFORMED ON REQUEST.. Aerobic Bottle Gram Stain (Final [**2180-3-12**]): GRAM POSITIVE COCCI IN CLUSTERS. REPORTED BY PHONE TO [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 85896**],RN 12:15PM [**2180-3-12**]. Blood Culture, Routine [**3-8**] (Final [**2180-3-14**]): NO GROWTH. [**2180-3-7**] 11:38 pm BLOOD CULTURE Source: Venipuncture. **FINAL REPORT [**2180-3-14**]** Blood Culture, Routine (Final [**2180-3-14**]): NO GROWTH. Imaging: MRI/A of head and neck: IMPRESSION: 1. FLAIR abnormality in the subcortical left occipital lobe with some focal overlying cortical involvement and no evidence of associated hemorrhage, restricted diffusion, or definitive enhancement. The differential diagnosis includes low-grade primary glial neoplasm and tumefactive demyelination. 2. Unremarkable MRA of the head and neck without evidence of tumor vascularity, shunting, or flow-limiting stenosis. 3. Sinus disease as described above, the activity of which is to be determined clinically. TTE: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. No masses or vegetations are seen on the aortic valve. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. The pulmonary artery systolic pressure could not be determined. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. IMPRESSION: No echo evidence of endocarditis. Brief Hospital Course: 26 year old RH man with an unremakable PMH who was last seen in his USOH in the early am (prior to going to work) and then at noon (normal conversation with his wife over the phone) p/w two subsequent seizures with associated leukocytosis, fever, non-blanching erythematous rash, conj. hemorrhage, rhabdomyolisis, ARF, transaminitis with a L parietal lesion on MRI representative on edema w/o [**Year/Month/Day **] enhancement. NEURO. Unclear what the unifying diagnosis is at time of presentation. DDx included an underlying primary CNS malignancy with edema, leading to seizure and subsequent rhabdomyolisis, ARF, though given fever and rash an infectious process (viral HSV, EBV, HHV-6) could not be definitively ruled out. In addition, a metastasis from a lymphoma in this patient was also considered. OSH LP negative and viral studies w/ cultures pending. Patient treated empirically with Acyclovir/CFTX/Vancomycin as per ID recommendation for possible coverage of HSV encephalitis (atypical presentation), possible meningitis and/or endocarditis with vancomycin. No stigmata of endocarditis were noted and TTE was negative. BCx were negative. Additionally, vasculitis etiology was considered, however ESR was 1 and ANCA was negative. He underwent a repeat LP for cytology which showed 5 cells, normal protein and gluocose. Opening pressure was 32. Viral studies inclusind HSV, VZV, EBV, HHV-6 were negative. Lyme serology and CSF were negative Olygoclonal bands were obtained with concern for atypical ADEM and were negative. Neuro-oncology was consulted who recommended outpatient follow up for biopsy of brain tumor after normalisation of high CK and improvement in general medical condition. EEG was obtained and showed spikes nearly Q1-2mins w/o NCSE, thus patient was continued on Dilantin with goal of > 10 corrected for albumin, which was later changed to keppra which was continued as outpatient. PULM. Pt. was extubated on HD1. No further respiratory issues were noted, after trasnfer to floor. HEME/RENAL. CK on arrival ~ 18K treated with moderate IVF rate, and rose to peak of 100 K. Pt. was treated with D5HCO3 and NS titrated to goal UOP of > 200cc/hr with aid of lasix. Cr peaked at 1.9 and microscopic analysis was notable for granular casts concerning for tubular renal injury. Cr at time of discharge was 4000s, with rapid downward trend. ID. Pt. w/ fever on presentation and recurrence on HD2. He was empirically treated with IV ABx for etiologies concerning above, however no clear source was identified. BCx, UCx were pending and CXR was negative for infection. There was opacification of sinuses, however patient did report URI sx prior to presentation. He was continued on oral antibiotics for total of 7 days for presumptiveaspiration pneumonia. Medications on Admission: none Discharge Medications: 1. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*2* 2. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q24H (every 24 hours) for 3 days. Disp:*9 Tablet(s)* Refills:*0* 3. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 3 days. Disp:*9 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Left parietal area wedge shaped brain lesion ? neoplastic Rhabdomyolyis- recovering aspiration pneumonia Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: You were admitted for evaluation of seizure. You were initially admitted to ICU for monitering. You were found to have a wedge shaped lesion on left side of brain. You were seen by Neuro oncology team who suggested biopsy as an outpatient in next few weeks after the general condition permits. You had a condition called rhabdomyolysis which results from injury to muscles. You were evaluated by renal team, and treated with IV fluids with very good response. You were found to have aspiration pneumonia for which you recieved/will be recieving antibiotics for total duration of 1 week. You were started on a medicine called keppra for control of seizures which you will be taking even after discharge. Please take your medicines as directed. Please call 911 or your doctor if any questions or concerns. Followup Instructions: Please follow up with 1. Neuro oncology Provider: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2180-3-27**] 4:00 2. Renal Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 721**] Date/Time:[**2180-4-25**] 2:30 3. Primary care Provider: [**First Name8 (NamePattern2) 1112**] [**Last Name (NamePattern1) 18569**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2180-3-28**] 1:45 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5379**] MD, [**MD Number(3) 5380**]

[ "507.0", "780.39", "348.5", "799.02", "873.0", "348.30", "728.88", "372.72", "191.3", "584.9", "276.6", "692.9" ]

icd9cm

[ [ [] ] ]

[ "96.71", "86.59", "03.31" ]

icd9pcs

[ [ [] ] ]

20251, 20257

17023, 19824

347, 376

20406, 20406

4676, 4681

21382, 22036

3251, 3442

19879, 20228

20278, 20385

19850, 19856

20554, 21359

3457, 3462

14875, 17000

277, 309

404, 3044

4696, 14831

20421, 20530

4103, 4657

3066, 3072

3088, 3235

5,548

185,624

43353

Discharge summary

report

Admission Date: [**2123-5-10**] Discharge Date: [**2123-5-15**] Date of Birth: [**2047-9-28**] Sex: F Service: MEDICINE CHIEF COMPLAINT: Shortness of breath and cough. HISTORY OF PRESENT ILLNESS: The patient is a 77 year old woman with a history of coronary artery disease, chronic renal failure, congestive heart failure, hypertension, hypercholesterolemia, and atrial fibrillation. She presented with a three day history of increasing shortness of breath, cough and fevers. The patient normally requires oxygen at home (started [**10-28**]), however, she has appreciated increasing shortness of breath and cough producing green sputum for the three days prior to presentation. She also states that she has had chills for one day prior to presentation. She states that she has been short of breath since [**2122-6-27**], and has been hospitalized once when she required mechanical ventilation. She states by the fall of [**2120**], she could walk approximately one half mile and go up one flight of stairs. Of note, the patient underwent cardiac catheterization after her mitral valve repair and aortic valve repair in [**2122-6-27**]. Cardiac catheterization showed a 50% left anterior descending stenosis. She was admitted in [**Month (only) 359**] of that same year for congestive heart failure, oxygen saturation down to 85% on ambulating. Her ejection fraction on echocardiography was greater than 55% and she was discharged on home oxygen after being diagnosed with congestive heart failure secondary to diastolic dysfunction. She underwent outpatient evaluation with pulmonary function testing which showed normal lung function with the exception of decreased diffusion capacity and a computed tomogram nine days prior to presentation showed moderate emphysema. The patient denies paroxysmal nocturnal dyspnea, orthopnea, increased lower extremity edema or weight changes. However, she states she did have chest pain in the Emergency Department. Her oxygen saturation there was 84% and she had a temperature of 102.6. She received Levofloxacin 500 mg intravenously for a chest x-ray suggestive of pneumonia. She also received Furosemide 40 mg intravenously twice followed by another 60 mg once. She had arterial blood gas performed there as well which showed 7.47/37/59 on six liters nasal cannula. She received Albuterol and Ipratropium nebulizers with resolution of her chest pain. She also was placed on intravenous Nitroglycerin drip, temporarily placed on BiPAP due to increased respiratory rate and distress. Her repeat blood gas was as follows: 7.42/43/61 with an oxygen saturation of 95% in room air on BiPAP. She was admitted to the Medical Intensive Care Unit for treatment of pneumonia. PAST MEDICAL HISTORY: 1. Congestive heart failure with diastolic dysfunction. 2. Hypertension. 3. Hypercholesterolemia. 4. Atrial fibrillation. 5. Status post mitral valve repair and aortic valve repair. 6. Gastroesophageal reflux disease. 7. Coronary artery disease. 8. Chronic renal failure with baseline creatinine of 2.1 to 2.6. MEDICATIONS ON ADMISSION: 1. Hydralazine 10 mg p.o. q6hours. 2. Warfarin 2 mg in the evening. 3. Furosemide 40 mg twice a day. 4. Atenolol 75 mg daily. 5. Atorvastatin 10 mg in the evening. 6. Lansoprazole 30 mg p.o. once daily. 7. Paxil 20 mg p.o. once daily. 8. Lorazepam 1 mg in the evening as needed. 9. Iron Sulfate. 10. Vitamin D. 11. Calcium Carbonate. ALLERGIES: No known drug allergies. SOCIAL HISTORY: She lives alone. She quit smoking tobacco fifteen years ago. She has a previous forty pack year history. PHYSICAL EXAMINATION: Temperature is 101, heart rate 56, blood pressure 124/38, respiratory rate 36, oxygen saturation 94% on four liters. Blood gases as stated above. In general, she is a pleasant elderly woman in moderate respiratory distress. Head, eyes, ears, nose and throat - Moist mucous membranes. Extraocular movements are intact. The throat is clear. Neck reveals no jugular venous distention. There is no hepatojugular reflux. There is no lymphadenopathy. Chest - Bibasilar crackles and rhonchi without wheezing. Heart - Irregularly irregular, normal S1 and S2, I/VI systolic murmur at the apex. Abdomen - Normal bowel sounds, soft, nontender, nondistended, organs are not palpable. Extremities - Warm with trace lower extremity edema. Vascular - +2 dorsalis pedis pulses. LABORATORY DATA: White blood cell count 11.6, hematocrit 35.1, platelet count 234,000. Initial chemistry panel was significant for a hemolyzed potassium specimen level of 7.4 and the repeat was 4.4. Serial CK and troponin levels revealed myocardial infarction. Urinalysis showed a urinary tract infection as well. Electrocardiogram showed atrial fibrillation at 55 beats per minute, normal axis, approximately 1.0 millimeter ST segment depressions in limb leads II and III, as well as anterior leads V4 through V6. HOSPITAL COURSE: After a brief stay in the Intensive Care Unit, the patient was transferred to the Medical floor after her oxygen requirement decreased and she was able to maintain adequate oxygen saturation without mechanical ventilation. Physical examination upon transfer was significant for temperature of 98.2, heart rate 80, blood pressure 122/44, oxygen saturation 92% on four liters. Lung examination at that point revealed decreased breath sounds at both bases with dullness bilaterally and egophony at the right base. [**Doctor Last Name **] was poor air movement and bilateral wheezing. With the exception of trace pedal edema, the remainder of the examination was unchanged. The remainder of the hospital course was summarized by systems. 1. Pneumonia - The patient continued to receive Levofloxacin 250 mg every 48 hours (dose was decreased given the patient's chronic renal failure). She had decreased cough. There was no sputum production and her oxygen requirements decreased to no supplementation except while walking. This represents return to her baseline as described above. The patient received bronchodilator therapy for two days while on the Medical floor after transfer from the Intensive Care Unit for persistent wheezing. This resolved prior to her discharge. 2. Cardiology - The patient was continued on her Warfarin anticoagulation with adequate maintenance of anticoagulation. There were no changes made in her Aspirin, Atorvastatin, Hydralazine or Metoprolol doses. Likewise, she remained free of congestive heart failure on her standing Furosemide dose. 3. Gastroesophageal reflux disease - No changes were made in her proton pump inhibitor for the duration of her hospital stay. 4. Depression - No changes were made in her selective serotonin reuptake inhibitor. 5. Osteoporosis - For osteoporosis, the patient was continued on Calcium Carbonate and Vitamin D. DISPOSITION: The patient was evaluated by physical therapy service and deemed safe to go home. VNA services were also arranged for her to have outpatient pulmonary rehabilitation evaluation. Her home oxygen was also reinitiated. DISCHARGE DIAGNOSES: 1. Pneumonia. 2. Rheumatic heart disease, status post aortic valve and mitral valve repair. 3. Coronary artery disease. 4. Hypertension. 5. Hypercholesterolemia. 6. Depression. 7. Gastroesophageal reflux disease. 8. Osteoporosis. DISCHARGE STATUS: The patient was discharged to home with evaluation for home pulmonary physical rehabilitation. She was instructed to make an appointment with her primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **] , within two weeks. MEDICATIONS ON DISCHARGE: 1. Atorvastatin 10 mg p.o. once daily. 2. Hydralazine 10 mg p.o. q6hours. 3. Iron Sulfate 325 mg p.o. once daily. 4. Calcium Carbonate 500 mg once daily. 5. Vitamin D 400 units once daily. 6. Paroxetine 20 mg once daily. 7. Pantoprazole 40 mg p.o. once daily. 8. Aspirin 325 mg p.o. once daily. 9. Robitussin 5 to 10 ml every six hours as needed. 10. Levofloxacin 250 mg p.o. every 48 hours for another ten days. 11. Warfarin 2 mg p.o. at bedtime. 12. Furosemide 40 mg p.o. twice a day. 13. Metoprolol 50 mg p.o. twice a day. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**] Dictated By:[**Name8 (MD) 7102**] MEDQUIST36 D: [**2123-5-20**] 15:24 T: [**2123-5-20**] 17:47 JOB#: [**Job Number 93345**]

[ "486", "496", "427.31", "428.0", "585", "733.00", "410.71", "428.30", "401.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7112, 7621

7647, 8448

3118, 3500

4962, 7091

3648, 4944

159, 191

220, 2750

2772, 3092

3517, 3625

18,233

191,900

6486

Discharge summary

report

Admission Date: [**2131-10-17**] Discharge Date: [**2131-11-6**] Date of Birth: [**2063-6-17**] Sex: M Service: MEDICINE Allergies: Compazine / Phenergan / Percocet Attending:[**First Name3 (LF) 477**] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: Central line placement History of Present Illness: Mr. [**Known lastname 24529**] is a 68 year-old male with recently diagnosed locally advanced esophageal adenocarcinoma receiving neoadjuvant chemoradiotherapy s/p 5-FU/cisplatin cycle #1 on [**2131-10-8**], also with a history of DM type 2, HTN and COPD, who is being transferred from the floor for further management of hypotension. * He initially presented to [**Hospital3 417**] hospital on [**2131-10-15**] with a [**3-2**] day history of diffuse cramping abdominal pain, associated with N/V. There, he was reportedly afebrile, and labs were remarkable for WBC 3.9, Hct 37.8, Na 134, K 3.7, Cl 98, HCO3 28, BUN 27, Creat 1.6, AST 21, ALT 22, ALP 76, Amylase 118 (peak 139 on [**10-16**]), lipase normal, TG 91. An AXR showed no pathology, a RUQ U/S was remarkable for a mildly dilated CBD 10.3 mm without other abnormalities, and a CT revealed no obvious explanation for his abdominal symptoms. He was made NPO, hydrated, and eventually transferred to [**Hospital1 18**] on [**2131-10-17**] for consideration of MRCP. * While on the floor, he developed a fever to 101.9, and was placed on Unasyn for coverage of ? pancreaticobiliary process. His abdominal pain persisted. Around 0030 on [**10-18**], his blood pressure was noted to be 66/35 with HR 135 (down from 113/65, HR 126 earlier in night). No foley in place. He was given IV NS bolus 1 liter, and [**Hospital Unit Name 153**] team was called for further evaluation. * In ICU, pt was initially treated with IVF and mild pressors for hypotension. Pressors were weaned on [**10-19**] in AM. [**Name (NI) 24895**] pt was evaluated for persistent fevers, neutropenia and abdominal pain. Pt thought to have both entercolitis as complication of 5FU and also ileus (increased output from G-tube). The patient was kept on vancomycin and cefepime given that he was severely neutropenic with potential GI infection. Pt was also evaluated by both surgery and GI who do not recommend intervention at this time, but to continue Abx and NPO. Rad onc evaluated pt and may continue XRT monday. Additionally pt was followed by oncology who recommend checking dihydropyramadine level. . Pt currently has no complaints. He has no pain, no nausea or vomiting. He has no pain, headache, shortness of breath, chest pain, dizziness. He does have mouth sores that have been bothering him since the intial chemotherapy. Past Medical History: 1. Recently diagnosed locally advanced esophageal adenocarcinoma diagnosed in [**8-/2131**], status post cycle 1 of 5FU and Cisplatin [**10-8**], receiving concomitant XRT prior to surgical resection. No distant metastases. 2. COPD 3. History of recurrent gallstone pancreatitis with resultant chronic pancreatitis, status post cholecystectomy. 4. DM type 2 5. GERD 6. Hypercholesterolemia 7. Status post POC and J-tube placmement on [**9-21**]. Social History: He lives at home with his wife and children. Ex-smoker, quit years ago. Occasional EtOH. Speaks cantonese Family History: NC Physical Exam: VITALS: T 98.8 HR 109 regular, BP 115/61, RR 20, Sat 94% 4L. GEN: Alert and oriented without distress HEENT: Anicteric. Mucositis. EOMI NECK: JVP flat. No palpable lymphadenopathy. RESP: occasional crackles on right lower base, otherwise clear CVS: RRR. Distant heart sounds, no audible murmur. GI: Moderate abdominal distension, hypoactive but present bowel sounds. J-tube in place. Mild diffuse tenderness to palpation without voluntary guarding, no rebound, no rigidity. EXT: Without edema Back: no spinal tenderness Neuro: Reflexes: 2+ patellar, downgoing toes, strength 5/5 UE, LE with intact sensation to touch LE. CN II-XII intact, EOMI, no nystagmus Pertinent Results: [**2131-10-17**] 05:20PM BLOOD WBC-0.6*# RBC-3.91* Hgb-12.4* Hct-36.4* MCV-93 MCH-31.8 MCHC-34.1 RDW-14.5 Plt Ct-88*# [**2131-10-19**] 03:09AM BLOOD WBC-0.3* RBC-3.11* Hgb-9.9* Hct-28.7* MCV-92 MCH-31.7 MCHC-34.3 RDW-14.7 Plt Ct-30* [**2131-10-21**] 12:01AM BLOOD WBC-0.2* RBC-2.92* Hgb-9.7* Hct-27.2* MCV-93 MCH-33.2* MCHC-35.6* RDW-14.6 Plt Ct-19* [**2131-10-22**] 12:00AM BLOOD WBC-0.3* RBC-2.58* Hgb-8.1* Hct-24.2* MCV-94 MCH-31.6 MCHC-33.6 RDW-15.0 Plt Ct-12* [**2131-10-23**] 07:32PM BLOOD Hct-26.1* [**2131-10-26**] 12:00AM BLOOD WBC-1.4*# RBC-3.10* Hgb-9.4* Hct-27.6* MCV-89 MCH-30.4 MCHC-34.1 RDW-17.0* Plt Ct-39* [**2131-10-28**] 12:00AM BLOOD WBC-6.0# RBC-2.67* Hgb-8.3* Hct-24.4* MCV-91 MCH-31.0 MCHC-34.0 RDW-16.6* Plt Ct-35* [**2131-10-30**] 12:00AM BLOOD WBC-7.7 RBC-2.95* Hgb-8.9* Hct-27.1* MCV-92 MCH-30.3 MCHC-32.9 RDW-16.9* Plt Ct-78* [**2131-11-2**] 12:00AM BLOOD WBC-4.2 RBC-3.08* Hgb-9.4* Hct-28.3* MCV-92 MCH-30.6 MCHC-33.3 RDW-16.9* Plt Ct-208# [**2131-11-4**] 12:00AM BLOOD WBC-3.9* RBC-2.77* Hgb-8.5* Hct-25.2* MCV-91 MCH-30.7 MCHC-33.8 RDW-16.8* Plt Ct-248 [**2131-11-5**] 12:00AM BLOOD WBC-3.6* RBC-2.77* Hgb-8.4* Hct-25.4* MCV-91 MCH-30.4 MCHC-33.3 RDW-16.7* Plt Ct-286 [**2131-10-17**] 05:20PM BLOOD Gran Ct-360* [**2131-10-20**] 03:50AM BLOOD Gran Ct-40* [**2131-10-23**] 12:00AM BLOOD Gran Ct-110* [**2131-10-26**] 12:00AM BLOOD Gran Ct-920* [**2131-10-28**] 12:00AM BLOOD Gran Ct-4980 [**2131-10-29**] 12:00AM BLOOD Gran Ct-[**Numeric Identifier 24896**]* [**2131-10-31**] 12:00AM BLOOD Gran Ct-3270 [**2131-10-17**] 05:20PM BLOOD Glucose-176* UreaN-27* Creat-1.0 Na-131* K-3.5 Cl-100 HCO3-20* AnGap-15 [**2131-10-18**] 01:37PM BLOOD Glucose-140* UreaN-28* Creat-1.1 Na-136 K-3.9 Cl-112* HCO3-17* AnGap-11 [**2131-10-20**] 02:28PM BLOOD Glucose-124* UreaN-19 Creat-0.9 Na-138 K-3.3 Cl-109* HCO3-21* AnGap-11 [**2131-10-21**] 03:15PM BLOOD Na-141 K-3.9 Cl-110* HCO3-22 AnGap-13 [**2131-10-21**] 03:15PM BLOOD Na-141 K-3.9 Cl-110* HCO3-22 AnGap-13 [**2131-10-24**] 12:00AM BLOOD Glucose-168* UreaN-22* Creat-0.8 Na-141 K-3.4 Cl-110* HCO3-26 AnGap-8 [**2131-10-27**] 12:19AM BLOOD Glucose-132* UreaN-22* Creat-0.8 Na-139 K-4.6 Cl-108 HCO3-25 AnGap-11 [**2131-10-30**] 12:00AM BLOOD Glucose-120* UreaN-15 Creat-0.9 Na-136 K-4.4 Cl-108 HCO3-23 AnGap-9 [**2131-11-2**] 12:00AM BLOOD Glucose-106* UreaN-7 Creat-0.7 Na-137 K-3.8 Cl-111* HCO3-21* AnGap-9 [**2131-11-4**] 02:13AM BLOOD Glucose-86 UreaN-6 Creat-0.8 Na-141 K-3.9 Cl-111* HCO3-26 AnGap-8 [**2131-11-5**] 12:00AM BLOOD Glucose-96 UreaN-8 Creat-0.9 Na-137 K-4.0 Cl-108 HCO3-25 AnGap-8 [**2131-10-17**] 05:20PM BLOOD ALT-16 AST-20 LD(LDH)-171 AlkPhos-86 Amylase-84 TotBili-0.5 [**2131-10-20**] 03:50AM BLOOD ALT-10 AST-14 LD(LDH)-145 AlkPhos-57 Amylase-111* TotBili-0.3 [**2131-10-24**] 12:00AM BLOOD ALT-4 AST-12 LD(LDH)-143 AlkPhos-40 Amylase-34 TotBili-0.7 [**2131-10-31**] 12:00AM BLOOD ALT-5 AST-16 LD(LDH)-203 AlkPhos-78 Amylase-31 TotBili-0.3 [**2131-10-18**] 01:33AM BLOOD CK-MB-2 cTropnT-<0.01 [**2131-10-18**] 01:37PM BLOOD CK-MB-2 cTropnT-LESS THAN [**2131-10-17**] 05:20PM BLOOD Calcium-8.0* Phos-1.4*# Mg-1.6 [**2131-10-20**] 07:36PM BLOOD Albumin-2.3* Calcium-7.0* Phos-1.3* Mg-2.0 [**2131-10-24**] 12:00AM BLOOD Albumin-2.1* Calcium-7.5* Phos-1.5* Mg-1.8 [**2131-10-27**] 12:19AM BLOOD Calcium-7.6* Phos-3.2 Mg-1.8 [**2131-10-30**] 12:00AM BLOOD Calcium-7.4* Phos-2.5* Mg-2.0 [**2131-11-2**] 12:00AM BLOOD Calcium-7.6* Phos-2.0* Mg-1.6 [**2131-11-5**] 12:00AM BLOOD Calcium-7.9* Phos-3.2 Mg-1.6 [**2131-10-21**] 12:03AM BLOOD Triglyc-50 [**2131-10-23**] 12:00AM BLOOD Triglyc-74 [**2131-10-18**] 01:33AM BLOOD Cortsol-35.7* [**2131-10-18**] 01:37PM BLOOD Cortsol-24.9* [**2131-10-18**] 08:39PM BLOOD Cortsol-24.6* . . Microbiology: All Blood Cx, Wound Cxs, Urine Cx, & Stool Cxs: NEGATIVE . . Imaging: CHEST (PORTABLE AP) [**2131-10-17**] 4:41 PM IMPRESSION: No evidence of pneumonia or CHF. . CT PELVIS W/O CONTRAST [**2131-10-18**] 5:54 PM IMPRESSION: 1. Normal pancreatic contour without a significant amount of surrounding soft tissue stranding to suggest inflammation. The pancreas is incompletely evaluated without IV contrast. 2. Long segment of multiple smoothly, circumferentially thickened loops of distal jejunum and ileum. Given the patient's neutropenia, the etiology is likely infectious. Inflammation, ischemia, vasculitis, or hemorrhage are also possible. 3. Small intra-abdominal ascites. 4. Tiny bilateral pleural effusions with dependent atelectasis. . CHEST PORT. LINE PLACEMENT [**2131-10-18**] 3:12 AM IMPRESSION: Successful placement of left subclavian line. No pmeumothorax . CHEST (PORTABLE AP) [**2131-10-18**] 1:28 AM IMPRESSION: No evidence of free air. . ABDOMEN (SUPINE & ERECT) PORT [**2131-10-18**] 1:04 AM IMPRESSION: 1. Distended air-filled small bowel loops consistent with ileus. 2. No evidence of pneumoperitoneum. . ECHO Study Date of [**2131-10-18**] Conclusions: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Left ventricular systolic function is hyperdynamic (EF>75%). 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. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. . CT PELVIS W/CONTRAST [**2131-10-24**] 2:44 AM IMPRESSION: 1. Moderate distention of most of the small bowel. Diffuse wall thickening in the small bowel is considerably improved. The appearance is most suggestive of an ileus, as no transition point suggesting obstruction is visualized. 2. Normal appearance of the colon. There is contrast within the colon, which may be from a recent CT scan. If so, lack of passage of that contrast would also suggest a degree of ileus. 3. Jejunostomy tube in suitable position. . CT PELVIS W/CONTRAST [**2131-10-30**] 1:11 PM IMPRESSION: No significant change from prior. Again seen are distended loops of small bowel, without evidence of a transition point or obstruction. Findings are again consistent with an ileus. . CHEST (PORTABLE AP) [**2131-10-30**] 11:18 AM IMPRESSION: 1. No evidence of pneumothorax. 2. Linear opacities in the left base, most likely represent atelectasis. However, pneumonia cannot be completely excluded. . CHEST (SINGLE VIEW) [**2131-11-6**] 11:22 AM IMPRESSION: AP chest compared to [**10-27**] through [**10-30**]. Small regions of consolidation in the periphery of the left lung are new and may represent early foci of pneumonia. There is no pleural effusion or pulmonary edema. Cardiomediastinal silhouette is normal. Post-resection changes are noted in the right lower anterior ribs, partially resected. There is no pneumothorax. Tip of a right subclavian central venous line projects over the SVC. A dilated loop of bowel in the midline simulates pneumoperitoneum, but no free subdiaphragmatic gas is present. . ABD (SINGLE VIEW ONLY) [**2131-11-6**] 11:21 AM FINDINGS: Single supine radiograph was obtained following injection of approximately 30 cc of Conray through the patient's existing J-tube. This was then followed by 10 cc saline flush. A J-tube is present with the tip terminating in the left lower quadrant with intraluminal opacification of loops of small bowel. No extraluminal contrast is seen. Nonspecific loops of air-filled small bowel are again seen, most pronounced in the right upper quadrant which may be consistent with reported history of resolving ileus. Cholecystectomy clips and surgical clips in the left mid abdomen are also noted. . Brief Hospital Course: 68 yo male with esophageal carcinoma on neoadjuvant chemoradiotherapy, s/p cycle 1 of 5FU and Cisplatin, with abdominal pain, fever, and hypotension. . . 1) Hypotension: The patient has hypotension at the beginning of the hosptia course that responded well to agressive IVFs and 12 hours of neostigmine. He did not have any ischemic changes on EKG and enzymes were negative for troponin leak. He was also continued on broad spectrum antibiotics for presumed sepsis and he responded well. He was monitored daily in this regard and had transient episodes of asymptomatic hypotension that responded well to NS boluses. He was hemodynamically stable upon discharge. . . 2) Febrile neutropenia: Symptoms localize to abdomen, attributable to 5-FU toxicity with superimposed mucositis. Infectious work-up negative and the patient was continued on broad spectrum antibiotic coverage until he was afebrile with an ANC > 1000. Antibiotics were tapered gradually and the upon completion of antibiotic removal the patient remained afebrile with an adequte ANC count. otherwise remarkable for negative U/A, CXR without infiltrate, blood cultures pending, but currently negative. His Neulasta was continued until the ANC reached appropriate levels and his levels normalized to acceptable levels. . . 3) Abdominal pain: Likely mucositis due to side effects from chemotherapy as there was no infections etiology found. The patient also had an ileus that was thought to be due to the mucositis. He had a J-tube put in prior to his arrival to the flooe for future use, and this was initially not used as a source of nutrition given his ileus. he was given daily TPN with good result. He was followed by Surgery for the initial hospital course while he had the ileus, but once his febrile neutropenia resolved and his ileus resolved the Surgery service signed off. He was started on tube feeds through the J-tube and after toelrating the TFs for 48 hours, his diet was advanced from clears to soft foods. After advancement of his diet, he developed hypotension, fever to 102, and abdominal distension. The tube feeds were promptly stopped, broad spectrum antibiotics were started, and abdominal imaging was done. These images were negative for perforation but showed a continual ileus. At this point all nutrition was stopped and the patient defervesed over the course of 24 hours. His distension resolved, his hypotension resolved, he became afebrile and antibiotics were stopped without complication. Oral nutrition was again started slowly and TFs were not restarted. His diet was advanced slowly and the patient was able to tolerate the reinstitution of diet with moderate abdominal pains. On the day of discharge the patient's J-tube was dislodged and fell out. he was promptly seen by Surgery who put the tube back in through the established tract and the patient had confirmatory imaging. This was stitched back into place without complication. The patient was discharged without tube feed supplementation as he was able to tolerate POs. . . 4) Esophageal cancer: The patient underwent daily radiation to his esophageal cancer without complication. There were periods of anemia for which he required blood transfusions. He also required a platelet transfusion while in house. . . 5) DM type 2: Actos on hold, patient placed on sliding scale and maintained within normal limits. . . 6) COPD: Continued Albuterol and Atrovent, Spiriva. There were no active issues in this regard during this hopsitalization. . . After discussion with the patient, the patient's family & the medical staff, all were in agreement that the patient was a suitable candidate for discharge. Medications on Admission: Pancreatic lipase 4 capsules with each meal and 2 with snacks Pepcid 20 mg PO QD Albuterol and atrovent as needed Actos 45 mg PO QD Lisinopril 5 mg PO QD MVI daily Spiriva inhaler daily Lipitor 40 mg PO QHS Protonix 40 mg PO QAM Oxycodone prn Antiemetics prn Discharge Medications: 1. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. Disp:*30 Capsule(s)* Refills:*0* 3. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*30 30* Refills:*2* 4. Albuterol Sulfate 0.083 % Solution Sig: [**1-29**] Inhalation Q6H (every 6 hours) as needed. Disp:*30 30* Refills:*0* 5. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule, Delayed Release(E.C.) Sig: Two (2) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*30 Cap(s)* Refills:*2* 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:*30 Tablet(s)* Refills:*2* 7. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. Disp:*30 Tablet(s)* Refills:*2* 8. 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* 9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed. Disp:*30 Tablet(s)* Refills:*2* 10. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*30 Tablet(s)* Refills:*3* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: Primary Diagnosis: 1. Esophageal cancer 2. Hypotension 3. Febrile neutropenia . Secondary Diagnosis: 1. Diabetes mellitus 2. COPD Discharge Condition: Afebrile. Hemodynamically stable. Tolerating POs, ambulating without difficulty. Discharge Instructions: 1. Please take all medications as prescribed. 2. Please call your primary doctor or return to the ED with fever, chills, chest pain, shortness of breath, vomiting blood or any other concerning symptoms. 3. Please make all scheduled appointments. Followup Instructions: Appointment with Dr. [**First Name (STitle) **] [**Name (STitle) **] on [**2131-11-20**] @ 4:30 pm. [**Name6 (MD) **] [**Name8 (MD) 490**] MD, [**MD Number(3) 491**] Completed by:[**2131-11-8**]

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icd9cm

[ [ [] ] ]

[ "99.15", "99.04", "96.6", "92.29", "38.93", "00.17", "97.03", "99.05" ]

icd9pcs

[ [ [] ] ]

17055, 17110

11752, 15430

305, 329

17284, 17367

4033, 11729

17662, 17888

3335, 3339

15740, 17032

17131, 17131

15456, 15717

17391, 17639

3354, 4014

254, 267

357, 2725

17232, 17263

17150, 17211

2747, 3194

3210, 3319

13,110

182,995

2593

Discharge summary

report

Admission Date: [**2153-1-15**] Discharge Date: [**2153-1-25**] Service: MEDICINE Allergies: Feldene / Darvocet-N 50 / Tramadol Attending:[**First Name3 (LF) 2901**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: Cardiac catheterization Temporary HD line placement, HD line removal Hemodialysis History of Present Illness: [**Age over 90 **] yr old woman with history of htn, chf, prior CABG in [**2144**] and prior NSTEMI in [**2150**] and [**2152-9-20**] that was treated conservatively presented to [**Hospital **] Hospital on [**2153-1-13**] with 10/10 chest pain associated with N/V on and off since Saturday. The pain comes at rest, is not associated with exertion or SOB. Denies diaphoresis. Describes it as pain and pressure. At [**Location (un) **] her pain resolved with 3 SL nitro, and her imdur was increased. Initial troponins were negative, but rose to peak of 1.34. On the morning of [**1-15**] she had an episode of nausea, wretching, chest pressure. She was found to have new lateral ST changes - 2mm STD in V4-V5. Trop of 1.34. Resolved with reglan, NTG. She was loaded with plavix and started on heparin gtt. Also, CXR revealed possible right lower lobe pneumonia and question of CHF. She was treated with Levaquin (3 days of 250mg IV) and 40 IV Lasix on day of transfer with only moderate UOP. Vital signs at OSH: 99.4, hr 79, rr 20, 93% on 3L, 131/65. . On arrival to floor she was comfortable on 3L NC O2, without chest pain or shortness of breath. . On the morning of transfer she developed severe chest pressure and pain with associated N/V. An ECG showed 2-3mm depressions in V2-6 with 2mm elevation in aVR consistent with left main disease. She was given NTG SL x1 with resolution of her CP as well as Zofran for nausea. She was continued on her heparin drip, loaded with Intergrillin 12.24mg, and started on Integrilin 1mcg/kg/min and sent emergently to the cath lab. Past Medical History: 1. CAD s/p CABG 2. CHF- preserved EF but multiple admissions for CHF exacerbations, 2+ MR [**First Name (Titles) **] [**Last Name (Titles) **] 3. DM2- on glyburide as outpatient 4. HTN 5. CKD- baseline creatinine ? 6. Hypothyroidism 7. s/p appendectomy 8. Colon cancer s/p hemicolectory [**2142**] 9. s/p cholecystectomy [**53**]. s/p abdominal hysterectomy 11. s/p benign breast tumor 12. Anemia of chronic disease- baseline hematocrit 30 . Cardiac Risk Factors: Diabetes, Hypertension . Cardiac History: CABG, in [**2144**] anatomy as follows: bypass from the ascending thoracic aorta to the OM and D1 with SVG and to D1 with LIMA . Percutaneous coronary intervention, in [**2144**] anatomy as follows: 1. Left main and three vessel coronary artery disease. 2. Normal ventricular function. Social History: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. Lives with her husband, ambulates with a cane. Physical Exam: VS: 98.7 Tm 100.0 103/49 72 20 95% on 3L GEN: Pleasant elderly woman in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVP of 8 cm. CV: Midline sternotomy scar, PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. III/VI SEM at USB. No thrills, lifts. No S3 or S4. PULM: Resp were unlabored, no accessory muscle use. Bibasilar crackles present with no wheezes ABD: BS+. Soft, NTND. No HSM or tenderness. Ext: 1+ non pitting edema. No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ Pertinent Results: LABS ON ADMISSION: . [**2153-1-15**] 11:35PM WBC-8.9 RBC-3.49* HGB-11.2* HCT-32.4* MCV-93 MCH-32.1* MCHC-34.6 RDW-16.1* [**2153-1-15**] 11:35PM NEUTS-85.1* LYMPHS-10.8* MONOS-3.8 EOS-0.1 BASOS-0.2 [**2153-1-15**] 11:35PM BLOOD PT-15.5* PTT-57.1* INR(PT)-1.4* . [**2153-1-15**] 11:35PM BLOOD Glucose-147* UreaN-59* Creat-2.0* Na-129* K-4.3 Cl-93* HCO3-26 AnGap-14 [**2153-1-15**] 11:35PM BLOOD Calcium-9.9 Phos-3.4 Mg-1.6 . CARDIAC ENZYMES: [**2153-1-15**] 11:35PM BLOOD cTropnT-0.36* proBNP-[**Numeric Identifier 13087**]* [**2153-1-15**] 11:35PM BLOOD CK(CPK)-52 [**2153-1-16**] 06:50AM BLOOD cTropnT-0.43* [**2153-1-16**] 06:50AM BLOOD CK(CPK)-55 [**2153-1-16**] 08:53PM BLOOD cTropnT-0.77* [**2153-1-16**] 08:53PM BLOOD CK(CPK)-43 [**2153-1-17**] 06:07AM BLOOD cTropnT-0.89* [**2153-1-17**] 06:07AM BLOOD CK(CPK)-32 [**2153-1-18**] 06:33AM BLOOD cTropnT-0.80* [**2153-1-18**] 06:33AM BLOOD CK(CPK)-33 . MICROBIOLOGY: Blood culture [**1-15**] + [**1-16**] - no growth FINAL [**2153-1-23**] - urine culture no growth FINAL [**Date range (1) 13088**] - blood culture no growth to date . RADIOLOGY: . Cardiac Cath ([**2153-1-16**]): COMMENTS: 1. Selective angiography demonstrated multivessel coronary artery disease. The left main demonstrated diffuse disease with a calcifed 80% distal lesion that extended into both the left circumflex and left anterior descending artery. The right coronary artery was not engaged. 2. Placement of a 9F 30cc IABP via the left femoral artery. 3. Successful PTCA and stenting of the proximal left circumflex artery with a Xience (3x18mm) drug eluting stent. Final angiography demonstrated no angiographically apparent dissection, no residual stenosis and TIMI III flow throughout the vessel. (SEE PTCA comments) 4. Successful PTCA and stenting of the proximal left anterior descending artery and distal left main with a Cypher (3.0x18mm) drug eluting stent postdilated with a 3.5mm balloon. Final angiography demonstrated no angiographically apparent dissection, no residual stenosis and TIMI III flow throughout the vessel (See PTCA comments). 5. Successful closure of the right femoral arteriotomy site with a Mynx closure device. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Successful PTCA and stenting of the left main, LAD and LCX with drug eluting stents 3. Successful closure of the right femoral arteriotomy site with a Mynx closure device. 4. Placement of an IABP . [**2153-1-23**] - chest x-ray portable - CHEST PORTABLE: Comparison is made to prior examination of [**2153-1-16**]. There is mild cardiomegaly. This is unchanged. There is haziness of the pulmonary vasculature and mild blunting of the costophrenic angles. Overall, the appearance of the lungs has improved, with a more patchy opacity in the right lower lobe, being less prominent. A central venous line is seen with its tip at the multiple sternal cerclages are noted from prior cardiac surgery. IMPRESSION: Cardiomegaly with CHF, improved compared to prior study. No definite evidence of pneumonia. . 1/27.09 - chest x-ray PA/Lateral - FINDINGS: In comparison with the study of [**2151-6-8**], bilateral pleural effusions are noted. The prominence of markings at the bases and the pleural fluid makes it difficult to assess for the possibility of a supervening pneumonia. . [**2153-1-18**] - renal ultrasound - RENAL ULTRASOUND: The right kidney measures 10.8 cm. The left kidney measures 10.1 cm. There is no hydronephrosis, stone, or solid renal mass visualized. The bladder was empty with a Foley catheter in place. IMPRESSION: No hydronephrosis. . EKG [**2153-1-17**] - Sinus rhythm. Non-specific inferior ST-T wave flattening. Compared to the previous tracing of [**2153-1-16**] the anterolateral ST segment depression appears less prominent. Otherwise, no diagnostic interim change. Clinical correlation is suggested. Brief Hospital Course: [**Age over 90 **] year old female with history of CAD s/p CABG, HTN, DM2 who presented from OSH with chest pain with positive troponin, CHF exacerbation with possible superimposed PNA. . # CAD - patient with extensive CAD history with 3 vessel disease and previous CABG. Patient's troponin elevated at OSH but no acute ECG changes. Patient started on plavix and heparin gtt at OSH. Cardiologist note at OSH did recommend conservative treatment given advanced age and CRI however was transferred here for cardiac caatherization. Trop-T on transfer here was 0.36, CK 52. Lateral EKG ST depressions resolving. On the floor she developed a STEMI and was sent to cath for high risk intevention. The patient was alert during this process and consented to the procedure. She understood the risks and benefits of cath and the medications she was given. On heparin gtt at transfer to cath with integrillin bolus on board. In the cath lab intra-aortic balloon pump was placed for LM protection. Balloon was then removed and patient remained hemodynamically stable. Underwent PCI to LM-LAD and LCx. Catherization was complicated by contrast induced nephropathy discussed below. . #. Pump - most recent echo from [**9-/2152**] (OSH) demonstrates EF 40%, 2+MR [**First Name (Titles) **] [**Last Name (Titles) **] to distal inferior, inferoseptal and apical hypokinesis. Patient was given IV lasix at OSH (patient on lasix 40mg PO daily, metolazone 5mg PO daily at home) as thought that hypervolemic on exam, BNP [**Numeric Identifier 13087**]. Patient's weight has been slightly increased at home. Baseline weight 136 lbs. No O2 requirement at home. Prior to catheterization she received 5mg PO metolazone followed by 60mg IV lasix. On exam here at [**Hospital1 18**] patient with crackels at lung bases, pitting edema on right. As patient had renal failure, initially lasix was held, once creatinine improved to baseline patient started back on home dose of lasix. As no oxygen requirement currently, did not restart outpatient metolazone. Would consider addition of metolzaone only after patient has maximized lasix dose rather than adding additional [**Doctor Last Name 360**]. Patient already on aspirin, statin, beta blocker. Patient not on ACE inhibitor as outpatient. Did not start in the setting of acute on chronic renal failure, plan is to hold off on starting ACE inhibitor for now. Renal will initiate ACE inhibitor as outpatient. . #. Possible pneumonia: Patient with possible RLL infiltrate at OSH, given 3 days of levaquin for CAP. Patient without significant cough, chest x-ray without definitive evidence of pneumonia, and patient only febrile once. No additional antibiotics given. . #. Acute on Chronic renal insufficiency: with baseline Cr 1.6. Creatinine worsened progressively after catheterization, thought to be likely contrast-induced ATN. The patient expressed her desire not to be on permanent hemodialysis but a willingness to undergo temporary dialysis if recovery of renal function could be reasonably expected. A temporary HD line was placed. The patient acutely became more hypoxic and apparently volume overloaded shortly after placement of HD line, and dialysis was initiated with improvement in oxygenation. Urine output improved and Creatinine improved to baseline. HD line was removed. Renal was consulted and followed inpatient. Patient to follow up with Dr. [**Last Name (STitle) 118**] on discharge. Plan not to discharge on ACE inhibitor given acute renal failure and readdress on follow up. . #. Hyponatremia: Noted to be chronic issue for the patient. Na 129 on transfer here, Na was 132 at OSH on [**1-14**], on discharge Na improved to 135. Patient as above appeared volume overloaded on exam to thought to be secondary to hypervolemic hyponatremia and improved with HD and improved cardiac function. . # Hypertension - patient maintained as outpatient on hydral, norvasc, imdur, as well as beta blocker. Patient should be maintained on outpatient ACE inhibitor however did not start in house given renal failure. Continued hydral and amlodipine for afterload reduction, however would consider discontinue of hydral when able to start ACEi. . #. Anemia: Pt admitted w a baseline Hct ~32, but post-procedurally dropped to ~25 current 26. Patient got 1 unit of blood in the setting of dialysis. Have not given additional blood since patient has completed dialysis. Patient on Procrit as an outpatient as well as iron, likely anemia of chronic disease. Patient had stool guiac which was weakly positive x1 and subsequently negative. No obvious GI bleeding. Patient should have routine outpatient screening colonoscopy if she has not had already Medications on Admission: Medications on transfer: 1. Hydralazine 50 mg PO Q8H 2. Acetaminophen 325-650 mg PO Q6H:PRN 3. Insulin SC 4. Allopurinol 100 mg PO EVERY OTHER DAY 5. Isosorbide Mononitrate 60 mg PO BID 6. Amlodipine 5 mg PO BID 7. Levofloxacin 250 mg IV Q24H, day 1=[**1-13**] 8. Aspirin 81 mg PO DAILY 9. Levothyroxine Sodium 112 mcg PO DAILY 10. Ascorbic Acid 500 mg PO DAILY 11. Metolazone 5 mg PO DAILY Give prior to lasix dose 12. Calcium Carbonate 1500 mg PO DAILY 13. Metoprolol Tartrate 50 mg PO TID 14. Clopidogrel 75 mg PO DAILY 15. Multivitamins 1 TAB PO DAILY 16. Docusate Sodium 100 mg PO BID:PRN constipation 17. Ondansetron 4-8 mg IV Q8H:PRN 18. Polyethylene Glycol 17 g PO DAILY 19. Eptifibatide 1 mcg/kg/min IV DRIP INFUSION Duration: 18 Hours 20. Senna 1 TAB PO BID:PRN constipation 21. Ferrous Sulfate 325 mg PO DAILY 22. Simvastatin 40 mg PO DAILY 23. Furosemide 60 mg IV ONCE 24. Guaifenesin [**4-29**] mL PO Q6H 25. Vitamin D 400 UNIT PO DAILY 26. Heparin IV per Weight-Based Dosing Guidelines . HOME MEDICATIONS: norvasc 5mg [**Hospital1 **] iron 325mg [**Hospital1 **] simvastatin 20mg daily imdur 60mg [**Hospital1 **] lopressor 50mg tid hydralazine 50mg q6 hours levoxyl 0.112mg daily allopurinol 100mg daily MVI daily potassium 30meq daily calcium carb 1500mg daily vitamin D 400 daily zaroxylyn 5mg daily miralax 17gm daliy lasix 40mg po daily weekly procrit injection Sl nitro prn compazine 10mg prn nausea vicodin 1-2 tabs Q6hr prn zantac 150mg prn Discharge Medications: 1. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 4. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Polyethylene Glycol 3350 100 % Powder Sig: Seventeen (17) g PO DAILY (Daily) as needed for constipation. 10. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO BID (2 times a day): hold in AM if having dialysis . 11. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet Sublingual once a day as needed for chest pain: After 5 minutes, 12. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) 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. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, fever. 15. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): please hold for BP < 100 . 16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): please hold for BM > 2 per day. 17. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): please hold for BP < 95. 18. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 19. Tums 300 mg (750 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO three times a day as needed for indigestion. 20. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO every eight (8) hours: please hold for BP < 100. would d/c once starts ACE inhibitor as per renal. Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 1439**] [**Last Name (NamePattern1) 13089**] Care Center - [**Location (un) 1439**] Discharge Diagnosis: Primary: Non-Q wave Myocardial infarction . Secondary: Diabetes mellitus type 2 Hypertension Hypothyroidism Chronic renal insufficiency Anemia of chronic disease Discharge Condition: Good, hemodynamically stable, afebrile, > 2 L of UOP in last 24 hours Discharge Instructions: You were admitted for treatment of chest pain from a heart attack. You underwent cardiac catheterization to open up the blockage. You also had worsening of your pre-existing renal insufficiency, likely related to the contrast given during catherization. You received emergent hemodialysis after a temporary HD line was placed. Your urinary function improved significantly and your creatinine improved and your temporary HD line was removed. . You were also treated for pneumonia, and completed your antibiotic course prior to arrival at [**Hospital1 18**]. . As you have heart failure it is important that you weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1500ml. . The following changes were made to your home medications: 1) Your hydralazine dose was lowered 2) Your allopurinol dose was decreased based on your renal function to every other day 3) Your daily potassium was stopped 4) Your norvasc was changed to 10 mg PO daily (previously 5 mg PO BID) 5) Your iron supplementation was changed to daily 6) Your Zaroxyln was discontinued 7) Your dose of simvastatin was increased 8) You were started on calcium acetate 9) Vicodin was discontinued, Tylenol started alone for pain control 10)Your ranitidine was discontinued as H2 blocker unlikely to be a good choice for elderly female (tums PRN instead) . If you experience any worsening chest pain, SOB, decreased UOP, nausea/vomiting, or have any other concerns please [**Name6 (MD) 138**] your MD or return to the ED. Please keep the follow up appointment that we have made for you below. Followup Instructions: We have made you a follow up appointment to see one of our kidney doctors [**2-14**] at 3 pm with Dr. [**Last Name (STitle) 118**]. [**Hospital 23**] clinic center, [**Location (un) 436**]. We would like you to discuss possible outpatient Epogen therapy at that time. . CARDIOLOGY: Patient requesting to follow up with Dr. [**Last Name (STitle) 911**] here at [**Hospital1 18**] rather than Dr. [**Last Name (STitle) 13090**] in [**Location (un) **]. We have made a follow up appointment with Dr. [**Last Name (STitle) 911**] for [**2-8**] 2:40 pm - [**Hospital Ward Name 23**] 7. . In addition, please arrange to follow up with your primary care doctor Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9346**]. He can be reached at ([**Telephone/Fax (1) 13091**]. You should make an appointment to see him within 2-4 weeks. . [**Hospital1 599**] of [**Location (un) 1439**]: please call [**Hospital1 **] and page #[**Numeric Identifier 8680**] to follow up on microbiology cultures which are still pending in 3 days. You can call ([**Telephone/Fax (1) 2529**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**] Completed by:[**2153-1-26**]

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Discharge summary

report

Admission Date: [**2197-6-17**] Discharge Date: [**2197-6-19**] Date of Birth: [**2117-9-16**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2704**] Chief Complaint: CC: SOB Major Surgical or Invasive Procedure: Cardiac catheterization on [**2197-6-17**] Intubated [**2197-6-17**] Extubated [**2197-6-19**] History of Present Illness: HPI: 79 yo Haitian female with h/o breast ca and possible lung CA presents with sudden onset of SOB. Daughter states that she thought her O2 (uses home o2) was not working, said she felt SOB and called out for help. She did not note any chest pain at the time. EMS was called and she was intubated in field. She was hypotensive in the ER (btwn 1am -3 am bp 70-118/38-94 and HR 66-84). An R IJ line was attempted to be inserted at this time, but caused a hematoma. Pt was still hypotensive so left sc line was put in and caused a second hematoma. She was started on dopamine in the ER and then changed to levophed b/c she got tachycardic. An EKG showed ST elevations in leads I, II AVR and V2-V6. Pt was taken to cath emergently d/t ST changes and hypotension thought to be from cardiogenic shock. Past Medical History: PMH: unclear, daughter is a poor historian, has h/o breast ca and possible pulmonary fibrosis, may also have dx of lung ca, HTN Social History: Social hx: pt lives at home with daughter, has been noted to be very depressed lately d/t the loss of two family members. Does not drink or smoke. Family History: Fam hx: father had angina Physical Exam: PE: Tm 97.7 Tc 97.3 BP assisted diastolic 123-145, mean arterial bp 73-87 P 64-76 R 18-26 O2 sat 98% I/O 1043/423 Gen: awakes to pain HEENT: PERRL, hematoma on right neck covered by bandage, large nodule present on left side of neck, feels somewhat soft Pulm; coars rhonchorous breathe sounds bilaterally Chest: right breast removed s/p mastectomy Cardio; difficult to hear heart with loud breathe sounds Abd: soft, ND, breathe sounds transmitted to abd Ext: feet feel cold, pulses hard to palpate Skin: Where left subclavian line placed there is a large hematoma, that is soft to push on Pertinent Results: Cath showed: LMCA, LCX: no significant disease LAD: mild diffuse irregularirties RCA: 50-60% ostial with catheter damping LV: LVEF 20% with apical ballooning --moderately elevated left sided and severely elevated right sided filling pressures; severe pulm htn, severely depressed CO, apical ballooning syndrom vs acute myocarditis. co 2.6 ci 1.5 MAPs: RA 19 [**MD Number(3) 64077**] 22 AO 64 labs at admit: pH 7.30 pCO2 44 pO2 229 HCO3 23 BaseXS -4 na 132 cl 104 bun 14 gluc 89 AGap=11 k 4.4 hco3 21 cr 0.9 CK: 197 MB: 26 MBI: 13.2 Trop-*T*: 1.46 Ca: 7.3 Mg: 1.5 P: 3.7 wbc 19.3 (prev was 14.7) hgb 11.2 D plts 245 hct 35.6 (previous was 43.8) PT: 14.5 PTT: 38.7 INR: 1.4 CXR: satisfactory ETT placement, diffuse bilateral alveolar opacities. Differential includes multifolca PNA, ARDS, pulm edema. Large left and probable right sided pleural effusion. Massive gastric distension. . Echo [**6-19**]: Conclusions: The left atrium is normal in size. 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 is normal. Right ventricular systolic function appears depressed. There is a prominence of the non-coronary sinus. The ascending aorta is moderately dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. . [**2197-6-19**] 05:15AM BLOOD WBC-16.4* RBC-2.83* Hgb-8.2* Hct-23.8* MCV-84 MCH-28.8 MCHC-34.3 RDW-14.7 Plt Ct-119* [**2197-6-18**] 08:31PM BLOOD Hct-25.6* [**2197-6-18**] 11:42AM BLOOD Hct-28.0* [**2197-6-18**] 05:16AM BLOOD WBC-12.8* RBC-3.36* Hgb-9.4* Hct-27.8* MCV-83 MCH-27.9 MCHC-33.7 RDW-14.5 Plt Ct-147* [**2197-6-17**] 11:20PM BLOOD Hct-29.5* [**2197-6-17**] 04:05PM BLOOD WBC-13.1* RBC-3.93* Hgb-10.8* Hct-32.9* MCV-84 MCH-27.6 MCHC-32.9 RDW-14.3 Plt Ct-184 [**2197-6-17**] 04:11AM BLOOD WBC-19.3* RBC-4.15* Hgb-11.2*# Hct-35.6* MCV-86 MCH-27.0 MCHC-31.5 RDW-13.9 Plt Ct-245 [**2197-6-17**] 12:10AM BLOOD WBC-14.7* RBC-5.07 Hgb-14.4 Hct-43.8 MCV-87 MCH-28.5 MCHC-32.9 RDW-13.6 Plt Ct-302 [**2197-6-19**] 05:15AM BLOOD Plt Ct-119* [**2197-6-18**] 05:16AM BLOOD Plt Ct-147* [**2197-6-17**] 12:10AM BLOOD Plt Ct-302 [**2197-6-19**] 05:15AM BLOOD Glucose-92 UreaN-20 Creat-1.0 Na-134 K-3.8 Cl-105 HCO3-22 AnGap-11 [**2197-6-18**] 05:16AM BLOOD Glucose-100 UreaN-17 Creat-1.0 Na-134 K-3.9 Cl-104 HCO3-21* AnGap-13 [**2197-6-17**] 12:10AM BLOOD UreaN-14 Creat-1.2* [**2197-6-18**] 05:16AM BLOOD CK(CPK)-158* [**2197-6-17**] 04:05PM BLOOD CK(CPK)-238* [**2197-6-17**] 04:11AM BLOOD CK(CPK)-197* [**2197-6-17**] 12:10AM BLOOD Amylase-157* [**2197-6-18**] 05:16AM BLOOD CK-MB-9 cTropnT-0.51* [**2197-6-17**] 04:05PM BLOOD CK-MB-20* MB Indx-8.4* cTropnT-0.86* [**2197-6-17**] 04:11AM BLOOD CK-MB-26* MB Indx-13.2* cTropnT-1.46* [**2197-6-17**] 12:10AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-13.1 Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2197-6-19**] 12:22PM BLOOD Type-ART pO2-56* pCO2-47* pH-7.32* calHCO3-25 Base XS--2 [**2197-6-19**] 05:19AM BLOOD Type-ART pO2-126* pCO2-40 pH-7.39 calHCO3-25 Base XS-0 [**2197-6-17**] 01:58AM BLOOD Type-ART Rates-/16 Tidal V-500 PEEP-5 O2 Flow-100 pO2-129* pCO2-55* pH-7.22* calHCO3-24 Base XS--5 Intubat-INTUBATED [**2197-6-17**] 10:43AM BLOOD Lactate-1.5 [**2197-6-17**] 04:45AM BLOOD Lactate-1.9 Brief Hospital Course: *SOB: This 79 yo Haitian female with h/o breast ca and possible lung CA presented with sudden onset of SOB. EMS was called and she was intubated in field. She was hypotensive in the ER (btwn 1am -3 am bp 70-118/38-94 and HR 66-84). An R IJ line was attempted to be inserted at this time, but caused a hematoma. Pt was still hypotensive so a left SC line was put in and caused a second hematoma. She was started on dopamine in the ER and then changed to levophed b/c she got tachycardic. An EKG showed ST elevations in leads I, II AVR and V2-V6. Pt was taken to cath emergently d/t ST changes and hypotension thought to be from cardiogenic shock. The cath showed: LMCA, LCX: no significant disease LAD: mild diffuse irregularirties RCA: 50-60% ostial with catheter damping LV: LVEF 20% with apical ballooning --moderately elevated left sided and severely elevated right sided filling pressures; severe pulm htn, severely depressed CO, apical ballooning syndrom vs acute myocarditis. co 2.6 ci 1.5 MAPs: RA 19 [**MD Number(3) 64077**] 22 AO 64 An echo was done during the cath that showed no evidence of a pericardial effusion. A balloon pump was also placed at the time of cath. Her groin was oozing at the cath site. Pt was given protamine to reverse the heparin. It was decided to hold her heparin drip until the AM and then start at a low dose b/c of hematomas and bleeding. It was thought that the patient had Takotsubo cardiomyopathy secondary to the stress of watching the news related to terrorist activity in [**Location (un) 311**]. ASA, plavix and beta-blocers were not started because the patient had clean coronaries. One day after admission the balloon pump was pulled. An echo was done two days after admission and showed mild symmetric left ventricular hypertrophy with preserved global systolic function. Right ventricular free wall hypokinesis c/w possible ischemia (given normal PA systolic pressure). Mild aortic regurgitation. Pt's CXR at admission showed possible ARDS, pneumonia or pulmonary edema. Pt could have had fluid overload in lungs secondary to systolic dysfuction. [**Month (only) 116**] also have had PNA, especially since WBC was elevated. Pt did not have fevers, however. There was also a h/o pulmonary fibrosis, breast and lung cancer. She received captopril 6.5 mg to diurese pt and help her CHF. She was also given ipratropium inhalers. One day after admission the family indicated to the social worker that the patient had been dc'd to home hospice care two weeks prior but the patient refused hospice and did not fill her narctoics for pain. A palliative care consult was obtained. Patient was still intubated but her respiratory status was not improving to a great degree. Patient and patient's family made the decision to extubate the patient knowing that she would most likely die when extubated. This was per the family consistent with the patient's previous expressed wishes. Of note patient's hct dropped from 43 at admission to 23 on [**6-19**]. Family was informed of the necessity of a transfusion but refused blood transfusions. The patient was made comfort measures only and extubated with family present consistent with the wishes of all. The patient was extubated on [**2197-6-19**]. She was pronounced dead at 7:0 pm on [**2197-6-19**] with the family at her side. Family declined to have an autospys performed. Acute blood loss anemia: Pt's hct has dropped significantly in the past day. This can be explained by two hematomas and oozing from the cath. It is possible that she is bleeding from somewhere else. -will re-check hct in pm to see if pt stable -check stool guiacs . Medications on Admission: MEDS: unknown, may include diovan Discharge Medications: patient expired Discharge Disposition: Expired Discharge Diagnosis: patient expired Discharge Condition: patient expired Discharge Instructions: patient expired Followup Instructions: patient expired

[ "428.0", "428.40", "425.4", "496", "785.51", "162.9", "515", "174.8" ]

icd9cm

[ [ [] ] ]

[ "99.20", "96.71", "88.53", "88.56", "97.44", "37.61", "37.23", "38.93" ]

icd9pcs

[ [ [] ] ]

9571, 9580

5801, 9447

324, 420

9639, 9656

2230, 5778

9720, 9738

1578, 1605

9531, 9548

9601, 9618

9473, 9508

9680, 9697

1620, 2211

276, 286

448, 1247

1269, 1398

1414, 1562

16,129

152,472

1396

Discharge summary

report

Admission Date: [**2177-9-17**] Discharge Date: [**2177-9-25**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4052**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None. History of Present Illness: This is an 86 y/o man with h/o CLL, CABG, and mitral valve replacement who presents with weakness and SOB for 3 days. He lives in an [**Hospital3 **] facility and was being visited by his son thought he looked very out of breath and weak. He insisted that he see his doctor, who noted the pt to be tachypnic to 36 and tachycardic to 107, and sent pt to the ED for evaluation. Mr [**Known lastname 6115**] complained of occasional cough that was productive of white phlegm. He denied CP, HA, fevers, chills, abdominal pain, black/bloody stools, diarrhea, nausea, vomiting, dysuria, lower extremity edema, and calf pain. No sick contacts. Pt lives in [**Location 8411**] building. . In ED he presented with a temp of 100.1 and a sat of 99 on a NR (EMT's note 90% on RA). He recieved IVF and a dose of levofloxacin for RUL pneumonia confirmed by CXR. Past Medical History: Acute rheumatic fever, which then required mitral valve replacement (St. [**Male First Name (un) 1525**]) CLL (dx [**2175**]/[**2176**]) Three-vessel CABG for coronary artery disease Hyperlipidemia Skin cancer Social History: The patient is a widower and former [**Company 378**] electronics mechanic. He lives at [**Hospital3 **] here in [**Location (un) **]. He has three adult children. He denies tobacco, alcohol, and IVDU. Family History: Non-contributory. Physical Exam: T: 97.7, HR 100, RR 24, 110/62, 92% RA Gen: NAD, pleasant elderly man. HEENT: NC/AT, scar s/p squamous cell removal on scalp. EOMI, PEERLA, dry MM, no JVD, OP clear, no LAD. CV: Irregularly irregular. Lungs: +sternal wound scar, decreased breath sounds on RUL, rhonchi heard 1/2 up lungs b/l. Abd: NTND, normoactive bowel sounds, no RG. Ext: no LE edema, +1 pulses b/l DP Neuro: A&O x3, CN II-XII intact, normal sensation in UE, decreased sensation on dorusm of feet b/l. Normal position sense. Normal muscle tone, bulk, and strength. Pertinent Results: Imaging: [**2177-9-17**]: CXR SINGLE AP PORTABLE VIEW OF THE CHEST: Extensive opacity of the right upper lobe is consistent with pneumonia. Otherwise the lungs are grossly clear. There is no pneumothorax. Blunting of the left CP angle could be pleural thickening of chronic small pleural effusion. The cardiac size is normal. Mediastinal and hilar contours are unremarkable. Patient is post median sternotomy and CABG. IMPRESSION: Right upper lobe pneumonia. . [**2177-9-18**]: CXR FINDINGS: An AP semi-upright portable chest radiograph. Air space consolidation involving the right upper lobe, densest peripherally not significantly different compared to yesterday's study. Slight blunting of the left costophrenic angle is also unchanged. Taking into account head position, slight leftward tracheal deviation below the thoracic inlet is unchanged as far back as the patient's first study from [**2176-7-17**]. CONCLUSION: No significant interval radiographic change in right upper lobe pneumonia. . [**2177-9-19**]: CXR FINDINGS: Lung volumes are slightly diminished. There is relatively stable right upper lobe consolidation consistent with lobar pneumonia. Post-surgical changes consistent with prior median sternotomy and CABG are stable. Otherwise, no significant interval change. IMPRESSION: Within differences of inspiratory effort, the right upper lobe lobar pneumonia is stable. Minimal bibasilar atelectasis is seen. . [**2177-9-20**]: CXR Compared with one day earlier and allowing for differences in technique, no significant change is detected. . Again seen is dense consolidation of the right upper lobe, most pronounced laterally, with relative sparing of the medial aspect of the apex. The patient is status post sternotomy, with borderline cardiomegaly. Again seen is pleural thickening along left mid and lower chest walls. No CHF. No gross right effusion. . [**2177-9-22**]: CXR FINDINGS: Since prior examination, there has been no significant interval change. Again noted, extensive right upper lobe opacity with air bronchograms. Sternotomy wires and surgical clips unchanged. No evidence of pneumothorax. No evidence of CHF or pulmonary edema. Small right pleural effusion. IMPRESSION: Persistent right upper lobe pneumonia, without significant interval changes. No evidence of CHF or pulmonary edema. . [**2177-9-22**]: CT Chest IMPRESSION: Multifocal pneumonia, including right upper lobe consolidation and early right lower lobe consolidation. Left basilar opacity may represent atelectasis or another focus of consolidation. Giving areas of sparing in the left upper and right middle lobe, ARDS is felt unlikely. . Lab values: CBC [**2177-9-17**] WBC-42.4* RBC-2.41* Hgb-8.1* Hct-24.2* MCV-100* MCH-33.7* MCHC-33.7 RDW-22.4* Plt Ct-124* [**2177-9-18**] WBC-33.3* RBC-1.94* Hgb-6.7* Hct-19.8* MCV-102* MCH-34.6* MCHC-33.9 RDW-22.0* Plt Ct-98* [**2177-9-24**] WBC-45.3* RBC-2.86* Hgb-9.5* Hct-27.8* MCV-97 MCH-33.2* MCHC-34.2 RDW-21.5* Plt Ct-139* [**2177-9-25**] WBC-42.8* RBC-2.74* Hgb-8.8* Hct-26.1* MCV-95 MCH-32.0 MCHC-33.6 RDW-21.1* Plt Ct-150 . CBC Diff: [**2177-9-17**] Neuts-8* Bands-1 Lymphs-90* Monos-1* Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2177-9-23**] Neuts-33* Bands-0 Lymphs-67* Monos-0 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 . Coags: [**2177-9-17**] PT-46.6* PTT-55.6* INR(PT)-5.4* [**2177-9-24**] PT-34.5* PTT-37.5* INR(PT)-3.7* [**2177-9-25**] PT-38.3* PTT-39.2* INR(PT)-4.3* [**2177-9-18**] Fibrino-527* . Chemistries: [**2177-9-17**] Glucose-121* UreaN-50* Creat-2.3* Na-132* K-4.4 Cl-103 HCO3-22 AnGap-11 [**2177-9-25**] Glucose-118* UreaN-42* Creat-1.8* Na-136 K-4.1 Cl-106 HCO3-25 AnGap-9 . Other: [**2177-9-18**] LD(LDH)-328* TotBili-0.6 [**2177-9-18**] CK(CPK)-35* [**2177-9-18**] CK-MB-NotDone cTropnT-0.02* . [**2177-9-22**] proBNP-[**Numeric Identifier 8412**]* [**2177-9-18**] Calcium-8.1* Phos-3.3 Mg-2.3 [**2177-9-25**] Calcium-8.5 Phos-3.3 Mg-2.0 [**2177-9-18**] Hapto-111 [**2177-9-19**] IgG-5652* . ABGs: [**2177-9-18**] pO2-63* pCO2-33* pH-7.47* calTCO2-25 Base XS-0 Intubat-NOT INTUBA [**2177-9-19**] pO2-104 pCO2-33* pH-7.48* calTCO2-25 Base XS-1 [**2177-9-17**] Lactate-1.4 [**2177-9-19**] Lactate-2.0 [**2177-9-18**] Hgb-7.5* calcHCT-23 [**2177-9-18**] freeCa-1.22 Brief Hospital Course: This is an 86 yo male with hx of CLL, CABG/MVR who presented with urine legionella Ag positive PNA and new onset AF. . 1. Hypoxia: The patient was initially admitted 3 days of SOB, tachypnea, productive cough, and tachycardia. In the ED, CXR showed RUL consolidation. He was diagnosed with pneumonia and initially treated with levofloxacin, ceftazidime, and vancomycin. On hospital day #2, the patient was noted to have an increasing O2 requirement (satting low 80s on 10L NC) and an ABG ABG 7.47/33/63 on 95% fm. He was transferred to the MICU and did well, with progressing decrease in O2 requirement, and urine Legionella antigen was found positive. He was switched to only levofloxacin (14 day course) for treatment. He initially responded well to the treatment, and was transferred to the medicine team on the floors. . While on the floor, the patient began to develop an increased O2 requirement. The etiology of his increased requirement was thought to be multifactorial: anemia secondary to CLL, RUL and RLL legionella PNA, and mild CHF (further discussion of problems below). On repeat CXR, the patient was found to have multifocal PNA, spreading to RLL as well. Pulmonology consult was called who recognized the "textbook" course of Legionella -- worsening upon initial treatment but with subsequent improvement. . The patient also developed symptoms of mild CHF, most likely secondary to his decreased EF (last checked in [**2176**] was 40-45%) and volume overload. The patient responded well to furosemide. Upon discharge, the patient was satting 97% on RA and had no symptoms of shortness of breath. His lung exam findings had considerably improved with crackles limited to the bases of the lung fields. The patient was discharged on a 14 days course of levofloxacin and VNA. . 2. afib/CVS: The patient had an extensive prior history of cardiovascular disease, including CAD with CABG and mitral valve replacement secondary to rheumatic fever. His ejection fraction was last checked in [**2176**] and was found to be 40-45%. During his hospital course, he developed crackles in the bases of the lungs, increased O2 requirement, and although no indication of CHF on CXR, he was found to have an elevated BNP. The diagnosis of mild CHF was made and he was treated with furosemide PRN. He responded well, with improved oxygenation as he became euvolemic and his PNA improved. This episode of mild CHF was thought to be due to an episode of atrial fibrillation which was new in onset and was most likely secondary to infection and increased metabolic demands. He was treated with metoprolol for rate control and was already on warfarin for MVR prophylaxis. His Atenolol was changed to metoprolol as the patient has chronic renal insufficiency. The dose was steadily increased to 100 mg PO BID for rate control. Finally, his CAD was treated with atorvastatin and the BB. . 3. Anemia: The patient has a baseline anemia with Hct ranging from 24-30. The anemia is likely secondary to CLL. He was treated with iron supplementation and was transfused with three units PRBCs to increase his 02 carrying capacity in the setting of severe PNA. He was continued on aranesp, B12, and folate. Upon discharge, the patient's Hct was 26.1 and stable. . 4. Acute on Chronic Renal Failure: The patient had a baseline creatinine level of 1.7-1.9. During his hospital course, the patient was found to have increasing Cr levels, highest at 2.3. He was found to be prerenal with a calculated FeNa of 0.17% on [**9-18**]. He was given fluids in the ICU for dehydration. Although legionella can cause renal failure, pre-renal azotemia was thought to be the cause of this patient's acute renal failure. His I/Os were monitored. Upon discharge, his renal failure was improving with a Cr of 1.8 and he was thought to be back to his baseline. . 5. Thrush: During the hospital stay the patient developed dry mouth with some irritation. Upon visual inspection, he was noted to have white exudate on the internal buccal mucosa. The development of thrush is presumably due to the patient's immunocompromised state secondary to his CLL. The patient was given a Nystatin oral solution. . 6. CLL: Patient's diff is 90% lymphocytes which is consistent with CLL. The infection with legionella PNA was thought to be attributable to the patients immunocompromised status secondary to his CLL. Medications on Admission: atenolol 25mg daily warfarin Lipitor 10mg daily folic acid vitamin E Caltrate B12 Aranesp Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. Caltrate Plus Tablet Sig: One (1) Tablet PO once a day. 5. Vitamin B-12 1,000 mcg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day. 6. med please take your Aranesp as previously directed. 7. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. Ipratropium Bromide 0.02 % Solution Sig: 1-2 puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:*qs 1* Refills:*0* 9. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation Q4-6 prn. Disp:*qs 1* Refills:*0* 10. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 6 days. Disp:*6 Tablet(s)* Refills:*0* 11. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for mouth irritation/white exudate for 7 days: Please take for mouth irritation or white exudate. Disp:*140 ML(s)* Refills:*0* 12. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Please do not take this medication on [**9-25**] or [**9-26**]. Disp:*30 Tablet(s)* Refills:*2* 13. Outpatient Lab Work Please check PT, PTT, and INR on saturday and phone results to Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 608**]. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary: Legionella Pneumonia new onset atrial fibrillation . Secondary: CAD s/p 3vessel CABG Chronic Lymphocytic Lymphoma acute Rheumatic Fever -> s/p mitral valve replacement hyperlipidemia Sq cell skin CA removed from scalp [**5-10**] Discharge Condition: Good. Pt sating 97% on room air with ambulation. Discharge Instructions: Please call you PCP or return to the ER if you experience increasing shortness of breath, lightheadedness, chest pain or any other symptoms that concern you. . Please take all medications as prescribed. Note, please discontinue the atenolol as this has been replaced with metoprolol. You have also been startd on an antibiotic called levofloxacin. Please take all dosages as directed. . Please do not take your coumadin tonight [**9-25**] or friday night [**9-26**] as your INR is high. Please resume your coumadin 2mg Qhs on saturday night unless Dr. [**Last Name (STitle) 1266**] changes the dosage. He will call you with a change if it is necessary. . Please get your blood checked on saturday. The results will be sent to your PCP. [**Name10 (NameIs) **] any changes need to be made to your coumadin regimen, he will call you and tell you what the changes are. Followup Instructions: Please follow up with your PCP [**Name9 (PRE) **],[**Name9 (PRE) **] [**Telephone/Fax (1) 608**] upon discharge. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 4055**] Completed by:[**2177-9-27**]

[ "427.31", "276.51", "V45.81", "585.9", "482.84", "285.29", "112.0", "398.91", "272.4", "799.02", "584.9", "V43.3", "204.10", "414.00" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

12481, 12539

6476, 10862

270, 277

12821, 12872

2216, 6453

13785, 14051

1623, 1642

11004, 12458

12560, 12800

10888, 10981

12896, 13762

1657, 2197

223, 232

305, 1155

1177, 1388

1404, 1607

9,063

185,758

25799

Discharge summary

report

Admission Date: [**2158-7-14**] Discharge Date: [**2158-7-18**] Date of Birth: [**2085-1-18**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 30**] Chief Complaint: lethargy/ chills/ disorientation Major Surgical or Invasive Procedure: R IJ line placed in ED History of Present Illness: 73 year old, history of prednisone for chronic RA, hx of DVT now on [**Location (un) **] filter, asthma, recently went onto trip to [**Country 13622**] Republic. He returned at yesterday and stopped over at [**Location (un) 2848**]. He remembered taking some hot dogs and spirit before he took flight to come back to [**Location (un) 86**]. his return trip to [**Location (un) 86**], he was noted to have chills, increasing lethargy, disorientation and "asking strange question." He was subsequently brought by EMS from airport. Of note, his daughter also consumed hot dog but reportedly was still well. Denies any recent sick contact or bug bites. Past Medical History: Rheumatoid arthritis on prednisone chronically Hx of DVT and s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 260**] filter Asthma ??CAD S/P cholecystectomy s/p bilateral knee replacement Social History: retired painter, lives alone and independent, denies tob and alcohol Family History: history heart disease Physical Exam: [**Hospital Unit Name 153**] on admission: BP 88/49 P 80s R 14 O2 90s on 2L Gen: NAD HEENT: PERRL, sclrae aniceteric, OP clear, dry MM Neck: flat JVD, supple CV: RRR, no m/r/g Chest: bibasilar crackles Abd: S, NT/ND+BS, no HSM Ext: WWP, no edema or rashes neuro: A+O x 3, motor and sensory grossly intact Pertinent Results: [**2158-7-14**] 12:20PM BLOOD WBC-PND RBC-PND Hgb-PND Hct-PND MCV-PND MCH-PND MCHC-PND Plt Ct-PND [**2158-7-14**] 04:05AM BLOOD WBC-31.1* RBC-5.38 Hgb-17.2 Hct-48.2 MCV-90 MCH-32.0 MCHC-35.7* RDW-13.2 Plt Ct-275 [**2158-7-14**] 12:20PM BLOOD Neuts-PND Lymphs-PND Monos-PND Eos-PND Baso-PND [**2158-7-14**] 04:05AM BLOOD Neuts-65 Bands-19* Lymphs-4* Monos-4 Eos-1 Baso-0 Atyps-3* Metas-4* Myelos-0 [**2158-7-14**] 04:05AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL [**2158-7-14**] 12:20PM BLOOD Plt Ct-PND [**2158-7-14**] 04:05AM BLOOD Plt Smr-NORMAL Plt Ct-275 [**2158-7-14**] 04:05AM BLOOD PT-14.0* PTT-28.2 INR(PT)-1.3 [**2158-7-14**] 08:25AM BLOOD Glucose-129* Na-142 K-2.8* Cl-112* HCO3-20* AnGap-13 [**2158-7-14**] 04:05AM BLOOD Glucose-115* UreaN-30* Creat-1.9* Na-140 K-5.4* Cl-99 HCO3-19* AnGap-27* [**2158-7-14**] 12:20PM BLOOD ALT-PND AST-PND LD(LDH)-PND AlkPhos-PND TotBili-PND [**2158-7-14**] 08:25AM BLOOD LD(LDH)-134 [**2158-7-14**] 04:05AM BLOOD ALT-46* AST-93* CK(CPK)-168 AlkPhos-59 Amylase-53 TotBili-1.7* [**2158-7-14**] 12:20PM BLOOD Lipase-PND [**2158-7-14**] 04:05AM BLOOD cTropnT-0.01 [**2158-7-14**] 04:05AM BLOOD CK-MB-1 [**2158-7-14**] 08:25AM BLOOD Calcium-7.4* Phos-1.3* Mg-1.0* [**2158-7-14**] 04:05AM BLOOD Albumin-4.2 Calcium-9.9 Phos-1.1* Mg-1.7 [**2158-7-14**] 12:42PM BLOOD Lactate-2.8* [**2158-7-14**] 11:07AM BLOOD Lactate-2.5* [**2158-7-14**] 09:59AM BLOOD Lactate-2.3* K-3.0* [**2158-7-14**] 08:58AM BLOOD Lactate-3.0* [**2158-7-14**] 07:25AM BLOOD Lactate-3.33* [**2158-7-14**] 06:15AM BLOOD Lactate-3.6* [**2158-7-14**] 04:32AM BLOOD Lactate-5.1* [**2158-7-14**] 07:25AM BLOOD Hgb-13.9* calcHCT-42 O2 Sat-71 [**2158-7-18**] 10:25AM BLOOD WBC-10.8 RBC-4.66 Hgb-14.8 Hct-43.7 MCV-94 MCH-31.9 MCHC-34.0 RDW-13.3 Plt Ct-206 [**2158-7-18**] 10:25AM BLOOD Plt Ct-206 [**2158-7-18**] 10:25AM BLOOD PT-13.2 PTT-32.9 INR(PT)-1.2 [**2158-7-18**] 10:25AM BLOOD Glucose-148* UreaN-18 Creat-0.9 Na-138 K-4.3 Cl-103 HCO3-29 AnGap-10 [**2158-7-18**] 10:25AM BLOOD Calcium-9.2 Phos-1.7* Mg-2.0 . CXR [**2158-7-14**]: Prominence of the pulmonary vessels without frank pulmonary edema . [**2158-7-14**] Blood Cultures: No growth [**2158-7-14**] Urine cultures: No Growth [**2158-7-14**] 8:30 pm STOOL CONSISTENCY: SOFT Source: Stool. **FINAL REPORT [**2158-7-17**]** FECAL CULTURE (Final [**2158-7-16**]): NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [**2158-7-16**]): NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final [**2158-7-17**]): NO OVA AND PARASITES SEEN. . CHARCOT-[**Location (un) **] CRYSTALS PRESENT. . This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. FECAL CULTURE - R/O YERSINIA (Final [**2158-7-16**]): NO YERSINIA FOUND. FECAL CULTURE - R/O E.COLI 0157:H7 (Final [**2158-7-16**]): NO E.COLI 0157:H7 FOUND. [**2158-7-14**] 8:36 pm STOOL CONSISTENCY: SOFT **FINAL REPORT [**2158-7-17**]** OVA + PARASITES (Final [**2158-7-17**]): NO OVA AND PARASITES SEEN. . CHARCOT-[**Location (un) **] CRYSTALS PRESENT. . [**2158-7-15**] 3:19 pm STOOL CONSISTENCY: SOFT **FINAL REPORT [**2158-7-17**]** OVA + PARASITES (Final [**2158-7-17**]): NO OVA AND PARASITES SEEN. . [**2158-7-17**] RUQ US: No evidence of biliary obstruction. [**2158-7-17**] CT Chest: 1. Lesion between left atrium and esophagus corresponds to a fluid density oval structure surrounded by fat. The latter likely reflects fat that has herniated into the posterior mediastinum through the esophageal hiatus. The etiology of the oval- shaped lesion is uncertain, but could represent an esophageal duplication cyst or other benign finding. A necrotic lymph node is less likely. By report, the patient underwent an outside CT years ago. Direct comparison to the older study is recommended to document long-term stability and to exclude an acute process. 2. Small bilateral pleural effusions, increased since study from [**7-14**]. 3. Focal area of cystic bronchiectasis in the lingula with a small fluid level, indicative of secretions. Findings are likely sequela of prior pneumonia. 4. Borderline enlarged precarinal mediastinal lymph node. . [**2158-7-18**] Bone Scan: No definite evidence of osteomyelitis or osseous metastases. Brief Hospital Course: ICU Course: 73 year old, p/w acute history of chills/lethargy/disorientation, WBC of 30K, lactate 5, admit to [**Hospital Unit Name 153**] for sepsis protocol (Sepsis-hyperthermia + WBC 30; shock + lactate). #Sepsis of unclear etiology. Given the pt hisotry of chronic steroid use and his travel history, the initial differential diagnosis was wide. Apart from the usual sources malaria, typhoid fever and traveler diarrhea were considered. THe pt was started on Levofloxacin and Metronidazole in the ED. A CXR was unsuggestive for pneumonia, a CT w and w/o contrast of the abdomen and pelvis was negative. The WBC of initally 30K was trending down from with ABX treatment. A urine culture did not reveal any infectious course. Stool and blood cultures were pending. The pt was continued on a stress dose of steroids given is chronic steroid intake. to follow mental status closely .. #ARF - Creatinine was elevated (1.9) on admission. The cause was thought to be prerenal in context of a sepsis. The pt was treated with fluid boluses and urine output was monitored. The Cr came down quickly and is now 0.9. Because no previous data was available, it is difficult to estimate the pt's baseline. .. #Gap metabolic acidosis and metabolic alkalosis was thought to be a combination of lactic acidosis, vomiting and contraction alkalosis. The pt was treated with aggressive IVF resucitation as by the must protocoll and electrolytes were repleted accordingly. His acid base disorder has resolved. .. #Increased LFT from first specimen, are thought to be due to hemolysis as all follow up LFTs were normal and no other history or clinical symptoms consistent with a liver disease were given. .. #CV- An echo on admission showed a left atrium that is mildly dilated. The right atrium that is moderately dilated. Overall left ventricular systolic function that is low normal (LVEF 50-55%). The pt never presented shortness of breath, edema or any other signs of heart failure. An EKG did not show any ischemic changes. Cardiac enzymes were negative x1. The rhythm-frequent PVC were thought to be in the setting of his sepsis. They resolved when the pt became afebrile. .. #FEN-oral intake #PPX-hep sc #COde-Full code #Communication -daughter Course on the floor: Mr. [**Known lastname **] was transferred to the floor from the [**Hospital Unit Name 153**] The day before discharge. While on the floor he was transitioned to po prednisone to complete a steroid taper, and his diet was advanced. He had a RUQ ultrasound which showed no obstruction. He had a CT of the chest which showed a lesion between the L atrium and the espohagus which may be fat, but could be a cyst or other lesion. He had a CT 5 yrs ago in TN, and this study will need to be compared to that study. He also had a bone scane which showed no sign of osteomyelitis or osseous metastases. He was stable overnight, and discharged on [**2158-7-17**] with a CD/ROM of his prior Ct and possible further work up of the mass seen on CT. Of note, his stool O&P were still pending on discharge, but came back negative. The source of his sepsis was never found. Medications on Admission: prednisone 5mg QD gold 3mg QD calcium carbonate 500mg QD colchicine 0.6mg QD HCTZ 25 QD ASA 81mg QD B12 injections Tylenol 650mg QD Aleve Fosamax Discharge Medications: 1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 10 days. Disp:*10 Tablet(s)* Refills:*0* 2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 10 days. Disp:*30 Tablet(s)* Refills:*0* 3. Prednisone 5 mg Tablet Sig: Five (5) Tablet PO once a day: please take 6 tablets for 2 days starting [**2158-7-19**], then 4 tablets for 2 days, then 2 tablets for 2 days, then 1 tablet daily. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: primary: sepsis secondary: acute renal failure, asthma, DVT, rheumatoid arthritis Discharge Condition: Patient is feeling well, afebrile, hemodynamically stable, eating, walking. Discharge Instructions: > 101, nausea & vomiting, dizziness, alteration in your mental status, confusion. Followup Instructions: PLease call your PCP to follow up on your return home. Completed by:[**2158-10-11**]

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Discharge summary

report

Admission Date: [**2195-2-18**] Discharge Date: [**2195-4-2**] Date of Birth: [**2150-1-20**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 613**] Chief Complaint: Unresponsive. Major Surgical or Invasive Procedure: Thoracentesis Intubation History of Present Illness: Mr. [**Known lastname 4610**] is a 45 year-old male with IDDM complicated by prior DKA/gastroparesis, history of UGIB (most recently [**1-/2195**]), mild systolic dysfunction, as well as polysubstance abuse with active cocaine and marijuana use prior to admission, who was transferred from [**Hospital3 3583**] on [**2-18**] after being found unresponsive with BS13. He was given Glucagon, initial vitals T92.9, HR91, BP150/90, RR24, 96%RA. His labs were significant for leukocytosis with bandemia, BUN 62, creatinine 2.5, non-anion gap acidosis with bicarb 9, and elevated LFTs. He was empirically given Ceftriaxone, and transferred to [**Hospital1 18**]. . At [**Hospital1 18**], initial vitals T98.4, HR108, 166/104, RR16, Sat 90%RA. The patient complained of diffuse abdominal pain. ABG with 7.21/28/58 leading to intubation. He was empirically started on Levofloxacin and Clindamycin. . Of note, he was recently admitted to [**Hospital1 18**] [**2195-1-22**] to [**2195-1-30**] for treatment of an upper GI bleed [**1-22**] bleeding artery treated with epinephrine and clipping, complicated by NSTEMI, aspiration pneumonia and CHF. Past Medical History: - DMI c/b episodes of DKA and hypoglycemia - Gastroparesis - Diabetic nephropathy - IgA Nephropathy - PVD - h/o osteomyelitis of the 5th MTP s/p surgery [**9-23**] - Hx of UGIB: [**3-10**] grade V esophagitis; no active bleeding; [**2195-1-25**]: Grade V esophagitis, bleeding artery (s/p epi and clipping); [**2194-1-27**]: esophagitis, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear, non-bleeding angiectasias (s/p [**Hospital1 **]-cap electrocautery); [**8-24**]: esophagitis, duodenitis, barrett's esophagous and bx with [**Female First Name (un) **] - h/o Candidal Esophagitis - Anemia - Peripheral neuropathy - CHF - EF 50% - Hypothyroidism - s/p NSTEMI ([**1-/2195**]) - segmental infectious colitis ([**2192**] @ [**Hospital3 3583**]) - CRI (baseline 1.1-1.5) - HIV negative [**2195-2-18**] Social History: He lives with his brother and is separated from his current wife. [**Name (NI) **] has children from previous marriage. He smokes 1 pack per day for 30 years. He uses cocaine about 2-3 times per month, the last time was the Thursday prior to this admission. He denies alcohol use. Family History: His mother had an MI at the age of 54, and his father has diabetes. Physical Exam: Afebrile, HR 80s, BP 132/80, RR 16, 94%on 2.4L, 88% on RA, urine output 2 liters midnight to noon on [**2195-3-29**]. Gen: speaking in full sentences, A&Ox3, NAD HEENT: EOMI, PERRLA CV: RRR, no m/r/g PULM: decreased air movement esp at bases, bilateral basilar rales ABD: anasarca, diffuse tenderness Ext: anasarca, weak DP pulses Pertinent Results: Relevant laboratory data on admission: [**2195-2-18**] 08:45PM WBC-12.1*# RBC-3.49* HGB-10.5* HCT-30.9* MCV-89 MCH-30.0 MCHC-33.9 RDW-16.4* NEUTS-90.4* BANDS-0 LYMPHS-6.1* MONOS-2.7 EOS-0.7 BASOS-0.1 . GLUCOSE-66* UREA N-63* CREAT-2.3* SODIUM-149* POTASSIUM-5.5* CHLORIDE-126* TOTAL CO2-10* ANION GAP-19 CALCIUM-7.6* PHOSPHATE-6.9*# MAGNESIUM-1.7 . ALT(SGPT)-160* AST(SGOT)-224* CK(CPK)-265* ALK PHOS-339* AMYLASE-126* TOT BILI-0.1 LIPASE-118* . LACTATE-1.5 . Relevant laboratory data on discharge: [**2195-4-1**] 05:55AM WBC-8.8 RBC-2.63* Hgb-7.9* Hct-24.4* MCV-93 MCH-30.1 MCHC-32.5 RDW-17.6* Plt Ct-227 . Glucose-40* UreaN-56* Creat-2.0* Na-135 K-5.0 Cl-98 HCO3-34* AnGap-8 Calcium-8.5 Phos-5.4* Mg-2.0 . ALT-50* AST-17 AlkPhos-412* TotBili-0.2 . Tox screens: [**2195-2-18**] 08:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2195-2-18**] 08:45PM URINE bnzodzp-NEG barbitr-NEG opiates-POS cocaine-POS amphetm-NEG mthdone-NEG . [**2195-3-4**] 01:23PM URINE cocaine-POS . [**2195-3-13**] 05:54PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2195-3-13**] 05:54PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG . U/A: [**2195-2-18**] 09:11PM URINE RBC-0 WBC-21-50* BACTERIA-OCC YEAST-FEW EPI-0-2 [**2195-2-18**] 09:11PM URINE BLOOD-LG NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD . Relevant studies: CT HEAD W/O CONTRAST ([**2195-2-18**]): No evidence of acute intra or extra-axial hemorrhage. The [**Doctor Last Name 352**]- white matter differentiation appears preserved. There is no hydrocephalus or shift of normally midline structures. There is partial opacification of the ethmoid and sphenoid sinuses, and nasopharynx in this intubated patient. No skull fractures are identified. There is moderate scalp soft tissue swelling, which has developed since the prior examination, and is most evident over both temporalis muscles. . CT ABDOMEN W/O CONTRAST ([**2195-2-18**]): 1. Diffuse abnormality of the entire length of small bowel with fold and wall thickening and impressive wall edema. This is concerning for ischemic bowel, although no assessment can be made as to the patency of the mesenteric veins or arteries or the enhancement characteristics of the bowel mucosa. Notably, there is no pneumatosis, and no portal venous gas is identified. 2. Patchy opacities in both lower lobes. 3. 5 mm renal stone. . UNILAT LOWER EXT VEINS RIGHT ([**2195-2-18**]): Normal compressibility, color flow, and Doppler waveforms are seen in the deep venous system from the right common femoral vein to the right popliteal. The left common femoral vein is also normal. . ECHO ([**2195-2-20**]): The left atrium is dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is mild global left ventricular hypokinesis (ejection fraction 40-50 percent). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. The right ventricular cavity is dilated. Right ventricular systolic function appears depressed. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. No vegetations seen on any valve. Compared with the findings of the prior report (images reviewed) of [**2195-1-27**], the left ventricular ejection fraction is increased. The absence of a vegetation by 2D echocardiography does not exclude endocarditis if clinically suggested. . BILAT LOWER EXT VEINS ([**2195-2-24**]): Color and Doppler son[**Name (NI) 1417**] of bilateral common femoral, superficial femoral, and popliteal veins were performed. Normal flow, augmentation, compressibility, and waveforms are demonstrated. Intramural thrombus is not identified. . ECHO ([**2195-2-25**]): No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). Right ventricular chamber size is normal. Right ventricular systolic function is borderline normal. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [**2195-2-20**], biventricular function has improved. . RENAL U.S. ([**2195-3-6**]): The right kidney measures 12.6 cm. The left kidney measures 11.1 cm. The kidneys are diffusely increased in echogenicity, unchanged since the prior study. There is no evidence of hydronephrosis or nephrolithiasis. In the lower pole of the left kidney is a 7-mm anechoic thin-walled cyst consistent with a simple cyst. The previously identified 5 mm right renal stone seen on a CT from [**2195-2-18**] is not identified on this study. The bladder wall appears somewhat irregular, but lumen is not fully distended making this difficult to interpret. Small amount of ascites seen along the lateral margin of the liver, incompletely characterized. . CT TRACHEA W/O C W/3D REND ([**2195-3-8**]): There is high-attenuation material within the esophagus with Hounsfield units 60 consistent with blood given the patient's history of upper GI bleed. An area of irregularity is seen on the posterior tracheal wall, best demonstrated on series 3, image 55. A small tubular fistula is demonstrated. There is high- attenuation material with air bubbles seen within the posterior trachea. This is approximately 1.75 cm above the carina and is concerning for tracheoesophageal fistula. The lobar bronchi remain patent. Multiple high- attenuation (41.5 H) parenchymal consolidations are noted bilaterally which may be consistent with aspiration of hemorrhagic products, infection, or ARDS. There are bilateral pleural effusions. The osseous structures are unremarkable. Incidental note is made of a left sided subclavian central venous catheter. . DUPLEX DOPP ABD/PEL ([**2195-3-13**]): The liver is normal in echotexture without focal hepatic lesions. There is no intra- or extra-hepatic biliary ductal dilation; the common bile duct is 4 mm in diameter. The gallbladder is not distended and there is no evidence of stones or sludge within its lumen. The portal vein is patent with flow in an appropriate direction. Note is made of bilateral pleural effusions and a small to moderated amount of ascites in the right upper quadrant. The spleen appears unremarkable. Color Doppler son[**Name (NI) 1417**] of the hepatic veins, portal veins, inferior vena cava, hepatic arteries, splenic vein, and superior mesenteric vein demonstrate normal flow and waveforms. . MRCP ([**2195-3-18**]): 1. Markedly limited examination due to patient motion and patient body habitus (large effusions, apparent anasarca). 2. Large bilateral pleural effusions and pulmonary consolidation. 3. No obvious biliary dilatation. Suspected tiny cysts within the right lobe of the liver, which are incompletely evaluated. 3. Apparent diffuse anasarca. 4. Probable cyst, lower pole right kidney. . CT CHEST W/O CONTRAST ([**2195-3-23**]): 1. Diffuse areas of septal thickening, ground glass attenuation and patchy consolidation show overall slight improvement compared to [**2195-3-8**]. This may be due to edema, infection, or ARDS. 2. Worsening atelectasis in right middle lobe. 3. Peribronchiolar opacities within right lower lobe, concerning for active infection involving the small airways. 4. Large pleural effusions, slightly increased compared to prior study. 5. Diffuse anasarca. . BILAT UP EXT VEINS US ([**2195-4-1**]): [**Doctor Last Name **] scale and Doppler son[**Name (NI) 867**] were performed of the upper extremities bilaterally. Left-sided PICC line is noted. There is normal compressibility, flow, augmentation, and waveforms of the internal jugular, subclavian, axillary, brachial, and cephalic veins bilaterally. Brief Hospital Course: 1. IDDM: Patient has known insulin depedent diabetes and was initially admitted with hypoglycemic coma. He was treated with Glucagon and dextrose infusions, and admitted to the ICU. While in the ICU, he was placed on an insulin drip for glycemic control, and converted to Glargine and RISS at the time of transfer to the floor. On the floor, he experienced recurrent hypoglycemic episodes, and was transferred back to the ICU on [**3-5**], where Lantus was held and changed to NPH. He experienced recurrent isolated hypoglycemic events, treated with D5 as needed. NPH was changed back to glargine prior to discharge, and patient's blood sugars remained under relatively stable control. While on TPN, regular insulin was added to his TPN. . 2. Hypoxemic respiratory failure: His respiratory failure was felt to be multifactorial. He was intubated in the emergency department for airway protection and hypoxemia with ABG 7.21/28/58. His initial CXR was remarkable for a LLL infiltrate suggestive of pneumonia, and he was empirically treated with Zosyn (10-day course, completed on [**2-28**]). Subsequent CXRs showed diffuse bilateral infiltrates suggestive of possible aspiration +/- CHF +/- ARDS, with effusions. A thoracentesis was performed on [**2-25**] with studies consistent with a transudative effusion. He was succesfully extubated, and remained stable from a respiratory standpoint despite persistent findings of multifocal opacities on CXR. . While in the [**Hospital Unit Name 153**] for his upper GI bleed, he was also noted to have occasional hemoptysis and the possibility of a TE fistula was raised. A CT trachea obtained on [**3-8**] was also concerning for a TE fistula, and he was taken for a combined rigid bronchoscopy and EGD on [**3-10**] which showed no TE fistula and normal airways. . On [**3-19**], he had a rising temperature, tachycardia, and increasing oxygen requirements. Given concern for recurrent aspiration pneumonia, he was restarted on Zosyn and completed a 7 day course ending on [**3-26**]. . 3. Cardiac: While in hospital, he had an MB leak to 27, with stable mildly elevated troponins (albeit in the setting of renal failure). Whereas the possibility of NSTEMI was raised, it did not appear to be consistent with such an event. He was initially placed on ASA, which was subsequently held given his upper GI bleed. An echocardiogram obtained on [**2195-2-25**] showed improved EF versus prior with EF 50-55%, without WMA. Further cardiac evaluation was not pursued. . 4. Anasarca: His anasarca is likely multifactorial, with contributions from hypoalbuminemia secondary to malnutrition and nephrotic-range proteinuria. His mild systolic dysfunction was not thought large contributor. While in the ICU, he was diuresed with a Lasix drip. This was changed to intravenous boluses, and eventually to PO lasix. At the time of discharge, he was on Diuril 250 PO BID, with lasix 80 [**Hospital1 **]. He was also started on lisinopril for renal protective effects. . 5. Chronic diarrhea: An initial CT abdomen obtained in the emergency department was remarkable for diffuse bowel wall edema. The possibility of mesenteric ischemia was raised, but felt unlikely in the setting of normal lactate. He was initially empirically started on Zosyn and Flagyl. An infectious work-up was performed and negative, with stool cultures, O&P, and C. diff X 3 negative. Flagyl was discontinued on [**2-23**] (5-day course). He was placed on bowel rest while in the ICU, with TPN. . Review of his prior history revealed chronic diarrhea, and prior colonoscopies with biopsies negative for sprue. Given a peripheral eosinophilia, strongyloides antibody and TTG were sent, both of which returned negative. The case was reviewed with GI, and diabetic enteropathy is felt to be the leading diagnosis. . 6. GI bleed: On [**3-7**], he developed hematemesis with repeated vomiting of bright red blood. An NG tube was placed, with positive NG lavage that did not clear with NS. He was transferred to the ICU for further management. An EGD performed on [**3-7**] showed a large clot occupying the entire esophagus, but the bleeding site could not be visualized. A repeat EGD on [**3-8**] revealed similar findings. Another EGD on [**3-10**] showed severe esophagitis, without active bleeding, felt to be the source of his recent bleed. Biopsy was not performed, for fear of precipitating further bleeding. He was transfused a total of 13 units of PRBCs while hospitalized. He was given a PPI drip while in the unit. He was continued on IV bolus PPI [**Hospital1 **] prior to being changed to [**Hospital1 **] PO PPI. He was transferred back to the floor on [**3-11**]. On [**3-13**], he had a milder recurrent upper GI bleed. An NG tube was placed, and he was transfued 1U for Hct drop. His NG tube was eventually removed on [**3-15**], and his diet slowly advanced. At the time of discharge he was tolerating a soft diet without further bleeding. He was given instructions to continue a PPI [**Hospital1 **] and carafate. He was also scheduled to return for a repeat EGD with biopsy. . 6. Polysubstance abuse: His initial tox screen was positive for cocaine, and a repeat urine tox screen on [**3-4**] was again positive for cocaine despite patient denial. Repeat tox screen on [**3-14**] was negative. . 7. Renal failure: Mr. [**Known lastname 4610**] has known baseline chronic renal insufficiency attributed to DM nephropathy and IgA nephropathy, with baseline creatinine 1.1-1.3. At the time of admission, his creatinine was noted to be elevated at 2.1, and peaked at 3.4 on [**2195-3-3**], with subsequent slow improvement. As discussed above, he was started on an ACE-I for proteinuria. At the time of discharge, his creatinine was stable around 2.0 . 8. Abnormal LFTs: While in the hospital, he was noted to have intermittent elevated transaminases, with persistently elevated ALP with periodic rise. Hepatology was consulted, and an extensive work-up was recommended. A RUQ U/S was obtained on [**3-13**], remarkable for normal liver texture, and no biliary pathology. An MRCP performed on [**3-18**] was limited by patient motion, but did not show any gross pathology. Hepatitis serologies, HCV VL, HIV, CMV, ceruloplasmin, AMA and [**Doctor First Name **] were all negative. EBV IgG was positive with negative IgM. He appeared to have baseline abnormalities, and his periodic exacerbations appeared to be associated with TPN. His Atorvastatin was discontinued on [**3-13**]. . 9. Dental caries: Patient had complaints of tooth pains. In the setting of fevers and leukocytosis without known source, a dental consult was called to rule out tooth abscess. There was no evidence for acute infection, but several caries were identified for extraction. He was discharged with instructions to follow up for outpatient extractions. . 10. Prophylaxis: He received a [**Hospital1 **] PPI and SQ heparin prophylaxis. . 11. Code: Full . 12. Access: A PICC was placed [**2195-3-5**] and replaced on [**2195-3-12**]. A right IJ CVL was placed on [**2195-3-8**] and pulled on [**3-12**]. Medications on Admission: (per family at [**Hospital1 46**]) insulin coreg 12.5mg qd carafate 1gm qid lisinopril 10mg qd reglan 10mg tid toprol XL 50mg qd Protonix 40mg qd Levothyroxine 75 mcg qd hydralazine 10mg qd lasix 40mg qd lomotil q6-8h prn Discharge Medications: 1. Chlorothiazide 250 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 5. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a day). 6. Isosorbide Dinitrate 10 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 7. Hydralazine 25 mg Tablet Sig: Three (3) Tablet PO Q6H (every 6 hours). 8. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q4H (every 4 hours). 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 10. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. 11. Calcium Acetate 667 mg Capsule Sig: Three (3) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 12. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 13. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for Pain. 15. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 16. Insulin Glargine 100 unit/mL Solution Sig: Two (2) unit Subcutaneous at bedtime. 17. Insulin Lispro (Human) 100 unit/mL Solution Sig: 0-10 units Subcutaneous QACHS as needed for per sliding scale. Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: 1) Type I Diabetes Mellitus - Uncontrolled with complications 2) Grade V Esophagitis 3) Acute Blood Loss Anemia 4) Anemia of Chronic Disease 5) Proteinuria secondary do Diabetic nephropathy as well as IgA Nephropathy 6) Anasarca secondary to hypoalbuminemia 7) Coronary Artery Disease 8) Congestive Heart Failure with cardiomyopathy 9) H/o active Crack Cocaine use 10) Malnutrition - severe 11) Chronic diarrhea secondary to diabetic enteropathy 12) Chronic metabolic acidosis secondary to renal disease 13) Multifocal noscoomial pneumonia 14) Hypothyroidism 15) Cholestatic hepatitis secondary to TPN Discharge Condition: Stable Discharge Instructions: 1) Continue your medications as prescribed. 2) Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 1 gm sodium diet. 3) Follow up as directed below. 4) Call your doctor or go to the emergency room if you have chest pain, shortness of breath, palpitations, lightheadedness, nausea, fevers, or any other concerns. Followup Instructions: 1) You are scheduled for a repeat endoscopy on [**2195-4-28**] at 10 am. - Please do not eat or drink after midnight the night prior. 2) Follow up with your primary doctor, Dr [**First Name (STitle) **], on [**2195-5-25**] at 3pm. - Call [**Telephone/Fax (1) 250**] if you have questions, or need to reschedule. 3) You were seen by a dentist during this hospitalization and found to have multiple caries. Please make an appointment to have teeth #8, 9, and 14 extracted. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2195-4-2**]

[ "511.9", "276.2", "V58.67", "558.9", "428.21", "530.82", "305.60", "412", "790.4", "337.1", "250.63", "250.33", "285.1", "573.8", "583.81", "584.5", "530.12", "414.8", "521.00", "507.0", "287.5", "261", "250.43", "244.9", "273.8", "518.81" ]

icd9cm

[ [ [] ] ]

[ "44.13", "96.72", "34.91", "96.04", "33.23", "99.04", "38.93", "45.13", "96.34", "99.15" ]

icd9pcs

[ [ [] ] ]

20171, 20268

11295, 18388

327, 354

20914, 20923

3115, 3140

21314, 21938

2680, 2749

18660, 20148

20289, 20893

18414, 18637

20947, 21291

2764, 3096

3614, 11272

274, 289

382, 1520

3154, 3600

1542, 2366

2382, 2664

15,506

103,573

27927

Discharge summary

report

Admission Date: [**2108-8-5**] Discharge Date: [**2108-8-9**] Service: MEDICINE Allergies: Morphine Attending:[**First Name3 (LF) 348**] Chief Complaint: GI bleed transfer from OSH Major Surgical or Invasive Procedure: Upper GI Endoscopy History of Present Illness: 81 year old with past medical history significant for Atrial fibrillation, myelodysplasia, HTN, Bladder cancer, and [**Hospital **] transferred from OSH to [**Hospital1 18**] for evaluation and further treatment of GI bleed. Patient was seen at OSH on [**2108-8-2**] with new-onset symptoms of dysphagia while trying to swallow pills. Given patient's new-onset dysphagia, smoking history, and CT findings of esophageal thickening, patient underwent upper GI endoscopy with biopsy and dilatation of distal esophagus, which demonstrated a normal-appearing esophagus. Upon returning home s/p endoscopy, patient noted severe left lower sternal pain and was then admitted to the hospital. On first day of admission, patient had hematochezia and Hct dropped from ?? to 25. A second endoscopy was performed which demonstrated a esophageal mucosal tear and treated with epinephrine. Patient reports having had third endoscopy on day of admission, which demonstrated no further bleeding. ROS: + weight loss x 10 pounds over one week, occurred in the past month; + maroon stools denies fatigue, night sweats, fevers, chills, chest pain, SOB, nausea/vomiting, abdominal pain, change in urine, BRBPR Past Medical History: 1. Myelodysplasia with anemia 2. Atrial Fibrillation 3. Lupus Anticoagulant 4. Polyclonal gammopathy 5. Hypertension 6. CAD s/p MI in [**2081**] 7. PVD s/p Aorto-femoral bypass 8. Bladder Cancer - [**2095**] - treated with BCG Social History: Patient lives with daughter and husband. [**Name (NI) **] 4 children Recently moved from [**State 108**] to live with her daughter ~60 year PPY smoking history, quit smoking in [**2081**] s/p MI denies EtOH and drug use Family History: Asthma Physical Exam: T 98.1 BP 122/60 HR 72 RR 20 PO2 95% RA Gen: alert, oriented, pleasant, appears stated age HEENT: PERRL, no scleral injection, no nasal discharge, no oral ulcers or sores CV: irregularly irregular, no m/r/g, no JVP Pulm: decreased breath sounds in left lower base Abd: +BS, soft, nontender, no rebound, + bruit Ext: no edema Neuro: CN 2-12 intact and symmetric bilaterally; [**5-2**] UE and LE strength symmetric bilaterally Skin: multiple bruises on lower extremity, no rash Pertinent Results: [**2108-8-5**] 09:45PM GLUCOSE-88 UREA N-22* CREAT-0.7 SODIUM-137 POTASSIUM-3.6 CHLORIDE-108 TOTAL CO2-19* ANION GAP-14 [**2108-8-5**] 09:45PM ALBUMIN-2.8* CALCIUM-7.8* PHOSPHATE-2.0* MAGNESIUM-1.5* [**2108-8-5**] 09:45PM WBC-4.5 RBC-3.08* HGB-9.8* HCT-26.9* MCV-87 MCH-31.7 MCHC-36.2* RDW-17.1* [**2108-8-5**] 09:45PM NEUTS-78* BANDS-0 LYMPHS-15* MONOS-5 EOS-1 BASOS-0 ATYPS-1* METAS-0 MYELOS-0 [**2108-8-5**] 09:45PM PLT SMR-LOW PLT COUNT-72* [**2108-8-5**] 09:45PM PT-15.3* PTT-26.5 INR(PT)-1.4* Brief Hospital Course: This is a 82 yo female with pmhx significant for atrial fibrillation, bladder cancer s/p BCG rx, CAD, HTN who presented for further follow-up and treatment of esophageal bleed s/p endoscopy and resulting esophageal tear on [**2108-8-2**]. . 1. Esophageal Bleed - Patient developed esophageal bleed s/p upper GI endoscopy on [**2108-8-2**], although endoscopy on [**2108-8-5**] did not demonstrate continued bleeding. On second day of admission, patient continued to report maroon stools and had several episodes of hemoptysis. Patient was transferred to MICU for urgent upper GI endoscopy, which demonstrated an adherent clot in the distal esophagus at 38cm without any active bleeding. A repeat EGD on [**8-8**] demonstrated a large 2cm x 1cm esophageal mucosal tear on the posterior wall with adherent clot at 38 cm at the proximal end of the tear. The clot was removed and some blood was seen at the base. [**Hospital1 **]-CAP Electrocautery was applied for hemostasis successfully. She was maintained on IV PPI with stable Hct checked q6 for the next 30 hours. Her Hct was stable upon discharge, she was tolerating a regular diet and po pain meds. . 2. Mediastinal LAD - Patient's initial presentation of dysphagia was most likely secondary to mediastinal LAD with unclear etiology. Differential diagnosis includes lymphoma, primary lung cancer, or recurrence of prior cancer. CT of the chest at [**Hospital1 18**] demonstrated large LAD in the mediastinum and chest. It is not clear to us if this a new process or an old process that has been stable. We attempted to contact her PCP regarding this, but were unsuccessful. In any case, she needs a follow-up CT of the chest in [**3-2**] months. If there is any change in the lymphadenopathy, she may need further work-up by biopsy or bronchopscopy. . 3. Atrial Fibrillation - Patient has a history of atrial fibrillation. She was previously on coumadin but was discontinued in [**2095**] after bladder cancer for unclear reasons. Patient was maintained on telemetry, without any events. She was not maintained on digoxin here as her rate was well controlled with low-dose BB. . 4. MDS w/ thrombocypenia: baseline plts in the 80s and has remained stable, receives procrit as outpatient to maintain Hct. She was given Procrit here prior to discharge and is to follow-up with her PCP for outpatient dosing. . 5. CAD s/p MI - Not on ASA at home given MDS as above. Continue low-dose BB. Restart ACE-I as outpatient. . 6. HTN - on low-dose BB. Holding Hyzaar, given recent acute events. Plan to restart as outpatient. . 7. COPD - continue nebs, no active issues . 8. code- full, HCP [**Name (NI) 2048**] [**Name (NI) 68020**] [**Telephone/Fax (1) 68021**] . Medications on Admission: 1. Metoprolol 2. Hyzaar 3. Potassium 4. Digoxin 5. Pulmicort 6. Combivent 7. MVI Discharge Medications: 1. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-30**] Puffs Inhalation Q6H (every 6 hours) as needed. 2. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary - esophageal tear s/p multiple EGD's with successful stabilization Seconday - MDS, A fib, CAD, PVD, HTN Discharge Condition: Stable Hct, no further bleeding Discharge Instructions: -continue with medications as prescribed -please see your PCP [**Last Name (NamePattern4) **] [**1-30**] weeks for follow-up, call his office to make an appointment -you need follow-up re: lymph nodes in the chest, please speak to your PCP regarding this [**Name9 (PRE) 19288**] there any symptoms of swallowing difficulty, breathing difficulty, vomiting blood, dizziness/lightheadedness, chest pain, black stools/blood in stools or any other concerning symptoms, please seek medical attention immediately Followup Instructions: Please see Dr. [**Last Name (STitle) 3373**] in [**1-30**] weeks for follow-up. Call [**Telephone/Fax (1) 68022**] to schedule an appt for follow-up. Completed by:[**2108-8-9**]

[ "427.31", "785.6", "443.9", "998.11", "289.81", "238.7", "414.01", "285.9", "493.20", "862.22", "401.9", "E879.8" ]

icd9cm

[ [ [] ] ]

[ "42.33", "45.13", "99.04" ]

icd9pcs

[ [ [] ] ]

6341, 6347

3038, 5747

241, 261

6504, 6538

2503, 3015

7092, 7272

1982, 1991

5878, 6318

6368, 6483

5773, 5855

6562, 7069

2006, 2484

174, 203

289, 1479

1501, 1729

1745, 1966

27,927

164,655

31141

Discharge summary

report

Admission Date: [**2175-10-29**] Discharge Date: [**2175-11-9**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2901**] Chief Complaint: vtach Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 32978**] is an 83 yo man with pmhx CAD s/p multiple stents, Afib, CHF with EF 30%, s/p prophylactic AICD in [**2173**], HTN, hyperlipidemia who presented from his nursing home with sustained VTach. Patient reports that this morning he was "not feeling well and unable to get confortable." He is unable to provide any more specific details but endorses feeling short of breath. He denies any chest pain. He did not lose consciousness. Family states that nursing staff found him to be tachypneic, tachycardic, and hypotensive. . On review of symptoms, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for the presence of ankle edema and dyspnea on exertion. It is notable for the absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope or presyncope. . At [**Hospital1 **], BP 86/50, HR 125-130, SpO2 84-85% on RA. On arrival to ED at [**Hospital1 18**], T 97.8, HR 129, BP 90/45, RR 20, SpO2 99%. In the ED, rhythm spontaneously conveted to atrial fibrillation with a rate in the 70's. Device was interrogated by EP fellow, revealing no detected VT. CXR was performed and patient received ASA 325 mg. Past Medical History: VT CAD s/p multiple stents CHF with EF 15-20% pericardial effusion s/p pericardial window x2 ICD [**3-/2173**] for primary prevention HTN hypercholesterolemia PVD Social History: Social history is significant for the absence of current tobacco use. Smoked [**6-4**] cig per day x 20 years and quit in [**2138**]. Occasional ETOH, few beers per month. No illicits Family History: Daughter died at 52 of arrythmia. No family history of CAD or cancer. Physical Exam: VS: T 97.5, BP 99/59, HR 86, RR 22, O2 97% on 2L Gen: cachectic elderly white male in NAD, resp or otherwise. Oriented x1. 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. irregular, irregular rhythm, normal S1, S2. No S4, no S3. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. + crackles at the bases with scattered rhonchi. Abd: flat, soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: 2+ pitting edema in lower extremities. No femoral bruits. Skin: + gluteal ulcer. No stasis dermatitis, 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: WBC 5.6, Hct 27.5, Plt 194 . 140 | 107 | 23 ----|-----|---< 84 3.7 | 26 |1.0 . CK 20, Trop 0.05 INR 2.3 Lactate 1.6 UA - negative . CXR performed on [**2175-10-29**] demonstrated: 1. Enlarging moderate pleural effusions. 2. Persistent bibasilar opacities which may represent atelectasis and/or airspace consolidation. 3. Mild central pulmonary vascular congestion with no evidence of alveolar edema. Brief Hospital Course: VT: Patient presented with recurrence of sustained ventricular tachycardia on amiodarone + digoxin + Toprol. ICD interrogation revealed that his Vtach was not detected due to irregularithy of the rhythm (e.g., interspersed PVC's). Following transfer he spontaneously converted to atrial fibrillation. His ICD was reprogrammed at this time to fire at a rate of 110, and he was started on Mexilitine, and continued on amiodarone. He persisted in having VT that was not sensed by the ICD. He was put on a lidocaine drip, which controlled the VT. After further conversations with the family, he was made DNR/DNI, and but defibrillation in the VT zone were kept on. He does not want external defibrillation. Additionally, VT zone detection was made more sensitive (8 beats, 12 redetect). Lidocaine was dc/ed. He was continued on mexilitine to medically reduce further episodes of VT. Digoxin was discontinued as it was felt that digoxin could potentially contribute to increased arrhythmogenicity. His beta blocker was reduced due to hypotension. He was continued on anticoagulation for his underlying atrial fibrillation. . Acute on chronic systolic CHF: On admission, he was found to be fluid overloaded. Heart failure exacerbation was in the setting of VT and increased cardiac demand. A repeat echocardiogram showed severe global left ventricular hypokinesis (LVEF = 25-30 %). He was diursed with IV lasix and was relatively euvolemic on discharge. He was discharged on lasix 120 po daily. . CAD: He had a small troponin leak in the setting of VT. His CAD was medically managed with ASA, statin, beta blocker. . Anemia: On admission, his Hct was found to be 27. His hct normalized to his baseline of ~30-31 on discharge. Iron studies revealed anemia of chronic illness. Epo was discontinued as he had no evidence of renal insufficiency, and no indication for it. Iron was also discontinued as there was no evidence for iron deficiency anemia. . Pneumonia: found on chest x ray, sputum cultures showing MSSA. patient started on vanc/zosym. changed to ceftriazone when sensitivities came back . UTI: Patient was he was found to have a klebsiella UTI for which he was started on bactrim, which was dc/ed when he started treatment for pneumonia. he is currently on ceftriazone. Medications on Admission: 1. Aspirin 325 mg daily 2. Ranitidine HCl 150 mg daily 3. Simvastatin 20 mg daily 4. Amiodarone 200 mg Tablet [**Hospital1 **] 5. Furosemide 40 mg PO BID 6. Metoprolol Tartrate 25 mg daily 7. Digoxin 0.0625 mg daily 8. Warfarin 1.5 mg daily 9. Diamox 250 mg daily 11. Colace 100 mg [**Hospital1 **] 11. FeSO4 325 mg [**Hospital1 **] 12. Mag Oxide 400 mg QID 13. Miconazole Nitrate to sacrum TID 14. K-Dur 40 meq QAM, 20 meq qPM 15. Senna 2 tabs QHS PRN 16. Ipratropium neb q6 hours PRN 17. Darbopoeitin alfa 100 mcg QFRI Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily) as needed for constipation. 5. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 6. Colace 100 mg Capsule Sig: One (1) Capsule PO bid prn. 7. Atrovent 0.03 % Aerosol, Spray Sig: One (1) Nasal four times a day. 8. Furosemide 80 mg Tablet Sig: One (1) Tablet PO twice a day. 9. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day. 10. Warfarin 1 mg Tablet Sig: One (1) Tablet PO at bedtime. 11. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: One (1) Inhalation q6h PRN. 12. Ceftriaxone 1 gram Piggyback Sig: One (1) Intravenous once a day for 9 days. 13. Mexiletine 200 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 14. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 15. Guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO Q6H (every 6 hours). 16. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) neb Inhalation every four (4) hours as needed for shortness of breath or wheezing. 17. Acetylcysteine 10 % (100 mg/mL) Solution Sig: One (1) neb Miscellaneous Q6H (every 6 hours) as needed. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Primary: Ventricular tachycardia Pneumonia UTI . Secondary: CAD Anemia Discharge Condition: Stable. SBP's 85-95. Discharge Instructions: You were admitted after having persistent irregular heart rhythm called ventricular tachycardia. Your ICD was tested and several settings on your device were modified to make your device more sensitive for detecting irregular heart rhythms. In addition, a few of your medications were adjusted to reduce your likelihood of developing arrhythmias in the future. Please see below for your medication modifications. . You also currently have pneumonia and a urinary tract infection, for which you are on an IV antibiotic. . THE FOLLOWING MEDICATION CHANGES WERE MADE DURING THIS HOSPITALIZAITON: 1) Your digoxin was discontinued. 2) You were started on an antiarrythmic called mexiletine. 3) Your metoprolol xl (toprol xl) was decreased to 25 mg daily. 4) Your mag oxide and your kdur were also discontinued. 5) Diamox, Darbopoeitin, and supplemental iron were also discontinued. 6) Your coumadin dose was decreased to 1mg daily. 7) Your lasix dose has been increased to 120 mg daily. . If you have any of the following symptoms you should return to the ED or see your PCP: [**Name10 (NameIs) **] pain, difficulty breathing, hypotension (SBP persistently <75), loss of consciousness or any other serious concerns. Followup Instructions: 1. You should schedule an appointment with your cardiologist, Dr. [**Last Name (STitle) 23682**] [**Telephone/Fax (1) 73509**] in 1 to 2 weeks. Please call on Tuesdays or Wednesdays between [**1-3**] p.m. to schedule this appointment. . 2. We have also scheduled an appointment with you with Dr. [**Last Name (STitle) 2232**] in the Division of Electrophysiology at [**Hospital6 2561**] on [**2175-12-10**] at 230pm. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**] Completed by:[**2175-11-9**]

[ "V45.82", "V53.32", "428.0", "425.4", "272.4", "414.01", "401.9", "427.1", "486", "599.0", "285.29", "428.23", "427.31" ]

icd9cm

[ [ [] ] ]

[ "89.49" ]

icd9pcs

[ [ [] ] ]

7857, 7936

3616, 5906

269, 275

8051, 8074

3191, 3593

9339, 9916

2179, 2250

6478, 7834

7957, 8030

5932, 6455

8098, 9316

2265, 3172

224, 231

303, 1774

1796, 1961

1977, 2163

73,175

137,764

13255

Discharge summary

report

Admission Date: [**2156-3-13**] Discharge Date: [**2156-3-23**] Date of Birth: [**2083-4-8**] Sex: F Service: MEDICINE Allergies: Penicillins / Cephalosporins / Clindamycin / Latex Attending:[**First Name3 (LF) 1145**] Chief Complaint: STEMI Major Surgical or Invasive Procedure: BMS placement in LAD Swann-ganz catheter and Cordis placement in L subclavian (now removed) Chest tube placement R PICC line placement History of Present Illness: This is a 73 yo female with a history of diabetes with retinopathy and neuropathy who was transferred from rehab to [**Hospital3 4107**] for chest pain, found to have ST-elevation in anterior precordial leads and transferred to [**Hospital1 18**] for further management. Patient recently had left knee arthroscopy for Charcot joint and left knee pain and had been in rehab after that. She was discharged to home from rehab 3 weeks ago, and last night, she awoke from sleep with sudden onset of chest pain radiating to back and bilateral arms. She was sent to [**Hospital1 2519**] ED where ECG showed ST elevations in V1-V4. Patient received ASA 325mg, heparin bolus, eptifibatide bolus, 300mg clopidogrel load, atorvastatin 80mg and was transferred to [**Hospital1 18**]. In the catheterization lab here, she received another 300mg clopidogrel. Angiography demonstrated proximal LAD occlusion that was intervened upon with BMS, which improved patient's chest pain down to 2/10. Serial stenoses were also noted in the LCx and RCA. . On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS:: (+) Diabetes, (+)Dyslipidemia, (+)Hypertension 2. CARDIAC HISTORY: #. Coronary artery disease - STEMI, 3 vessel disease on angiography in [**3-/2156**], s/p bare metal stent to proximal LAD 3. OTHER PAST MEDICAL HISTORY: #. Diabetes mellitus c/b nephropathy, neuropathy, and retinopathy #. Left knee and ankle DJD #. GERD #. Morbid obesity #. S/p Right fibular fracture #. Chronic renal failure, baseline creatinine 1.5 per records #. S/P Right cataract surgery #. S/P amputation of second and third right toes #. S/P Appendectomy #. S/P Tonsillectomy #. Anemia of chronic disease Social History: -Tobacco history: Non-smoker -ETOH: denies EtOH Family History: No family history of early MI, otherwise non-contributory. Physical Exam: GENERAL: Elderly female, obese, NAD HEENT: Right surgical pupil, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple with no JVD CARDIAC: RRR, normal S1, S2. Systolic murmur at RUSB. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, obese, NTND. No HSM or tenderness. EXTREMITIES: 3+ pitting oedema bilaterally SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Femoral 2+, Right femoral hematoma, DP 2+ PT 2+ Left: Femoral 2+ DP 2+ PT 2+ Pertinent Results: **LABS ON ADMISSION** [**2156-3-13**] 04:52AM WBC-14.4* RBC-3.83* HGB-11.2* HCT-31.8* MCV-83 MCH-29.2 MCHC-35.1* RDW-16.3* [**2156-3-13**] 04:52AM PLT COUNT-242 [**2156-3-13**] 04:52AM PT-13.5* PTT-62.0* INR(PT)-1.2* [**2156-3-13**] 04:52AM CALCIUM-9.3 PHOSPHATE-3.7 MAGNESIUM-1.9 [**2156-3-13**] 04:52AM CK-MB-198* MB INDX-10.6* cTropnT-22.7* [**2156-3-13**] 04:52AM CK(CPK)-1867* [**2156-3-13**] 04:52AM GLUCOSE-258* UREA N-25* CREAT-0.9 SODIUM-133 POTASSIUM-3.9 CHLORIDE-99 TOTAL CO2-25 ANION GAP-13 [**2156-3-13**] 10:58AM CK-MB-101* MB INDX-8.3* [**2156-3-13**] 10:58AM CK(CPK)-1213* [**2156-3-13**] 11:44PM CK-MB-20* MB INDX-15.0* cTropnT-9.88* [**2156-3-13**] 11:44PM CK(CPK)-133 . [**2156-3-14**] 03:35AM BLOOD %HbA1c-7.4* [**2156-3-14**] 03:35AM BLOOD Triglyc-60 HDL-44 CHOL/HD-2.2 LDLcalc-39 [**2156-3-16**] C.Diff: negative x 1 . **IMAGING** [**2156-3-13**] EKG Sinus rhythm. Occasional atrial ectopy. There are Q waves in the anterolateral leads with ST segment elevation consistent with anterolateral myocardial infarction, most likely acute. No previous tracing available for comparison. Low QRS voltage in the limb leads. Clinical correlation is suggested. 99 80 126 392/460 -174 -98 85 . [**2156-3-13**] CARDIAC CATH 1. Selective coronary angiography of this right dominant system revealed three vessel disease. The LMCA had no angiogarphically apparent flow limiting disease. The LAD had a total occlusion in the proximal segment. The LCX mid segment through the take off of the second OM was diffusely diseased with up to 60% stenosis. The first OM had a 60% stenosis. The RCA proximal segment was diffusely diseased with 80% stenosis. The RCA distal segment had a 90% stenosis, with small distal vessels. 2. Limited resting hemodynamics demonstrated normal systemic pressure with central aortic pressure 125/68 mm Hg. 3. Successful PTCA and stenting of the proximal LAD total occlusion with a 2.5x23mm Minivision stent that was postdilated to 2.5mm. Final angiography revealed no residual stenosis, no angiographically apparent dissection and TIMI III flow. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Normal systemic arterial pressure. 3. Successful stenting of the proximal LAD. 4. Anterior STEMI of unknown duration. . [**2156-3-13**] ECHO The left atrium and right atrium are normal in cavity size. Left ventricular wall thicknesses and cavity size are normal. There is moderate regional left ventricular systolic dysfunction with akinesis of the mid to distal anterior wall, anterior septum and the apex and hypokinesis of the distal inferior segment. A left ventricular mass/thrombus cannot be excluded. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. Mild to moderate ([**2-6**]+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. . IMPRESSION: moderate focal LV systolic dysfunction consistent with large LAD infarction. Diastolic dysfunction. At least mild to moderate mitral regurgitation. Mild pulmonary artery hypertension. . [**2156-3-13**] CXR IMPRESSION: Tiny left apical PTX. Left lower lobe atelectasis. PA catheter as described above. . [**2156-3-14**] CXR IMPRESSION: Increased density in the right upper lung zone with the exception of a relative lucent [**Name2 (NI) **]. I suspect pneumothorax may have increased - Inspiratory and expiratory films are recommended. Increased airspace density could be explained by some asymmetric edema. I also suspect increased atelectasis at the left base. . [**2156-3-15**] CT ABD/CHEST/PELV IMPRESSIONS: 1. PA catheter from left subclavian approach terminates in the left pulmonary artery. 2. Likely organized hematoma anterior to superior portion of left upper lobe, just inferior to left subclavian puncture site. 3. Moderate right and moderate- to- large left pleural effusion, with slightly increased density of the left pleural effusion, likely representing some component of hemothorax. 4. Collapsed left lower lobe and lingula, and atelectasis along the posterior right lower lobe. Patchy consolidation and ground-glass opacity in the left upper lobe, likely atelectasis although infection cannot be excluded. 5. Delayed nephrograms, likely relating to underlying renal insufficiency. 6. Cholelithiasis. 7. Mild stranding in the right groin region, likely post-procedural; no retroperitoneal hematoma seen. . [**2156-3-23**] - chest x-ray (PRELIM READ)- No change in appearance of the chest compared to [**2156-3-22**] including left apical pneumothorax. . Shoulder x-ray [**2156-3-22**] - FINDINGS: Four views of the shoulder demonstrate the shoulder in good alignment without fracture or dislocation. As described on the chest x-ray, there is an alveolar infiltrate in the left upper lobe and left loculated pneumothorax. These findings were discussed with the house staff caring for the patient at the time of dictating this report. Brief Hospital Course: 72 yo female with diabetes presenting with STEMI, s/p PCI to LAD. Course complicated after Swan placement with hemothorax requiring chest tube placement now s/p chest tube removal being evaluated for rehab placement. . # CORONARIES: Patient presented with a STEMI, found to have culprit lesion in LAD on cath, S/P BMS to LAD. Cardiac enzymes trending down. Patient was changed from low dose simvastatin to full strength atorvastatin in the setting of acute MI. In addition, patient placed on full strength aspirin and started on plavix. Patient was started on beta blocker after hemodynamics normalized and increased as tolerated by blood pressure. Initially post-STEMI patient was found to be tachycardic and hypotensive which improved with fluid administration. Initially beta blocker was held in the setting of recent STEMI and with hypotension and restarted when patient was hemodynamically stable. . # Hemothorax / pneumothorax - Patient had subclavian line placed in the context of ICU admission which was complicated by hemothorax. Thoracic surgery was consulted and a chest tube was placed. Initially chest tube was placed to suction and eventually weaned to water seal. Patient required 4U pRBC after 1.5L blood removed from chest tube. Patient had chest tube removed on [**2156-3-20**] and subsequently had a persistent left apical PTX. Pneumothorax initially was stable and then appeared to increase in size. Reconsulted thoracic surgery regarding apical pneumothorax and recommended repeating films to demonstrate stability. Patient had daily hcts drawn and prior to discharge had stable crit for three days. . # Fever: Patient spiked fever overnight 2/13-14/09. UA revealed UTI, urine culture with Klebsiella pneumonia. Blood cultures no growth to date. Chest x-ray without acute new infiltrate. Patient without productive cough. No diarhea. C. diff negative x1. STarted ciprofloxacin for UTI. Patient without symptoms. Discontinued foley and changed patient to tylenol PRN from standing in order to better monitor fever curve. In addition, there is an opacity in the RLL on CXR which could be atelectasis from PTX but concerning for PNA([**3-21**]). Following for now as UTI is a more likely explanation for fever. . # PUMP ?????? Patient with ischemic cardiomyopathy with LVEF 30-35%. Mild pulmonary artery hypertension. Repeat echo on admission demonstrates LV apical hypokinesis so there is risk for LV thrombus. Patient was started on IV heparin. Coumadin was initiated after the chest tube was removed and hematocrit was stable. INR now 2.1, so no additional heparin needed on discharge. Patient with coumadin with goal INR [**3-9**]. Of note, discussed anticoagulation with outpt opthalmologist given risk of vitreous hemorrhage and no contraindication to coumadin from ophthalmologic perspective. Given low EF attempted to keep patient even to negative. Patient maintained on aspirin, statin, beta blocker. Initially held ACE inhitor given acute renal failure which was improved back to baseline and ACEI restarted. # LUE swelling- Patient noted to have left upper extremity swelling greater than right which is now resolved. Of note, patient had CVL on that side. LUE US negative for clot so likely just third spacing of fluid assymetric. . # ARF now resolved: Cr increased since admission from 0.9 to 2.3, now improved to baseline (1.2). Etiology likely secondary to hypotension vs. constrast induced nephropathy. Patient maintained good urine output. Initially held ACE inhibitor in the setting of ARF which was restarted when renal function improved. Medications were renally dosed and nephrotoxins were avoided. . # Rhythm: NS for now with some atrial ectopy. No events of telemetry. Patient was continued on telemetry. . # Diabetes - Continue glargine, sliding scale, diabetic diet . # Chronic pain and acute pain ?????? controlled, patient states she has not needed chronic pain medications. INitially pain management with long acting morphine in the context of chest tube. After chest tube removal patient did not require chronic narcotics. Discontinued MS contin and using Percoset for breakthrough pain. Patient evaluated by physical therapy for knee pain. . FEN: Heart-healthy, low-sodium, diabetic diet . ACCESS: PIV's, PICC placed [**2156-3-17**] and d/c on day of discharge . PROPHYLAXIS: PPI, bowel regimen, coumadin . CODE: Full Medications on Admission: #. Simvastatin 10mg daily #. Valsartan 160mg daily #. Glargine 48 units qAM and humalog sliding scale #. Lidoderm patch #. Oxycodone SR 20mg [**Hospital1 **] #. Vicodin 5/500 1-2 tabs PO q4H PRN #. MiraLax PRN constipation #. Pantoprazole 40mg daily #. Procrit 20,000 units qweekly PRN for Hct < 30 Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Continue daily for at least 3 months and preferably one year. Do not stop unless Dr. [**Last Name (STitle) **] tells you to. . 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for bloating. 8. Polyethylene Glycol 3350 100 % Powder Sig: Seventeen (17) grams PO DAILY (Daily) as needed for constipation. 9. Latanoprost 0.005 % Drops Sig: One (1) Drop(s) LEFT EYE Ophthalmic HS (at bedtime). 10. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 11. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 12. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): Complete 7-day course [**Date range (3) 40373**]. 13. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever, pain. 14. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 15. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Insulin Glargine 100 unit/mL Solution Sig: Forty Eight (48) units Subcutaneous once a day. 17. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Insulin Lispro 100 unit/mL Solution Sig: sliding scale units Subcutaneous three times a day: check FS and give humalog per sliding scale before meals. . 19. Vicodin 5-500 mg Tablet Sig: 1-2 Tablets PO four times a day as needed for pain. 20. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day: Hold HR< 55, SBP< 100. Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: Primary: ST-elevation myocardial infarction with BMS to LAD Hemothorax . Secondary: Coronary artery disease Diabetes mellitus with nephropathy, neuropathy, retinopathy Hypertension Dyslipidemia Discharge Condition: Good, hemodynamically stable, afebrile. INR 2.1 Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs in 1 day or 6 pounds in 3 days. Adhere to 2 gm sodium diet Fluid Restriction: 1500ml . You were admitted for management of your chest pain after transfer from [**Hospital3 **]. You were found to be having a heart attack (STEMI) and were treated with cardiac catheterization and stent placement in one of your blocked heart vessels. You had very low blood pressures, so a special monitoring line was placed. You developed bleeding around your left lung, and a chest tube was placed to help drain the fluid. You blood pressure has improved, and your chest pain resolved. The chest tube was removed, and you were re-started on Coumadin. . The following medication changes were made: - STOP Simvastatin - START Atorvastatin 80mg PO qhs - START Aspirin 325mg PO qday - START Plavix 75mg PO qday - CONTINUE Ciprofloxacin 500mg PO bid x 7 days ([**Date range (1) 40374**]) - STOP Diovan - START Lisinopril 5 mg daily - START Toprol XL 50 mg daily ... ... . You should follow-up with your cardiologist and PCP 1-2 weeks after discharge from rehab. . If you experience any worsening chest pain, shortness of breath, weakness, bleeding, or have any other concerns please [**Name6 (MD) 138**] your MD or return to the ED. Followup Instructions: Please see your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**2-6**] weeks after discharge from [**Hospital 38**] Rehab. . We have made you an appointment with Cardiology: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 62**] Date/Time: [**4-26**] at 3:20pm. After you are home from [**Hospital 38**] Rehabilitation, you should talk to Dr. [**Last Name (STitle) **] about cardiac rehabilitation. Completed by:[**2156-3-24**]

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icd9cm

[ [ [] ] ]

[ "38.93", "37.22", "00.40", "36.06", "99.20", "88.56", "89.64", "34.04", "00.45", "00.66" ]

icd9pcs

[ [ [] ] ]

15773, 15870

8917, 13303

316, 453

16108, 16158

3457, 5568

17490, 18041

2730, 2790

13662, 15750

15891, 16087

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2132, 2255

271, 278

481, 2017

2286, 2648

2039, 2112

2664, 2714

29,893

197,962

31802

Discharge summary

report

Admission Date: [**2113-11-2**] Discharge Date: [**2113-11-29**] Date of Birth: [**2034-11-6**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 668**] Chief Complaint: Abdominal pain, intraperitoneal bleed from ruptured hepatoma Major Surgical or Invasive Procedure: 1. Diagnostic abdominal aortogram and celiac arteriogram, supra selective left hepatic artery catheterization with microsphere embolization of bleeding arterial branch. 2. Exploratory laparotomy, evacuation large amount of intra-abdominal blood and hematoma, cautery of right hepatic lobe ruptured hepatoma 3. Tracheostomy History of Present Illness: 78 F with history of hepatic cirrhosis of unclear etiology with history of shunt, TIAs, HTN, presented to [**Hospital 1562**] Hospital with abdominal pain and hypotension and tachycardia. HCT was 27. CT scan of the abdomen revealed a 3x3 cm right lobe hepatic mass with 1.4 cm vascular aneurysm and active extravasation of blood into peritoneum and a large amount of blood in peritoneum. Patient subsequently decompensated and became progressively more tachycardic and hypotensive. She was intubated, fluid resuscitated, and transferred to the [**Hospital1 18**] for further management. Past Medical History: Hepatic cirrhosis s/p operative shuntting at [**Hospital1 2025**] approximately 12 years ago (per husband), HTN, TIAs/stroke with residual left sided paralysis, C.diff colitis, GERD, hearing loss, macular degeneration. Social History: Distant smoking history. Rare, occasional alcohol. Physical Exam: The patient has passed away Pertinent Results: EEG FINDINGS: ABNORMALITY #1: Several bursts of mixed theta and delta frequency slowing were noted in a generalized distribution. ABNORMALITY #2: The background was slow, typically in the 5 Hz range, and disorganized. A superimposed faster beta rhythm was also noted in a generalized distribution. BACKGROUND: As above. HYPERVENTILATION: Could not be performed as this was a portable study. INTERMITTENT PHOTIC STIMULATION: Could not be performed as this was a portable study. SLEEP: No normal waking or sleeping morphologies were noted. CARDIAC MONITOR: Showed a generally regular rhythm with an average rate of 96 bpm. IMPRESSION: This is an abnormal portable EEG due to frequent bursts of generalized mixed frequency slowing in the setting of a slow and disorganized backgroung suggestive of a widespread encephalopathy consistent with bilateral subcortical or deeper midline dysfunction. Medications, metabolic disturbances, infection, and anoxia are among the common causes of encephalopathy. No focal, lateralized, or clearly epileptiform features were noted although encephalopathic pictures can sometimes obscure focal findings. No electrographic seizures were noted. The degree and evolution of the encephalopathy is uncertain and should be correlated with clinical exam or if follow up EEG if necessary. MR HEAD W & W/O CONTRAST [**2113-11-22**] 4:49 PM [**Hospital 93**] MEDICAL CONDITION: 79 year old woman with abnormal EEG, altered mental status, vent dependent REASON FOR THIS EXAMINATION: Please evaluate for structural cause of altered mental status CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 79-year-old woman with abnormal EEG, altered mental status, please evaluate for obstructive causes of altered mental status. COMPARISON: CT head from [**2113-11-9**]. FINDINGS: There is evidence of low signal with susceptibility artificat from chronic blood products at the right basal ganglia extending into the temporal lobes along the sulci. There is also associated dilation of the temporal [**Doctor Last Name 534**] of the ventricle. This could be from chronic hemorrhage in that area with associated volume loss of the temporal lobe. There are bilateral hyperintensities noted in the region of basal ganglia in the pre-gadolinium T1-weighted images, features, usually associated with hepatic insufficiency. Periventricular white matter hyperintensity suggestive of chronic microangiopathic ischemic disease is noted. There is mild prominence of the ventricles and the sulci suggestive of age related atrophic changes. There are no areas of abnormal enhancement or acute hemorrhage, masses, mass effect or midline shift. No diffusion abnormalities are noted. No osseous or soft tissue abnormalities are noted. Visualized portions of the sinuses demonstrate mucus retention cyst in the right maxillary sinus. Some fluid is noted in the left ethmoid sinus. IMPRESSION: Areas of susceptibility artifact in the right basal ganglia suggestive of chronic right basal ganglia hemorrhage. No acute intracranial process or hemorrhage or mass effect. Brief Hospital Course: ICU course: Patient arrived to the [**Hospital1 18**] on [**11-2**]. She was found to be hypotensive to 50 mm Hg systolic and in cardiac arrest. She received 1 amp of Epi and fluid/colloids with good response. She was taken emergently to angiography for intervention and localization of bleed. Diagnostic abdominal aortogram and celiac arteriogram, supra selective left hepatic artery catheterization with microsphere embolization of bleeding arterial branch. She continued to require resuscitation and had rising intraabdominal pressures. In the setting of high ventilatory pressures there was significant concern for the development of abdominal compartment syndrome. She was taken emergently for exploratory laparotomy, evacuation of large amount of intra-abdominal blood/hematoma, cautery of right hepatic lobe ruptured hepatoma. She was closed primarily and transferred to the surgical ICU for further resuscitation. Her hypothermia was normalized as was her coagulopathy. Over the next several days her hematocrit stabilized and acidemia improved. Drain outputs diminished and she was diuresed with Lasix with good response. She was extubated on POD . Because of concern for aspiration a Speech and Swallow evaluation was obtained on [**11-6**] and showed "silent" aspiration with severe oropharyngeal dysphagia. She was started on tube feeds. On [**11-8**] she developed epistaxis, likely [**2-17**] nasogastric tube. ENT service was consulted and their exam showed senechii and dried blood with some areas of erosion overlying the mucosa. A Dobbhoff catheter was placed in the contralateral nostril and tube feeding was resumed and advanced to goal. She had no further bleeding from her nasopharynx. Patients respiratory status improved and she was extubated on [**2113-11-5**] (POD 3). She was actively diuresed with Lasix with good results. On POD 4 a bedside swallowing consult was obtained and patient was found to be "silently aspirating" and had severe dysphagia. PO trials were held and tube feeds were continued. On POD 7 patient became more confused and less responsive. A CT scan of her head was obtained ( [**2113-11-9**]) and showed no acute pathology. Lactulose was started for an elevated ammonia level. On POD 8 a RUQ ultrasound was obtained and showed normal vascular flows and cirrhotic liver. On [**11-11**] patient became progressively hypoxic with increased work of breathing and was re-intubated. Over the following several days she developed a leukocytosis and fevers. She was started on vancomycin. Blood, sputum, urine and line cultures were sent and eventually returned with MRSA from her sputum as well as blood. She was continued on vancomycin with goal level 15-20. Attempt to wean ventilatory support were unsuccessful. A meeting with the family was held and the family expressed interest in continuing support. Given her failure to wean off of ventilatory support, a tracheostomy was placed on [**11-17**]. She continued to require intermittent Haldol/Ativan for agitation. Hematocrit continued to be stable. The patient remained intermittently agitated without significant change in neurological status and unable to be weaned off of the vent. On [**11-24**] social work met with the family and agreed to make the patient CMO and extubate on Wednesday [**11-29**]. On [**11-29**] the ventilator was removed and the paitient made comfort measures only and passed away at 1 pm. Medications on Admission: Lisinopril, cardizem, thyroxine Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Ruptured hepatic hepatoma Discharge Condition: expired Discharge Instructions: none Followup Instructions: none

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icd9cm

[ [ [] ] ]

[ "54.19", "96.6", "43.41", "21.03", "31.1", "99.06", "50.29", "96.71", "96.04", "99.05", "88.47", "99.04", "96.72", "99.07", "39.79" ]

icd9pcs

[ [ [] ] ]

8332, 8341

4793, 8221

375, 701

8411, 8421

1690, 3059

8474, 8482

8303, 8309

3096, 3171

8362, 8390

8247, 8280

8445, 8451

1642, 1671

275, 337

3200, 4770

729, 1317

1339, 1559

1575, 1627

156

168,847

4479+4480

Discharge summary

report+report

Admission Date: [**2120-5-20**] Discharge Date: [**2120-6-10**] Date of Birth: [**2057-11-11**] Sex: M Service: BLOOMGART INTERNAL MEDICINE HISTORY OF PRESENT ILLNESS: A 62 male, status post abdominal aortic aneurysm repair with known thoracic aneurysm presents with sudden onset of back pain described as tearing, brought to the emergency department with vital signs of heart rate of 60, blood pressure of 164/80. CTA showed a type B dissection from the distal aorta to the left subclavian to aorto-[**Hospital1 **]-femoral graft with a true celiac lumen, half FMA true lumen and half false lumen and left renal true lumen but with right renal false lumen. Transferred to the Intensive Care Unit on labetalol and Nipride. REVIEW OF SYSTEMS: Positive for nausea and emesis times one at home, one episode of loose stool at home, positive shortness of breath, no jaw or arm pain, no palpitations, no fevers or chills, no confusion and no weakness, numbness or tingling. PAST MEDICAL HISTORY: Deep venous thrombosis, osteoarthritis. PAST SURGICAL HISTORY: Status post 8 cm abdominal aortic aneurysm repair, status post wound dehiscence. SOCIAL HISTORY: History of tobacco use. One pack per day tobacco history. Quit [**12-11**]. Lives in [**Location 4310**] with his wife. Two to three alcoholic beverages per week. MEDICATIONS ON ADMISSION: Lopressor 25 mg p.o. b.i.d., aspirin 81 mg p.o. q.d. No known drug allergies. PHYSICAL EXAMINATION: Patient was afebrile with heart rate of 60, blood pressure 120/53, respiratory rate 18, 94 percent on 4 liters. In general he is alert, oriented times three lying flat on a stretcher in moderate distress. HEENT: NPAT, pupils equal, round, reactive to light, extraocular movements intact. Oropharynx moist mucous membranes without erythema or exudate. Neck supple, full range of motion, no lymphadenopathy, no bruits. CV: Regular rate and rhythm, normal S1 and S2 without murmurs, rubs or gallops. Chest clear to auscultation throughout. Abdomen obese, positive bowel sounds, midline scar, nontender, no masses, no audible bruits. Extremities: 1+ pretibial edema, no cyanosis, no clubbing. Pulses: 2+ dorsalis pedis and posterior tibial, femoral, radial. Neurologic: Sensation intact 5 out of 5 strength, 2+ refluxes upper extremity and lower extremity bilaterally. LABORATORY VALUES: On admission WBC 13.8, hematocrit 45, platelets 237 with a normal differential. Chemistries: sodium 142, potassium 4.6, chloride 103, bicarb 28, BUN 30, creatinine 1.0, glucose 111, coagulation profile normal. CK was 129, troponin was less than .01. CTA showed an acute aortic dissection beginning distal to the left subclavian and extending down to the aorto-[**Hospital1 **]-femoral graft. Celiac showed a two lumen SMA half true, half false with contrast to arcades. Left renal true lumen, right renal false lumen with decreased enhancement with contrast. ASSESSMENT: A 62 year-old male status post abdominal aortic aneurysm repair and aorto-[**Hospital1 **]-femoral graft now with acute type B dissection with SMA and right renal artery involvement. No evidence of compromise to viscera. Patient was admitted for medical management. HOSPITAL COURSE BY PROBLEM: 1. Aortic dissection: Patient was started on a labetalol and Nipride drip with a goal of systolic blood pressure of less than 120. He was continued on those drips with titration for the first four days of his hospitalization. At that time other antihypertensives were added including an ACE inhibitor, hydralazine and spironolactone. At the time of dictation the patient has been weaned off his Lebatolol and Nipride drip. He has also been weaned off most of his antihypertensive medications and is currently on a regimen that includes an ACE inhibitor, hydrochlorothiazide, beta blocker and Clonidine. His Clonidine is slowly being titrated off as the ACE inhibitor is titrated up. Eventually he will only a regimen of an ACE inhibitor beta blocker and hydrochlorothiazide. His blood pressure currently is 120/80. 2. MRSA pneumonia. The patient developed acute hypoxia during this hospitalization and has sputum cultures positive for MRSA. He was treated with a ten day course of Vancomycin and a 14 day course of levofloxacin. He was intubated for six days during the course of his hospitalization for acute mental status changes and in the setting of benzodiazepine use and hypoxia thought to be secondary to his pneumonia. At the time of dictation the patient has an oxygen requirement of three liters, is saturating in the high 90s and the goal of care is to wean oxygen as tolerated in the rehabilitation setting. 3. Constipation: The patient was continued on a bowel regimen including Colace, Senna, Dulcolax, enemas and lactulose. 4. Acute mental status changes: Probably secondary to benzodiazepine use. During the subsequent course of his hospitalization patient was taken off benzodiazepines and for the remainder he should avoid benzodiazepines as they clear cause mental status changes. 5. Fluid, electrolytes and nutrition: The patient after intubation was maintained on a low sodium diet. He was diuresed after extubation. 6. Prophylaxis: Patient is on a proton pump inhibitor and received subcutaneous heparin while he was immobile. Currently the patient is ambulating for deep venous thrombosis prophylaxis. CONDITION AT DISCHARGE: Stable. CONDITION STATUS: To rehabilitation. DISCHARGE MEDICATIONS: Tylenol 325 to 650 p.o. q 4 to 6 p.r.n., albuterol nebs 1 q three hours p.r.n., Captopril 37.5 mg p.o. t.i.d., hydrochlorothiazide 25 mg p.o. q.d., Atrovent MDI 2 puffs q 4 hours p.r.n., Clonidine .1 mg p.o. q 6 hours times four doses, folic acid 1 mg p.o. q.d., Guaifenesin 5 to 10 ml p.o. q 6 p.r.n., heparin 5,000 units subcutaneous q 12 hours while immobilized, Lopressor 25 mg p.o. b.i.d., Protonix 40 mg p.o. q.d., Senna 2 tabs p.o. b.i.d., p.r.n. FOLLOW UP: Patient will follow up with his primary care physician and vascular surgeon, Dr. [**Last Name (STitle) 1391**] after his rehabilitation stay. [**Doctor Last Name **], [**Doctor Last Name **] R. M.D. [**MD Number(1) 19181**] Dictated By:[**Last Name (NamePattern1) 2706**] MEDQUIST36 D: [**2120-6-7**] 15:50 T: [**2120-6-7**] 16:59 JOB#: [**Job Number 19182**] Admission Date: [**2120-5-20**] Discharge Date: [**2120-6-10**] Date of Birth: [**2057-11-11**] Sex: M Service: MED ADDENDUM: See previous dictation for hospital course summary. The patient remained in the hospital for an additional four days, awaiting placement in rehabilitation center. All medications and discharge information remained the same from previous dictation for [**2120-6-7**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 5825**] Dictated By:[**Last Name (NamePattern1) 19183**] MEDQUIST36 D: [**2120-7-27**] 16:05:22 T: [**2120-7-27**] 17:55:28 Job#: [**Job Number 19184**]

[ "507.0", "584.9", "428.0", "518.81", "441.03", "482.41", "564.00", "V09.0", "401.9" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

5505, 5960

1376, 1456

1083, 1165

5972, 7064

1479, 3225

5433, 5481

768, 995

3253, 5418

190, 748

1018, 1059

1182, 1349

27,061

102,921

10493

Discharge summary

report

Admission Date: [**2173-12-2**] Discharge Date: [**2173-12-7**] Date of Birth: [**2120-11-3**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3556**] Chief Complaint: Elective admission for flexible bronchoscopy with bilateral lung lavage Major Surgical or Invasive Procedure: Flexible bronchoscopy with bilateral lung lavage History of Present Illness: 53M h/o pulmonary alveolar proteinosis (PAP) diagnosed in [**9-/2173**], DM2, HTN, dyslipidemia, admitted to MICU for closer monitoring after undergoing bilateral lung lavage, each with 13L NS for PAP, for which he was intubated. Pt's R lung lavage was performed on [**2173-12-2**], and his L lung lavage was performed on [**2173-12-6**]; each procedure was uncomplicated. After his second lavage, pt was briefly hypotensive to SBP 80's, placed on neosynephrine and IVF, but was quickly weaned off pressors. . PAP had been diagnosed in [**10-7**] after pt presented with increasing SOB, pleuritic CP, and hypoxemia, during which time he underwent wedge resection of the RML and RLL confirming PAP on pathology. Flow cytometry to check for hematologic malignancy was negative. . ROS: Unable to be performed given pt sedated, intubated. Past Medical History: # HTN # Diabetes mellitus type II # Hypercholesterolemia # Obesity # Erectile dysfunction s/p prostate surgery [**2168**] # Umbilical herniorrhaphy [**2165**] Social History: # Personal: Originally from [**Male First Name (un) 1056**], but has been living in [**Location (un) 86**] for 18 years. Married to second wife for 18 years; two children from his first marriage. # Professional: Currently unemployed; previously worked as a custodian. # Substance use: Denies tobacco use, alcohol, or drugs. Family History: # Mother, died 77: CVA associated with DM and HTN # Father, died 80: Prostate cancer # Siblings (7 brothers, 5 sisters): DM, HTN, CAD Physical Exam: VS: T 97.2, BP 125/75, HR 71, O2sat 99 on AC/Vt 600x RR 14, PEEP 5, FiO2 1.0 ABG: pH 7.46, pCO2 39, pO2 138, HCO3 29 General: Intubated HEENT: NCAT Neck: No JVD noted, supple, no TMG Chest: CTAB on anterior and lateral exam CV: RRR, S1 and S2 WNL, no m/r/g Abd: Obese, ND, NT, BS+, no masses or hepatosplenomegaly Ext: No c/c/e, warm, good pulses Pertinent Results: Admission labs: . [**2173-12-2**] 08:04PM GLUCOSE-127* UREA N-12 CREAT-0.6 SODIUM-142 POTASSIUM-3.5 CHLORIDE-109* TOTAL CO2-25 ANION GAP-12 [**2173-12-2**] 08:04PM CALCIUM-8.1* PHOSPHATE-4.4# MAGNESIUM-1.8 [**2173-12-2**] 08:04PM WBC-17.6* RBC-3.37*# HGB-10.6*# HCT-31.4* MCV-93 MCH-31.6 MCHC-33.9 RDW-13.2 [**2173-12-2**] 10:33PM HCT-35.3* [**2173-12-2**] 08:04PM PLT COUNT-356 [**2173-12-2**] 09:40AM NEUTS-59 BANDS-0 LYMPHS-30 MONOS-4 EOS-0 BASOS-2 ATYPS-5* METAS-0 MYELOS-0 . Imaging: . CHEST (PORTABLE AP) [**2173-12-2**] 9:32 PM . 1. Standard position of NG and ET tube. 2. Significant increase in bilateral perihilar and lower lobe consolidations which might reflect recent bronchoalveolar lavage in a patient with known alveolar proteinosis. Differential diagnosis might include pulmonary edema, although it is less likely. Close followup would be recommended. . CHEST (PORTABLE AP) [**2173-12-6**] 7:39 PM . Comparison is made with prior study of [**2173-12-3**]. ET tube is in standard position. There is no pneumothorax. If any, there is a small left pleural effusion. Cardiomediastinal contours are unchanged. There are low lung volumes. There has been mild improvement in the lung aeration, mostly in the left lung base. Brief Hospital Course: A/P: 53M h/o PAP, DM2, HTN, admitted for elective whole lung lavage, performed in two stages, intubated post-procedure, with quick extubation. # Pulmonary alveolar proteinosis: R lung lavaged on [**2173-12-2**], left lung lavaged on [**2173-12-6**]. BAL negative for PCP and fungal infection, with no organisms noted on Gram stain; cultures pending on discharge. After procedure, pt's ambulatory O2sat noted to be 97% on room air. . # Fluid overload: After R lung lavage, pt autodiuresed well after receiving 13L in lavage fluid. Repeat chest x-ray showed improved pulmonary edema and stable bibasilar opacities and interstial opacities, likely from underlying disease. . # Leukocytosis: Considered [**1-1**] lung procedure. Pt afebrile, BAL sent from lavage for nocardia and PCP. [**Name10 (NameIs) **] demonstrates no obvious infiltrate suspicious for PNA. Blood, urine cx sent, all NGTD. BAL neg culture for bacteria/PCP/fungus. WBC normalized upon discharge. . # Transient Hct drop, hyponatremia: Considered [**1-1**] fluid received during lung lavage, corrected later upon repeat labs. . # DM2: Home regimen of metoformin and pioglitazone held while inpatient; covered with HISS Q6H. . # HTN: Normotensive, and continued on home regimen of valsartan 80mg daily, carvedilol 25mg [**Hospital1 **], ASA 81mg daily. Pt confirmed that he did not take HCTZ at home, and this was therefore removed from his medication list on discharge. . # GERD: Home regimen of ranitidine 150mg daily and esomeprazole 40mg daily; pt continued on H2 blocker only as inpatient. . # Full code Medications on Admission: Carvedilol 25mg [**Hospital1 **] ASA 81mg daily Valsartan 80mg daily Pioglitazone 45mg daily Metformin 1000mg [**Hospital1 **] Montelukast 10mg daily Ranitidine 150mg daily Esomeprazole 40mg daily Discharge Medications: 1. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 2. Valsartan 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 3. Montelukast 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 4. Ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO once a day. Disp:*30 Capsule(s)* Refills:*2* 5. Esomeprazole Magnesium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 6. Pioglitazone 45 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 7. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 8. Carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis # Pulmonary alveolar proteinosis . Secondary diagnosis # Hypertension # Diabetes mellitus type 2 # Dyslipidemia Discharge Condition: Breathing normally on room air. Ambulatory oxygen saturation 97%. Discharge Instructions: You were hospitalized so that doctors [**First Name (Titles) **] [**Last Name (Titles) **] out your lungs with fluid, because you have pulmonary alveolar proteinosis. After the procedure, we measured the level of oxygen in your blood while you were walking and it was 97%, indicating that you were breathing well. . You will go home and continue taking the same medications as before. We have confirmed with the hospital pharmacist as well as your medical records that you should be taking carvedilol 25mg twice daily. We have also confirmed with you directly that you do not take hydrochlorothiazide. . You have an appointment to see doctors in the [**Name5 (PTitle) 11063**] Pulmonary clinic (telephone [**Telephone/Fax (1) 10084**]), on [**2173-12-14**] at 11 am. . You have an appointment with Dr. [**Last Name (STitle) 2168**], your lung doctor (tel. [**Telephone/Fax (1) 612**]), to follow up about your lung disease. . You should also make an appointment to see your primary care doctor in one month. . If you experience worsening shortness of breath, fever, or any other symptoms you are concerned about, please call your doctor and go immediately to the nearest emergency room. Followup Instructions: THIS IS YOUR [**Telephone/Fax (1) **] PULMONOLOGY DOCTOR APPOINTMENT: Date/Time:[**2173-12-14**] 11:00 . THIS IS YOUR LUNG DOCTOR APPOINTMENT: DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2173-12-21**] 12:00 . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 3749**], MD Phone:[**Telephone/Fax (1) 3241**] Date/Time:[**2174-1-3**] 11:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5465**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2174-1-3**] 11:30 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**] Completed by:[**2173-12-8**]

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icd9cm

[ [ [] ] ]

[ "33.24", "38.91" ]

icd9pcs

[ [ [] ] ]

6360, 6366

3635, 5221

387, 437

6540, 6608

2362, 2362

7845, 8590

1845, 1980

5469, 6337

6387, 6519

5247, 5446

6632, 7822

1995, 2343

276, 349

465, 1304

2378, 3612

1326, 1486

1502, 1829

8,109

192,031

49866

Discharge summary

report

Admission Date: [**2156-1-11**] Discharge Date: [**2156-1-23**] Date of Birth: [**2088-6-21**] Sex: F Service: MEDICINE Allergies: IV Dye, Iodine Containing Contrast Media Attending:[**First Name3 (LF) 594**] Chief Complaint: Respiratory distress secondary to pneumonia, leading to ARDS Renal failure Major Surgical or Invasive Procedure: 1. Endotracheal intubation 2. Arterial line placement 3. Central venous line placement 4. HD line placement 5. Initiation of hemodialysis History of Present Illness: Ms [**Known lastname 33858**] is a 67-year-old woman with stage IV-V CKD preparing for renal replacement therapy, hypertension, insulin-dependent DM, anemia, hypertension, and gout, who presented to [**Hospital1 **] [**Location (un) 620**] ED yesterday for nausea, vomiting, diarrhea for one week, and a cough that had worsened after an episode of emesis. She had been prescribed a z-pack by her PCP several days prior to presentation for presumed URI, but had not taken them due to a concern of worsening diarrhea. On arrival in [**Location (un) 620**], she appeared pale and lethargic and had projectile vomiting. She was intubated for hypoxic respiratory failure with O2 sats in 70-80s. She had 300 cc bilious output from her OGT. CXR showed a RML consolidation suggestive of pneumonia, and patient was given ceftriaxone and metronidazole out of concern for respiratory failure due to aspiration pneumonia. She was also given duonebs, three doses of IV lopressor, and 250 cc IVF, followed by 60 mg IV furosemide due to CXR signs of pulmonary edema. Labs revealed elevated leukocytosis with left shift, mild hyponatremia & hyperkalemia, acute on chronic kidney injury, normal lactate, and hypoxemia. Cardiac enzymes were elevated (trop 0.071 -> 0.244, MB 6.7) and there was concern patient had suffered an NSTEMI. She was given PR aspirin, started on a heparin gtt and transferred to [**Hospital1 18**] CCU, with change of sedation from propofol to fentanyl & midazolam en route. . Overnight in the CCU, further review of ECG revealed sub-mm ST depressions in V3-V6. The patient had a bedside TTE that showed mildly reduced LVEF 45% and mild-mod MR. Antibiotics were broadened to vancomycin, levofloxacin, piperacillin/tazobactam and metronidazole. She was given a dose of furosemide 40 mg IV at 0100. RIJ was placed in effort to preserve peripheral vessels for dialysis access. Her MAP were generally stable but started to decrease in the 50s around 7:00 am. CVP between [**5-11**]. She was bolused 1L NS. Repeat labs revealed ongoing leukocytosis with bandemia and stabilization of creatinine. TroponinT peaked at 2.73, with CK-MB in [**11-22**] range. Her ventilator settings have been on assist/control 400x16-17, with FiO2 60-80% and PEEP 12. . This morning, the patient is inubated and partially sedated, but is interactive, answering questions and following commands. She endorses nausea, diarrhea, and discomfort from the ETT. She says she has had subjective fevers and acknowledges that she was not taking antibiotics at home, but cannot recall what they were prescribed for. Denies chest pain, abdominal pain. Past Medical History: -Stage IV-V kidney disease with baseline creatinine 3.5 (first fistula attempt failed awaiting second evaluation for fistula) -intermittent hyperkalemia -anemia secondary to renal disease on Aranesp -known kidney stone -hypertension -gout -diabetes on insulin - diabetic neuropathy s/p L 5th toe amputation Social History: Marital Status: Single. Children: None. Occupation: Office Manager for an Insurance Agency. Tobacco: None. Alcohol: None. Family History: Fam hx + for hypertension. Mother: died AMI age 57 was diabetic Father:Died AMI age 82 was diabetic Siblings 4 sisters, 2 with diabetes and alive, one sister died of COPD and the other of pancreatic carcinoma Physical Exam: Admission exam: General: Intubated, awake, interactive, appears older than stated age HEENT: +mild conjunctival injection, no icterus/pallor. PERRL 3 -> 2 mm bilaterally. MMM Neck: supple, RIJ in place without surrounding erythema or drainage, no JVP or LAD CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Lungs: Diffuse rhonchi and occasional wheeze with vent sounds heard anteriorly and laterally. Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly Ext: warm, thin, no edema or cyanosis, 2+ DP/PT/radial. No foot ulcers; s/p L 5th toe amp Neuro: Strength limited due to sedation but generally [**4-8**] without focal deficits. 2+ reflexes bilaterally, gait deferred Discharge exam: 92, 98% on 3L, 140/75 General: awake, appropriate HEENT: no icterus/pallor. PERRL Neck: supple, R tunneled line without surrounding erythema or drainage, no elevation of JVP CV: RRR, normal S1 + S2, Lungs: crackles improved, no wheezes Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly Ext: warm, thin, no edema or cyanosis, 2+ DP/PT/radial. No foot ulcers; s/p L 5th toe amp Neuro: increased strength, gait deferred Pertinent Results: Labs upon admission: [**2156-1-11**] 07:25PM BLOOD WBC-21.1*# RBC-3.27* Hgb-9.6* Hct-28.9* MCV-88 MCH-29.4 MCHC-33.3 RDW-15.6* Plt Ct-223 [**2156-1-11**] 07:25PM BLOOD Neuts-75* Bands-19* Lymphs-2* Monos-3 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-1* NRBC-1* [**2156-1-11**] 07:25PM BLOOD PT-12.8* PTT-90.0* INR(PT)-1.2* [**2156-1-11**] 07:25PM BLOOD Glucose-257* UreaN-81* Creat-3.5* Na-142 K-5.1 Cl-98 HCO3-24 AnGap-25* [**2156-1-11**] 11:00PM BLOOD ALT-26 AST-55* LD(LDH)-356* AlkPhos-78 TotBili-0.2 [**2156-1-12**] 05:59AM BLOOD Lipase-9 [**2156-1-11**] 07:25PM BLOOD CK-MB-19* MB Indx-8.6* cTropnT-2.49* [**2156-1-11**] 11:00PM BLOOD CK-MB-17* cTropnT-2.73* [**2156-1-12**] 05:59AM BLOOD CK-MB-11* MB Indx-8.6* cTropnT-2.25* [**2156-1-11**] 07:25PM BLOOD Calcium-9.1 Phos-5.0* Mg-2.3 [**2156-1-13**] 03:00AM BLOOD Albumin-2.5* Calcium-7.9* Phos-4.2 Mg-1.8 [**2156-1-11**] 09:03PM BLOOD Type-ART pO2-65* pCO2-40 pH-7.44 calTCO2-28 Base XS-2 Labs prior to discharge: Micro: Date 6 Lab # Specimen Tests Ordered By All [**2156-1-11**] [**2156-1-12**] [**2156-1-13**] [**2156-1-14**] [**2156-1-17**] [**2156-1-19**] All BLOOD CULTURE Influenza A/B by DFA Rapid Respiratory Viral Screen & Culture SPUTUM STOOL URINE All INPATIENT [**2156-1-19**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL INPATIENT [**2156-1-19**] BLOOD CULTURE Blood Culture, Routine-PENDING [**2156-1-19**] BLOOD CULTURE Blood Culture, Routine-PENDING [**2156-1-17**] STOOL FECAL CULTURE-FINAL; CAMPYLOBACTER CULTURE-FINAL; CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL [**2156-1-14**] STOOL FECAL CULTURE-FINAL; CAMPYLOBACTER CULTURE-FINAL; FECAL CULTURE - R/O VIBRIO-FINAL; FECAL CULTURE - R/O YERSINIA-FINAL; FECAL CULTURE - R/O E.COLI 0157:H7-FINAL; CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL [**2156-1-14**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL [**2156-1-13**] URINE Legionella Urinary Antigen -FINAL [**2156-1-12**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL [**2156-1-12**] Influenza A/B by DFA DIRECT INFLUENZA A ANTIGEN TEST-FINAL; DIRECT INFLUENZA B ANTIGEN TEST-FINAL [**2156-1-12**] Rapid Respiratory Viral Screen & Culture Respiratory Viral Culture-FINAL; Respiratory Viral Antigen Screen-FINAL [**2156-1-12**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL [**2156-1-11**] BLOOD CULTURE Blood Culture, Routine-FINAL [**2156-1-11**] BLOOD CULTURE Blood Culture, Routine-FINAL [**2156-1-11**] URINE URINE CULTURE-FINAL [**2156-1-11**] URINE Legionella Urinary Antigen -FINAL . Reports: [**2156-1-11**] TTE: Poor image quality. The left atrium is moderately dilated. The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is probably mildly depressed (LVEF= 45 %). A regional wall motion abnormality cannot be excluded (poor images of the mid to distal LV). 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. An eccentric, posteriorly directed jet of mild to moderate ([**1-5**]+) mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade. . [**2156-1-12**] CXR: IMPRESSION: AP chest reviewed in the absence of recent chest radiographs. ET tube, right internal jugular line, and nasogastric tube are in standard placements respectively. In addition to a widespread infiltrative pulmonary abnormality that could be pulmonary edema, there is more focal consolidation and a strong suggestion of cavitation in the juxtahilar right lung, pneumonia until proved otherwise. Since the heart is normal size and pleural effusion is small, if any, this could be noncardiac edema. No pneumothorax . [**1-14**] CT chest/abd: IMPRESSION: . 1. Cystic lesion in the left adnexa, similar in appearance to [**2147**], but larger. Extending superiorly from the cystic structure, there is soft tissue prominence alone the course of the left gonadal vein. The cystic structure may represent the left ovary with cysts. Alternatively, the soft tissue prominence more superiorly may be a prominent left ovary. Additional differential considerations for the soft tissue prominence include fluid tracking along the pelvic wall/gonadal vein, hemorrhage or a fibrous lesion. The right ovary is normal size but also appears cystic, similar to [**2147**]. The ovaries could be evaluated by nonurgent/outpatient pelvic ultrasound. Consider nonurgent/outpatient pelvic MRI to evaluate left soft tissue prominence as it is probably too high to be evaluated by ultrasound. If pelvic MRI is going to be performed, the ovaries could be evaluated at that time. 2. Bilateral consolidations and nodular opacities compatible with multifocal pneumonia & ARDS, with aspiration being a consideration as well given the predominantly dependent distribution. 3. While no pulmonary mass is definitely identified, it could be obscured by the consolidation. Small bilateral pleural effusions. 4. Fat-containing ventral hernias. 5. Extensive atherosclerosis, which has significantly increased since [**2147**]. . [**1-20**] Renal US: IMPRESSION: 1. Non-obstructive renal calculi within the upper pole of the right kidney. Limited views of the left kidney. No evidence of hydronephrosis bilaterally. 2. Limited Doppler images show normal arterial and venous flow at the renal hilum. [**1-22**] CXR: IMPRESSION: 1. New right internal jugular hemodialysis catheter ends in the right atrium just beyond the atriocaval junction. 2. Worsening mild pulmonary edema. 3. Stable bilateral moderate pleural effusions. Brief Hospital Course: This is a 67-year-old woman with a history of CKD stage IV-V, DM2, HTN, anemia, and gout, presenting with hypoxemic respiratory failure [**2-5**] multifocal pneumonia/ARDS, with cardiac enzyme leak c/w NSTEMI, intubated, then extubated. Hospital course c/b worsening of her CKD requiring initiation of hemodialysis. # HYPOXEMIC RESPIRATORY STATUS/ARDS: Due to infectious process given bilateral multifocal infiltrates seen on CXR, leukocytosis with bandemia, and history of productive cough. Sputum unrevealing and all cultures negative. Finished 10 day course of vancomycin, zosyn, levaquin with resolution of her fevers and leukocytosis. The patient was initially intubated and ventilated using ARDSnet protocol. The ventilator was easily weaned and she was maintained on nasal cannula after extubation. After extubation, the patient continued to have pulmonary edema due to her worsening renal failure and anuria. The patient was started on HD and weaned off her O2. Even after diuresis, the patient had a R sided effusion on CXR. This is likely fluid, but she should be re-imaged in 1 month to check for resolution. . # CHRONIC KIDNEY DISEASE: The patient had stage 4 CKD before admission, with the plan to initiate dialysis in the near future. During the admission, the patient's kidney function continued to decline and she was anuric. Due to her fluid overload, HD was started. She tolerated tunneled line placement and three consecutive session of HD and UF. The patient was started on Sevelemar and nephrocaps. Her medications were renally dosed. She will need to f/u with renal and continue TIW HD. . # NSTEMI: The patient had ST depressions and increased troponins. She was medically managed on aspirin, statin, and metoprolol. Her EKG normalized and TTE did not show wall motion abnormlaities. She will need cardiology f/u and possible stress. Also, an ACEI should be started once the patient is established with HD. . # NORMOCYTIC ANEMIA: Hgb just below baseline, no signs of acute bleeding. Iron studies in past suggestive of anemia of chronic inflammation. No schistocytes reported on CBC; has elevated LDH but normal total bili argues against hemolysis. The patient will need Epo supplementation. . # HYPERLIPIDEMIA: A statin was continued. . # DM: Glargine was increased to 15 for hyperglycemia. Patient did not need sliding scale coverage. . TRANSITIONAL ISSUES: 1. Cystic lesion in the left adnexa, similar in appearance to [**2147**], but larger. Extending superiorly from the cystic structure, there is soft tissue prominence alone the course of the left gonadal vein. The cystic structure may represent the left ovary with cysts. Alternatively, the soft tissue prominence more superiorly may be a prominent left ovary. Additional differential considerations for the soft tissue prominence include fluid tracking along the pelvic wall/gonadal vein, hemorrhage or a fibrous lesion. The right ovary is normal size but also appears cystic, similar to [**2147**]. The ovaries could be evaluated by nonurgent/outpatient pelvic ultrasound. Consider nonurgent/outpatient pelvic MRI to evaluate left soft tissue prominence as it is probably too high to be evaluated by ultrasound. If pelvic MRI is going to be performed, the ovaries could be evaluated at that time. . 2. We recommend chest xray in [**4-9**] weeks (by [**3-5**]) to ensure resolution of pleural effusion . 3. Cardiology outpatient follow-up for NSTEMI. . 4. Patient should start ACE-I once creatinine is stable Medications on Admission: Allopurinol 200 mg daily atenolol 25 mg twice daily Aranesp 60 mg q. 2 weeks Lasix 80 mg daily Lantus 12 units at night nifedipine extended release 90 mg daily Renagel 800 mg t.i.d. with meals aspirin 325 mg daily iron 325 mg daily guanfacine 1 mg nightly for hypertension Lidoderm patch Zocor 20 mg nightly multivitamin Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Tablet, Chewable(s) 2. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 3. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 4. insulin glargine 100 unit/mL Solution Sig: Fifteen (15) units Subcutaneous at bedtime. 5. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. darbepoetin alfa in polysorbat 60 mcg/mL Solution Sig: Sixty (60) mcg Injection every other week. 7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO once a day. Tablet(s) 9. allopurinol 100 mg Tablet Sig: Two (2) Tablet PO once a day. Tablet(s) 10. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day): Please continue until patient is out of bed. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Pneumonia End-Stage Renal Disease, on Dialysis 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 33858**], It was a pleasure taking care of you during this admission. You were admitted to the hospital for difficulty breathing due to pneumonia, which was made worse because of your renal failure. During the first portion of your stay, you required a breathing tube to support you, but you were able to gradually come off of the breathing support. Unfortunately, you experienced a further worsening of your renal failure, and had to be started on dialysis, which your body has been responding to well. Several changes have been made to your medication regimen. STOP taking Lasix (furosemide) STOP taking nifedipine STOP taking guanfacine STOP taking Zocor START taking Metoprolol 25 mg Tablet -- one half tab 2 times a day START taking Atorvastatin 40 mg Tablet -- one tab at bedtime CHANGE Aspirin 325mg daily to 81mg daily . It is very important that you see cardiology as an ouptatient as you had a small heart attack while you were here. You should also ask your nephrologist or primary care doctor about starting a medication called an ACE inhibitor for your blood pressure and your heart. Followup Instructions: Department: PAT-PREADMISSION TESTING When: TUESDAY [**2156-1-27**] at 7:45 AM With: PAT-PREADMISSION TESTING [**Telephone/Fax (1) 2289**] Building: CC [**Location (un) 591**] [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: WEST [**Hospital 2002**] CLINIC When: WEDNESDAY [**2156-2-4**] at 8:30 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2540**], RN [**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: WEST [**Hospital 2002**] CLINIC When: WEDNESDAY [**2156-3-17**] at 8:30 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], 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 [**2156-2-11**] 09:00a Cardiology clinic: [**Doctor Last Name **]-CC7 SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] CC7 CARDIOLOGY (SB)

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icd9cm

[ [ [] ] ]

[ "96.6", "96.72", "39.95", "38.95" ]

icd9pcs

[ [ [] ] ]

15572, 15638

10778, 13141

375, 514

15728, 15728

5063, 5070

17062, 18201

3651, 3862

14645, 15549

15659, 15707

14300, 14622

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13162, 14274

261, 337

542, 3166

5084, 10755

15743, 15886

3188, 3496

3512, 3635

78,102

172,235

35108

Discharge summary

report

Admission Date: [**2186-10-8**] Discharge Date: [**2186-10-24**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2901**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Cardiac Catheterization with two bare metal stents to Right Coronary Artery History of Present Illness: 87 yo female with history of dementia presented to [**Hospital1 **] [**Location (un) 620**] on [**2186-10-8**] with chest pain and diaphoresis, transfered to [**Hospital1 18**] for immediate cath as thought to have an inferior STEMI, with ST elevations and CKs ranging from 150-155. She was found to have a chronic total occlusion of the RCA which was stented. She was hypoxic and hypotensive with a PCWP of 20-25 in the catheterization lab and was admitted to the CCU post-operatively for additional management. Soon thereafter the patient stabilized and was transferred to a general medical floor on [**2186-10-11**] for ongoing management while she recovered from her recent MI and additional care of her multiple co-morbidities, including COPD, Anemia, Alzheimer's type dementia, rheumatoid arthritis. Of note, she had a leukocytosis to 33 with 92% neutrophils, hyponatremia, transaminitis, and an elevated LDH in addition to her cardiac issues. Mrs.[**Known lastname 80177**] hyponatremia and transaminitis resolved but her leukocytosis and elevated LDH remained active issues. Infectious work up revealed negative blood and urine cultures, and a CT torso significant for multi-focal ground glass opacities consistent with edema vs. a multi-lobar infectious process, and one enlarged 17x17mm subcarinal lymph node was found as well. She was started on levofloxacin for presumed PNA on [**10-10**]. Soon after the patient was transferred to the general medical floors, she began to have persistent bouts of NSVT noted on telemetry. Fortunately, she remained asymptomatic during these episodes but the NSVT runs became increasingly more prolonged with telemetry tracings demonstrating 60-70 beat runs of ventricular tachycardia. The patient had no chest pain, dizziness or shortness of breath compliants at that time and her blood pressures were stable. A cardiology consult was called and the patient was transferred to the [**Hospital1 1516**] inpatient cardiology service. While on the inpatient cardiology service the patient continued to have multiple episodes of ventricular tachycardia lasting as long as 50-60 minutes. She converted back to normal sinus, sinus bradycardia and occasional AV-block (I and II) on her own on multiple occasions but generally required additional Amiodarone and Lidocaine boluses to resolve her VT episodes. This VT was felt to be secondary to her scarred and irritated myocardium status-post recent inferior MI. The patient continued to be completely asympomatic and hemodynamically stable during these episodes of VT. The EP team was consulted and involved in Mrs.[**Known lastname 80177**] management. She was initially evaluated for a defibrillator but it was decided that she would have poor quality of life with a device given the frequency of her VT and she was also a poor surgical candidate given her multiple co-morbidites. A more detailed EP study with possible ablation was also explored but the patient continued to have bradycardia, hemodynamic instability and an acute PNA infection. Thus, this option was deferred in favor of trying additional medical management. She was continued on metoprolol 50mg twice a day and her electrolyes were closely monitored and repleted while on the cardiology service. Due to her bradycardia with Amiodarone she was switched to Quinidine for control of her VT episodes. EP started quinidine 324mg Q8H on [**2186-10-16**], as they were moving away from a plan to ablate her. Unfortunately, she did not tolerate Quinidine well and was admitted to the CCU for monitoring of hemodynamically unstable bradycardia and the alarming onset QT prolongation after initiating therapy with quinidine. Past Medical History: CHF with a "dilated ventricle" Rheumatoid arthritis on prednisone and methotrexate history of falls, including pelvic fracture after a fall in [**Month (only) 956**] Anemia COPD/bronchiectasis Pneumonia status post intubation in [**7-25**] urinary incontinence Alzheimer's type dementia Social History: Lives in [**Hospital3 **], independent with ADLs, but meals are supplied and daughter helps the patient with her daily medications by setting up her pill box for dispensing her daily medications appropriately. The patient smoked approximately 1PPD x30 years but quit 40 years ago. She also drank 1-2 drinks/night until 10 years ago, tapered down to 1 small drink once or twice a week more recently. She denies any history of illicit drug use. Family History: No family history of sudden cardiac death or early CAD. Physical Exam: VS: T=95.1...BP=90-104/40s...HR=40s...RR=15 GENERAL: Elderly woman, thin, answering questions appropriately HEENT: NCAT. Sclera anicteric. PERRL, EOMI. OP with dry mucous membranes and visible oral thrush NECK: Supple with no JVD CARDIAC: Regular rhythm, bradycardic, no audible murmurs LUNGS:Bilateral crackles when listening anteriorly ABDOMEN: Soft, NTND. No HSM or tenderness. Tympanitic to percussion throughout EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: CXR [**2186-10-18**]: Small bilateral pleural effusions are unchanged. Patchy poorly marginated opacities in the upper lung zones are unchanged. There is minimal improvement in the previously described opacity at the right lung base. Cardiomediastinal contours are unchanged. Note is again made of diffuse aortic calcification. CARDIAC CATH REPORT [**2186-10-8**] : 1. Selective coronary angiography of this right dominant system revealed 1 vessel coronary artery disease. The LMCA had mild disease. The LAD was calcified with serial 30-40% stenoses. The LCx was calcified with a proximal 40% stenosis in OM1. The RCA was calcified with total occlusion at the mid segment. There were faint collaterals filling the distal portion of the RCA from the left coronary artery. 2. Resting hemodynamics revealed elevated right sided filling pressures with a RVEDP of 14mm Hg. There was mild to moderate pulmonary arterial hypertension with a PA pressure of 45/19 mm Hg. Systemic arterial pressure was elevated at 210/80 mm Hg prior to administration of NTG drip IV. The cardiac index was depressed at 1.8 L/min/m2. The PVR was 5.2 Wood unit. 3. Successful PTCA and placement of two overlapping 2.5x18mm Mini Vision bare-metal stents in the mid-RCA were performed. The stents were post-dilated using a 3.0mm balloon. Final angiography showed normal flow, no apparent dissection, and no residual stenosis. (See PTCA comments) [**2186-10-9**] CHEST CT: 1. Predominant central and dependent pulmonary ground-glass opacities with underlying fissural thickening which is more consistent with edema. Diffuse infectious process is also possible. 2. Perihepatic ascites and periportal edema, could be due to underlying CHF. 3. Old renal infarcts and narrowing of bilateral renal artery at origin, concern for renal artery stenosis. 4. Multiple bilateral renal hypodense lesions, most likely renal cysts 5. Unhealed old fractures of the left superior and inferior pubic ramus. 6. Osteopenia. Degenerative changes of bilateral hips. [**2186-10-21**] LABS: Hct 32.3, Hgb 10.4, Na 130, K 4.9, BUN 14, Cr .5 [**2186-10-8**] 06:56PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.050* [**2186-10-8**] 06:56PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-LG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2186-10-8**] 03:33PM estGFR-Using this [**2186-10-8**] 03:33PM CK-MB-9 [**2186-10-8**] 03:33PM CALCIUM-8.0* PHOSPHATE-4.3 MAGNESIUM-1.9 CHOLEST-96 [**2186-10-8**] 03:33PM TRIGLYCER-52 HDL CHOL-27 CHOL/HDL-3.6 LDL(CALC)-59 [**2186-10-8**] 03:33PM WBC-33.2* RBC-2.57* HGB-7.9* HCT-24.4* MCV-95 MCH-30.8 MCHC-32.4 RDW-16.0* [**2186-10-8**] 03:33PM CALCIUM-8.0* PHOSPHATE-4.3 MAGNESIUM-1.9 CHOLEST-96 [**2186-10-8**] 03:33PM ALT(SGPT)-110* AST(SGOT)-186* CK(CPK)-144* ALK PHOS-191* TOT BILI-0.6 [**2186-10-8**] 10:20AM HGB-10.6* calcHCT-32 O2 SAT-83 [**2186-10-8**] 10:20AM GLUCOSE-230* K+-5.9* [**2186-10-8**] 10:20AM TYPE-ART O2 FLOW-2 PO2-60* PCO2-26* PH-7.22* TOTAL CO2-11* BASE XS--15 [**2186-10-8**] 10:45AM O2 SAT-90 Brief Hospital Course: Mrs. [**Known lastname 13099**] is an 87 female who was admitted on [**2186-10-8**] with an inferior STEMI and underwent emergent cardiac catheterization which revealed total occlusion of the mid segment of the RCA. She had two overlapping bare metal stents placed. During the procedure she was hypoxic and hypotensive with a PCWP of 20-25 so she was transferred to the CCU for post-operative monitoring. After stabilization, she was transferred to the general medicine service on [**10-11**]. She was noted to have a leukocytosis to 33 with 92% neutrophils, hyponatremia, transaminitis, and an elevated LDH in addition to her cardiac problems. Of note, the patient also has several additional active co-morbidities which include COPD, chronic anemia, Alzheimer's type dementia, hypothyroidism and rheumatoid arthritis. The patient's hyponatremia and transaminitis resolved but her leukocytosis and elevated LDH persisted. An infectious work up revealed negative blood and urine cultures. A CT of her torso was significant for multi-focal ground glass opacities consistent with edema vs. a multi-lobar infectious process and one enlarged 17x17mm subcarinal lymph node was described as well. She was started on levofloxacin for presumed PNA on [**10-10**]. During her stay on the general medicine service she began to experience multiple episodes of NSVT, which were asymptomatic. On the evening of [**2186-10-11**] she triggered for a 60 beat run of NSVT, and was transferred to the [**Hospital1 1516**]/general cardiology service for further management on [**2186-10-12**]. The patient's arrhythmia was initially managed solely with metoprolol and then an amiodarone drip was started on [**2186-10-13**] at 4AM by nightfloat after the patient had a 60 minute episode of ventricular tachycardia and EP was consulted. They did not want to perform VT ablation in the setting of the patient's possible pneumonia and leukocytosis and recommended stopping the Amiodarone load and continuing the metoprolol. She continued to experience hemodynamically stable NSVT on this regimen and eventually recieved additional doses of lidocaine to help control her episodes of hemodynamically stable NSVT. The lidocaine had limited success and it was felt that Amiodarone may have been contributing to the patient's bradycardia. Eventually EP started quinidine 324mg Q8H on [**2186-10-16**] to try to gain better control of the patient's ventricular tachycardia as they were moving away from a plan to ablate her and wanted to avoid Amiodarone. The patient was transferred back to the CCU on [**2186-10-17**] for monitoring of hemodynamically unstable bradycardia and new onset QT prolongation soon after initiating therapy with Quinidine. She triggered for bradycardia to the 30-40 range and appeared diaphoretic and pale with systolic blood pressures ranging from 70-90 range which was a marked dip from her baseline 120-130 systolic ranges. An EKG revealed a prolonged QTc to 580 with sinus bradycardia. The team stopped quinidine, azithromycin, and metoprolol and gave a one-time dose of atropine and IV magnesium. She was also bolused with 500cc of NS. Soon after quinidine was discontinued the patient's VT eventually stabilized and her electrolytes were closely monitored. While in the CCU the patient's CAD management was continued with daily Aspirin, Plavix, Metoprolol and statin therapy. Mrs. [**Known lastname 80178**] hyponatremia resolved and her earlier bouts of hyponatremic were considered to be secondary to dehydration. PO hydration was encouraged and gentle IVFs were also supplemented. The patient has severe joint deformities secondary to her rheumatoid arthritis. During her CCU stay she was continued on her maintenance steroids with Prednisone daily and her methotrexate medications were held secondary to her acute illness. The patient's low Hct levels were felt to be due to her chronic anemia. An anemia workup was consistent with anemia of chronic disease with mixed Fe-deficiency. During her hospital stay she was given several units of blood and she was continued on iron supplements and folate. In terms of her Alzheimer's type dementia the patient was alert and oriented to person, place and time for the majority of her hospital stay with only minimal prompting on occasion. Initially the patient's Aricept and Namenda were continued but were eventually held as they are shown to cause QTc prolongation and were felt to be dangerous given the patients recent bradycardia and heart block history. The patient's leukocytosis showed only mild improvement while on the CCU service despite continued antibiotics for her PNA. Repeat CXRs showed bilateral patchy infiltrates consistent with possible aspiration and a small consolidation was noted at the patitn's left upper lung lobe. Albuterol and Atrovent nebs were continued PRN for ongoing COPD management as well as additional therapy to help patient with shortness of breath associated with her suspected pneumonia. Mrs.[**Known lastname 80177**] WBC trended down initially. The patient's recent MI may have also contributed to her leukocytosis. She remained afebrile. Ground glass opacities seen at bases on Chest CT seem more likely due to volume overload than infectious infiltrate. Blood/Urine Cultures were unremarkable. WBC was followed closely and there was a small concern for occult malignancy. SPEP was collected and revealed immunoglobulins within normal ranges. A speech and swallow evaluation was done and it was felt that the patient was not a major aspiration risk. On [**2186-10-17**] her PNA coverage was broadened to Vancomycin and Zosyn for presumed HAP as she had persistent WBC elevations while on Levofloxacin coverage. On [**2186-10-19**] the patient began to display worsening shortness of breath and a new development of fluid overload alongside declining oxygen saturation levels. This was felt to be secondary to an acute CHF exacerbation and she was given morphine, nitroglycerin drip and diuresed with Lasix to help manage her CHF. CXRs showed bilateral effusions and physical exam revealed bilateral crackles at the mid-lower lung fields. The patient continued to have progressively worsening PO intake and higher oxygen demands to remain comfortable. The patient lost her peripheral IV access on [**2186-10-21**] and the patient as well as her family expressed that she did not want any more needle sticks for blood draws and the patient did not want any additional IVs. The importance of IV access was explained to the patient and her family. The ability to more easily and quickly treat and respond her worsening CHF with IV Lasix, IV nitroglycerin and pain medications through an IV access route was conveyed to the patient and her family and documented. Despite this attempt to continue IV therapy the patient refused and requested that the team "limit" her medications. At that juncture, Palliative Care was consulted and several family meetings were held. Ultimately, the patient and her family expressed the shared desire to pursue comfort care measures. The patient's medications were reduced to a small list at that point, including SL nitroglycerin PRN, oral morphine liquid solution, oral lasix as tolerated and ipratropium nebulizers PRN. She was switched to Tylenol for control of her painful arthritis symptoms. At time of discharge home with hospice services on [**2186-10-24**] the patient was switched to Morphine 10 mg/5 mL Solution 5-15 mg PO Q2H (every 2 hours) as needed for shortness of breath or wheezing. Medications on Admission: MEDICATIONS: (on admission) metoprolol succinate 12.5mg daily furosemide 20mg daily levothyroxine 112mcg daily prednisone 4mg QAM and 2mg QPM methotrexate 17.5mg every Friday tylenol 1-2 tabs tid etodolac 400mg [**Hospital1 **] cerefolin (vitamin) daily folic acid 1mg daily iron 65mg daily stool softener, dulcolax, and MoM prn claritin 10mg daily detrol LA 4mg daily namenda 10mg daily aricept 5mg daily Natural Tears eye gtt Astelin nasal spray [**Hospital1 **] . Medications on Transfer to the CCU: Metoprolol 50mg [**Hospital1 **] Levofloxacin 750mg q 48hr Lisinopril 5mg daily Lasix 10mg daily Albuterol Ipratroprium Donepezil 5mg po qhs Namenda 10mg daily Ferrous Sulfate 325mg daily Tolterodine 2mg po BID Pantoprazole 40mg Prednisone 2mg qpm & 4mg qam Levothyroxine 112mcg Folic Acid Heparin 5000u sc tid Senna prn Colace 100mg [**Hospital1 **] Aspirin 81mg Plavix 75mg Nasal saline spray Discharge Medications: 1. Morphine 10 mg/5 mL Solution Sig: 5-15 mg PO Q2H (every 2 hours) as needed for shortness of breath or wheezing. Disp:*120 cc* Refills:*0* 2. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-18**] Sprays Nasal TID (3 times a day) as needed. 3. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain, diaphoresis. Disp:*30 Tablet, Sublingual(s)* Refills:*0* 4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN (as needed) as needed for rash. Disp:*1 bottle* Refills:*0* 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 6. Tylenol Arthritis Pain 650 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day as needed for pain. Discharge Disposition: Home With Service Facility: Hospice of the Good [**Doctor Last Name 9995**] Discharge Diagnosis: Coronary Artery Disease Inferior ST Elevation Myocardial Infarction Ventricular Arrhythmia Pneumonia Hyponatremia Dementia Discharge Condition: stable DNR/DNI/CMO Discharge Instructions: You were admitted to the hospital because of chest pain. You were found to be having a small heart attack for which you received two stents. You were found to have some elevated bood counts and liver enzymes that were consistent with a heart attack. You then started having a rapid heart beat (short runs of ventricular tachycardia). Your heart rate became too slow with the medicine used to treat this so it was stopped. . You have decided that you do not wish to have aggressive care that is focused on curing your medical problems. Instead you have indicated that you wish to be kept comfortable and take only medicines that you need for this. We have started morphine to help your breathing. We have stopped most of your medicines. Followup Instructions: Primary care Doctor: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4469**]. [**Street Address(2) **] [**Apartment Address(1) **] [**Hospital3 **] Internal Medicine [**Hospital1 **], [**Numeric Identifier 4474**] Phone: ([**Telephone/Fax (1) 75565**] Fax: ([**Telephone/Fax (1) 74540**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**] Completed by:[**2186-10-24**]

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icd9cm

[ [ [] ] ]

[ "00.66", "00.46", "99.04", "37.23", "36.06", "00.40", "88.56", "38.93" ]

icd9pcs

[ [ [] ] ]

17852, 17930

8545, 16088

274, 352

18097, 18118

5457, 8522

18906, 19373

4849, 4906

17036, 17829

17951, 18076

16114, 17013

18142, 18883

4921, 5438

224, 236

380, 4062

4084, 4373

4389, 4833

67,408

118,358

47724

Discharge summary

report

Admission Date: [**2140-9-27**] Discharge Date: [**2140-10-10**] Date of Birth: [**2080-1-30**] Sex: M Service: MEDICINE Allergies: lisinopril Attending:[**First Name3 (LF) 86897**] Chief Complaint: hypoxemic respiratory failure Major Surgical or Invasive Procedure: Endotracheal intubation Central line A-line History of Present Illness: 60M with newly diagnosed small cell lung cancer, s/p 1st cycle of chemo (cisplation/etoposide [**2060-9-11**]) 2 weeks ago presenting with fever to 101.7 and dyspnea. Endorses mild cough and chest pain. . In the ED inital vitals were, 99.6 108/53 82%. ECG showed sinus tach. CXR showed large pneumonia. He was given vanc, zosyn and tylenol. Requiring NRB. 96%. had been maintaining pressures but then dropped to 80s. Patient did not want central line. He was given a total of 4L NS and BP was in 90s on transfer. On arrival to ICU, pt is comfortable. He states that symptoms of fever, dyspnea and pleuritic chest pain came on relatively suddenly yesterday. He lives alone and has no sick contacts. [**Name (NI) **] has no other symptoms. Past Medical History: Past Medical History: 1. small cell lung cancer: presented with R arm and shoulder pain x 3 weeks and weight loss 15lbs in 4 months. CT on [**2140-9-1**] showed a 11CM RUL mass with mediastinal involvement. Biopsy of Right supraclavicular LN showed small cell lung cancer. MRI brain and PET scan no distant metastasis and his disease is consistent with limited stage small cell lung cancer. Current treatment: concurrent chemoXRT with Cisplatin 80mg/m2 iv day 1 + etoposide 100mg/m2 iv days [**1-18**] every 4 weeks for total 4 cycles with neulasta support. XRT is planned to start on [**2140-9-29**]. 2. Hypertension. 3. History of two colonic polyps removed in [**2137**], and an additional polyp removed in [**2140**]. 4. Multiple oral surgeries, currently with upper and lower dentures. Social History: He smokes 1ppd x40yrs. He was a heavy drinker but has been only drinking ETOH occasionally since 4 months ago. Widower, 4 children. Family History: His father has a history of hypertension and died in his 60s. His mother died in her 70s of unknown causes. There is no known family history of cancer. Physical Exam: Tmax: 37.3 ??????C (99.1 ??????F) Tcurrent: 37.2 ??????C (98.9 ??????F) HR: 84 (81 - 92) bpm BP: 147/65(86) {119/55(74) - 147/70(86)} mmHg RR: 21 (20 - 26) insp/min SpO2: 92% Heart rhythm: SR (Sinus Rhythm) Wgt (current): 64.2 kg (admission): 50.2 kg General Appearance: No acute distress Eyes / Conjunctiva: right sided ptosis, miosis, o/p clear Cardiovascular: (S1: Normal), (S2: Normal) no m/g/r Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Breath Sounds: Rhonchorous: ) Abdominal: Soft, Non-tender, Bowel sounds present Extremities: Right lower extremity edema: absent, Left lower extremity edema: asent, No(t) Cyanosis, No(t) Clubbing Skin: Warm Neurologic: Attentive, Follows simple commands, Responds to: Not assessed, Movement: Not assessed, Tone: Not assessed Discharge Exam: Vitals - Tm:99.7 Tc:99.7 BP: 120/50 HR:87 RR:18 02 sat: 95%RA, I/O: 744/500 GENERAL: Pleasant, thin man. Sitting up comfortably.AAOx3. HEENT: EOMI, PERRLA, anicteric sclera, pink conjunctiva, MMM, OP clear CARDIAC: rapid rate, reg rhythm, S1/S2, no mrg LUNG: Nonlabored on RA. coarse crackles in left lung diffusely ABDOMEN: Thin. nondistended, nontender in all quadrants, no rebound/guarding EXTREMITIES: no cyanosis or clubbing, 1+ edema bilaterally in LE NEURO: CN II-XII intact. No gross motor or sensory loss. Pertinent Results: ADMISSION LABS: [**2140-9-27**] 09:35PM BLOOD WBC-26.0*# RBC-3.83* Hgb-10.4* Hct-29.5* MCV-77* MCH-27.3 MCHC-35.3* RDW-14.6 Plt Ct-609* [**2140-9-27**] 09:35PM BLOOD Neuts-87* Bands-3 Lymphs-4* Monos-2 Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-2* [**2140-9-27**] 09:35PM BLOOD Glucose-130* UreaN-37* Creat-1.5* Na-127* K-4.5 Cl-85* HCO3-27 AnGap-20 [**2140-9-27**] 09:44PM BLOOD Lactate-1.9 [**2140-9-27**] 11:13PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.011 [**2140-9-27**] 11:13PM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [**2140-9-27**] 11:13PM URINE RBC-5* WBC-<1 Bacteri-NONE Yeast-NONE Epi-<1 [**2140-9-27**] 11:13PM URINE CastHy-60* OTHER PERTINENT LABS: JAK2: pending MICROBIOLOGY: [**2140-9-27**] BCx: negative [**2140-9-28**] Legionella Ag: positive [**2140-9-28**] BAL: GNRs, Legionella culture pending [**2140-9-29**] BCx: negative [**2140-9-30**] SputumCx: sparse yeast [**2140-9-30**] BCx: negative [**2140-9-30**] Cdiff: negative [**2140-10-3**] Cdiff: negative STUDIES: [**2140-9-27**] CXR: IMPRESSION: New left mid and lower lung field consolidation highly concerning for pneumonia. Known right apical mass appears slightly decreased in size compared to the prior exam. Trace left pleural effusion. [**2140-9-28**] CT CHEST W/O CONTRAST IMPRESSION: 1. Extensive consolidation involving the majority of the left lung. This is new from [**2140-9-9**] and consistent with extensive pneumonia. Trace left pleural effusion. The majority of opacification is related to consolidation as opposed to effusion. No endobronchial lesion identified. 2. Interval cavitation of known right upper lobe mass. Two additional right lower lobe lesions with cavitation concerning for metastatic deposits. Peripheral to the right upper lobe lesion, additional areas of post-obstructive inflammation/infection or possible lymphangitic carcinomatosis are seen. [**2140-10-3**] LIVER OR GALLBLADDER US (SINGLE ORGAN) IMPRESSION: 1. Normal liver echotexture. No intrahepatic bile duct dilation. 2. New mild abdominal ascites and a small right pleural effusion. DISCHARGE LABS: [**2140-10-10**] 07:00AM BLOOD WBC-12.3* RBC-3.33* Hgb-9.0* Hct-27.6* MCV-83 MCH-27.2 MCHC-32.7 RDW-17.4* Plt Ct-1424* [**2140-10-10**] 07:00AM BLOOD Glucose-104* UreaN-8 Creat-0.6 Na-137 K-4.4 Cl-100 HCO3-29 AnGap-12 [**2140-10-10**] 07:00AM BLOOD ALT-57* AST-44* LD(LDH)-403* AlkPhos-134* TotBili-0.4 [**2140-10-10**] 07:00AM BLOOD Calcium-9.0 Phos-4.0 Mg-1.6 Brief Hospital Course: PRINCIPLE REASON FOR ADMISSION Mr. [**Known lastname **] is a 60 year old man with h/o recently diagnosed SCLC, s/p C1 Cis/Etoposide, who was admitted to the [**Hospital Unit Name 153**] with fever and hypoxemic respiratory failure requiring intubation, found to have Legionella PNA. #. Legionella PNA: Patient was admitted to [**Hospital Unit Name 153**] after presenting to ER with hypoxia hypotension. Patient required intubation and levophed for respiratory and circulatory support. Chest Xray and CT showed extensive pneumonia. Patient was empirically started on vancomycin, zosyn and levofloxacin. Patient was also trreated with flagyl and cefepime during ICU stay. Antiobiotics were narrowed to levofloxacin after bronchial washings and urine were positive for legionella. Patient was successfully extubated and transferred to the OMED floor on standing albuterol and ipratropium. Oxygen was weaned as tolerated and patient was discharged satting mid90s on RA with plan to complete 21 day course of levofloxacin on [**2140-10-19**]. #. Leukocytosis: Patient with impressive leukocytosis during admission, peaking at 53.7 on [**10-3**]. Suspect due to infection and effect of neulasta following chemotherapy. Trended down and was 12.3 at discharge. #. Thrombocytosis: Plt count steadily increased during stay, up to 1449 on [**10-9**]. Etiology was originally attributed to acute phase reactant due to PNA and malignancy. To evaluate for myeloproliferative effect, JAK2 level was measured, and pending at time of discharge. Patient was started on ASA 81 daily. #. SCLC: Patient presented during C1 Cis/Etoposide. Patient underwent 3 fractions XRT as previously planned after transfer to the floor and is to continue follow up with radiaton oncology as outpatient. #. Anemia: HCT trended down after admission to 25.8, and patient was provided 1 unit pRBC in the [**Hospital Unit Name 153**] with appropriate increase. After transfusion, HCT again declined and stabilized around 25. Iron studies were suggestive of anemia of chronic inflammation. However, due to suspicion of iron deficiency driving thrombocytosis, patient was treated with IV iron and transfused another unit pRBCs. Patient noted to have a rash the day prior to discharge, c/w with drug rash, unclear if related to prior [**Name (NI) **] or iron. PO supplementation was discontinued - can be re-evaluated as an outpatient. # LE Edema: Following aggressive fluid ressucitation in the [**Hospital Unit Name 153**], patient developed impressive bilateral LE edema. Patient was treated with IV lasix and compression stockings with good effect. He was discharged on Lasix PO. #. HTN: Home BP medications were held during hospitalization due to sepsis and hypotension. Upon transfer to floor, patient remained normotensive without treatment. On discharge, he was not restarted on his home medications of dyazide and amlodipine. TRANSITIONAL ISSUES - f/u JAK2 - f/u BAL Legionella Culture (sent to state lab) - monitor HCT, consider restarting iron supplementation - f/u LE edema, d/c Lasix prn Medications on Admission: allopurinol 300 mg Tab 1 Tablet(s) by mouth twice a day lorazepam 0.5 mg Tab 1 Tablet(s) by mouth every 6 hours as needed OxyContin 10 mg 12 hr Tab one Tablet(s) by mouth twice a day oxycodone 5 mg Cap 1 to 2 Capsule(s) every 4 to 6 hours as needed zofran 8mg q8 prn compazine 10 q4-6h prn magic mouthwash 15cc q4-6h prn triamterene-hctz 37.5/25 daily amlodipine 10mg daily Discharge Medications: 1. allopurinol 300 mg Tablet Sig: One (1) Tablet PO twice a day. 2. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 3. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for Pain. 4. ondansetron HCl 8 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea. 5. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. 6. magic mouthwash Sig: One (1) treatment every 4-6 hours as needed for mucositis. 7. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 9 days: Take through [**10-19**]. Disp:*9 Tablet(s)* Refills:*0* 8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*0* 9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*0* 10. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. Disp:*60 Tablet(s)* Refills:*0* 11. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 12. oxycodone 20 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO Q12H (every 12 hours). Disp:*60 Tablet Extended Release 12 hr(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary: Legionella Pneumonia Secondary: Small cell lung cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [**Known lastname **], You were admitted to the hospital because you had a bad pneumonia called legionella. You went to the ICU where a tube was placed in your throat to help you breathe and medicines to keep your blood pressures up were used. We started antibiotics and soon you started to feel better. While you were here, your platelets (part of your blood that cause clotting) became very high, so we started you on an baby aspirin. This was likely caused by your infection, but low amounts of iron could also cause it, so we gave you extra iron and a transfusion of blood. Please note the following changes to your medications: START Levaquin 750mg daily through [**10-19**] START Aspirin 81mg daily START Lasix 40mg daily INCREASE Oxycontin to 20mg twice daily START Colace and Senna for constipation STOP Amlodipine and Dyazide. Followup Instructions: Please attend your Radiation Oncology Treatments as previously scheduled [**Hospital Ward Name 332**] Basement Radiation Oncology; [**Hospital1 18**]; [**Hospital Ward Name 516**]; [**Location (un) **]; [**Location (un) 86**]. Please call the oncology office to follow up with Dr. [**First Name (STitle) **] the week of [**2140-10-17**] Phone: [**Telephone/Fax (1) 17667**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 86898**]

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icd9cm

[ [ [] ] ]

[ "38.97", "96.04", "96.72", "92.29", "33.24", "96.6" ]

icd9pcs

[ [ [] ] ]

11025, 11082

6236, 9306

303, 349

11189, 11189

3699, 3699

12242, 12712

2095, 2249

9731, 11002

11103, 11168

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1946, 2079

44,808

140,128

40529

Discharge summary

report

Admission Date: [**2138-7-9**] Discharge Date: [**2138-7-17**] Date of Birth: [**2093-2-12**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 922**] Chief Complaint: Chest Pain/ Abnormal Stress test Major Surgical or Invasive Procedure: [**2138-7-10**] Cardiac catheterization [**2138-7-11**] Coronary artery bypass grafting x2 with left internal mammary to the left anterior descending coronary artery as well as reverse saphenous vein graft from the aorta to the first diagonal coronary artery. 2. Core matrix reconstruction of the pericardium. 3. Endoscopic greater saphenous vein harvesting. History of Present Illness: 45 year old male with no past medical history admitted with chest pain. Per patient he has never had chest pain until about 2 months ago when he started experiencing squeezing chest discomfort that felt like someone was grabbing the left side of his chest. This usually occurred while he was working (he does carpentry work which involves heavy lifting at times) or running. It is sometimes associated with left arm numbness relieved by resting and raising his arm above his head. He has no associated SOB, diaphoresis, nausea, or palpitations. . He went to his PCP for an annual check up in [**Month (only) **] and cholesterol was: CHOL 203 [**2138-5-23**] HDL 47 [**2138-5-23**] LDL 115 [**2138-5-23**] TRIG 204 [**2138-5-23**] . He then was re-evaluated with these episodes of chest pain and underwent an ETT during which he exercised for 11 mins on a [**Doctor First Name **] and was stopped [**3-5**] SOB. The ETT showed some arrhythmia with ventricular couplets that resolved with exercise and upsloping ST depressions inferiorly and laterally that resolved within 80ms. It was reported as "probably negative for ischemia". He called back to his PCP's a few weeks later with continuing reports of chest pain. The PCP was concerned for ongoing angina and ordered a stress echo. Stress ECho on the day of admission which showed Nondiagnostic ST changes and normal LV function at rest but Mid anterseptum and apical septum became moderately hypokinetic with exercise and he had his typical symptoms of arm numbness and chest discomfort during this time. His PCP called him with the results and he reported no chest pain but did however report ongoing arm discomfort off and on during the day - even with rest since the stress test. He was on his way home to [**Location (un) 17927**] from the stress test but the MD advised him to take an aspirin and go to the nearest ER, however patient preferred to come to [**Hospital1 18**]. . In the [**Hospital1 18**] ED patient's initial VS were: 98 97 134/84 16 100%. Exam was unremarkable and patient was having no symptoms. EKG NSR, no stemi, no significant st changes. nl axis. d/w [**Location (un) 2274**] cards who wanted to hold on heparin given normal ekg and flat enzymes with out pain but admit for possible cath in am for concern of unstable angina. Past Medical History: Migraines Social History: Former EMT. Now works construction. Divorced. Has GF, [**Female First Name (un) **]. Lives in [**Location 17927**]. -Tobacco history: Never -ETOH: Rarely -Illicit drugs: Denies IVDU and cocaine use. Family History: No family history of early MI. Colon cancer on dad's side. Physical Exam: VS: T 97.8 HR 82 BP 128/85, RR 18, 96RA GENERAL: Alert, interactive, appropriate, no acute distress. HEENT: Sclera anicteric. MMM. NECK: Supple. JVP flat CARDIAC: RRR, no m/r/g. No thrills, lifts. No S3 or S4. LUNGS: CTAB, no crackles, wheezes, rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. PULSES: Right: DP 2+ Left: DP 2+ Brief Hospital Course: Mr. [**Known lastname 88750**] was admitted on [**2138-7-9**] for Chest pain with positive stress test and was scheduled for next day cardiac catheterization. Cardiac catheterization was demonstrated one vessel disease. The LAD had a proximal 90% stenosis with an aneurysmal section of vessel followed by a 60% stenosis. The 60% stenosis was just prior to the origin of a moderate sided D2. Inability to recanalize the lesion necessitated bypass surgery. Over the course of hospitalization he had no episodes of acute chest pain, dyspnea, palpitations, syncope, or presyncope. His serial cardiac biomarkers remained negative, and his EKG remained unchanged from initial. He was treated with daily 325mg ASA, beta blocker. On [**7-11**] he underwent a coronary artery bypass grafting. Please see the operative note for details. He tolerated the procedure well and was transferred in critical but stable condition to the surgical intensive care unit. He soon was extubated and weaned from pressors. He was transferred to the surgical step down floor. His chest tubes and epicardial wires were removed. He did spike a temperature to 101.3 and was started on Ciprofloxacin for a + UA. Culture was negative so antibiotics were stopped. He contiued to have low grade temperatures and underwent fever workup including infectious disease consult. There was no evidence of infection and he was discharged home on post operative day six as white blood cell count remains normal. Plan for follow up in clinic next week for wound check. Medications on Admission: NONE Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 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. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain, fever. 5. metoprolol tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day): 75 mg three times a day . Disp:*135 Tablet(s)* Refills:*0* 6. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 7. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): check LFT in 1 month . Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 2203**] VNA Discharge Diagnosis: Coronary artery disease s/p CABG Migranes Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with dilaudid and tylenol prn Incisions: Sternal - healing well, no erythema or drainage Leg Right - healing well, no erythema or drainage. Edema none Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr [**Last Name (STitle) 914**] at 7/5 at 2:15 PM Wound check on [**7-22**] at 10:15am [**Hospital **] medical building - cardiac surgery office [**Telephone/Fax (1) 170**] PCP Dr [**Last Name (STitle) 31093**] [**Telephone/Fax (1) 88751**] [**7-23**] at 12noon Your PCP will refer you to a cardiologist when you follow up in the office Please have LFT check in 1 month - PCP office will order and follow up on result as your were started on lipitor **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:[**2138-7-17**]

[ "413.9", "414.01", "346.90", "780.62", "414.11" ]

icd9cm

[ [ [] ] ]

[ "39.61", "37.49", "36.15", "36.11", "88.56" ]

icd9pcs

[ [ [] ] ]

6226, 6285

3754, 5289

341, 703

6371, 6607

7448, 8150

3302, 3362

5344, 6203

6306, 6350

5315, 5321

6631, 7425

3377, 3731

269, 303

731, 3037

3059, 3070

3086, 3286

5,993

183,105

19632

Discharge summary

report

Admission Date: [**2144-9-7**] Discharge Date: [**2144-9-16**] Date of Birth: [**2070-2-17**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 44522**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Bronchoscopy History of Present Illness: Pt is a 74 y/o male with a h/o right RCC s/p nephrectomy ([**2121**]) with subsequent mets to lung s/p xrt and left mainstem bronchus stenting ([**2141**]-[**2143**]) on study chemotx who presents with three days of worsening shortness of breath, productive cough, and fever. He has been dyspneic for months now, but this began to worsen over the past few days. He was to be admitted today for a blood transfusion, but in the [**Hospital **] clinic was found to be tachycardic to 130, hypotensive to the 90's, and hypoxic to 80% on 2l-nc with a temp of 96.6. He was sent to the ED for evaluation. . In the ED, he was in significant respiratory distress and persistently hypoxic, so he was intubated. Dopamine was begun to support his bp. Vanco/levo/flagly were initiated for presumed pneumonia with sepsis. A chest x-ray showed a left mid-lung zone infiltrate and right mid-lung zone increased interstitial markings, no pleural effusions, felt to be consistent with his metastatic disease with a post-obstructive pneumonia. Past Medical History: 1.)Right renal cell carcinoma: diagnosed [**2121**] with nephrectomy in [**2121**], no recurrence until [**2141**] when found to have metastatic disease to lung, underwent xrt then left mainstem bronchial stent with subsequent argon plasma coagulation distal to sent for bleeding friable mucosa. Currently on Sorafenib experimental chemotherapy protocol, started cycle 2 [**8-24**]; CT-chest on [**7-21**] showed progression of disease. 2.)BPH 3.)Nephrolithiasis 4.)Peptic ulcer disease 5.)Squamous cell cancer 6.)Rheumatic fever as a child 7.)Bilateral cataract surgery Social History: Rev [**Known lastname **] is a Jesuit priest and former literature proffersor at [**University/College **]. Family History: His mother died of an MI at 81, and his brother from prostate cancer at 65 Physical Exam: t 97.5, bp 114/66, hr 82, rr 15, spo2 100% gen- intubated, sedated male, looks stated age heent- anicteric sclera, op clear cv- rrr, s1s2, no m/r/g pul- moves air well, diffuse rhonchi, bronchial bs over left lung abd- soft, nd, nabs, no organomegaly back- no sacral edema extrm- no cyanosis/edema, warm/dry nails- no clubbing, no pitting/color changes/indentations neuro- sedated, does not respond to stimuli, cn intact Pertinent Results: [**2144-9-7**] 04:10PM WBC-22.9*# RBC-3.22* HGB-8.6* HCT-27.2* MCV-84 MCH-26.6* MCHC-31.6 RDW-15.9* [**2144-9-7**] 04:10PM NEUTS-92* BANDS-6* LYMPHS-1* MONOS-1* EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2144-9-7**] 04:10PM PT-14.9* PTT-35.6* INR(PT)-1.5 [**2144-9-7**] 04:10PM PLT SMR-VERY HIGH PLT COUNT-887*# [**2144-9-7**] 04:10PM ALBUMIN-2.6* [**2144-9-7**] 04:10PM GLUCOSE-98 UREA N-46* CREAT-1.5* SODIUM-137 POTASSIUM-5.3* CHLORIDE-101 TOTAL CO2-23 ANION GAP-18 [**2144-9-7**] 04:10PM ALT(SGPT)-17 AST(SGOT)-22 ALK PHOS-170* AMYLASE-54 TOT BILI-0.4 [**2144-9-7**] 04:18PM LACTATE-2.5* [**2144-9-7**] 04:45PM URINE GRANULAR-[**2-29**] COARSE & FINE GRANULAR CASTS* HYALINE-0-2 [**2144-9-7**] 04:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-NEG [**2144-9-7**] 09:01PM CALCIUM-6.5* PHOSPHATE-5.0* MAGNESIUM-1.6 ........... CXR [**9-7**] IMPRESSION: Area of consolidation in the left mid lung zone with prominent interstitial markings in the right mid lung zone. The lung findings are consistent with the given history of metastatic disease within the chest with post-obstructive consolidation. ............ EKG [**9-7**] Sinus tachycardia Lateral ST-T changes may be due to myocardial ischemia Repolarization changes may be partly due to rate Low QRS voltages in limb leads Since previous tracing, lateral ST-T wave changes - consider ischemia ............... Renal U/S IMPRESSION: 1. Status post right nephrectomy with no definite mass or fluid collection identified in the nephrectomy bed. 2. Left-sided extra renal pelvis without hydronephrosis or mass. 3. Incidental note is made of gallstones and sludge with questionable gallbladder wall edema. Please correlate with patient's symptoms. If there is clinical concern for cholecystitis, this could be further evaluated with a dedicated gallbladder ultrasound or with HIDA scan. 4. Right pleural effusion. .............. [**2144-9-14**] CT Chest IMPRESSION: Significant interval progression of both metastatic renal cell carcinoma and widespread intrathoracic infection as follows: 1. New large cavitary abscess involving the left lower paraspinal pleural space, probably due to lower lobe bronchopleural fistula. 2. Despite interval decrease in size of a large subcarinal mass (that nevertheless infiltrates and probably occludes the esophagus) and preserved patency of the stented, tumor-encased left main bronchus, increasing right hilar adenopathy and multiple new lung nodules represent increased metastatic burden. 3. Right upper lobe cavity and new multifocal consolidation represents widespread infection. 4. Left bronchial stent is patent but tissue extending from its proximal extent threatens to occlude the right main bronchus .............. [**2144-9-16**] Bronchoscopy INDICATIONS FOR PROCEDURE: Evaluation of airway patency. DESCRIPTION OF PROCEDURE: Lidocaine was instilled through the Reverend [**Known lastname 53197**] endotracheal tube to suppress cough. The patient received sedation per ICU protocol. The bronchoscope was then inserted into the airways and airway inspection was performed at the level of the carina. There was noticed to be significant tumor burden, which was occluding right main stem bronchus. The tumor was partially occluding the left main stem bronchus orifice as well. The bronchoscope was then navigated around the tumor in the left main stem bronchus where the stent was identified, which was widely patent. Distal airways were all patent. Bronchoscope was then carefully navigated around the tumor into the right main stem bronchus, which showed distal patency distal to the proximal tumor occlusion. FINDINGS: 1. Tumor at the level of the carina. 2. Tumor at the level of the carina obstructing right main stem bronchus approximately 80%. 3. Tumor at the main stem carina obstructing the left main stem bronchus approximately 40% to 50%. 4. Stent in left main stem bronchus widely patent. 5. Distal airways, distal to proximal obstruction, patent. SPECIMENS OBTAINED: None. COMPLICATIONS: None. Brief Hospital Course: 74 y/o male with metastatic renal cell carcinoma s/p left mainstem stenting admitted with pneumonia and resultant sepsis and respiratory failure. . #Respiratory failure - Initially the respiratory failure was thought to be d/t either a CAP or postobstructive PNA, and the patient was treated with levofloxacin, vancomycin, and flagyl for possible aspiration PNA. Gram stain showed GPC in prs, chains, and clusters, as well as GNR's. Respiratory culture grew OP flora and moderate growth of beta streptococci, not group B. Metronidazole was stopped and the patient was treated with levofloxacin and vancomycin for a total of 7 days. Addidionally, the patient was wheezy on physical exam and was given albuterol and atrobent nebulizers, as well as steroids in the setting of hypotension and an inadequate [**Last Name (un) 104**] stim. The patient was difficult to wean from the vent, and the ventilator readings suggested an element of resistance. A CT scan was done to assess progression of metastatic RCC, and found cancer had progressed while on sorafenil study drug. A bronchoscopy was performed which showed 80% stenosis of right main and 40-50% stenosis of left main. A discussion was held with the patient's sister, brother, and health care proxy, as well as the BC communinty of priests, and it the decision was made to withhold futher aggressive measures such as stent placement in the right bronchus in the setting of known progression of disease. This decision was made taking into account the best interests of the patient and his presumed wishes. Antiobiotics and steroids were stopped, and the patient was extubated at 1 p.m. on [**9-16**] with family and friends present. Morphine was started prior to extubation and titrated to patient comfort. The patient slowly become hypoxic with hypertension and tachycardia. Over the course of four hours his respirations slowed, he became progressively hypoxia and hypotension ensued. Approximately 15 close family and friends were present, praying and playing music, and the patient expired surrounded by loved ones. . #Sepsis - The patient presented with an elevated white count, fevers, tachycardia, tachypnea, and hypotension. Fluid boluses and phenylephrine were used to maintain MAP >65. After adequate fluid resuscitation, the patient's pressure stabalized. However, he had sustained Aflutter causing hypotension and levophed was needed until the Aflutter was controlled/resolved (see below). After resolution of Aflutter, the patient remained normotensive until his death. The white count trended down, he became afebrile, and gram stain of blood cultures was negative and there was no growth on blood cultures. On the day of his death antibiotics and steroids were stopped. . #Metastatic RCC - Interval progression on CT of [**2144-9-14**] with new pulmonary nodules and cavitary lesions. Bronchoscopy showed evidence of right bronchus stenosis of 80% and left bronchus stenosis of 40-50%. Hem/Onc spoke with the patient/family/health care proxy and were unable to offer any further treatment options. With the known progression of disease while on study drug, the decision was made to make the patient CMO. The patient was extubated as above. . #Aflutter - The patient had no history of Aflutter prior to this hospital admission. Initially the flutter was controlled intermittently with IV Lopressor and diltiazem, but was unsuccessful. Amiodarone was started transiently but stopped per recommendation of cardiology d/t it's ability to make Aflutter worse. D/C cardioversion was attempted and successful, but the patient only remained in NSR for approx 36 hrs. A diltiazem drip was started for rate control, and this was successful. The patient was transitioned to PO dilt and was not tachycardic until after extubation. . #ARF - Initially renal failure was thought to be due to prerenal etiology, and FENA was consistent with this. However, renal funciton continued to worsen and urine was spun and muddy brown casts were seen, leading to a diagnosis of ATN. Renogel was started for an elevated phosphorous, and renal followed the patient daily. No indication for HD and no further intervention. . #FEN - Patient had an OGT in place and he received TF's with little residuals. The OGT was d/c'd when the patient was extubated. . #Access - right ij . #Comm -- with hcp, father [**Name (NI) **], phone # [**Telephone/Fax (1) 53198**] Medications on Admission: Doxazosin Ranitidine Zolpidem Lorazepam Albuterol Flunisolide Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Metastatic renal cell carcinoma Pneumonia Discharge Condition: Deceased Discharge Instructions: None Followup Instructions: None

[ "427.5", "427.32", "584.5", "038.9", "785.52", "197.0", "510.0", "518.84", "V10.52", "507.0", "486" ]

icd9cm

[ [ [] ] ]

[ "99.62", "99.04", "33.22", "96.72", "00.17", "96.6", "96.04" ]

icd9pcs

[ [ [] ] ]

11389, 11398

6816, 11248

335, 349

11483, 11493

2679, 6793

11546, 11553

2147, 2223

11360, 11366

11419, 11462

11274, 11337

11517, 11523

2238, 2660

276, 297

377, 1409

1431, 2005

2021, 2131

533

100,009

21119

Discharge summary

report

Admission Date: [**2162-5-16**] Discharge Date: [**2162-5-21**] Date of Birth: [**2101-7-30**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1505**] Chief Complaint: Angina Major Surgical or Invasive Procedure: [**2162-5-17**]: CABGx4 LIMA-> LAD, RSVG-> Diagonal, Posterior Descending Artery, Obtuse marginal [**2162-5-19**]: Right Atrial lead placement History of Present Illness: 60yo man with known coronary disease (AMI in [**2143**] and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LCx [**2155**]). Doing well until last week when he developed angina initially with exertion then progressed to rest angina. Each episode was releived with SL NTG, no episode lasting more than 5 minutes. He presented to cardiologist for treatment. He was admitted to MWMC, a cardiac catheterization revealed 3 vessel disease. He was transferred to [**Hospital1 18**] for coronary bypass grafting. Cardiac Catheterization: Date: [**2162-5-11**] Place: MWMC -LAD- chronic total occlusion proximally(distal filling via collaterals) -RCA- chronic total occlusion of non-dominant RCA 90% -LCx- new complex 90% stenosis of prox LCx involving the bifurcation of the LCx proper and large OM2. Old stent in LCx is widely patent -mod LV systolic dysfx, with anterior, apical, and infero-apical AK and reduced EF 30% LVEDP 36mmHg No valvular dz Past Medical History: CAD-(AMI [**2143-7-3**], [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LCx [**6-/2155**]) Cardiomyopathy- EF 35-45% depending on study Ventricular tachycardia s/p AICD [**8-/2155**] Atrial flutter s/p ablation [**8-/2155**] Hypertension Dyslipidemia Insulin dependent diabetes Mellitus Obesity Conduction disease-LAFB Peripheral vascular disease s/p Right fem-[**Doctor Last Name **] bypas [**3-/2161**] Left leg claudication Right thigh tumor s/p radiation and excision [**2141**]'s Social History: Race: caucasian Last Dental Exam: Lives with: wife Occupation: [**Name2 (NI) 56028**] owns company Tobacco: 2ppd x20 yrs quit [**2143**] ETOH: occaisional Family History: Father died 50yo cirrhosis, mother died 42yo MI Physical Exam: Pulse: 58 Resp: 16 O2 sat: 97%-RA B/P Right: 124/76 Left: Height: 5'[**62**]" Weight: 259 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema -none Varicosities: None [x]. Well healed right vein harvest site. Neuro: Grossly intact Pulses: Femoral Right: +2 Left:+2 DP Right:+2 Left:+2 PT [**Name (NI) 167**]: +2 Left:+2 Radial Right: +2 Left:+2 Carotid Bruit none Right: +2 Left:+2 Pertinent Results: [**2162-5-17**]: Prebypass The left atrium is dilated. No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. No spontaneous echo contrast is seen in the body of the right atrium. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity is severely dilated. There is moderate regional left ventricular systolic dysfunction with hypokinesis of the apex and septum. Overall left ventricular systolic function is mildly depressed (LVEF=30-35%). The estimated cardiac index is depressed (<2.0L/min/m2). Focal abnormalities are seen in the mid and apical anteroseptal wall, apical anterior wall, mid and apical inferoseptal wall, apical inferior wall. NO thrombus was seen in LV apex. Right ventricular chamber size and free wall motion are normal. The descending thoracic aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened with focal calcification of the non-coronary cusp which moves poorly. There is a minimally increased gradient consistent with minimal aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**1-3**]+) mitral regurgitation is seen. There is no mitral valve prolapse or flail segments. There is no pericardial effusion. Postbypass The patient is A-paced and on a phenylephrine infusion. Biventricular systolic function is unchanged. Mitral regurgitation remains mild-to-moderate. The thoracic aorta is intact post decannulation. [**2162-5-20**] 05:00AM BLOOD WBC-10.9 RBC-3.73* Hgb-11.2* Hct-31.7* MCV-85 MCH-30.1 MCHC-35.4* RDW-13.9 Plt Ct-114* [**2162-5-20**] 05:00AM BLOOD Glucose-151* UreaN-19 Creat-0.7 Na-135 K-3.9 Cl-100 HCO3-28 AnGap-11 [**2162-5-16**] 05:00PM BLOOD ALT-66* AST-55* LD(LDH)-206 AlkPhos-73 TotBili-0.3 Brief Hospital Course: The patient was admitted to the hospital and brought to the operating room on [**2162-5-17**] where the patient underwent Coronary artery bypass graft x 4. See operative note for details. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The Electrophysiology team was consulted now due to non capturing atrial lead after permanent pacemaker was initially interrogated and epicardial wires were removed. Ventricular lead and ICD were functioning appropriately. The right atrial lead was revised on [**5-19**] without complication. He is to follow up the device clinic at [**Hospital1 **] in 2 weeks - operative note was given to patient to bring to follow up appointment. The patient was neurologically intact and hemodynamically stable on no inotropic or vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. Lisinopril was restarted for better blood pressure. The patient was transferred to the telemetry floor for further recovery. Chest tubes were discontinued without complication on post operative day 3. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 4 the patient was ambulating freely, the sternal and pacer pocket wound was healing and pain was controlled with oral analgesics. He is to continue on 1 week of antibiotics per EP s/p atrial lead placement. The patient was discharged home with VNA services in good condition with appropriate follow up instructions. All follow up appointments were arranged. Medications on Admission: Lisinopril 20' Atenolol 100' Vytorin [**10/2131**] QHS Fenofibrate 200' ASA 325' NTG-sl/PRN Insulin-NPH 22u QAM/24u QPM- followed by [**Last Name (un) **] Insulin- Humalog SS MVI Calcium 600' Plavix - last dose:[**2162-5-12**] Allergies: NKDA Discharge Medications: 1. fenofibrate 160 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 2. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 3. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*1* 4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*100 Tablet(s)* Refills:*0* 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 7. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*65 Tablet(s)* Refills:*0* 9. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 10. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 7 days. Disp:*28 Capsule(s)* Refills:*0* 11. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* 12. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO once a day for 7 days. Disp:*7 Tablet, ER Particles/Crystals(s)* Refills:*0* 13. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 14. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 15. NPH insulin human recomb 100 unit/mL Suspension Sig: One (1) Subcutaneous twice a day: Take 22 units in AM and 24 units in PM. Disp:*QS 1 month * Refills:*0* 16. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 1110**] VNA Discharge Diagnosis: Coronary Artery Disease CAD-(AMI [**2143-7-3**], [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LCx [**6-/2155**]),Cardiomyopathy- EF 35-45% Ventricular tachycardia s/p AICD [**8-/2155**], Atrial flutter s/p ablation [**8-/2155**], Hypertension, Dyslipidemia,Insulin dependent diabetes Mellitus, Obesity, Conduction disease-LAFB, Peripheral vascular disease s/p Right fem-[**Doctor Last Name **] bypas [**3-/2161**], Left leg claudication, Right thigh tumor s/p radiation and excision [**2141**]'s Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Percocet Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. 1+ Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr [**Last Name (STitle) **] on [**6-10**] at 1:45pm [**Telephone/Fax (1) 170**] Cardiologist: Dr. [**Last Name (STitle) 1295**] on [**6-14**] at 3:30pm EP [**Hospital 19721**] Clinic at [**Hospital1 **] in [**1-3**] weeks: Call for appointment - [**Telephone/Fax (1) 6256**] Wound check appointment in [**Hospital **] Medical office building [**Telephone/Fax (1) 170**] Date/Time:[**2162-5-26**] 12:00 Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) 27187**] in [**4-6**] weeks [**Telephone/Fax (1) 3658**] Follow up with [**Hospital **] [**Hospital 982**] Clinic to be arranged by patient **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:[**2162-5-24**]

[ "285.9", "V15.3", "401.9", "426.2", "440.21", "V58.67", "414.2", "278.00", "996.04", "250.00", "V45.82", "414.8", "V15.82", "272.0", "411.1", "414.01", "V45.02", "V85.35" ]

icd9cm

[ [ [] ] ]

[ "39.61", "37.95", "36.15", "36.13" ]

icd9pcs

[ [ [] ] ]

8722, 8781

4786, 6542

317, 462

9334, 9551

2914, 4763

10391, 11276

2156, 2206

6838, 8699

8802, 9313

6568, 6815

9575, 10368

2221, 2895

271, 279

490, 1447

1469, 1967

1983, 2140

10,872

155,973

17121

Discharge summary

report

Admission Date: [**2109-6-24**] Discharge Date: [**2109-7-10**] Date of Birth: [**2049-9-6**] Sex: M Service: MEDICINE/[**Doctor Last Name 1181**] B HISTORY OF PRESENT ILLNESS: The patient is a 59 year-old male with a past medical history significant for coronary artery disease status post myocardial infarction, obstructive sleep apnea, hypertension and chronic obstructive pulmonary disease who presented to outside [**Hospital3 3583**] with two day history of malaise, shortness of breath, and right leg pain. On the day of admission to outside hospital, the patient was two weak to get off of couch with increased shortness of breath and EMS found the patient cool, dry and cyanotic with O2 sats at 50% on room air. At outside hospital Emergency Department the patient received intravenous Solu-Medrol, Zithromax, Lasix, Etomidate, Lidocaine and Lovenox. Initial arterial blood gas 7.13/104/88. The patient became hypotensive subsequently suffered PEA arrest. The patient was resuscitated with Dopamine, epinephrine times five, atropine times three and started on a Levophed drip after he was intubated. The patient was then transferred to [**Hospital1 1444**] for further management. In the Emergency Room the patient was weaned off of the Levophed and arterial blood gas was 7.45/36/140 on FIO2 of 100%. PAST MEDICAL HISTORY: 1. Coronary artery disease status post myocardial infarction. 2. Hypertension. 3. Obstructive sleep apnea. 4. Chronic dermatitis. 5. Chronic obstructive pulmonary disease. ALLERGIES: Penicillin, sulfa, Glucophage. MEDICATIONS ON ADMISSION: 1. Aspirin 325 mg po q.d. 2. Norvasc 10 mg po q.d. 3. Isosorbide dinitrate 120 mg po q.d. 4. Actos 15 mg po q.d. 5. Nitroglycerin tab prn. PHYSICAL EXAMINATION ON ADMISSION: Temperature 102.6, blood pressure 130/74, pulse 106, respirations 16. In general, the patient was sedated, but responsive to pain in moderate distress. HEENT pupils are equal, round and reactive to light. Sclera were anicteric. Mucous membranes are moist. Neck supple, nontender, no JVD. Chest end expiratory wheezes in left lower lobe, bilateral basilar crackles. Cardiovascular regular rate and rhythm, normal S1 and S2. No murmurs, rubs or gallops. Abdomen obese, soft, nontender, nondistended, normoactive bowel sounds. Extremities 1+ edema bilaterally, nonpitting, +2 dorsalis pedis pulses bilaterally. No cyanosis. LABORATORIES ON ADMISSION: White blood cell count 12.4 with a differential of neutrophils 93%, 0 bands, 6% lymphocytes, hematocrit 37.2, platelets 223, sodium 139, potassium 4.7, chloride 99, bicarb 21, BUN 67, creatinine 2.5, glucose 350. Calcium 7.6, magnesium 1.8, phosphorus 4.7. CPK initially 652 then 684 and then 693 and then 584. CKMB initially 8% and then 5% and then 4% and then 3%. Troponin initially 7.3, then 8.3 and then 9.0. PT 15.6, PTT 35.0, INR 1.6. Urinalysis leukocyte esterase moderate, blood large, nitrate negative, negative glucose, white blood cell greater then 50, red blood cell 11 to 20. Chest x-ray on admission alveolar edema, left lower lobe infiltrate/effusion. Electrocardiogram on admission right bundle branch block, which is old, 1 to [**Street Address(2) 1766**] elevations in V1 to V4 with normalized T wave V1 to V4. HOSPITAL COURSE: 1. Respiratory failure: The etiology thought to be secondary to congestive heart failure from myocardial infarction versus questionable pneumonia versus PE with right bundle branch block and ST elevations. The patient was diuresed and started on heparin for suspicion of PE. CT on [**6-25**] was negative for PE and heparin was discontinued. It was suspected that cardiac ischemia was leading to congestive heart failure possibly secondary to obesity hypoventilation syndrome. Bronchoscopy showed erythematous airways, mucous plugging was suctioned from the right, BAL showed gram positive cocci in pairs and Vanc. Vanc was started for possible staph pneumonia along with Levaquin and Flagyl. The patient was extubated on [**6-28**]. On [**6-29**], the patient desatted to 78% and was thought to be secondary to mucous plugging (the patient is on CPAP at home for sleep apnea). The patient continued to have a significant oxygen requirement throughout his stay in the MICU. The patient was also fluid overloaded and significantly diuresed after 5 liters of diuresis. Oxygenation subsequently improved and the patient was weaned to O2 nasal cannula. Vancomycin was discontinued on [**7-4**]. On transfer to the floor the patient remained on BiPAP (15/8) for obstructive sleep apnea and was maintained on 5 liters shovel mask. The patient maintained saturations between 94 to 97% on 5 liters shovel mask throughout his stay on the floor with no further episodes of respiratory distress. 2. Cardiac: The patient most probably suffered an acute myocardial infarction with troponin elevated and ST elevations on electrocardiogram in leads V3 and V4 upon transfer to [**Hospital1 346**]. The patient was started on heparin and beta blocker and troponins were cycled. CKs trended downward after admission and a non Q wave myocardial infarction was thought to be due to demand ischemia. In additional thought at the time that the patient's respiratory failure was due to congestive heart failure secondary to an myocardial infarction. Throughout the patient's stay at the MICU the patient was persistently tachycardic and hypertensive secondary to pain. Cardiac consult on [**2109-7-4**] suggested concern for an left anterior descending coronary artery occlusion since significant electrocardiogram findings and from history. Cardiologist recommended catheterization and continued diuresis. Catheterization on [**2109-7-4**] showed 80% stenosis in the mid left anterior descending coronary artery, 70% stenosis at the second diagonal and 70% lesion in the OMI and 40% in the mid right coronary artery. The patient successfully underwent stenting of the left anterior descending coronary artery. On the last two days of MICU stay the patient had several episodes of six beat runs of nonsustained ventricular tachycardia, but was asymptomatic. On arrival to the floor the patient had only one episode of six beat run of nonsustained ventricular tachycardia also asymptomatic. The patient complained of chest pain once, but was relieve with Maalox. The patient otherwise remained stable cardiac wise upon discharge. 3. Renal: The patient had increased BUN and creatinine of 67 and 2.5 on admission, which improved throughout the hospital course and currently is 1.0. Acute renal failure was most likely due secondary to acute tubular necrosis in the setting of his myocardial infarction. At one point during MICU stay creatinine improved to 0.4, but then trended gradually upward secondary to diuresis. 4. Gastrointestinal: The patient had increased AST of 1760 and increased ALT of 1361 on admission. Increased transaminases were most likely secondary to shock liver. Liver enzymes trended downward and remained stable after transfer to the medicine floor. 5. Congestive heart failure: The patient most likely has congestive heart failure secondary to myocardial infarction. The patient was significantly diuresed in the MICU and was considered to be dry on arrival to the floor. Diuretics were held for two days and the patient was restarted on po 40 mg Lasix dose prior to discharge. The patient diuresed well throughout hospital stay. 6. Gout: The patient had left and right hand swelling during MICU stay thought may be secondary to gout flare. The patient was started on Vioxx at 50 mg for three days and then decreased to 25 mg a day. The patient continues to have gouty pain in his right and left lower extremity and feet. We continued Vioxx for several days to alleviate gouty pain. Should most likely discontinue Vioxx one to two days after discharge. 7. Dermitis: The patient had swelling and erythema and dermatitis changes consistent with his chronic dermitis. Dermatology was consulted and recommended betamethasone times fourteen days. The patient still has a seven day course remaining. 8. Anemia: The patient's hematocrit remained stable and above 31 to 32 after transfer to the floor. The patient had transfusion criteria transfused less then 30 secondary to cardiac disease. 9. Physical therapy: Physical therapy was consulted for mobility and strength training after transfer to the floor. Physical therapy recommended transfer to rehab. 10. Deep venous thrombosis prophylaxis: The patient was started on subcutaneous heparin and given Pneumoboots. DISCHARGE DIAGNOSES: 1. Acute myocardial infarction. 2. Congestive heart failure. 3. Bacterial pneumonia. 4. Coronary artery disease. 5. Obstructive sleep apnea 6. Gout. DISCHARGE MEDICATIONS: 1. Lasix 40 mg po q.d. 2. Diltiazem extended release 180 mg po q.d. 3. Isosorbide mononitrate extended release 10 mg po q.d. 4. Atenolol 75 mg po b.i.d. 5. Lisinopril 30 mg po q.d. 6. Vioxx 25 mg po q.d. 7. Ipratropium bromide inhaler q 6 hours. 8. Albuterol nebulizer q 6 hours. 9. Plavix 75 mg po q.d. 10. Pravastatin 20 mg po q.d. 11. Protonix 40 mg po q.d. 12. Betamethasone ointment b.i.d. 13. Terbinafine 1% cream q.d. 14. Colace 100 mg po b.i.d. 15. Albuterol ipratropium inhaler three to four puffs q 4 hours prn. 16. Sliding scale insulin. 17. Aspirin 325 mg po q.d. FOLLOW UP PLANS: The patient should follow up with primary care physician in two weeks. The patient should follow up with outpatient cardiologist for EP studies to workup nonsustained ventricular tachycardia, arrhythmias. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**] Dictated By:[**Doctor Last Name 48088**] MEDQUIST36 D: [**2109-7-10**] 09:10 T: [**2109-7-10**] 09:20 JOB#: [**Job Number 48089**]

[ "507.0", "496", "428.0", "427.1", "410.71", "780.57", "518.81", "482.41", "584.5" ]

icd9cm

[ [ [] ] ]

[ "38.93", "36.07", "37.23", "96.71", "99.20", "33.24", "96.04", "36.01", "88.56" ]

icd9pcs

[ [ [] ] ]

8639, 8795

8818, 9875

1609, 1775

3303, 8341

8360, 8618

199, 1339

2449, 3285

1361, 1583

53,321

172,393

44031

Discharge summary

report

Admission Date: [**2118-12-5**] Discharge Date: [**2118-12-13**] Date of Birth: [**2040-4-6**] Sex: F Service: NEUROSURGERY Allergies: Tegretol Attending:[**First Name3 (LF) 1835**] Chief Complaint: mental status changes Major Surgical or Invasive Procedure: [**2118-12-6**]: stereotactic brain biopsy [**2118-12-6**]: IVC Filter placement History of Present Illness: This is an 78 year old woman with a history of metastatic breast cancer who was experiencing trigeminal neuralgia. The son reports she complained of left cheek pain so severe that she could not eat and loss about 30lbs in 6 weeks. She underwent ablation on [**11-25**] which yielded no relief, she then underwent a L infraorbital V2 neurectomy also at [**Hospital3 2358**]. She was discharged to her nursing facility 3 days ago. She was noted to be more confused and had difficulty with speech. A MRI Brain from [**10/2118**] did not show any lesion or infection. The son denies any knowledge of a fever. Past Medical History: Breast Cancer s/p mastectomy, w/mets (liver lesions seen on last staging imaging but patient did not want to biopsy). Stroke [**2117-12-11**] MS [**First Name (Titles) 94549**] [**Last Name (Titles) 2325**] bundle branch block Dysphagia Social History: Lives in a nursing facility, son [**Name (NI) **] is the [**Name (NI) 3508**] can be reached at [**Telephone/Fax (1) 94550**]. Married, husband is currently in hospice secondary to a stroke suffered about a year ago. Family History: NC Physical Exam: On Admission: O: T: 98.3 BP: 137/71 HR: 85 R 16 O2Sats 98% on 2L Gen: WD/WN, comfortable, NAD. HEENT: Left lip bruising- per son this was from surgical tape removal Extrem: Warm and well-perfused. cooperative with exam, normal affect. Neuro: Mental status: Awake and alert, unable to participate fully in exam Orientation: Unable to assess secondary to aphasia Language: Expressive aphasia, nonsensical speech Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 2 to 1.5 mm bilaterally. III, IV, VI: Extraocular movements appear intact but difficult to fully assess given level of participation V, VII: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-labial flattening/ + bruising VIII: Hearing appears to be intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Unable to assess XII: Tongue midline Motor: MAE- BUE purposeful/ antigravity/ grasps appear full as well as biceps. BLE antigravity L > R. No pronator drift Sensation: Intact to light touch PHYSICAL EXAM UPON DISCHARGE: EO voice, expressive aphasic, able to say name then perseverates PERRL, + commands with all 4 with good strength Pertinent Results: [**12-6**] LENIS- IMPRESSION: 1. Extensive occlusive thrombosis involving the right lower extremity deep veins extending from the calf veins to the level of the common femoral vein. 2. No DVT in the left lower extremity deep veins. [**12-7**] NCHCT- IMPRESSION: High density demonstrated in the region of the known ring-enhancing lesion centered in the left temporal lobe compatible with a component of post-biopsy parenchymal hemorrhage. There is a larger region of high attenuation throughout the left temporal lobe which either may represent delayed hyperenhancement and/or a component of hemorrhage. If of clinical concern, MR can be obtained for differentiation. [**12-8**] Head CT /c contrast: IMPRESSION: Persistent though collapsed area of rim enhancement demonstrated with central hypoattenuation and surrounding edema centered within the left temporal lobe after known aspiration. No evidence of interval hemorrhage. [**2118-12-7**] CXR Small left pleural effusion is unchanged. No lung opacities of concern. Top normal heart size. Mediastinal and hilar contours are unchanged. Moderate atherosclerotic calcification in aortic arch is present. A skinfold in the right upper lateral lung should not be confused for pneumothorax. Focal dense calcification in the left lateral aspect of upper neck is probably within the carotid artery. The study and the report were reviewed by the staff radiologist. [**2118-12-8**] PICC placement 1. Left PICC with tip 2 cm beyond the superior cavoatrial junction. This finding was discussed with [**Doctor Last Name 2048**] of IV nursing by Dr. [**First Name (STitle) **] at 10:40 on [**2118-12-8**]. 2. Small left pleural effusion [**2118-12-9**] Video Swallow 1. Silent aspiration with thin liquids. 2. Intermittent penetration with nectar-thick liquids. [**2118-12-6**] Abcess GRAM STAIN (Final [**2118-12-6**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND IN SHORT CHAINS. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S). WOUND CULTURE (Preliminary): Due to mixed bacterial types (>=3) an abbreviated workup is performed; P.aeruginosa, S.aureus and beta strep. are reported if present. Susceptibility will be performed on P.aeruginosa and S.aureus if sparse growth or greater.. HAEMOPHILUS SPECIES NOT INFLUENZAE. MODERATE GROWTH. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # 337-5158L [**2118-12-6**]. STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP. MODERATE GROWTH. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # 337-5158L [**2118-12-6**]. VIRIDANS STREPTOCOCCI. SPARSE GROWTH. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # 337-5158L [**2118-12-6**]. EIKENELLA CORRODENS. MODERATE GROWTH PRESUMPTIVE IDENTIFICATION. IDENTIFICATION PERFORMED ON CULTURE # 337-5158L [**2118-12-6**]. VIRIDANS STREPTOCOCCI. SPARSE GROWTH. SECOND MORPHOLOGY. GRAM POSITIVE RODS. RARE GROWTH. CORYNEFORM BACILLI, UNABLE TO FURTHER IDENTIFY. IDENTIFICATION PERFORMED ON CULTURE # 337-5158L [**2118-12-6**]. ANAEROBIC CULTURE (Final [**2118-12-12**]): FUSOBACTERIUM NUCLEATUM. MODERATE GROWTH. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # 337-5158L [**2118-12-6**]. PREVOTELLA SPECIES. MODERATE GROWTH. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # 337-5158L [**2118-12-6**]. ACID FAST SMEAR (Final [**2118-12-7**]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final [**2118-12-7**]): NO FUNGAL ELEMENTS SEEN. ACID FAST CULTURE (Preliminary): [**2118-12-6**] swab GRAM STAIN (Final [**2118-12-6**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND IN SHORT CHAINS. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S). Reported to and read back by [**Doctor First Name 3239**] [**Doctor Last Name **] @0824, [**2118-12-7**]. WOUND CULTURE (Final [**2118-12-12**]): Due to mixed bacterial types (>=3) an abbreviated workup is performed; P.aeruginosa, S.aureus and beta strep. are reported if present. Susceptibility will be performed on P.aeruginosa and S.aureus if sparse growth or greater.. Susceptibility testing requested by DR. [**Last Name (STitle) 32437**] #[**Numeric Identifier 19455**] [**2118-12-10**]. HAEMOPHILUS SPECIES NOT INFLUENZAE. SPARSE GROWTH. BETA LACTAMASE POSITIVE. STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP. HEAVY GROWTH. Sensitivity testing performed by Sensititre. SENSITIVE TO CLINDAMYCIN MIC <= 0.12MCG/ML. VIRIDANS STREPTOCOCCI. SPARSE GROWTH. CLINDAMYCIN <=0.12 MCG/ML . EIKENELLA CORRODENS. MODERATE GROWTH. PRESUMPTIVE IDENTIFICATION. GRAM POSITIVE RODS. SPARSE GROWTH. CORYNEFORM BACILLI, UNABLE TO FURTHER IDENTIFY. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP | VIRIDANS STREPTOCOCCI | | CLINDAMYCIN----------- S S ERYTHROMYCIN----------<=0.25 S <=0.25 S PENICILLIN G----------<=0.06 S 1 I VANCOMYCIN------------ <=1 S <=1 S ANAEROBIC CULTURE (Final [**2118-12-12**]): FUSOBACTERIUM NUCLEATUM. MODERATE GROWTH. BETA LACTAMASE NEGATIVE. PREVOTELLA SPECIES. MODERATE GROWTH. BETA LACTAMASE POSITIVE. ACID FAST SMEAR (Final [**2118-12-7**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): A swab is not the optimal specimen for recovery of mycobacteria or filamentous fungi. A negative result should be interpreted with caution. Whenever possible tissue biopsy or aspirated fluid should be submitted. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. A swab is not the optimal specimen for recovery of mycobacteria or filamentous fungi. A negative result should be interpreted with caution. Whenever possible tissue biopsy or aspirated fluid should be submitted. POTASSIUM HYDROXIDE PREPARATION (Final [**2118-12-6**]): Test cancelled by laboratory. PATIENT CREDITED. Inappropriate specimen collection (swab) for Fungal Smear (KOH). Brief Hospital Course: This is a 78 year old woman was admitted to the neurosurgery service on [**2118-12-5**]. A family meeting was held to discuss goals of care. It was decided to perform a brain biopsy to further assess this temporal lesion. Lower extremity duplexes were also performed revealing an extensive clot in her right leg. The family also agreed to IVC filter placement. Preoperative labs and studies were ordered including an infectious work up. On [**12-7**] she underwent IVC Filter placement and a brain biopsy/aspiration. This was without complication. She was extubated post operatively and started on triple antibiotics. Post op Head CT revealed no hemorrhage. Head CT with contrast on [**12-8**] revealed partial resolution of abscess with peristent edema. She was neurologically stable and afebrile. ID was consulted and recommended increasing the doses of her antibiotics. A PICC line was requested in anticipation of long term antibiotics and lack of venous access. On [**12-9**] she was again stable therefore she was cleared for transfer to the stepdown unit and a slow decadron taper was ordered. It was recommended that she be started on anticoagulation treatment for her DVT therfore she was started on Lovenox and ASA 81mg. On [**12-11**],The patient exam was stable. The patient is alert to name but dysphasic, eyes are open spontaneously, follows commands with promting. The patient will move toes and lift legs off the bed to command. The patient is purposeful with upper extremities and strength is full although pt does not participate in isolated muscle motor exam. Infectious disease recommended discontinuation of vancomycin, initiation of CeftriaXONE 2 gm IV Q12H, and continuation of MetRONIDAZOLE (FLagyl) 500 mg IV Q8H. Infectious disease would also like to have the patient follow up with them in 4 weeks with a MRI Brain with and without contrast. The patient's son and health care proxy was updated over the telephone regarding the infectious disease recommendations and changes to the antibiotics. The patient was anxious throughout the day and given 0.5 ativan with good relief of anxiety. Serum magnesium and postassium were low and were repleated. She was hypertensive to 180's on [**2118-12-11**] but responded well to lopressor and hydralazine. She was afebrile and neurologically unchanged on [**12-12**]. She had an MRI brain on [**12-13**] and was being prepared for transfer to rehab. Her MRI showed no acute abnormalities, her exam was stable, and she was deemed fit for transfer to rehab on the morning of [**2118-12-13**]. Medications on Admission: Valium 5mg PRN, Miralax 17gm Daily, Omeprazole 20mg QD, Metoprolol 12.5mg QD, Amitripyline 25mg QHS, Carbamazepine 100mg [**Hospital1 **], Senna 2 tabs QHS, Exemestane 25mg QD, Vit C 1000mg [**Hospital1 **] Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever. 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. senna 8.6 mg Capsule Sig: One (1) Tablet PO HS (at bedtime). 4. ascorbic acid 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. exemestane 25 mg Tablet Sig: One (1) Tablet PO Daily (). 6. insulin regular human 100 unit/mL Solution Sig: sliding scale Injection ASDIR (AS DIRECTED). 7. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 9. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 10. enoxaparin 60 mg/0.6 mL Syringe Sig: Fifty (50) mg Subcutaneous Q12H (every 12 hours). 11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 12. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 13. quetiapine 25 mg Tablet Sig: 0.5 Tablet PO QHS (once a day (at bedtime)) as needed for insomnia. 14. dexamethasone 0.5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) for 1 days: 0800,1400,[**2106**] dosing. [**2118-12-13**] is last day. 15. metronidazole in NaCl (iso-os) 500 mg/100 mL Piggyback Sig: Five Hundred (500) mg Intravenous Q8H (every 8 hours): continue until f/u with [**Hospital **] clinic. 16. ceftriaxone in dextrose,iso-os 2 gram/50 mL Piggyback Sig: Two (2) gm Intravenous Q12H (every 12 hours): continue until f/u with [**Hospital **] clinic. 17. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush. Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital - [**Hospital1 8**] Discharge Diagnosis: Brain Abscess right lower extremity DVT Hypertension Discharge Condition: Awake and alert. Aphasic. Moves all extremities spontaneously. Follows simple commands. Discharge Instructions: General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You have dissolvable sutures so you may wash your hair and get your incision wet day 3 after surgery. You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? You are on ASA and Lovenox for DVT treatment. This should be continued for 3-6 months. You need to follow up with your PCP in regards to this. ?????? You have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) **], to be seen in __6_____weeks. ?????? You will also need to follow up with the [**Hospital **] clinic in 4 weeks (from [**12-7**]). You will need an MRI Brain with and without contrast prior to this appointment to determine the final duration of the antibiotics course. This appointment can be made with Dr. [**Last Name (STitle) **] [**Name (STitle) **] by calling [**Telephone/Fax (1) 457**]. ?????? You should also have weekly labs drawn to monitor the antibiotics therapy. Please have a CBC /c diff, ESR & CRP drawn weekly. These labs should be faxed to the [**Hospital **] clinic RN at [**Telephone/Fax (1) 1419**]. ?????? You do not require any follow up for your IVC Filter. Completed by:[**2118-12-13**]

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icd9cm

[ [ [] ] ]

[ "38.97", "93.59", "38.7", "01.13" ]

icd9pcs

[ [ [] ] ]

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295, 377

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2737, 4915

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146,812

30337

Discharge summary

report

Admission Date: [**2112-7-10**] Discharge Date: [**2112-7-15**] Date of Birth: [**2034-5-16**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 2181**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Patient had a repeat bronchoscopy on [**2112-7-11**], performed by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **], to observe the patency of the stent previously placed in his left mainstem bronchus for invasive esophageal cancer. Report stated that the stent was approximately 50% obstructed by tumor/granulation tissue, and showed proximal migration of the stent into the trachea, jailing the right mainstem bronchus. No significant change was noted from previuos bronchoscopy on [**2112-6-20**]. Recommendations were close surveillance with a follow up bronchoscopy in two weeks. Removal of the stent was not recommended due to tumor ingrowth, and balloon dilation of the stent would be considered if the patient continued to have problems with airway obstruction. History of Present Illness: 78M w/ esophageal CA (s/p resection and stent placement), prostate CA, and GERD presenting from an OSH after admission for respiratory failure. He was in his USOH until [**7-7**] when he became acutely dyspneic. He was intubated in the field by EMS and sent to an OSH where he was dx w/ MRSA PNA (ceftaz/azithro -> zosyn/azithro/vanco -> vanco alone). He failed extubation twice between [**7-7**] -> [**7-10**] because of secretions but was extubated successfully prior to transfer on [**7-10**]. . At [**Hospital1 18**], he underwent repeat broncoscopy showing a proximal migration of his stent w/ near-complete obstruction of the R mainstem bronchus. No intervention was attempted given the fact that there little change from his previous bronch in [**6-16**] and significant tumor ingrowth over the stent. He tolerated the procedure well w/out need for intubation and was called out to medicine for further management. Past Medical History: - Esophageal adenocarcinoma s/p Ivor-[**Doctor Last Name **] esophagectomy [**4-12**] with recurrence [**2110**], currently undergoing chemotherapy - s/p left mainstem bronchus stenting [**2-17**] [**2-12**] tumor invasion, complicated by cardiogenic shock, bronch in [**6-16**] revealed some proximal stent migration and nonobstructive (50-60% of lumen) tumor growth at the distal end of the stent - Prostate CA s/p XRT (dx ~10 years ago), currently on Casodex and Zoladex - Throat cancer in [**2096**] s/p radiation and surgery - GERD Social History: The patient [**Doctor Last Name **] with family ( wife and grand-daughter). He is a vacuum system mechanic,and was in the Navy before that. Patient reports being exposed to asbestos about 30 years prior, during his time in Navy shipyards. Patient admitted to ETOH use, approximately 4 cans per day. He has a 25 pack/year history of tobacco use, but quit in [**2096**]. Family History: Patient had a brother who died of esophageal cancer at age 65. Patient also mentioned that multiple deceased family members had carried a diagnosis of cancer,but he could not recall the specifics. Physical Exam: PE: 97.3, 180/90, 83, 20, 98% 4L Gen: Elderly [**Male First Name (un) 4746**] lying in bed in NAD HEENT: MMM, O/P clear, pupils equal and reactive, no cervical LAD CV: RRR, 2/6 SEM at the LUBS Lungs: Coarse inspiratory and expiratory breath sounds w/ a prolonged expiratory phase (L>R) Abd: S/NT/ND, +BS, -HSM Ext: No C/C/E, cool but quick capillary refill Neuro: Appropriate in conversation and moving all his extremities spontaneously Skin: No rashes Pertinent Results: [**2112-7-11**] 04:57AM BLOOD WBC-7.4 RBC-3.52* Hgb-11.6* Hct-33.8* MCV-96 MCH-32.9* MCHC-34.3 RDW-18.7* Plt Ct-175 [**2112-7-15**] 06:10AM BLOOD WBC-7.2 RBC-3.52* Hgb-11.8* Hct-33.4* MCV-95 MCH-33.5* MCHC-35.4* RDW-17.9* Plt Ct-214 [**2112-7-14**] 03:40AM BLOOD PT-12.5 PTT-26.0 INR(PT)-1.1 [**2112-7-11**] 04:57AM BLOOD Glucose-145* UreaN-20 Creat-0.9 Na-141 K-3.2* Cl-103 HCO3-30 AnGap-11 [**2112-7-15**] 06:10AM BLOOD Glucose-100 UreaN-9 Creat-0.8 Na-139 K-3.8 Cl-99 HCO3-34* AnGap-10 [**2112-7-14**] 03:07PM BLOOD Calcium-8.6 Phos-2.3* Mg-2.0 [**2112-7-13**] 08:04PM BLOOD Type-ART pO2-346* pCO2-51* pH-7.37 calTCO2-31* Base XS-3 [**2112-7-13**] 06:28PM BLOOD Type-ART pO2-160* pCO2-113* pH-7.05* calTCO2-33* Base XS--2RESPIRATORY CULTURE (Final [**2112-3-8**]): OROPHARYNGEAL FLORA ABSENT. STAPH AUREUS COAG +. RARE GROWTH. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. [**7-10**] UPRIGHT AP CHEST: A left central catheter has been placed via the subclavian approach, with the tip overlying the left side of the superior mediastinum and aorta. The left main stem bronchus stent protrudes into the trachea, at the carina. No pneumothorax is seen. There is a left pleural effusion, moderate and left lower lobe atelectasis. The right lateral costophrenic angle is excluded from the image, but appears blunted were seen. There are degenerative changes of the thoracic spine. IMPRESSION: 1. Probable arterial central catheter placement. This finding was discussed with Dr. [**Last Name (STitle) 656**] at the time of interpretation on [**7-12**]. 2. Left effusion and left lower lobe atelectasis. [**7-13**] Chest CT. IMPRESSION: 1. Progression of mediastinal metastatic disease, including lymphadenopathy and mediastinal and left hilar mass. 2. Progression of narrowing of left segmental bronchi distal to left mainstem bronchial stent. 3. Mixed interval behavior of pulmonary metastases, with individual nodules appearing stable to equivocally increased, but with increased left upper lobe opacity, possibly suggestive of lymphangitic spread of tumor. [**7-13**] ECG Sinus rhythm with ventricular and atrial premature beats. No significant change compared to the previous tracing of [**2112-7-10**] Brief Hospital Course: At [**Hospital1 18**], he underwent repeat broncoscopy showing a proximal migration of his stent w/ near-complete obstruction of the R mainstem bronchus. No intervention was attempted given the fact that there little change from his previous bronch in [**6-16**] and significant tumor ingrowth over the stent. He tolerated the procedure well w/out need for intubation and was called out to medicine for further management. . On the floor, the patient was stable and w/out significant complaints. He was continued on IV Vancomycin for his MRSA pneumonia. He notes that his breathing is much better than it was at home and he denied any CP, abdominal pain, N/V, diarrhea, weakness, paresthesias, HA, or dizziness. He developed tachycardia up to 150's on [**7-13**], unclear whether sinus or not. Tachycardia was ubnresponsive to fluid bolus. the paient was asymptomatic throughout episode. He was transferred to MICU, given Metoprolol 25mg TID, and his HR dropped to 80s. He has been stable in the 80's since receiving metoprolol. Radiation Oncology consulted with the patient, and after reviewing his old records, and discussing the patient's goals of treatment, it was decided not to proceed with further radiation. The patient was transferred back to the floor, where he remained stable. He had one episode of a 12 beat run of VT on [**7-14**]. He was completely asymptomatic, without chest pain or hypotension. His metoprolol was increased to 37.5mg PO tid, and he did not have any further runs of VT on [**7-15**]. The patient's breathing and cough continued to be a problem, and were both relieved with nebulizers, saline mask, mucinex, guafenesin with codeine. On [**7-15**], the patient was discharged per his request. He was afebrile, with stable vital signs. He was instructed to follow-up with interventional pulmonology, and to continue a course of linezolid. Medications on Admission: Lansoprazole 30 mg daily Albuterol/Ipratropium q6hrs prn Casodex 50 mg daily Zoladex every three months Cough syrup with codeine Discharge Medications: 1. Linezolid 600 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO twice a day for 6 days. Disp:*12 Tablet(s)* Refills:*0* 2. Linezolid 600 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO twice a day for 1 days. Disp:*2 Tablet(s)* Refills:*0* 3. Ipratropium Bromide 0.02 % Solution [**Month/Day (4) **]: One (1) Inhalation Q6H (every 6 hours). Disp:*QS 1 mth QS 1mth* Refills:*2* 4. Metoprolol Tartrate 25 mg Tablet [**Month/Day (4) **]: 1.5 Tablets PO TID (3 times a day). Disp:*135 Tablet(s)* Refills:*2* 5. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) [**Month/Day (4) **]: One (1) Capsule, Delayed Release(E.C.) PO once a day. 6. Insulin Regular Human 100 unit/mL Solution [**Month/Day (4) **]: per home sliding scale Injection ASDIR (AS DIRECTED). 7. Casodex 50 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO once a day. 8. Zoladex 10.8 mg Implant [**Month/Day (4) **]: One (1) Subcutaneous every three months. Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: MRSA Pneumonia multifocal atrial tachycardia Esophageal cancer Discharge Condition: stable, no O2 requirement, afebrile Discharge Instructions: Please take your medication as prescribed and go to your follow-up appointments. Please call your doctor or go to the emergency department if you have increased difficulty breathing, fever >100.4 or any other concerning symptoms. Followup Instructions: Provider: [**Name10 (NameIs) 454**],TEN [**Name10 (NameIs) 454**] Date/Time:[**2112-7-26**] 11:00 Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 3020**] Date/Time:[**2112-7-26**] 12:00 Provider: [**Name10 (NameIs) **],ROOM ONE IP ROOMS Date/Time:[**2112-7-26**] 12:00

[ "427.1", "482.41", "427.89", "197.0", "197.1", "285.22", "V10.46", "530.81", "996.59", "276.51", "196.1" ]

icd9cm

[ [ [] ] ]

[ "33.24" ]

icd9pcs

[ [ [] ] ]

9156, 9207

6143, 8023

292, 1074

9314, 9352

3678, 6120

9630, 9936

2990, 3189

8202, 9133

9228, 9293

8049, 8179

9376, 9607

3204, 3659

233, 254

1102, 2026

2048, 2587

2603, 2974

83,156

194,407

3813

Discharge summary

report

Admission Date: [**2117-3-27**] Discharge Date: [**2117-3-31**] Date of Birth: [**2076-1-12**] Sex: M Service: MEDICINE Allergies: Penicillins / Tegaderm Attending:[**First Name3 (LF) 10593**] Chief Complaint: DKA, AMS, Chest Pain Major Surgical or Invasive Procedure: none History of Present Illness: 41 year old man w/ poorly controlled DMI (neuropathy, retinopathy, nephropathy), CKD VI s/p fistula placement for diabetic nephropathy, hyperparathyroidism, HTN, CAD (s/p MI) and polysubstance abuse (heroin, marijuana, cocaine) who presents in DKA. The patient states that he last heroin 2 days ago. Since that time, he has not used his lantus. He notes that this morning, his brother found him passed out on the floor and brought him to an OSH. At the OSH, the patient's glucose was 1300, with a serum pH of 7.22 and anion gap of 24. He was also noted to have substernal chest pain. Trop I at the OSH 0.04 (normal range). The patient was altered and agitated. He was given 5mg haldol and 2mg ativan. The patient was transferred to [**Hospital1 18**] for further management. In the ED, initial VS were: 99.6 108 175/86 16 100% 3L NC. Fingerstick revealed glucose of 1200; anion gap . Labs with troponin T of 0.1, anion gap of 17. UA was without evidence of UTI. CXR with cardiomegaly, but without evidence of pneumonia. The patient was continued on a regular insulin drip at 10 units/hr. He was evaluated by transplant surgery, given new fistula placement - who recommended no change in management from perspective of fistula. On arrival to the MICU, patient's VS 98.6 176/89 92 100%RA. The patient complains of "not feeling well" but is without localizing symptoms. He does endorse an episode of coffee ground emesis and diarrhea. He complains of epigastric abdominal pain. Otherwise, no fevers, chills, neck stiffness, cough, shortness of breath, dysuria, frequency, urgency, rash. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies shortness of breath, cough, dyspnea or wheezing. Denies palpitations. Denies constipation. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: -- Diabetes Mellitus: diagnosed at age 2, poorly controlled; Last A1C = 9.4 ([**2115-1-4**]); complicated by neuropathy, nephropathy, and blindness -- Polysubstance Abuse, previous use of heroine, cocaine -- Hypertension -- History of coronary artery disease. He reports three MIs in the past: the first at age 20yo associated with steroids and BDP abuse, the second at age 28 associated with anxiety, and a third at age 34 associated with cocaine use. -- Hx osteomylitis (Coagulase negative staph and pseudomonas) -- arthroplasty R hallux [**2114-7-12**] -- Venous Stasis Dermatitis -- Legally Blind - s/p Vitreoectomies [**2101**] -- Chronic Renal Insufficiency, stage 4 -- proteinuria -- Bipolar Disorder -- Anxiety Disorder, NOS -- Hypercholesterolemia -- Hyperparathyroidism, secondary (Renal disease) Social History: The patient lives with his mother and brother. His mother is his healthcare proxy and administers all of his medications. The pt admits to using heroin in the past few days. He also smokes marijauna frequently. No recent cocaine use. He denies alcohol. Smoked 1 ppd x 4 months, but quit smoking. Pt was on methadone in the past, now on suboxone for the past 2 months. Family History: No history of kidney disease, DM or gout. No history of CAD in parents. Brother with substance abuse; Maternal Grandmother with hypertension, Lung ca, cardiovascular dz Physical Exam: On Admission: Vitals: 98.6 176/89 92 100%RA General: Alert, oriented to place, person, no acute distress; occasionally jerks head as if uncomfortable HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, 2/6 systolic flow murmur best heard in right and left 2nd intercostal space; no 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: Cool, well perfused, 2+ pulses, 1+ edema to ankle; no clubbing, cyanosis Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, sensation diminished to ankle and hands bilaterally; gait deferred Pertinent Results: [**2117-3-27**] 10:30PM GLUCOSE-731* UREA N-72* CREAT-4.7* SODIUM-127* POTASSIUM-3.8 CHLORIDE-92* TOTAL CO2-18* ANION GAP-21* [**2117-3-27**] 10:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2117-3-27**] 10:30PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS cocaine-NEG amphetmn-NEG mthdone-NEG . CXR [**2117-3-27**]: IMPRESSION: Apparent enlargement of the cardiac silhouette is most likely related to technique. No acute cardiopulmonary process. . Head CT [**2117-3-27**]: IMPRESSION: Extremely limited study with marked motion artifact. Within this limitation, no definite acute intracranial pathology. If there is strong clinical concern for pathology, then repeat imaging can be obtained when the patient is able to lie still. Brief Hospital Course: 41 year old male with DMI, CKD s/p fistula, polysubstance abuse, and [**Hospital **] transfered from [**Location (un) **] with DKA, altered mental status, and substernal chest pain. . #. Diabetic ketoacidosis / Diabetes mellitus type 1, uncontrolled, with complications: Patient with history of poorly controlled type 1 diabetes admitted with glucose 1200. At OSH ph 7.22, K 5.2, Anion gap 24. Started on an insulin drip at 10 units per hour (0.1 units/kg) at [**Hospital3 **]. On transfer here, glucose 731, K+ 5.8, pH 3.6, anion gap 17. Etiology of DKA most likely related to not taking lantus at home. Patient reports that he relapsed in his heroin addiction recently. He had not been taking his lantus for 2 days prior to admission. On the day of admission, the patient??????s brother found him passed out on the ground (from heroin/tylenol X 3). He assumed that the patient must be hypoglycemic so he gave him glucagon and soda. This probably explains why patient presented with glucose of 1200 but only a moderate anion gap. In terms of other possible precipitating factors, there was no evidence of infection on exam. No evidence of UTI on urinalysis. CXR without evidence of pneumonia. He may have had some transient cardiac ischemia as discussed below, but that was probably secondary to the acute illness rather than being causative of it. . He improved and was transferred to the floor. [**Last Name (un) **] Diabetology was consulted. He was continued on his home dose of Lantus 30 units qhs. [**Last Name (un) **] adjusted his Humalog sliding scale as indicated in the "Medications" section below. He will follow-up in the [**Hospital **] [**Hospital 982**] clinic. . #. Polysubstance abuse: Patient with positive opiates and THC at outside hospital. He states that he last used heroin 2 days prior to admission. He also states that he has been on suboxone for the past 2 months. When he presented he had jerky body movements and diarrhea which may have been from opiate withdrawal. After transfer to the general medical [**Hospital1 **] he felt generall well, and he had no signs of opiate withdrawal. He was not given Suboxone. He can resume Suboxone as an outpatient as previously prescribed. He was seen by Social Work. . # Hypertension, benign: Patient with hypertensive urgency to SBP 200 on admission, asymptomatic. Patient is on amlodipine, lasix, carvedilol at home. Per past clinic and ED notes, patient appears to be chronically hypertensive. Patient reports that his BP is rarely less than 150 systolic even when he is taking all of his meds. His amlodpine was increased to 10 mg daily, and clonidine was added for better BP control. . #. Encephalopathy: Patient transferred from OSH with altered mental status. Given haldol and ativan in the OSH ED for agitation. AMS likely was secondary to delirium from hyperglycemia/diabetic ketoacidosis. No localizing symptoms of infection. Head CT negative for ICH. The patient??????s mental status returned to baseline after resolution of DKA. . #. Chest Pain: Resolved. Trop was 0.10 at admission in the setting of 3 previous MIs and acute on chronic kidney injury. Repeat was 0.09, then 0.05. CK-MB normal x3 and EKG without evidence of acute ischemia. Patient likely had demand ischemia in the setting of DKA or hypertensive urgency or this is just his baseline due to renal failure. . # Acute on chronic kidney disease: Patient with diabetic kidney disease; CKD IV s/p fistula placement in the left arm. He continues to make urine. Most recent baseline appears to be around 3.5-4.0 although all of those numbers are from when patient is hospitalized. Patient likely had prerenal azotemia overlying his CKD, due to volume depletion from DKA. Creatinine normalized to baseline with volume repletion. He has a follow-up appointment scheduled in the Transplant Surgery clinic for evaluation of his L arm AV fistula. NP from the [**Hospital 1326**] clinic briefly evaluated the (nonpainful) swelling around his fistula site, and saw no need for intervention . # Abdominal pain/Diarrhea: Patient presented with abdominal pain, diarrhea, and one episode of emesis. These were likely from diabetic ketoacidosis as they improved with resolution of anion gap. Symptoms may also be exacerbated by opioid withdrawal. Patient did endorse coffee ground emesis and bloody stools, but has grossly brown stool with only trace guaiac positivity. C. diff was negative. After transfer to the medical floor, he had no further abdominal pain. . # Bipolar disorder: continued lamotrigine and abilify . # Normocytic Anemia: Unclear etiology. Hct was stable during this hospitalization (32 on last check). Patient did not have melena, hematochezia or emesis during the admission. Patient reported a prior history of coffee ground emesis and bloody stools, but on admission has grossly brown stool with only trace guaiac positivity. Anemia may be related to chronic kidney disease. Additional work-up can be considered as outpatient. . TRANSITIONAL ISSUES: ==================== - Further anemia workup per PCP (had guaiac-positive stools, but is on iron). Hct 32 on last check. - Follow-up of chronic kidney disease; Cr 3.6 on last check - Substance abuse treatment - Follow-up with [**Last Name (un) **] - HIV antibody test pending at the time of discharge - Titration of antihypertensives. Might consider adding ACE-inhibitor and titrating off clonidine. Medications on Admission: Confirmed with patient/family - Humalog SS with meals, 3U for 150-200 and 3U for every incr. of 50 thereafter. - Lantus 30 units SC daily - Clonazepam 1 mg TID - Simvastatin 20 mg PO qHS - Carvedilol 25 mg PO Bid - Amlodipine 5mg daily - Furosemide 80mg daily - Suboxone 8mg/2mg 1 [**Hospital1 **] - Calcitriol 0.5 mcg - 2 capsules daily - Omeprazole 20 mg daily - Abilify 20 mg daily - Lamictal 25mg AM 50mg PM - Vitamin D 400 mg daily - Fe 325mg [**Hospital1 **] - ASA 81mg Discharge Medications: 1. lamotrigine 25 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 2. lamotrigine 25 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 3. furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* 4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 6. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* 7. clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* 8. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 10. calcitriol 0.25 mcg Capsule Sig: Four (4) Capsule PO DAILY (Daily). 11. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 12. aripiprazole 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 14. insulin glargine 100 unit/mL Solution Sig: Thirty (30) UNITS Subcutaneous at bedtime. 15. Humalog 100 unit/mL Solution Sig: sliding scale Subcutaneous four times a day: Please follow Humalog sliding scale - you have been given a copy. . HUMALOG SLIDING SCALE Before Breakfast, Before Lunch, Before Dinner Glucose<80: 0 units Humalog 81-100: 2 units 101-150: 3 units 151-200: 5 units 201-250: 6 units 251-300: 7 units 301-350: 9 units 351-400: 10 units >401: 10 units . Before Bedtime (along with Lantus 30 units) Glucose<80: 0 units Humalog 81-100: 0 units 101-150: 0 units 151-200: 0 units 201-250: 2 units 251-300: 3 units 301-350: 4 units 351-400: 5 units >401: 6 units Discharge Disposition: Home Discharge Diagnosis: -Diabetic ketoacidosis -Diabetes mellitus type 1, uncontrolled, with complications -Chronic kidney disease, stage 4 -CAD s/p MI -Polysubstance abuse -Hypertension, benign Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for diabetic ketoacidosis. You should continue to take insulin every day, as instructed, to avoid this serious condition. It is also important that you eat on a regular basis, and that you avoid foods that can cause your blood sugar levels to rise excessively, as described to you by the Nutrition specialists. . Please follow-up in the [**Hospital **] [**Hospital 982**] clinic. Please call [**Telephone/Fax (1) 2378**] to set up an appointment to see your diabetologist. . You have an appointment scheduled for Friday [**2117-4-2**] to see a new primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **], at [**Hospital1 18**] in [**Location (un) 86**]. See below for the appointment information. Followup Instructions: Please call [**Telephone/Fax (1) 2378**] to set up an appointment to see your diabetologist at [**Last Name (un) **]. Department: [**Hospital3 249**] When: FRIDAY [**2117-4-2**] at 3:45 PM With: [**First Name8 (NamePattern2) 539**] [**Last Name (NamePattern1) **], 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 Dr [**First Name (STitle) **] is your new physician at [**Name9 (PRE) 191**]. She works closely with Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**First Name3 (LF) **] both will be involved in your care. Please call your insurance and name Dr. [**Last Name (STitle) **] as your PCP. [**Name10 (NameIs) **] MUST BE DONE BEFORE YOUR APPOINTMENT. Department: RADIOLOGY When: THURSDAY [**2117-4-15**] at 2:00 PM With: VASCULAR STUDY [**Telephone/Fax (1) 590**] Building: CC [**Location (un) 591**] [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: TRANSPLANT CENTER When: THURSDAY [**2117-4-15**] at 2:45 PM With: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

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Discharge summary

report

Admission Date: [**2172-4-7**] Discharge Date: [**2172-4-29**] Date of Birth: [**2115-6-19**] Sex: F Service: MEDICINE Allergies: Augmentin Attending:[**First Name3 (LF) 2712**] Chief Complaint: Falls, weight gain, dyspnea Major Surgical or Invasive Procedure: Intubation [**4-9**] Central venous line insertion [**4-9**] History of Present Illness: 56 yo F with chronic hep c and cirrhosis, HTN, hypercholesterolemia, h/o bowel obstruction, asthma, ascending aortic aneurysm, who is admitted directly from [**Hospital 6435**] clinic after presenting today weight gain, frequent falls, increased dyspnea on exertion, and LUQ pain, found to have new renal failure. She relates that she has been experiencing general decline over the past few months, but has been having more symptoms in the past 2 weeks. Has slowly gained about 30 lbs (unsure over what time period) in the form of worsening LE edema and increasing abdominal girth to the point that her pants no longer fit. Over this same time period, she has started falling more because she feels like her legs feel heavy and weak, and in the past week or so has fallen almost every day. Yesterday she had a fall where she scratched her leg on the metal of her car door, which subsequently bled profusely ("at least a pint") and required a two-layer stitch closure. Has also been having diarrhea for the past few months, feels like food "goes right through" her, small liquidy stools without associated abdominal pain. . Now over the past few weeks, she has been feeling nauseated and vomiting nearly every AM (clear, non-bloody). She also has been experiencing worsening dyspnea on exertion over the past few weeks, limiting her to [**11-7**] feet walking and [**5-24**] steps at a time on stairs. She doesn't think its her asthma, doesn't feel wheezy. No chest pain or orthopnea. Has been very thirsty and drink 2L H2O per day, but has been urinating less. Now in the past few days, started having LUQ pain that is worse with breathing, feels like it radiates to the back, cannot characterize the quality further. Given all of these worsening symptoms, she finally presented today to her PCP. . At her PCP's office, her exam was notable for [**3-22**]+ pitting edema of the lower extremities and a laceration on her left leg. Peak flow was 355, and CXR was normal. Labs revealed Cr elevation to 2.6 from baseline 0.6 in [**Month (only) 1096**], macrocytic anemia with hct of 26 (from 37), alb 2.1, and plts 145. Given her new acute renal failure and all these worrisome symptoms, she was directly admitted to [**Hospital1 18**] for further work up. . Currently, she is sitting in bed comfortably and can relate her story. She appears chronically ill, but she can easily give her history and cooperate with exam . ROS: + "feeling cold", shortness of breath, LUQ pain, nausea/vomiting, diarrhea - fever, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, chest pain, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: ?????? HEPATITIS C - Dx'd ~[**2142**] (likely from a needlestick), cirrhosis on [**12/2169**] bx, grade I varices on [**1-/2170**] EGD ?????? SCIATICA ?????? Depression ?????? Hypertension ?????? Asthma ?????? Hyperlipidemia ?????? Herpes infection ?????? Hematuria ?????? Thrombocytopenia ?????? Ascending aortic aneurysm - stable, 4.4 cm diameter [**2172-1-23**] ?????? Simple cyst of kidney Social History: Worked as a nurse for many years, previously as a VNA and more recently for ElderCare. Had to stop working this week due to her weakness and frequent falls. Lives with her husband in [**Name (NI) 976**], MA. Has one daughter (26 yo) who lives closer to [**Location (un) 86**]. Tobacco: none Alcohol: quit in [**2142**] Drugs: used marijuana, cocaine, PCP occasionally when younger, none since daughter was [**Name2 (NI) **] Family History: Aunt had ?metastatic breast cancer to liver, but otherwise no one with liver disease. Aunt and brother with [**Name2 (NI) 32071**] malformations of kidneys, but no other renal disease Physical Exam: Physical Exam on Admission VS - Temp 97.8F, BP 106/54, HR 90, R 16, O2-sat 100% RA GENERAL - middle aged woman sitting in bed, in NAD, family at bedside HEENT - NC/AT, PERRLA, EOMI, + scleral icterus, dry MM, icterus of underside of tongue NECK - supple, no JVD LUNGS - Bibasilar inspiratory crackles, no wheezes or rhonchi, good air movement, resp unlabored, no accessory muscle use HEART - RRR, nl S1-S2, loud 3/6 systolic murmur loudest at base ABDOMEN - +BS, obese, distended, + fluid wave. Liver feels enlarged, unable to palpate spleen. Tender to palp in LUQ over ribs, small elongated rubbery mass felt below skin at area of tenderness EXTREMITIES - [**3-22**]+ pitting edema of bilateral LE up to thighs. Left shin with stasis dermatitis changes and large laceration on lateral calf with ~ 10 stitches, small amount of pus draining at one corner. SKIN - scattered telangectasias across back and chest. Psoriasis plaques on right thigh and back. Intertriginous candidiasis below bilateral breasts NEURO - awake, A&Ox3, CNs II-XII grossly intact, no asterixis Pertinent Results: Admission Labs: [**2172-4-7**] 07:40PM BLOOD WBC-10.6 RBC-2.76*# Hgb-9.5*# Hct-29.8*# MCV-108*# MCH-34.5*# MCHC-31.9 RDW-14.6 Plt Ct-151# [**2172-4-7**] 07:40PM BLOOD Neuts-64.6 Lymphs-26.5 Monos-5.9 Eos-2.8 Baso-0.2 [**2172-4-7**] 07:40PM BLOOD PT-15.7* PTT-28.0 INR(PT)-1.5* [**2172-4-7**] 07:40PM BLOOD Ret Aut-3.6* [**2172-4-7**] 07:40PM BLOOD Glucose-109* UreaN-41* Creat-2.5*# Na-136 K-3.5 Cl-103 HCO3-24 AnGap-13 [**2172-4-7**] 07:40PM BLOOD ALT-74* AST-148* LD(LDH)-384* AlkPhos-112* TotBili-3.1* [**2172-4-7**] 07:40PM BLOOD Lipase-77* [**2172-4-7**] 07:40PM BLOOD Albumin-2.7* Calcium-8.0* Phos-3.7 Mg-2.1 Iron-55 [**2172-4-7**] 07:40PM BLOOD calTIBC-269 Hapto-21* Ferritn-196* TRF-207 Pertinent Interval Labs: [**2172-4-8**] 06:10AM BLOOD Hypochr-1+ Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL [**2172-4-8**] 06:10AM BLOOD AFP-10.0* Imaging: [**2172-4-7**] - Liver/Gallbladder U/S: Liver has a coarsened echotexture and nodular contour consistent with provided history of cirrhosis. No discrete lesion identified. No intrahepatic or extrahepatic biliary ductal dilatation present. The gallbladder is not distended and without gallstones. Gallbladder wall thickening is evident, likely due to chronic liver disease. The common bile duct is not dilated, measuring 5 mm. The pancreas is not well evaluated due to overlying bowel gas, though demonstrated portions are unremarkable. The spleen is not enlarged, measuring 11 cm. Demonstrated portions of the right kidney, inferior vena cava and aorta are unremarkable. Moderate-to-large amount of ascites identified in all four abdominal quadrants. DOPPLER: Doppler assessment of the main portal vein shows patency and hepatopetal flow. Normal waveforms are identified within the right middle and left hepatic veins and main hepatic artery. IMPRESSION: 1. Coarsened echotexture consistent with provided history of cirrhotic liver. 2. Hepatic vasculature is patent with appropriate directionality of flow and waveforms. 3. Ascites. 4. Thickened gallbladder wall. In absence of gallbladder distention or gallstones, this is most consistent with sequela of chronic liver disease. [**2172-4-8**] - Renal U/S: The left kidney is 10.6 cm and the right kidney is 11.2 cm. Subtle details of both kidneys are obscured by patient habitus. Within that constraint there is no hydronephrosis or nephrolithiasis. The urinary bladder is unremarkable. There is moderate ascites. IMPRESSION: No evidence of hydronephrosis. Interventions: [**2172-4-8**] - U/S guided paracentesis by IR Uncomplicated diagnostic and therapeutic paracentesis yielding 950 mL of clear yellow fluid. Brief Hospital Course: 56 yo F with chronic hep c and cirrhosis, HTN, hypercholesterolemia, h/o bowel obstruction, asthma, ascending aortic aneurysm, who is admitted directly from [**Hospital 6435**] clinic after presenting today weight gain, frequent falls, increased dyspnea on exertion, and LUQ pain, found to have new renal failure and likely decompensated liver failure. # Hypoxic respiratory failure. Unfortunately, peri-intubation for EGD, patient became hypotensive requiring pressors and upon intubation for EGD was noted to have progressively worsening bilateral, diffuse infiltrates on CXR. She became progressively more hypoxic and eventially was diagnosed with ARDS. Etiology of this was uncertain, with the likely explanation being volume overload in setting of anuric renal failure (see below), however, some concern was given to a pulmonary-renal syndrome given concominant renal failure. She underwent BAL on [**4-8**] which was concerning for diffuse alveolar hemorrhage vs. pulmonary edema w/ hemorrhage in setting of coagulopathy. ANCA, [**Doctor First Name **], Anti-GBM were negative, C3 was slightly low, but C4 was wnl. Given no improvement w/ CVVH (see below) initially, she was treated with an empiric course of IV solumedrol, in addition to vancomycin and cefepime, for empiric treatment of diffuse alveolar hemorrhage and pneumonia. The ultimate etiology of her resipratory failure remained unclear, however, was felt to be likely due to ARDS in setting of sepsis, volume overload with anuric renal failure. She wad doing well from a pulmonary stand point until [**4-28**] when she developed new pulmonary infiltrates thought to be a VAP. Antibiotics were broadened to Linezolid, Tobramycin, Zosyn, and Ambisome. On [**4-29**] in the afternoon, new bloody secretions were noted. Repeat Hct was 17 down from 23. Due to concern for pulmonary hemorrhage, repeat CXR was performed demonstrating worsening pulmonary infiltrates. At this point given respiratory failure, severe hypotension barely sustained with maximal dose of three pressors, and inability to safely connect patient to CVVH, patient was thought to have no further options for possible recovery. Additionally the source of her infection had not been identified. This was conveyed to the family who opted to withdraw care. Patient was started [**Female First Name (un) **] morphine drip. At 7:21 patient passed away peacefully with family at bedside. Husband requested an autopsy. The remaineder of her hospitalization remains below. # Shock. Felt to be likely due to sepsis, given hypotension and leukocytosis requiring pressors, however a source was never identified. All Bcx remained negative. No growth on sputum samples/BAL (negative for bacterial, viral, fungal, AFP organisms). UCx w/ [**Female First Name (un) 564**] as well as small growth of [**Female First Name (un) **] PARAPSILOSIS and YEAST from her peritoneal fluid. Patient was treated with Mycfungin starting on [**4-9**] to [**4-28**]. In addition, given her decompensation and suspecte sepsis, she was treated with Vancomycin IV ([**4-9**] - [**4-27**]), Cefepime/Flagyl IV ([**Date range (1) 31650**]) and Meropenem ([**4-17**]- [**4-27**]). Adrenal insufficiency was ruled out. repeat echocardiograms showed do demonstration of cardiogenic shock. It was not felt that anemia (see below) was a significant contributor to her hypotension initially, though may have ultimately contributed to her hypotension. # AMS. Immediately prior to MICU transfer on [**4-9**] patient was felt to have mild encephalopathy in setting of renal failure and liver cirrhosis. This encephalopathy worsened upon development of shock, worsening renal/liver function, sedation use. Unfortunately, after weaning of sedation, patient remained comatose. CT head x2 did not revale acute abnormality that would account for AMS. Continuous EEG showed encephalopathy but no acute seizures. Per discussion with neurology and given neck stiffness on exam, LP was performed and showed no evidence of infection. Patient was treated conservatively and her mental status improved slightly with waxing and [**Doctor Last Name 688**] On consultation with neurology, increased LE and UE tone was found along with posturing. MRI head revealed enlarged ventricles. There was some concern for increased intracranial pressure. LP was performed, but due to difficulty with procedure, the opening pressure was not able to be obtained. CSF WBC were 0, patietn was thought unlikely to have meningitis and empiric acyclovir was discontinued. Patient's mental status improvded, but waxed and waned over the several days after the LP. Neurosurgery was consulted regarding benefit of a shunt, however, per neurosurgery, patient's evolving clinical picture was not consistent with elevated intracranial pressure. Patient had been improving from a mental status perspective until the day prior to her death. # Right frontal hyperdensity on CT head. Incidental finding, was not present on CT earlier on admission. Etiology unclear, ? due to cirrhotic calcification vs. focal meningioma. # Lung mass: thought to be a soft tissue density on CT scan, which was thought not be a possible cause of infection. # Variceal bleed: on hospital day #2, patient developed acute n/v and hematemesis w/ hypotension. Patient was transferred to MICU for emergenct intubation with EGD for variceal bleed, tx w/ octreotide gtt x 72 hrs, pantoprazole gtt, and ceftriaxone 1g q24h. Emergent EGD showed grade II esophageal varices w/o evidence of active bleeding but blood in the antrum. Varices were banded, no further bleeding was noted during hospitalization. # Hepatitis C cirrhosis and liver failure. diagnosed 30 years ago, started interferon tx in [**2159**] but this was stopped due to a seizure. Dx'd with cirrhosis in [**12/2169**], has evidence of poor liver function with elevated INR, thrombocytopenia, increased MCV, and very low albumin. SBP was ruled out. MELD on admission of 19 and peaked at 40 w/ Tbili of 14 and INR of 4.0. She was treated for HRS w/ octreotide and levophed. Was felt not to be a transplant candidate given her multiorgan failure. # ARF: Cr found to be elevated to 2.6 from past baseline of 0.6 in 12/[**2171**]. No known renal disease. Initially felt to be pre-renal, however given decompensation, was treated for HRS and required CRRT, creatinine peaked at 5.1. Given concern for DAH, there was concern for pulmonary renal syndrome (see for w/up above). Pt was treated with a course of IV steroids and CVVH. Her renal function never recovered. She was dependent on CVVH for the remainder of her hsoptialziation. # Anemia: macrocytic. Initially felt to be due to variceal GIB in setting of acute HCT drop. Subsequently, felt to be due to slow bleeding in setting of gastropathy, phlebotomy, bleeding from IV and a-line sites. Fe studies were consistent w/ anemia of chronic disease. She required several units transfusion, initially for anemia of chronic disease, but also acute blood lose anemia. # LLE leg wound: Older wound is somewhat malodorous with some purulent discharge at margin. Otherwise, new laceratin is well-approximated with stitches, which were removed. The wound showed no signs of infection. Medications on Admission: Nadolol 40 mg Oral Tablet 1 tab po qd Montelukast (SINGULAIR) 10 mg Oral Tablet 1 tab po qd Fluticasone-Salmeterol (ADVAIR HFA) 250-50 mcg/actuation Inhalation HFA Aerosol Inhaler Inhale 2 puffs [**Hospital1 **] with spacer Quinapril 20 mg Oral Tablet 2 tab po qd Fluticasone 50 mcg/actuation Nasal Spray, Suspension 1 puff each nostril [**1-20**] qd as needed Furosemide (LASIX) 20 mg Oral Tablet 2 tab po qd Buproprion XL 150 mg daily Omezprazole 40 mg daily Sertraline 200 mg daily Ibuprofen 400 mg Oral Tablet as needed - uses ~ 1x/month Discharge Medications: na Discharge Disposition: Expired Discharge Diagnosis: na Discharge Condition: na Discharge Instructions: na Followup Instructions: na Completed by:[**2172-4-30**]

[ "272.4", "359.9", "785.51", "285.29", "356.9", "572.3", "311", "278.01", "780.01", "571.5", "441.2", "287.5", "493.90", "V49.86", "518.81", "038.9", "276.69", "456.20", "272.0", "251.2", "285.1", "E920.8", "348.30", "070.54", "584.9", "434.91", "E879.8", "891.0", "401.9", "275.42", "286.9", "785.52", "789.59", "997.31", "995.92", "112.3" ]

icd9cm

[ [ [] ] ]

[ "96.04", "33.24", "03.31", "42.33", "38.91", "54.91", "96.72", "38.95", "39.95", "96.6", "38.97" ]

icd9pcs

[ [ [] ] ]

15803, 15812

7913, 15184

297, 359

15858, 15862

5238, 5238

15913, 15946

3945, 4132

15776, 15780

15833, 15837

15210, 15753

15886, 15890

4147, 5219

230, 259

387, 3067

5254, 7890

3089, 3484

3500, 3929

2,786

154,026

8629

Discharge summary

report

Admission Date: [**2119-1-17**] Discharge Date: [**2119-1-27**] Service: MEDICINE Allergies: Haldol / Benadryl Attending:[**First Name3 (LF) 2186**] Chief Complaint: GIB Major Surgical or Invasive Procedure: RBC scan, angiography History of Present Illness: 87 y/o F w/PMH sig for multiple lower GIBs [**1-26**] diverticuli, DM, CRI on HD, PVD, CAD s/p intervention and HTN who was transferred to [**Hospital1 18**] from [**Hospital **] Hospital tonight for another GIB. On my exam, the pt is sleeping and her son, who is a physician and at the bedside, recounts her history. She has been in [**Hospital **] hospital since [**2119-1-13**], when she was transferred from this institution. She began rebleeding on Monday, 2 d PTA, and Hct dropped from 36 to 21.4. However, there was concern that the HCT of 21 was falsely low as it had been drawn from her port directly after being flushed. She bled Monday morning until Sunday morning and then stopped. She rec'd 4 units of prbcs over the course. Bleeding scan on the morning of admission(Tuesday) was normal, however she was not bleeding at that time. Later on Tuesday during HD she was noted to be bleeding again, Hct was checked and found to be 36, she was given a unit of PRBCs and on repeat Hct ~ 2 hrs post transfusion was 37. She was transferred here complaining of BRBPR and clots PR on arrival here. She is transferred to [**Hospital1 18**] for angio/embolization. . Of note, her hospitalization c/b hypotension necessitating holding of her diltiazem and BB today. She went into AF with RVR today after HD at OSH, but converted to NSR after diltiazem was administered. . She has had multiple admissions over the past year for GIB, FTT, acute on chronic RF, and PVD induced ulcer disease of her LE. Her most recent hospitalization at [**Hospital1 18**] ([**Date range (1) 30239**]) was notable for stable hct and no sign of GIB, but she did have oliguria, acidosis and respiratory distress requiring intubation and ICU admission. Nephrology was consulted and, in consult with the ethics service, decision was made to put on HD for a one month trial to see if she improves. She had become more alert and conversant during this period per her son. Past Medical History: 1. CRI now requiring hemodialysis 2. DM2 3. PVD c/b ulcers on both feet w/ active necrosis of the L heel 4. CAD s/p MI in [**2112**] treated w/ stent of the RCA and LAD 5. Hypothyroidism 6. Anemia 7. FTT 8. PAF 9. HTN 10. GIB w/ diverticula on colonoscopy Social History: The patient is a Spanish-speaking female who lived at [**Location (un) 931**] House Nursing Home, before going to rehab. Denies Tob, EtOH, or illicit drug use. Her son is a physician at [**Name (NI) **] Hospital. Family History: + DM Physical Exam: PE: T 98.3 BP 147/72-183/79 HR 73-102 RR 14-21 O2 100% RA I/O: [**Telephone/Fax (1) 30240**] 50kg Gen: Chronically-ill appearing elderly female, lying in bed scratching her skin HEENT: PERRLA, MM dry, anicteric sclerae Heart: RRR, [**1-30**] HSM loudest at LUSB Lungs: CTAB Abd: soft. NT/ND, +BS, No HSM. Ext: no edema b/t, necrotic areas b/l on both feet w/ large necrotic heel on L foot, severl toe ulcers, s/p R great toe ampuation, R heel ulcer healed. Skin: very long fingernails with dirt encrusted Neuro: A&O x 1 (self). following simple commands, mae, sleepy Pertinent Results: GI bleeding scan: IMPRESSION: No bleeding source identified. Normal bleeding scan. . Angiogram: IMPRESSION: Selective angiography of the celiac axis and superior mesenteric artery, as well as a non-selective aortography demonstrated no evidence of active gastrointestinal mesenteric bleed. No embolization was performed. Incidentally, a small aneurysm of the left hypogastric artery was demonstrated. There is severe atherosclerotic disease involving the splanchnic vessels and the aorta. . EKG: Sinus rhythm with atrial premature depolarizations. Left axis deviation. Left ventricular hypertrophy by voltage criteria in the limb leads. Diffuse non-diagnostic repolarization abnormalities. Compared to the previous tracing of [**2119-1-18**] multiple abnormalities persist without major change. . RUQ US: wnl Brief Hospital Course: A/P: 87 F with PMH GIB secondary to diverticul, DM2, ESRD on HD, HTN, presented with GIB. . 1. GIB: The patient presented from her OSH w/ recent GIB. The OSH course is noted in the HPI. Neither bleeding scan nor angiography showed any evidence of a bleeding lesion. She was transfused 2u in the MICU but her Hct remained stable after this time. GI again commented that the intervention of choice if she were to bleed would be a bleeding scan or angiography but that colonoscopy would be of limited utility. She had no further episodes of GIB prior to d/c and was maintained on protonix throughout her stay. The patient did well after transfer to the floor, not requiring further transfusions. . Apparently when this pt has GIB, she can lose a tremendous amount of blood, requiring [**5-3**] u rbc. The most likely source of her GIB is her L-sided diverticuli, although they have not been directly witnessed to bleed. Patient also has L hemorrhoids. . 2. Elevated LFTs: RUQ US is negative for acute cholecystitis. Patient is not on hepatotoxic meds. Etiology of elevated LFTs is unknown, patient is asymptomatic and has no pain. Please continue to follow as outpatient. . 3. CRI: The patient continued to receive HD during her stay in accordance with her outside schedule. . 4. Chronic Leukocytosis: The patient completed her 14d course of abx that she had previously been d/c on during her stay. After this, she was not given furhter abx and she remained afebrile. She continues to have a chronic leukocytosis. . 5. Afib: The patient's bb was originally held in the MICU [**1-26**] her GIB. She had several episodes of afib w/ rvr on the floor that responded to diltiazem. Her bb was reintroduced, and her rate was well controlled. She had an episode of afib w/ RVR at HD in the setting of her AM meds being held but this resolved w/ diltiazem administration. . 6. L heel ulcer: Patient has a large area of dry gangrene which remained clean and uninfected. Wound care changed dressings [**Hospital1 **]. . 7. UTI: Patient had multiple urine cultures positive for yeast. Patient took fluconazole x1. . 8. HTN: SBP 150-190, gradually controlled down to 130-150. Metoprolol was increased from 50 TID to 75 TID, and this was well tolerated. . 9. Hypothyroidism: Synthroid was continued per outpt regimen. . 10. DM2: For 40 ml/hr [**Name (NI) 30241**] TF, pt required 30 U Glargine. Since nutrition recommended decreasing TF to 30 ml/hr, pt's glargine was reduced to 20 U upon discharge. Medications on Admission: 1. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 2. Levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 5. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Piperacillin-Tazobactam 2.25 g Recon Soln Sig: 2.25 g Intravenous Q8H (every 8 hours) for 5 days. 8. Pantoprazole 40 mg Recon Soln Sig: Forty (40) mg Intravenous Q24H (every 24 hours). 9. Vancomycin 1,000 mg Recon Soln Sig: One (1) g Intravenous once a day as needed for subtherapeutic level for 7 days: please dose by level at HD to keep level > 15. Discharge Medications: 1. Levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Ipratropium Bromide 0.02 % Solution Sig: 1-2 puffs Inhalation Q6H (every 6 hours) as needed. 3. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 4. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl Topical TID (3 times a day) as needed for pruritis. 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 6. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 7. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 9. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 10. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours). 11. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units Subcutaneous QHS. Discharge Disposition: Extended Care Facility: [**Location (un) 4480**] Specialty Discharge Diagnosis: Primary diagnosis: GIB Secondary diagnosis: DM2, ESRD on HD, HTN Discharge Condition: Stable, VSS stable, MS clear. Discharge Instructions: Please return to the emergency room if you experience GI bleeding or any other concerning symptoms. Followup Instructions: 1. Follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 30176**], [**Telephone/Fax (1) 30242**]. Completed by:[**2119-1-27**]

[ "578.9", "250.40", "272.0", "244.9", "427.31", "707.19", "585.6", "263.9", "403.91", "440.24", "112.2", "285.9", "788.20" ]

icd9cm

[ [ [] ] ]

[ "88.47", "96.6" ]

icd9pcs

[ [ [] ] ]

8525, 8586

4196, 6696

229, 252

8695, 8726

3362, 4173

8874, 9089

2753, 2759

7548, 8502

8607, 8607

6722, 7525

8750, 8851

2774, 3343

186, 191

280, 2226

8651, 8674

8626, 8630

2248, 2506

2522, 2737

83,433

136,725

47982

Discharge summary

report

Admission Date: [**2125-7-2**] Discharge Date: [**2125-7-26**] Date of Birth: [**2044-5-25**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 165**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: [**2125-7-17**] Trach/PEG, [**2125-7-3**] AVR(tissue)/MVR(tissue)/aortic endarterectomy History of Present Illness: This 81-year-old patient with known rheumatic heart disease in atrial fibrillation on Coumadin presented with increasing shortness of breath. Further investigation with an echocardiogram demonstrated severe aortic stenosis with moderate to severe mitral regurgitation and moderate mitral stenosis with diminished left ventricular function. Ejection fraction of about 40%. Increasing symptoms. He was brought to the hospital for aortic and mitral valve replacements. Intraoperative echocardiogram confirmed severe aortic stenosis with mitral pathology with severe mitral annular calcification especially posteriorly. The coronary arteries had no critical disease on angiogram. Incision, routine median sternotomy. Past Medical History: rheumatic fever atrial fibrillation Colon CA high cholesterol disc fracrure after car accident 6wks ago, wears a brace Social History: Family History:Denies Lives with:alone; Widowed with 3 children Occupation:Retired from sales Tobacco:Denies ETOH:None Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: Pulse:82 Resp:20 O2 sat:98%RA B/P Right:115/77 Left: Height:5'8" Weight:187 lbs General: Lying in bed with RN holding pressure on groin Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [] Irregular [x] Murmur: 4/6 systolic murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema: none Varicosities: mild bilat Neuro: Grossly intact-non focal exam Pulses: Femoral Right: deferred Left:2+ DP Right: 2+ Left:2+ PT [**Name (NI) 167**]: 1+ Left:1+ Radial Right:2+ Left:2+ Carotid Bruit Right: no Left: no Pertinent Results: ECHO [**2125-7-17**] The right atrium is moderately dilated. Left ventricular wall thicknesses and cavity size are normal. There is severe global left ventricular hypokinesis with inferior akinesis (LVEF = 25-30 %). Right ventricular chamber size is normal. with depressed free wall contractility. A bioprosthetic aortic valve prosthesis is present. The transaortic gradient is normal for this prosthesis. A bioprosthetic mitral valve prosthesis is present. The transmitral gradient is normal for this prosthesis. No mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The inferior papillary muscle tip is partially mobile. There is mild pulmonary artery systolic hypertension. Compared with the prior study (images reviewed) of [**2125-7-2**], biventricular systolic function has worsened. Electronically signed by [**Name6 (MD) **] [**Name8 (MD) **], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2125-7-16**] [**2125-7-26**] 02:11AM BLOOD WBC-12.1* RBC-3.18* Hgb-9.9* Hct-30.8* MCV-97 MCH-31.0 MCHC-32.1 RDW-14.3 Plt Ct-305 [**2125-7-25**] 03:45AM BLOOD WBC-10.6 RBC-3.24* Hgb-9.8* Hct-30.7* MCV-95 MCH-30.3 MCHC-31.9 RDW-14.4 Plt Ct-324 [**2125-7-24**] 02:55AM BLOOD WBC-14.5* RBC-3.17* Hgb-9.7* Hct-29.9* MCV-94 MCH-30.7 MCHC-32.5 RDW-14.5 Plt Ct-323 [**2125-7-23**] 03:06AM BLOOD WBC-13.4* RBC-3.05* Hgb-9.8* Hct-29.0* MCV-95 MCH-32.0 MCHC-33.6 RDW-14.5 Plt Ct-265 [**2125-7-26**] 02:11AM BLOOD PT-23.1* PTT-31.1 INR(PT)-2.2* [**2125-7-25**] 03:45AM BLOOD PT-22.3* PTT-31.8 INR(PT)-2.1* [**2125-7-24**] 02:55AM BLOOD PT-22.4* PTT-32.2 INR(PT)-2.1* [**2125-7-23**] 03:06AM BLOOD PT-21.8* PTT-32.3 INR(PT)-2.0* [**2125-7-22**] 03:26AM BLOOD PT-23.4* PTT-33.5 INR(PT)-2.2* [**2125-7-21**] 08:21AM BLOOD PT-23.4* PTT-33.1 INR(PT)-2.2* [**2125-7-20**] 06:58AM BLOOD PT-21.3* PTT-33.3 INR(PT)-2.0* [**2125-7-19**] 04:28AM BLOOD PT-20.8* PTT-77.5* INR(PT)-1.9* [**2125-7-18**] 04:40AM BLOOD PT-15.2* PTT-79.8* INR(PT)-1.3* [**2125-7-17**] 09:49AM BLOOD PT-15.6* PTT-82.9* INR(PT)-1.4* [**2125-7-26**] 02:11AM BLOOD Glucose-117* UreaN-26* Creat-0.6 Na-142 K-4.3 Cl-98 HCO3-39* AnGap-9 [**2125-7-25**] 03:45AM BLOOD Glucose-128* UreaN-26* Creat-0.6 Na-141 K-4.2 Cl-99 HCO3-36* AnGap-10 [**2125-7-24**] 02:55AM BLOOD Glucose-118* UreaN-26* Creat-0.7 Na-136 K-4.2 Cl-94* HCO3-40* AnGap-6* [**2125-7-23**] 03:06AM BLOOD Glucose-124* UreaN-23* Creat-0.6 Na-137 K-4.3 Cl-97 HCO3-34* AnGap-10 [**2125-7-26**] 02:11AM BLOOD Calcium-9.3 Phos-4.3 Mg-2.4 [**2125-7-25**] 03:45AM BLOOD Calcium-9.2 Phos-4.1 Mg-2.3 Date INR Coumadin [**7-17**] 1.4 5mg [**7-18**] 1.3 5 [**7-19**] 1.9 5 [**7-20**] 2.0 5 [**7-21**] 2.2 3 [**7-22**] 2.2 4 [**7-23**] 2.0 4 [**7-24**] 2.1 4 [**7-25**] 2.1 5 [**7-26**] 2.2 5 Brief Hospital Course: Mr. [**Known lastname **] was admitted on [**2125-7-2**] and taken to the operating room on [**2125-7-3**] for Aortic valve replacement with a size 27 St. [**Male First Name (un) 923**] tissue valve, Mitral valve replacement with size 27 [**Company 1543**] Mosaic tissue valve and Aortic endarterectomy. Of note he was a difficult intubation with rigid epiglottis requiring [**Last Name (un) 101232**]. Post operatively Mr. [**Known lastname **] was admitted to the ICU intubated and sedated on levophed, dobuatmine, and propfol. On POD#0 Mr. [**Known lastname **] was in his baseline atrial fibrillation and hypotensive requiring volume and additional pressor and inotrope support. Mr. [**Known lastname **] remained intubated due to hemodynamic instability. Once hemodynamic stability was achieved on POD#3, sedation was weaned but he failed to awaken appropriately. Chest tubes and temporary pacing wires were removed. He was maintained on vancomycin from the perioperative period and Meropenum was added for copious secretions while cultures were pending. He completed a 7 day course of Vancomycin and Cefepime, which was discontinued on [**7-22**] and was afebrile with a stable WBC at the time of discharge. The patient failed extubation due to encephalopathy and inability to handle secretions. He received a trach and PEG on [**2125-7-17**]. He was tolerating trach collar and Passy Muir valve by the time of discharge to rehab. He is tolerating tube feeds at goal at the time of discharge. Coumadin was resumed for atrial fibrillation with a goal INR 2-2.5. He did have some post operative delirium and was started on Seroquel at night. Doses of Seroquel given during the day resulted in somnolence and were discontinued. He did pull his foley catheter and had to have a 3 way cathether placed with continuous bladder irrigation. His hematuria cleared and foley catheter was discontinued. He is discharged with a condom pouch. The patient was cleared by Dr. [**First Name (STitle) **] for discharge to [**Hospital1 69097**] on POD 23. All instructions/follow-up recommendations are sent with the patient. Medications on Admission: Clarithromycin 1000mg po PRN dental procedure Furosemide 40mg po BID Mon-Fri, 40mg daily Saturday/Sunday Simvastatin 40mg po daily Diovan 160mg po daily Verapamil 240mg po daily Coumadin 5mg daily except Fridays Benadryl 25 mg po qHS Coumadin -Last dose**[**6-28**] Allergies:Penicillin (rash) Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for temperature >38.0. 2. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO DAILY (Daily) as needed for constipation. 3. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 6-10 Puffs Inhalation Q6H (every 6 hours). 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for agitation/delerium. 6. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 7. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Six (6) Puff Inhalation Q6H (every 6 hours). 8. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO DAILY (Daily). 11. Warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 doses: dose coumadin daily for goal INR 2-2.5, dx: afib. 12. 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. 13. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Clinician to dose daily for goal INR 2-2.5 dx: afib (home dosing 5mg daily, x 0mg Fridays). 14. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED): dose per attached sliding scale Q6h. Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 1294**] Discharge Diagnosis: Hypertension, Hyperlipidemia, Atrial Fibrillation, Rheumatic Heart Disease, Aortic Stenosis,Spontaneous Bacterial Endocarditis [**2089**] after dental procedure, Colon CA [**2095**]'s s/p colectomy, Hard of hearing, Colon polyps s/p polypectomy, s/p colectomy,tonsillectomy, respiratory failure Discharge Condition: Alert and oriented x 1 nonfocal [**Doctor Last Name 2598**] to chair and stand pivot w/ assit of two Incisional pain managed with Tylenol Incisions: Sternal - healing well, no erythema or drainage Edema: trace trach: c/d/i PEG: c/d/i Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage. Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**] Monday [**2125-9-10**] at 1pm Please call to schedule appointments with your Primary Care/cardiologist Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] [**0-0-**] in [**1-27**] weeks [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2125-7-26**]

[ "427.31", "285.1", "396.0", "E928.9", "414.01", "V58.61", "398.91", "287.5", "401.9", "997.31", "518.81", "867.0", "440.0", "V10.05", "785.51", "272.4", "349.82", "272.0", "293.0" ]

icd9cm

[ [ [] ] ]

[ "39.61", "35.23", "96.71", "31.1", "33.24", "00.40", "38.93", "33.23", "38.91", "96.72", "96.04", "96.6", "43.11", "35.21", "38.14" ]

icd9pcs

[ [ [] ] ]

9087, 9161

5102, 7225

284, 374

9500, 9737

2243, 5079

10496, 11010

1418, 1500

7572, 9064

9182, 9479

7251, 7549

9761, 10473

1515, 2224

237, 246

402, 1122

1144, 1265

1281, 1281

46,067

132,911

6682

Discharge summary

report

Admission Date: [**2102-7-23**] Discharge Date: [**2102-8-2**] Date of Birth: [**2056-9-28**] Sex: F Service: SURGERY Allergies: Codeine / Morphine Sulfate / Hydromorphone Attending:[**First Name3 (LF) 1384**] Chief Complaint: Diabetes Mellitus-Insulin Dependent Elective admission for Pancreas Transplant Major Surgical or Invasive Procedure: s/p pancreas transplant [**2102-7-23**] History of Present Illness: 45-year-old woman with type 1 diabetes for more than 35 years with frequent episodes of hypoglycemia, hypercholesterolemia. No hypertension or coronary artery disease. Her renal function is normal and no proteinuria. She has baseline gastroparesis and mild stable retinopathy. Pretransplant Workup: Last cardiac stress done on [**2101-12-15**] was normal. All other pretransplant workup including Pap smear, mammogram, and serologies were updated. She has hepatitis B surface antibody positive.She has been active on blood group O list. She does not have any unacceptable antigens. Her calculated PRA is zero. Past Medical History: LMP: [**2102-7-4**] Diabetes: Insulin dependent since age 10. She was initially followed by the [**Last Name (un) **], now by Dr [**Last Name (STitle) 931**]. ? Endometriosis PSH: 1. Cesarean section x 3 2. Perforated R ear drum 4 years ago from infection. 3. 3rd molar extraction. 4. Scheduled for the resection of the R fallopian tube for ? mass and fulguration of the left tube for contraception. Family History: Mother: Dementia. Living: at age: 79. Father: Dissected aortic aneurysm in [**Country 4754**]. Deceased: at77. Physical Exam: Temp 97.0 Pulse 124 BP 113/70 RR 18 SATS 89% RA GEN cooperative, not in distress NEURO Oriented awake alert, no global or local deficits. HEENT no thyromegaly, no lymphadenopathy, no carotid bruit. CHEST clear bilaterally CARDIAC S1 S2 audible no murmurs appreciated. ABDOMEN soft, non tender, non distended, BS+, no masses no herniation, guaic not done. Transverse lower abd surgical scar for C-sections. EXT No edema, distal pulses palpable +2 Pertinent Results: Pertinent Labs on Discharge: [**2102-8-1**] 05:08AM BLOOD WBC-4.9 RBC-3.47* Hgb-10.1* Hct-29.3* MCV-84 MCH-29.0 MCHC-34.4 RDW-13.8 Plt Ct-506* [**2102-7-31**] 05:19AM BLOOD PT-13.3 PTT-24.4 INR(PT)-1.1 [**2102-8-1**] 05:08AM BLOOD Glucose-104* UreaN-6 Creat-0.4 Na-135 K-4.1 Cl-106 HCO3-24 AnGap-9 [**2102-7-29**] 04:57AM BLOOD ALT-10 AST-14 AlkPhos-51 Amylase-39 TotBili-0.4 [**2102-7-31**] 05:19AM BLOOD Calcium-8.6 Phos-4.7* Mg-1.7 [**2102-8-1**] 05:08AM BLOOD tacroFK-8.6 Brief Hospital Course: Ms. [**Known lastname 13224**] is a 45 YO woman with DM Type 1 who was admitted on [**2102-7-23**] to undergo a pancreas transplant. She was taken to the OR by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**], where a deceased donor pancreas transplant was performed. Postoperatively, she was extubated in the PACU. She required pressors to maintain BP goals. She complained of extreme pruritis, which was managed with Nubain, Benadryl, and Sarna lotion. She remained in the PACU through POD 1, where she was initially placed on an insulin drip with wonderful blood glucose control. She received 1 unit PRBCs. An ultrasound of the pancreas was performed which showed good flow. She had continued to have excellent urine output. Immunosuppression (ATG, Tacro, MMF, Methylpred) and antibiotic prophylaxis (Bactrim/Fluc/Valcyte) were initiated per protocol. A heparin drip was started. On POD 2 she was admitted to the SICU for continued pressor support. She was finally able to be weaned off on POD 3. Her BP, urine output, and blood glucose control remained adequate. Her pruritis continued and was successfully managed with pre-medication with Benadryl, Tylenol, and Methylpred prior to ATG administration. Ms. [**Known lastname 13224**] was transferred out of the SICU on POD 4. She reported new onset blurry vision, and an Ophthalmology consult was requested. Recommendations were for the patient to obtain [**Location (un) 1131**] glasses for presbyopia. Her diet was advanced as tolerated, however she had difficulty meeting adequate PO intake as she experienced persistent nausea in the setting of known gastroparesis. She required maintenance IVF for occasional orthostasis, with fluid boluses for two episodes of hypotension. She was eventually ordered for scheduled Reglan, with subsequent improvement in her nausea. A Nutrition consult was obtained, and supplements were started. She was slowly able to increase her caloric and fluid intake over the following days. Ms. [**Known lastname 13224**] did complain of low back pain that seemed to be associated with lying bed. She participated fully in physical therapy, and her pain improved as she was able to increase her activity. By POD 10 she was feeling well, her nausea had resolved, she had much improved PO intake, and her blood glucose remained stable. She was deemed appropriate for discharge [**2102-8-2**]. Medications on Admission: Lantus 17 U qhs Humolog PRN /ISS Simvastatin 40 mg qd Discharge Medications: 1. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. Sulfamethoxazole-Trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Tramadol 50 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 9. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). Disp:*120 Tablet(s)* Refills:*1* 10. Midodrine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 11. Tacrolimus 5 mg Capsule Sig: One (1) Capsule PO twice a day. 12. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO twice a day. 13. Kayexalate Powder Sig: Three (3) teaspoons PO As needed as needed for High Potassium level: The coordinator will call you when you need to take this. Discharge Disposition: Home Discharge Diagnosis: s/p pancreas transplant DM I gastroparesis orthostasis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call the Transplant Office [**Telephone/Fax (1) 673**] if you have any of the warnings signs or any concerns You will need to have blood drawn every Monday and Thursday at [**Last Name (NamePattern1) 439**], [**Hospital 2577**] Medical Office Building [**Location (un) 453**] Please check your blood glucose in the AM and PM. Call if greater than 170. You may shower. No heavy lifting/straining or driving the car. Try to drink at least 2 liters of fluid per day Followup Instructions: Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MSW Date/Time: [**2102-8-8**] 2:30pm Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Date/Time: [**2102-8-8**] 3:20pm

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icd9cm

[ [ [] ] ]

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icd9pcs

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39631

Discharge summary

report

Admission Date: [**2138-7-22**] Discharge Date: [**2138-8-19**] Date of Birth: [**2111-9-19**] Sex: M Service: MEDICINE Allergies: Cefepime Attending:[**First Name3 (LF) 3326**] Chief Complaint: Fever, diarrhea, lethargy Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname **] is 26M with history of hypoplastic MDS s/p single cord transplant with post transplant course c/b mucormycosis, CMV infection, Cdiff, and VRE bacteremia with h/o persistent pancytopenia thought to be [**3-20**] myelosuppression from CMV + antivirals. The patient has been in and out of the hospital with recurrent episodes of sinusitis and pneumonia, most recently discharged on [**2138-7-18**]. During this most recent admission, the patient was treated for pneumonia and respiratory cultures grew pan-sensitive Step pneumo. He also had CT chest and sinues which showed acute on chronic changes that were more concerning for bacterial infection, not fungal infection. Based on the imaging, it was decided to start the patient on meropenum, and he was d/ced with plan of 4 week course of ertapenem. The patient was seen in clinic yesterday, and was found to have low grade temperature to 100.3; he was transfused 1U PRBC and platelets. The patient reports having rigors and felt sick, which he why he went to OSH and as per report had temperature 103. The patient also reports having a worsening cough; also notes having increasing nasal secretions. On ROS, the patient reports fevers, and rigors at home. Denies any trouble breathing. Notes increasing nasal secretion. Denies any abdominal pain. Past Medical History: - Hypoplastic MDS. Transfusion dependent MDS diagnosed Fall [**2136**]. At admission he had a WBC of 3.3, Hct 11.5 and platelets of 5. Bone marrow biopsy demonstrated a hypocellular marrow with cytogenetic abnormalities consistent with hypoplastic MDS (deletion 7q and 13). MDS course complicated by mucor infection with infiltration into base of the tongue with bleeding requiring intubation and IR guided ablation of bleeding artery. Patient was managed with a single cord transplant on [**2137-6-24**] with reduced intensity Flu/MEL/ATG conditioning. Post transplant course complicated by non-GVH nausea. Recent course complicated by low grade temperature and +CMV viral load with proloinged admission for IV ganciclovir. - C. difficile infection [**10/2136**] - pericoronitis s/p extraction 4 teeth [**2137-1-24**] - peri-rectal abscess s/p drainage [**2137-2-27**] - Hemochromatosis - Transaminitis (felt most likely multifactorial; contributions by medications and hemochromatosis) . Pertinent Oncologic history (include past therapies, surgeries, etc): diagnosed with hypoplastic MDS in the fall of [**2136**]; transfusion dependent; mucor infection with infiltration into base of the tongue with bleeding requiring intubation and IR guided ablation of bleeding artery; single cord allo [**2137-6-24**] with reduced intensity Flu/MEL/ATG conditioning; CMV + CURRENT TREATMENT PLAN: allo assessment. Social History: -Moved from [**Country **] in [**2136**]. -lives with sister, brother-in-law, and their 2 children. -He has no pet exposures. -previously worked in warehouse packing boxes, has not worked since [**35**]/[**2136**]. He has a history of working for an oil company in [**Country **], though per reports worked mainly in office and had only occasional exposure to factory environment. -No significant tobacco history. -Occasional alcohol use -No illicit drug use Family History: Father died at age 73, per reports had "illness" and progressive weakness. Mother died of stroke at age 60. No known family history of cancer or bleeding disorders. Has 6 siblings who are healthy. Physical Exam: Admission PE: VS: 97.4 97/62 70 16 98RA General: pleasant, well appearing young gentleman, NAD, laying comfortably in bed HEENT: EOMI, PERRL CV: RRR, S1, S2, no murmurs/gallops/rubs appreciated lungs: coarse breath sounds throughout, with inspiratory crackles throughout abdomen: soft, nontender, nondistended, +BS extremities: warm, well perfused, no LE edema; L arm PICC with no erythema, no tenderness to palpation Neuro: moving all extremities spontaneously, muscle strength and sensation throughout Discharge PE: Called to bedside in early morning of [**8-19**] to pronounce patient. Carotid pulses were absent, heart sounds were also absent. No breath sounds were heard. Extremities were cool. The covering attending, the attending of record and the patient's outpatinet oncologist were notified. The patient was pronounced dead at 1:18 AM on [**2138-8-19**]. Pertinent Results: [**2138-8-18**] 03:30PM BLOOD WBC-0.1* RBC-1.89* Hgb-5.6* Hct-17.0* MCV-90 MCH-29.6 MCHC-32.8 RDW-18.5* Plt Ct-20*# [**2138-8-18**] 06:00AM BLOOD WBC-0.1* RBC-2.34* Hgb-7.0* Hct-20.2* MCV-86 MCH-29.8 MCHC-34.4 RDW-17.4* Plt Ct-12* [**2138-8-18**] 03:30PM BLOOD Fibrino-136* [**2138-8-18**] 06:00AM BLOOD Fibrino-167*# [**2138-8-18**] 03:30PM BLOOD Glucose-268* UreaN-59* Creat-1.3* Na-145 K-4.2 Cl-115* HCO3-5* AnGap-29* [**2138-8-18**] 06:00AM BLOOD Glucose-207* UreaN-55* Creat-1.1 Na-145 K-3.9 Cl-119* HCO3-8* AnGap-22* [**2138-8-17**] 09:00PM BLOOD Glucose-265* UreaN-49* Creat-0.9 Na-143 K-3.8 Cl-119* HCO3-10* AnGap-18 [**2138-8-17**] 01:00PM BLOOD Glucose-182* Na-146* K-3.6 Cl-122* HCO3-10* AnGap-18 [**2138-8-17**] 12:00AM BLOOD Glucose-244* UreaN-42* Creat-0.9 Na-143 K-3.9 Cl-119* HCO3-12* AnGap-16 [**2138-8-18**] 06:00AM BLOOD ALT-20 AST-156* LD(LDH)-2208* CK(CPK)-197 AlkPhos-164* TotBili-3.0* DirBili-1.1* IndBili-1.9 [**2138-8-17**] 12:00AM BLOOD ALT-17 AST-71* LD(LDH)-1436* AlkPhos-169* TotBili-1.6* [**2138-8-16**] 12:00AM BLOOD ALT-18 AST-65* LD(LDH)-1245* AlkPhos-165* TotBili-1.4 [**2138-8-18**] 05:04PM BLOOD Type-[**Last Name (un) **] pO2-43* pCO2-13* pH-7.13* calTCO2-5* Base XS--23 [**2138-8-18**] 06:01AM BLOOD Type-[**Last Name (un) **] pO2-31* pCO2-14* pH-7.36 calTCO2-8* Base XS--15 [**2138-8-17**] 02:41PM BLOOD Type-ART pO2-109* pCO2-11* pH-7.52* calTCO2-9* Base XS--9 [**2138-8-18**] 05:04PM BLOOD Lactate-14.5* [**2138-8-18**] 06:01AM BLOOD Lactate-6.7* [**2138-8-17**] 02:41PM BLOOD Lactate-2.5* Cl-126* PATH IMMUNOPHYNOTYPING [**8-7**] Red blood cells, granulocytes, were examined for phosphatidylinositol-linked antigens. Red blood cells express expected levels of DAF (CD55) and MIRL (CD59). Neutrophils (subset: 67%) show loss of GPI-linked protein. Immunophenotypic findings consistent with involvement by: An atypical granulocytic population (subset) with loss of CD55 (DAF) and CD59 (MIRL). The red blood cells do not show antigenic loss (patient has received blood transfusions). These findings (in a patient with a history of cord transplantation and transfusions) while suggestive of GPI-linked antigen loss need to be further ratified in the context of his original disease recurrence or donor related (cord blood transplant). Chimerism studies should be correlated. Further confirmatory testing with FLAER (send-out) can be considered, if Paroxysmal Nocturnal Hemoglobinuria is a differential diagnostic consideration. KARYOTYPE ([**8-1**]: 46,XY[30]) Imaging: CT SINUS/MANDIBLE/MAXILIMPRESSION [**7-23**]: Persistent opacities at the maxillary sinuses, ethmoidal, sphenoid and frontoethmoidal recesses as described above, with minimal improvement in the pattern of aeration, the attenuation in the paranasal sinuses is slightly heterogeneous, likely indicating inspissated secretions, the possibility of fungal colonization is also a consideration. CT chest [**8-12**] IMPRESSION: Anterior right upper lobe ground-glass opacity, new since the beginning of [**Month (only) 958**], has not changed since [**7-10**]. This finding is nonspecific. Ground glass opacity and centrilobular nodules in the left lower lobe, more characteristic of infection, have nearly completely resolved. Given the stability of the right upper lobe finding and resolution of other infection, the right upper lobe ground-glass opacities are less likely to be infectious and may be inflammatory or drug related. The need for followup CT should be dictated by clinical symptoms. CT ABD [**8-8**] IMPRESSION: 1. Heterogeneous enhancement of the kidneys is concerning for pyelonephritis. 2. Evidence of third spacing is evidenced by a moderate amount of pelvic ascites and trace pericholecystic fluid, both new from prior. 3. Hepatosplenomegaly, unchanged from prior studies. 4. No evidence of intra-abdominal abscess, however, attention on followup should be paid to a small hypodensity seen in the right pelvis, which most likely represents bowel. Liver US [**8-6**] IMPRESSION: 1. Equivocal patchy increase in hepatic parenchymal echogenicity suggestive of fatty infiltration. 2. Gallbladder wall edema, a nonspecific finding which could relate to third spacing, particularly in the setting of low serum albumin. No gallstones. 3. Marked splenomegaly, increased compared to [**2138-2-20**]. Brief Hospital Course: PRINCIPLE REASON FOR ADMISSION Mr. [**Known lastname **] is 26M with history of hypoplastic MDS s/p single cord transplant with post transplant course c/b mucormycosis, CMV infection, Cdiff, and VRE bacteremia with h/o persistent pancytopenia thought to be [**3-20**] myelosuppression from CMV + antivirals, recently discharged from hospital for PNA, now presenting with fevers and rigors in the setting of recent blood transfusion on [**2138-7-22**]. His fevers persisted despite antibiotics and the patient ultimately had a bone marrow biopsy that showed evidence of HLH. He was started on HLH [**2130**] protocol, and unfortunately became lethargic and tachycardic with severe metabolic acidosis anc respiratory alkalosis in the setting of severe diarrhea. Head CT was concerning for subacute ischemic stroke. Patient's metabolic disturbance worsened and he eventually became hypotensive and passes away the morning of [**8-19**]. ACTIVE PROBLEMS # Hypotension: On [**8-18**] and into the morning of [**8-19**] the patient became hypotensive with MAPs into the 40s. He continued to have significant metabolic derangements, most notably an AGMA. He was started on levophed but was unable to maintain pressures even at doses of 0.45 mcg/kg/min. He was given 4 amps of bicarb with little effect on his blood pressures. After discussion with his oncologist, the patient was deemed "CPR not indicated." Ultimately his BP was unable to sustain perfusion to his vital organs and he expired on [**2138-8-19**] at 1:18 AM. # Lethargy: Transferred to the [**Hospital Unit Name 153**] on [**8-17**] due to new onset tachycardia, hypertension, and worsening metabolic acidosis with respiratory alkalosis. Due to increased lethargy, a head CT was obtained which showed R sided hypodensity in the internal capsule/basal ganglia. The differential for this finding included stroke, infection or mass. An MRI was recommended to better characterize this lesion. Because this would require intubation and would not significantly alter management in the acute setting, MRI was deferred and blood pressures were monitored in the setting of a presumed infarct, initially allowing for permissive hypertension with SBPs into the 180s. As noted above, the patient progressively became hypotensive in the setting of a triple acid base disturbance, and eventually expired. # Diarrhea: The patient initially had diarrhea in the setting of his antibiotics. Stool studies and Cdiff were negative. Diarrhea became persistent on [**8-13**], and he developed a non-anion gap acidosis with Cl to 122 on [**8-16**]. After developing nausea on [**8-17**] and having a bicarb of 12, he became unresponsive to IVF boluses as above. # Metabolic derangements: Pt. was transferred to the [**Hospital Unit Name 153**] on [**2138-8-17**] with worsening metabolic acidosis. He was found to have a triple acid base disturbance consisting of the following: AGMA likely due to lactic acidosis [**3-20**] hypotension, NGMA likely [**3-20**] diarrhea and respiratory alkalosis of unclear etiology. The respiratory alkalosis was later attributed to a central process given the findings on head CT noted above. Ultimately the patient became unable to maintain systemic BPs in the setting of severe metabolic derangments and he expired. # Hemophagocytic lymphohistiocytosis: The patient was found to have HLH on bone marrow biopsy, which would account for his high fevers. He also had an elevated EBV and it was thought that this was viral driven HLH in the setting of his elevated EBV viral load. He was started on dexamethasone, etoposide, and cyclosporine prior to his passing. # Fevers: The patient initially presented with fevers in spite of being on ertapenum. It was thought that this could be a transfusion reaction to blood and platelet products that were received the day prior in clinic. A transfusion reaction work up was initiated, and the patient was also started on empiric Vanc/[**Last Name (un) **] in case infection was the underlying etiology. He was also continued on his prophylaxis with dapsone, posaconazole, and valgancyclovir. He was ultimately found to have HLH and was started on dexamethasone, etoposide, and cyclosporine. After starting the treatment, the patient defervesced, although meropenem was continued given persistent neutropenia. # Hypoplastic MDS s/p single cord transplant: The patient was platelet and PRBC transfusion dependent. He was transfused blood and platelets as needed to maintain Hgb <7, platelets <10. He needed [**Doctor First Name **] B negative blood which the blood bank specially stores. #Nausea/Vomiting: Overnight on [**8-17**] pt developed intractable vomiting unresposive to phenergan, compazine, zofran, reglan. He was started on 2.5 olanzapine and a scopalmine patch. # Tachycardia/Cardiac: The patient was been intermittently tachycardic throughout the admission, likely in the setting of intermittent fevers, vomiting, and his degree of anemia. His heart rates were monitored during the admission. On [**8-17**] he became tachycardic to [**Street Address(2) 87418**] depressions in II, III, AvF. These resolved with decreased heart rate on repeat EKG. # transfusion reaction: The patient was noted to have labs consistent with hemolysis during this admission, with positive Coombs test. Blood bank was involved in screening the patient's blood to identify which specific antibodies were causing him to have recurrent transfusion reactions. Medications on Admission: ertapenem 1 gm qday 4 weeks dapsone 100 mg daily folic acid 1 mg daily posaconazole 400 mg q12h valganciclovir 900 mg daily Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Hemophagocytic Lymphohistiocytosis, hypoplastic myelodysplastic syndrome Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A

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icd9cm

[ [ [] ] ]

[ "41.31", "99.25" ]

icd9pcs

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Discharge summary

report

Admission Date: [**2186-1-12**] Discharge Date: [**2186-1-15**] Date of Birth: [**2110-9-11**] Sex: F Service: MEDICINE Allergies: Codeine / Probenecid / Bactrim / Penicillins / Cephalexin / Hydroxychloroquine Attending:[**First Name3 (LF) 348**] Chief Complaint: SOB, cough Major Surgical or Invasive Procedure: None History of Present Illness: 75yoF with h/o RA, Zenker's diverticulum, diverticulitis s/p colostomy, breast ca s/p mastectomy presents with 6-day history of cough, pleuritic CP, chills, SOB, and low-grade fever. She was seen by her PCP 2 days prior to admission who prescribed Azithromycin after CXR showed pneumonia. She did not improve with this and continued to have cough productive of clear sputum and low-grade fevers - highest temp at home was 99.5. She also reports increased stoma output and abdominal pain after starting the Zpak as well as one episode of urinary incontinence this morning. . In the ED, initial vs were: T 99.0 P 103 BP 115/61 RR 24 O2 sat 95-97% on RA. CXR showed bibasilar opacities and pleural effusions suspicious for pneumonia as well as diffuse hyperinflation and subcutaneous air along the R chest wall vs. overlapping fat. She was given 1L NS as well as IV levofloxacin 750 mg. Labs revealed Na 127, Cr 0.4, WBC 13.6, Hct 34.8, and mildly elevated AlkP at 208. Blood cultures were sent. The patient was initially called out to the floor but had an episode of hypotension to the 80s systolic. One liter NS was given with improvement of SBP to the 90s. She reportedly has difficult access and fluid was administered through 1 PIV. She was then admitted to the ICU. . Of note, the patient has had a recent liver ultrasound as outpatient to evaluated elevated alkaline phosphatase and CEA of 9, but no abnormalities were noted on ultrasound aside from liver hemangiomas. . On the floor, VS are 97.8 90 104/64 25 92% on RA. She appears anxious but is breathing comfortably. She coughs frequently during the interview. On lung exam, transmitted upper airway wheezing and diminished breath sounds at the bases. She reports that at baseline she is able to walk gingerly without assitance. She has been having slightly decreased PO recently since starting the antibiotics. . Review of systems: (+) Per HPI - + for urinary frequency (-) Denies night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, constipation. Denies dysuria. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: Chronic Obstructive Pulmonary Disease Rheumatoid Arthritis Hypertension Hypothyroidism Mitrial valve prolapse Anemia Zenker's diverticulum Diverticulitis s/p colostomy - [**2170**] Breast cancer s/p L mastectomy Lymphedema Left arm Osteoarthritis Osteoporosis Bilateral knee replacement L Hip replacement Sjogren's Syndrome Elevated Alk Phos Social History: Lives at home with husband. [**Name (NI) **] home health care aide. Able to walk without assitance. Feeds herself with plastic silverware. - Tobacco: former smoker -> smoked for 7 years in her 20s - Alcohol: None - Illicits: None Family History: Father, grandfather and 2 aunts with [**Name2 (NI) **] Physical Exam: On admission to the MICU: Vitals: T 97.8 HR 90 BP 104/64 RR 25 92% on RA General: Thin, frail woman with temporal wasting in no apparent distress. Alert, oriented, pleasant. Coughs frequently during interview HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, thin, JVP not elevated, no LAD Lungs: Diminished breath sounds at bases, transmitted upper airway wheezes, no rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: thin, soft, non-tender, non-distended, bowel sounds present, ostomy appears healthy, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: dry skin, no rashes Neuro: CNII-XII intact, equal strength throughout . On Discharge: Vitals - Tm 98.0 Tc 98.0 BP 106/64 P:93 RR:18 SaO299% RA GENERAL: elderly female appearing cachectic with BL temporal wasting and prominant ribs and clavicals, breathing comfortably HEENT: no pharyngeal erythemia, mucous membs dry CHEST: CTABL no wheezes, no crackles, no ronchi CV: S1 S2 Normal in quality and intensity RRR no murmurs rubs or gallops ABD: Colostomy bag in place with minimal brown drainage. Non-distended, BS normoactive, Soft, non-tender. EXT: Ulnar deviation of phallanges. Swan-neck and deformities noted in BL hands with significant distortion of articular angles of fingers. NEURO: AAOx3 Pertinent Results: On admission: Na 127 K 5.6 Cl 92 HCO3 25 BUN 17 Cr 0.4 Glc 100 AlkP 208 T bili 0.4 Lip 24 WBC 13.6 (90.5 N, 6.5 L) Hct 34.8 (MCV 86) Plt 463 . Discharge: [**2186-1-15**] 07:00AM BLOOD WBC-8.3 RBC-3.75* Hgb-10.6* Hct-32.0* MCV-85 MCH-28.2 MCHC-33.1 RDW-12.4 Plt Ct-502* [**2186-1-15**] 07:00AM BLOOD Glucose-89 UreaN-8 Creat-0.3* Na-135 K-4.4 Cl-99 HCO3-29 AnGap-11 [**2186-1-15**] 07:00AM BLOOD Calcium-8.4 Phos-4.3 Mg-1.8 [**2186-1-14**] 06:20AM BLOOD calTIBC-186* Ferritn-250* TRF-143* . Micro: blood cultures: No growth to date at time of discharge. Urinary legionella negative . EKG: NSR, Nl axis and intervals; RBBB, TWI in V2 CXR [**2186-1-12**] FINDINGS: There are bibasilar opacities and pleural effusions, right greater than left. Fluid is seen in the right major and minor fissures. Although these opacities appear to include atelectatic changes, underlying pneumonia cannot be excluded. The mediastinal silhouette is unremarkable. There is diffuse hyperinflation suggestive of emphysema. . Note is made of diffuse osteopenia. The cortical contour of the left proximal humerus is irregular but incompletely visualized due to overlying external hardware. . IMPRESSION: 1. Bibasilar opacities and pleural effusions; pneumonia cannot be excluded. 2. Hyperinflation, likely secondary to COPD. Brief Hospital Course: 75yoF with h/o RA, Zenker's diverticulum, diverticulitis s/p colostomy, breast ca s/p mastectomy presents with 6-day history of cough, pleuritic CP, chills, SOB, and low-grade fever . # Bronchitis: On presentation was 95-97% on RA. CXR showed questionable bibasilar infiltrate with R > L pleural effusions. She was started on levofloxacin 750 mg IV for presumed community acquired pneumonia. Urinary legionella was negative, sputum culture grew yeast which is a contaminant. On reconsideration, cough and dyspnea are better explained by bronchitis than pneumonia given absence of radiographic or physical examination findings consistent with pneumonia. . # Hypotension: Blood pressure was 100s/60s on initial presentation to the ED but dropped to the 80s/50s. Blood pressure was fluid responsive and remained in the 100s/60s in the ICU for one night. Hypotension is related to reduced PO intake and loose stools and transient sepsis related to urinary tract infection. PO intake was encouraged she remained normotensive in the 100/50's throughout the remainder of her hospital stay. Amoldipine was held on admission and was not resumed on discharge as patient remained normotensive. . # Urinary tract infection: UA performed after admission was leukocyte esterase positive with many white blood cells and bacteria. Though epithelial cells were isolated in the UA suggesting that the speimenm was not a clean catch, the high number of whites and bacteria suggested that there may have been a true urinary tract infection. She denied dysuria however she is not a reliable historian. She had been started on levofloxacin as above and this was continued for a total of 5 days of treatment for urinary tract infection. . # Hyponatremia: Na 127 on admission. Thought to be [**2-15**] poor PO intake. Corrected to 133 on morning following admission. . # Rheumatoid arthritis: Patient with severe rheumatoid arthritis with significant deformities of her phalanges bilaterally. She had decided against DMARD therapy in the past and her disease has been managed symptomatically with tylenol and ibuprofen which was continued while in the hospital. . # Anemia: MCV 86. Chronic process, she is taking iron as an outpatient. Hct was stable during admission. . # Hypothyroidism: Continued home Levothyroxine 50 mcg qday . # Elevated AlkPhos: In work-up as outpt. Pt had recent RUQ U/S - normal except for hemangiomas . # Diet was with soft foods and Ensure pudding. . # The patient was confirmed DNR/DNI. HCP is her husband. Medications on Admission: Amlodipine 5 mg Levoxyl 50 mcg Diazepam 2mg [**Hospital1 **] prn anxiety Fexofenadine 60mg daily Iron Vit D 1000u daily MVI Discharge Medications: 1. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 1 days. Disp:*1 Tablet(s)* Refills:*0* 2. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. diazepam 2 mg Tablet Sig: One (1) Tablet PO once a day as needed for Anxiety/insomnia. 4. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO once a day. 5. Iron (ferrous sulfate) 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 6. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 7. multivitamin Tablet Sig: One (1) Tablet PO once a day. 8. acetaminophen 650 mg/20.3 mL Solution Sig: 20.3 mL PO Q6H (every 6 hours) as needed for pain. 9. ibuprofen 100 mg/5 mL Suspension Sig: Five (5) mL PO Q8H (every 8 hours) as needed for pain. 10. senna 8.6 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours as needed for constipation. 11. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day) as needed for constipation. Discharge Disposition: Home With Service Facility: [**Hospital 3894**] Healthcare Discharge Diagnosis: Primary: Urinary tract infection Bronchitis . Secondary:Chronic Obstructive Pulmonary Disease Rheumatoid Arthritis Hypertension Hypothyroidism Mitrial valve prolapse Anemia Zenker's diverticulum Diverticulitis s/p colostomy - [**2170**] Breast cancer s/p L mastectomy Lymphedema Left arm Osteoarthritis Osteoporosis Bilateral knee replacement L Hip replacement Sjogren's Syndrome Elevated Alk Phos Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Ms [**Known lastname 66084**], As you know, you were admitted to [**Hospital1 18**] for cough. Your blood pressure became dangerously low and you were admitted to the intensive care unit for one day where you were given fluids with improvement in your blood pressure. Your cough is related to bronchitis which will resolve over the course of the next two weeks. You were found to have a urinary tract infection which caused your blood pressure to be low. You were treated with antibiotics and will need to continue to take antibiotics after leaving the hospital. Your final day of antibiotics will be [**2186-1-16**]. . Your blood pressure was low while you were in the hospital and your outpatient Amoldipine was discontinued. Please discuss resuming this medication when you next see your primary care provider. . Medication changes: START taking the following mediction: Levofloxacin until [**2186-1-16**] . STOP taking the following medication: Amlodipine Followup Instructions: We recommend that you follow up with your primary care provider [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 40909**] [**Last Name (NamePattern1) 1124**] within 2 weeks. Please call to make an appointment at [**Telephone/Fax (1) 3530**].

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Discharge summary

report+addendum

Admission Date: [**2120-8-30**] Discharge Date: [**2120-9-4**] Date of Birth: [**2082-1-30**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2290**] Chief Complaint: weakness Major Surgical or Invasive Procedure: HD line placement [**2120-8-30**] History of Present Illness: Mr [**Name13 (STitle) 90856**] is a 38M with hx of HTN, CRI (bl cr 1.9) who p/w acute renal failure. . Patient followed closely by PCP and nephrologist. Seen by renal on [**8-16**], creatinine recorded as 5.4 however does not appear that work-up or treatment was initiated. . On [**8-26**] patient, developed nausea, vomiting, and diarrhea after dining out with his mother and subsequently was sick for 2.5d. Patient reports there may have been blood in the stool but on certain. Pertinent +/- + low grade temps, decreased urinary frequency, weakness "ordinary level" of cough and sneezing, - sweats, chills, sick contacts, confusion, SOB, LE edema, dysuria. hematuria . His mother was concerned about him so she took him to PCP on Thursday morning. They were called in the afternoon saying they had to go into the ED for abnormal labs and renal failure. Patient presented to [**Hospital 65230**] hospital, found to be in [**Last Name (un) **] with creatinine of ~13 and a K 6.0 with no EKG changes of concern. D50, insulin 10mg, and 1 amp bicarb given. Was hypotensive to 70's with was fluid responsive. In total received 5L of NS and upon patient request was transferred to the [**Hospital1 **]. . In the [**Hospital1 18**], initial VS 99.9 103 100/53 16 98% 3L. Initial labs, creatinine 13.9, K 5.8. Received calcium gluconate, insulin, lasix: with 200-300cc of UOP. Per report, respiratory status decompensated, patient placed on bipap and given ativan 0.5mg to anxiety. Decision made to admit to the ICU for HD and eval of [**Last Name (un) **]. . On arrival to the ICU patient relatively comfortable with shallow breathing and RR in the 20s. Renal was consulted for initiation of urgent dialysis . PCP clarification of chronic issues: 1. HTN. Patient with h/o long standing HTN needing control with several agents. Diuretics d/c'ed after elevation in creatinine. Most recent [**7-2**] SBPs 124/62, 126/60, per PCP [**Name Initial (PRE) 5348**] 130 - 150s in recent months. 2. Chronic kidney disease. In [**2117**] patient with nl renal function. Started on diuretics for SBP control with elevation to 4. Diuretics stopped with resolution of kidney function to 1.4- 1.5. Recent baseline 1.7-1.9. Seen by renal on [**8-16**] with creatinine 5.4; no note of work-up performed. Most recent outpatient creatinine 13.6 3. Anemia. Patient with progressive drop in HCT over year; [**4-10**]: 37.3 [**8-19**]: 33.3, [**8-29**]: 25. Work-up has yet to be formed. . Review of systems: (+) Per HPI; reports chronic back pain (-) Denies recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: 1. HTN. Patient with h/o long standing HTN needing control with several agents. Diuretics d/c'ed after elevation in creatinine. Most recent [**7-2**] SBPs 124/62, 126/60, per PCP [**Name Initial (PRE) 5348**] 130 - 150s in recent months. 2. Chronic kidney disease. In [**2117**] patient with nl renal function. Started on diuretics for SBP control with elevation to 4. Diuretics stopped with resolution of kidney function to 1.4- 1.5. Recent baseline 1.7-1.9. Seen by renal on [**8-16**] with creatinine 5.4; no note of work-up performed. Most recent outpatient creatinine 13.6 3. Anemia. Patient with progressive drop in HCT over year; [**4-10**]: 37.3 [**8-19**]: 33.3, [**8-29**]: 25. Work-up has yet to be formed. Social History: Lives with mom; paramedic - Tobacco: occassional cigars - Alcohol: 2-3cocktails/day - Illicits: denies Family History: Grandfather and uncle with kidney disease thought secondary to HTN Uncle: DM [**Name (NI) **] h/o heart Physical Exam: General: Alert, oriented, no acute distress, speaking in full sentences without obvious resp distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: thick, hard to discern JVP 2/2 habitus, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: distant heart sounds, RRR, no audible murmur, Abdomen: obese, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Admission Labs: [**2120-8-30**] 01:15AM URINE MUCOUS-MOD [**2120-8-30**] 01:15AM URINE HYALINE-21* [**2120-8-30**] 01:15AM URINE RBC-32* WBC->182* BACTERIA-MANY YEAST-NONE EPI-1 [**2120-8-30**] 01:15AM URINE BLOOD-LG NITRITE-NEG PROTEIN->600 GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-6.0 LEUK-MOD [**2120-8-30**] 01:15AM URINE COLOR-Amber APPEAR-Cloudy SP [**Last Name (un) 155**]-1.020 [**2120-8-30**] 01:15AM RET AUT-2.1 [**2120-8-30**] 01:15AM PT-14.6* PTT-25.0 INR(PT)-1.3* [**2120-8-30**] 01:15AM PLT SMR-NORMAL PLT COUNT-167 [**2120-8-30**] 01:15AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL [**2120-8-30**] 01:15AM NEUTS-68 BANDS-3 LYMPHS-11* MONOS-16* EOS-0 BASOS-0 ATYPS-0 METAS-1* MYELOS-1* [**2120-8-30**] 01:15AM WBC-9.7 RBC-2.52* HGB-8.3* HCT-24.6* MCV-98 MCH-33.1* MCHC-33.8 RDW-14.2 [**2120-8-30**] 01:15AM URINE GR HOLD-HOLD [**2120-8-30**] 01:15AM URINE OSMOLAL-310 [**2120-8-30**] 01:15AM URINE HOURS-RANDOM UREA N-210 CREAT-349 SODIUM-58 POTASSIUM-33 CHLORIDE-28 TOT PROT-1010 PROT/CREA-2.9* [**2120-8-30**] 01:15AM URINE HOURS-RANDOM [**2120-8-30**] 01:15AM TRIGLYCER-445* HDL CHOL-5 LDL([**Last Name (un) **])-<50 [**2120-8-30**] 01:15AM ALBUMIN-3.5 CALCIUM-7.7* PHOSPHATE-3.1 MAGNESIUM-1.5* [**2120-8-30**] 01:15AM CK-MB-6 [**2120-8-30**] 01:15AM cTropnT-0.02* [**2120-8-30**] 01:15AM LIPASE-134* [**2120-8-30**] 01:15AM ALT(SGPT)-43* AST(SGOT)-81* LD(LDH)-277* CK(CPK)-1417* TOT BILI-1.2 [**2120-8-30**] 01:15AM estGFR-Using this [**2120-8-30**] 01:15AM GLUCOSE-103* UREA N-110* CREAT-13.9* SODIUM-131* POTASSIUM-5.8* CHLORIDE-96 TOTAL CO2-19* ANION GAP-22* Notable Labs: [**2120-8-30**] 01:15AM BLOOD Ret Aut-2.1 [**2120-8-30**] 01:15AM BLOOD ALT-43* AST-81* LD(LDH)-277* CK(CPK)-1417* TotBili-1.2 [**2120-8-30**] 01:15AM BLOOD Lipase-134* [**2120-8-31**] 11:31AM BLOOD Lipase-526* [**2120-9-1**] 04:18AM BLOOD Lipase-590* [**2120-8-30**] 01:15AM BLOOD cTropnT-0.02* [**2120-8-30**] 01:15AM BLOOD CK-MB-6 [**2120-8-30**] 07:30AM BLOOD calTIBC-269 Hapto-414* Ferritn-819* TRF-207 [**2120-8-30**] 07:30AM BLOOD TotProt-5.6* Calcium-7.5* Phos-3.4 Mg-1.4* Iron-28* [**2120-8-30**] 01:15AM BLOOD Triglyc-445* HDL-5 LDLmeas-<50 [**2120-8-31**] 11:31AM BLOOD TSH-1.8 [**2120-8-30**] 12:27PM BLOOD Cortsol-43.0* [**2120-8-30**] 07:30AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE IgM HBc-NEGATIVE [**2120-8-30**] 07:30AM BLOOD PEP-NO SPECIFI [**2120-8-30**] 07:30AM BLOOD C3-177 C4-27 [**2120-8-30**] 12:27PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2120-8-30**] 07:30AM BLOOD HCV Ab-NEGATIVE [**2120-8-30**] 03:51AM BLOOD Lactate-0.8 [**2120-8-30**] 06:22AM BLOOD freeCa-1.00* Discharge Labs: [**2120-9-4**] 06:36AM BLOOD WBC-8.2 RBC-2.65* Hgb-8.6* Hct-26.9* MCV-101* MCH-32.3* MCHC-31.9 RDW-14.1 Plt Ct-416 [**2120-9-4**] 06:36AM BLOOD Glucose-95 UreaN-57* Creat-3.5*# Na-143 K-4.4 Cl-101 HCO3-31 AnGap-15 [**2120-9-4**] 06:36AM BLOOD ALT-44* AST-56* AlkPhos-36* TotBili-1.1 [**2120-9-4**] 06:36AM BLOOD Albumin-3.6 Calcium-9.7 Phos-4.4 Mg-1.5* EKG [**2120-8-30**]: Sinus tachycardia. Poor R wave progression. Tendency toward low voltage in the standard leads. No other diagnostic abnormality. No previous tracing available for comparison. TTE [**2120-8-30**]: The left atrium is elongated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The number of aortic valve leaflets cannot be determined. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Mild symmetric left ventricular hypertrophy with normal global and regional biventricular systolic function. CXR [**2120-8-30**]: IMPRESSION: No acute cardiopulmonary process. No pulmonary edema. RENAL ULTRASOUND [**2120-8-30**]: Transabdominal son[**Name (NI) 493**] images were obtained of the kidneys and bladder. The kidneys are normal in appearance bilaterally, without apparent masses, hydronephrosis or stones. The right kidney measures 13.8 cm. The left kidney measures 14.4 cm. The bladder is normal in appearance. IMPRESSION: Normal renal ultrasound without hydronephrosis. RUQ US [**2120-9-1**]: 1. Fatty liver; other forms of cirrhosis/fibrosis cannot be excluded. 2. No cholelithiasis; decompressed gallbladder with thickened wall may represent sequelae of CHF, hypoproteinemia, or liver dysfunction. No intra-or extra-hepatic biliary dilatation. Brief Hospital Course: Mr. [**Name14 (STitle) 90856**] is a 38M with hx of HTN, CRI (bl cr 1.9) who presented acute renal failure secondary to florid ATN of unclear etiology. 1. ACUTE ON CHRONIC RENAL FAILURE: The patient presented with a creatinine to 13.9 from baseline of 1.9, most likely due to urosepsis. He has suspected hypertensive nephropathy versus NSAID-induced nephropathy at baseline but was never biopsied. Nephrology was consulted, and microscopic review of the urine sediment revealed numerous brown casts consistent with florid ATN. Pt described several days of urinary urgency prior to the acute worsening of his symptoms. As he had several days of abdominal pain and diarrhea, hypovolemia was also suspected. Thus, his acute renal failure was likely exacerbated by a combination of hypovolemia and hypotension from urosepsis. TTP-HUS was ruled out with negative hemolysis labs and shiga toxin assays. Renal ultrasound revealed no hydronephrosis suggestive of post-renal obstructive nephropathy. Several other tests including HepB, HepC, complement, SPEP, [**Last Name (LF) 66046**], [**First Name3 (LF) **], and ANCA were all negative. Initial asymptomatic hyperkalemia to 6 was managed medically prior to HD line placement and hemodialysis on day 1. He was also dialyzed on days 2 and 3. His renal function continued to improve over the rest of his admission, with Cr down to 3.5 on discharge, and he had good urinary output. His HD line was removed on the day of discharge. Given his acute renal failure, the pt's lisinopril and spironolactone were both held. He was provided with an appointment with Renal outpatient clinic 1d after discharge. His nephrologist will help determine when it is safe to resume these medications. 2. HYPOTENSION: He developed low blood pressures in the 80s systolic on the evening of admission and throughout his MICU course. Per his report, he has a history of longstanding hypertension though his sytolics had appartently dropped to the 80s with enactment of a low Na diet. When a blood culture grew GNR, concern for sepsis mounted and cipro was added to ceftriaxone monotherapy treating a UTI. Pressors were not needed- his MAPS improved spontaneously. Random cortisol of 43 ruled out adrenal insuffiency. TTE revealed no major cardiac abnormality. Persisting hypovolemia is possible from his previous GI illness. On the medical floor, Pt's pressures remained stable at 120s-140s/50-60s. 3. E. coli BACTEREMIA/urinary tract infection: GNR later speciated as pan sensitive E coli grew from a [**8-30**] blood culture. Prior to receiving final reports of speciation and susceptibility, cipro was added to ceftriaxone on [**8-31**]. Surveillance cultures were henceforth negative and he remained afebrile. Cipro was stopped on [**9-2**] when sensitivities returned. He remained on iv ceftriaxone until the the day of discharge, when he was switched to cefpodoxime 200mg po bid for 9 more days to complete a 14 day course for complicated pyelonephritis / urosepsis. 4. Normocytic Anemia. patient with declining counts over preceding months from 37.3 in [**Month (only) 116**] to 25 on admission. Coags wnl. Iron studies most consistent with anemia of chronic disease, likely related to CKD. Will defer to outpatient management. 6. Elevated LFTs. Labs appear consistent with baseline. Likely secondary to NASH vs EtOH use. RUQ ultrasound was consistent with fatty infiltration. Will defer to outpatient management. 7. DIARRHEA: diarrheal illness subsided prior to admission. Stool studies for c dif and bacterial enteritis were negative. Transitional issues: - Restart lisinopril and spironolactone when clinically elevated. - Follow LFT abnormalities and consider further work-up as clinically indicated. - Follow anemia and consider further work-up as clinically indicated. Medications on Admission: Carvedilol 12.5mg PO BID Spironolactone 37.5mg PO qAM Levothyroxine 50mcg daily lisinopril 10mg PO BID Folic acid 1 tab po daily Allopurinol 100mg QD Lorazapem 0.5mg prn Folbic 2.5-25-2 mg po daily Vitamin D 5,000 unit Tablet once weekly on Sundays Discharge Medications: 1. cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day for 9 days. Disp:*18 Tablet(s)* Refills:*0* 2. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 5. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Folbic 2.5-25-2 mg Tablet Sig: One (1) Tablet PO once a day. 7. Vitamin D 5,000 unit Tablet Sig: One (1) Tablet PO once a week: on Sundays. 8. calcium acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*30 Capsule(s)* Refills:*0* 9. Outpatient Lab Work Please check CBC, Sodium, potassium, bicarbonate, chloride, BUN,Creatinine, glucose, calcium, magnesium and phosphate on [**2120-9-5**] and fax results to Dr [**Last Name (STitle) 61683**] at [**Telephone/Fax (1) 90857**] for review Discharge Disposition: Home Discharge Diagnosis: acute on chronic renal failure E. coli bacteremia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr [**First Name8 (NamePattern2) **] [**Known lastname 69502**], you were admitted to the hospital due to acute renal failure. This was likely due to a combination of having a severe urinary tract infection which spread to your blood stream and made your blood pressure low, with poor blood supply to your kidneys, and being on medications which directly act on the kidneys, which in combination sent you into renal failure. You required dialysis twice, and also received blood transfusions and you improved. Because your kidney function has not completely returned to [**Location 213**], it is important that you follow up with your doctors [**Name5 (PTitle) 4314**] [**Name5 (PTitle) **] that your kidney function can continue to be monitored closely. The following medications were added: CEFPODOXIME 200MG TABLET TWICE DAILY UNTIL [**2120-9-13**] . THE FOLLOWING MEDICATIONS WERE HELD: LISINOPRIL SPIRONOLACTONE. ***Please discuss with your nephrologist when it is safe to restart these medications. Followup Instructions: Name: [**Last Name (un) **],[**Name6 (MD) 90858**] A MD Location: Kidney & [**Hospital **] Clinic Address: [**First Name8 (NamePattern2) 90859**] [**Hospital1 10478**], [**Numeric Identifier 90860**] Phone: [**Telephone/Fax (1) 61684**] Appointment: Thursday [**2120-9-5**] at 2pm Please go to the lab to have your blood drawn first thing in the morning on Thursday so that Dr [**Last Name (STitle) 61683**] can review in time for your appointment. Name: [**Doctor Last Name **],SAQIB N. Address: [**Location (un) 90861**], [**Apartment Address(1) **], [**Location (un) 90862**],[**Numeric Identifier 90863**] Phone: [**Telephone/Fax (1) 74375**] *The office will call you at home to tell you when to come into the office since they are on a walk in basis. Completed by:[**2120-9-4**] Name: [**Known lastname 14331**],[**Known firstname 14332**] Unit No: [**Numeric Identifier 14333**] Admission Date: [**2120-8-30**] Discharge Date: [**2120-9-4**] Date of Birth: [**2082-1-30**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 6410**] Addendum: Dr. [**Last Name (STitle) 14334**] called and asked for the HPI to be clarified in the discharge summary. The physician reports that the pt was last seen in [**Hospital **] clinic with her on [**2120-6-17**]. She states that he did not go to his follow-up appointment scheduled for [**8-19**] due to a death in the family. He had his blood drawn, but never went to his follow-up appointment. [**First Name4 (NamePattern1) 14335**] [**Last Name (NamePattern1) **], MD PhD Discharge Disposition: Home [**First Name11 (Name Pattern1) 2162**] [**Last Name (NamePattern4) 6411**] MD [**MD Number(2) 6412**] Completed by:[**2120-9-8**]

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icd9cm

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265, 275

376, 2101

4852, 7575

14907, 15019

2117, 2837

3324, 4044

4060, 4165

81,864

120,978

2296

Discharge summary

report

Admission Date: [**2129-1-8**] Discharge Date: [**2129-1-24**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 30**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: - Endoscopy - Cystoscopy - Bilateral lower extremity angiography History of Present Illness: 85 year-old man with a remote history of CVA minimally verbal with residual right-sided defects who presents with dyspnea and increasing falls. Per his family he is generally unsteady on his feet but has been falling more recently. He fell several times at home today, hitting his forehead and nose. This morning, following the falls, he was not talking at all (usually communicates one word sentences and can yell for help). His family called EMS. Per their report, he has been complaining of foot pain, but denied shortness of breath or chest pain. When EMS found him, he was in respiratory distress, with a low saturation (number no[**Serial Number 12047**]) on room air. Per his primary NP, he speaks in one word sentences at baseline. He recently has been seen for difficulty walking, possilby related to plantar fascitis and in the past two days has been looking somewhat pale. On [**8-23**], he had a physical with labs: Hb/Hct 10.1/30.6 with MCV 87.9, B12 deficieny. BUN/Cr was 58/2.1 In the ED, initial VS were: 95.6 72 140/49 32 96 on NRB. He was tachypnic to 32, using accessory muscles. An EKG was attempted, but was limited due to motion. It was reviewed with cardiology, who recommended aspirin and blood given his elevated cardiac enzymes. He was treated with 600 mg PR aspirin. He was also noted to be in acute renal failure. His chest x-ray was suggestive of a RUL PNA. He was treated with continuius nebs, solumed 125, and mag 2g for h/o asthma. He had blood cultures, levoquin and flagyl for possible aspiration pneumonia. Given the right frontal head abrasion, he had a head/neck CT that was negative for acute bleed or fracure. Prior to transfer, VS: HR 92 BP 145/52 18 100% on continuous neb @ 12 L FM. His respiratory exam had improved from initially no air movement to increasing wheezing. He got kayexalate for an elevated K and 500 cc IVF. . Currently, he appears more comfortable. Past Medical History: 1. s/p CVA [**2114**] with R sided deficits 2. hypertension 3. asthma 4. peripheral vascular disease, s/p fem-[**Doctor Last Name **] 5. gout 6. CKD 7. BPH 8. B12 deficiency No history of caridiac interventions. Social History: Denies tobacco, alcohol. Lives at home with son and grandchildren. Is able to ambulate, including up stairs as they live on a second story apartment. Family History: Non-contributory Physical Exam: Vitals - per metavision GENERAL: Grunts, Alert, tracks people in room, cooperative with exam HEENT: O/P clear, dry mm CARDIAC: RRR, 2/6 systolic murmur at LUSB LUNG: transmitted upper airway sounds. clear lungs. ABDOMEN: soft, non-tender, non-distended EXT: WWP DERM: Bruise on right temple. RECTAL: Guiac (+) brown stool. Moderate prostate enlargement. Pertinent Results: LABS: ===== [**2129-1-8**] 07:30AM BLOOD WBC-10.5 RBC-3.00* Hgb-7.4*# Hct-25.3* MCV-84# MCH-24.6*# MCHC-29.2* RDW-14.4 Plt Ct-387 [**2129-1-8**] 11:50AM BLOOD WBC-8.3 RBC-2.77* Hgb-6.6* Hct-22.4* MCV-81* MCH-23.8* MCHC-29.5* RDW-15.3 Plt Ct-406 [**2129-1-10**] 05:55AM BLOOD WBC-11.0 RBC-3.72* Hgb-9.8* Hct-31.4* MCV-85 MCH-26.5* MCHC-31.3 RDW-16.1* Plt Ct-297 [**2129-1-8**] 07:30AM BLOOD Neuts-90.7* Lymphs-6.0* Monos-2.7 Eos-0.2 Baso-0.4 [**2129-1-9**] 05:12AM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-2+ Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Ovalocy-OCCASIONAL Burr-OCCASIONAL Tear Dr[**Last Name (STitle) **]1+ Fragmen-OCCASIONAL [**2129-1-8**] 11:50AM BLOOD PT-12.5 PTT-48.5* INR(PT)-1.1 [**2129-1-8**] 07:30AM BLOOD Glucose-161* UreaN-61* Creat-2.8*# Na-141 K-5.7* Cl-106 HCO3-21* AnGap-20 [**2129-1-10**] 05:55AM BLOOD Glucose-146* UreaN-44* Creat-2.1* Na-146* K-4.6 Cl-112* HCO3-23 AnGap-16 [**2129-1-8**] 07:30AM BLOOD CK(CPK)-679* [**2129-1-9**] 06:46AM BLOOD CK(CPK)-1143* [**2129-1-10**] 05:55AM BLOOD CK(CPK)-456* [**2129-1-8**] 07:30AM BLOOD CK-MB-37* MB Indx-5.4 proBNP-7573* [**2129-1-8**] 07:30AM BLOOD cTropnT-1.03* [**2129-1-9**] 02:30PM BLOOD CK-MB-24* MB Indx-2.6 cTropnT-1.67* [**2129-1-10**] 05:55AM BLOOD CK-MB-11* MB Indx-2.4 cTropnT-1.48* [**2129-1-10**] 05:55AM BLOOD Calcium-8.7 Phos-3.9 Mg-2.3 [**2129-1-8**] 11:50AM BLOOD calTIBC-523* Ferritn-15* TRF-402* [**2129-1-8**] 11:54AM BLOOD Type-ART pO2-63* pCO2-31* pH-7.42 calTCO2-21 Base XS--2 [**2129-1-8**] 07:32AM BLOOD Lactate-3.6* [**2129-1-9**] 11:27AM BLOOD Lactate-1.7 [**2129-1-24**] INR 4.3* MICROBIOLOGY: ============ [**1-8**] Blood Culture x 2: negative [**1-8**] Urine culture: negative [**1-8**] MRSA positive [**1-8**] Influenzae A & B: negative [**1-15**], [**1-16**] C. difficile: negative [**1-16**] Urine Culture: negative [**1-16**] Blood Culture x 2: negative [**1-19**] Urine Culture: negative [**1-20**] Urine Culture: negative [**1-20**] Blood Culture: pending STUDIES: ======== [**2129-1-8**] TTE The left atrium is moderately dilated. The right atrium is moderately dilated. Left ventricular wall thicknesses and cavity size are normal. There is mild to moderate regional left ventricular systolic dysfunction with akinesis of the mid- and distal septal segments, as well as of the apex and distal inferior wall. The remaining segments contract normally (LVEF = 40%), most c/w multivessel CAD. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. There is moderate aortic valve stenosis (valve area 1.1 cm2). Mild (1+) aortic regurgitation is seen. There is mild functional mitral stenosis (mean gradient 5 mmHg) due to mitral annular calcification. Moderate (2+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild to moderate regional left ventricular systolic dysfunction, c/w CAD. Moderate aortic stenosis. Mild aortic regurgitation. Moderate mitral regurgitation. Moderate tricuspid regurgitation. Moderate pulmonary hypertension. Compared with the report of the prior study (images unavailable for review) of [**2124-1-26**], new wall motion abnormalities are seen. Severity of all valvular abnormalities has progressed. Estimated pulmonary pressure is higher. [**2129-1-8**] PORTABLE CXR: SINGLE AP VIEW OF THE CHEST: Evaluation is somewhat limited by patient position and exclusion of the costophrenic angles bilaterally. Within these limitations, and allowing for technique, the heart size may be mildly enlarged. There are increased vascular markings and hilar fullness suggestive of volume overload but underlying infection is not excluded. The aorta is tortuous as before. IMPRESSION: Limited evaluation of the chest with probable cardiomegaly and pulmonary edema. Underlying infection not excluded. [**2129-1-8**] CT HEAD W/O CONTRAST: IMPRESSION: 1. No intracranial hemorrhage. No midline shift. Left frontal encephalomalacia. 2. No depressed skull fracture. 3. Mild opacification of the mastoid, more prominent on the left with no bony destruction. Correlate clinically. Mild ethmoidal sinus mucosal thickening. [**2129-1-8**] CT C-SPINE WITHOUT CONTRAST: IMPRESSION: 1. No acute fracture of the cervical spine. Severe degenerative changes predispose this patient to spinal cord injury with minor trauma. In the appropriate clinical context, (for example myelopathy), consider MR for further characterization. 2. Right apical nodule versus apical scarring. Recommend dedicated chest CT, which can be done as an outpatient. 3. Right pleural effusion. 4. Extensive degenerative changes at cranio-cervical junction. [**2129-1-15**] HAND (AP, LAT & OBLIQUE) LEFT IMPRESSION: 1. Nonspecific calcinosis. 2. Age indeterminate fracture deformity third metacarpal head, second proximal phalangeal head. 3. Extensive degenerative changes throughout the hand and the wrist as above. [**1-16**] PORTABLE CXR: Comparison is made with prior study [**1-12**]. There are lower lung volumes. Right lower lobe opacity has minimally increased; this is most likely atelectasis, but infectious process cannot be totally excluded. Right upper parahilar opacity is less conspicuous than before, not resolved. Minimal atelectasis in the left base is unchanged. There is no pneumothorax or pleural effusion. Cardiac size is top normal. [**2129-1-20**] ABDOMINAL XRAY: IMPRESSION: No evidence of obstruction or perforation [**2129-1-20**] SINGLE VIEW CXR: PA and lateral upright chest radiographs were reviewed in comparison to prior study obtained the same day earlier at 00:56 a.m. The lung volumes are lower than on the prior study, might explain bibasilar areas of atelectasis. Cardiomediastinal silhouette is unchanged including moderate cardiomegaly. There is improved degree of vascular congestion. There is no pneumothorax. PATHOLOGY: ========== Urine [**2129-1-15**]: NEGATIVE FOR MALIGNANT CELLS. Urine [**2129-1-18**]: PENDING [**2129-1-8**] 07:30AM PLT COUNT-387 Brief Hospital Course: Dyspnea: The patient presented with acute dyspnea with associated wheezing, initially requiring a NRB to maintain sats. His wheezing seemed to be a combination of upper airway expiratory wheeze and lower respiratory inspiratory wheeze. Out of concern for vocal chord dysfunction, he was evaluated by [**Month/Day/Year **] who found normal vocal cords. His lower respiratory wheeze was thought to be a COPD/asthma exacerbation complicated by a possible RUL pneumonia. He was treated with standing nebs, steroids, and ceftriaxone+levofloxacin with improvement in his wheezes and O2 requirement. After completing the above antibiotics course as well as a full course of Tamiflu, he remained stable. It should be noted that he often appears to be using accessory muscles and wheezing from his upper airway, however this resolves with positioning. Nursing concern was raised for aspiration on multiple occasions, however after multiple evaluations by S+S, he was consistently found to only aspirate thin liquids. NSTEMI: The patient also presented with positive cardiac biomarkers and inferolateral ST depressions concerning for ACS. An echocardiogram showed new focal wall motion abnormalities. Cardiology was consulted and felt that this was likely a demand event. He was started on ASA, Plavix, high dose statin, and metoprolol. He also received approximately 48 hours of IV heparin prior to determining that no intervention was planned. He was continued on the above medical management. His cardiac enzymes were trended throughout his stay due to multiple episodes of AFIB with RVR, however he never manifested demand ischemia, despite a persistently poor EKG of which Cardiology was aware. He later had melena, and his Plavix was stopped with agreement from Cardiology. Hematuria: The patient developed hematuria in the setting of Foley placement and heparin gtt. This recurred twice throughout his stay, and urology was consulted who performed cystoscopy, which revealed only Foley trauma. He was examined with renal u/s, which revealed no masses. Urine cytology was sent twice, the first of which did not reveal malignant cells. The second cytology sample is still pending. He retained greater than 1 liter of fluid with his last catheterization and required foley re-insertion. His foley has been left in place now for 7 days; a voiding trial can be attempted in [**1-30**] days with reinsertion of foley for failure to void. Atrial fibrillation with RVR: Several times during his stay on the floor, Mr. [**Known lastname **] went into AFIB with RVR. The first time this happened he required IV Lopressor 5mg x3 and diltiazem 15mg and 20mg IV. Thereafter (x3), he always achieved rate control with 15 and 20 of diltiazem push, and he would convert within 12 hours. He was anticoagulated as below and did not need further anticoagulation for his atrial fibrillation. Rate control appears to have been achieved with metoprolol 62.5 TID, which was converted to Toprol XL 150 mg daily. At 75mg TID, he was noted to have pauses on Telemetry and had a HR in the 50's. Peripheral arterial disease: On exam, several days after arriving to the floor, he was noted to have no DP pulses and delayed capillary refill on the left foot. Also noted to have cold and clamminess on the right foot. Vascular surgery consult was called, who asked for heparin bridge to Coumadin and took him to the OR for angiogram. It was felt that he would need surgical intervention but would need to be scheduled as outpatient. With anticoagulation, his color, cap-refill, and warmth improved bilaterally. His PT pulses were always dopplerable. The patient was found to have a supratherapeutic INR of 4.3. We recommend holding his coumadin for 2 days, and then restarting at 1mg daily with frequent INR checks. Guaiac positive stools: Several days after initiation of Coumadin, he was noted to have two, large, black grossly guaiac positive stools. He was made NPO except meds, started on protonix drip, and Gastric lavage was performed. Lavage was negative both by gastroccult and by visual exam. GI consult was called who planned for EGD. EGD was performed which revealed Dilaufoy's lesion vs. bleeding ulcer that was clipped. He was transfused pRBC for goal Hct 30. Anticoagulation was continued through this event because of risk to heart and limb in this patient. Falls: The patient had been having increased falls at home. A CT head/neck showed no acute trauma. The patient was evaluated by PT. Acute on Chronic renal failure: Creatine was 2.8 on arrival, up from a baseline of 2.0. Improved with blood and fluid hydration to 1.3. Hypertension: The patient was started on metoprolol and lisinopril. Foot Pain: During end of hospitalization, the patient developed exquisite foot pain, felt likely due to gout. He was treated with colchicine, which improved his discomfort. On day of discharge, he had mild erythema on the lateral dorsum of his left foot and tenderness at the 2nd MCP, though this was markedly improved since starting colchicine. He will continue on colchicine daily for the next three days. CODE: FULL (confirmed) Medications on Admission: Tricor 48 mg daily Nifedipine ER 90 mg daily Lisinopril 5 mg daily Calcium Citrate + D daily Flomax 0.4 mg daily Aspirin 81 mg daily Lipitor 20 mg daily Plavix 75 mg daily Multivitimin Folate Tylenol 650 mg as needed Toprol XL 100 mg daily Vitamin B12 100 mcg daily Omeprazole 20 mg daily Gabapentn 100 mg daily Discharge Medications: 1. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever. 6. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily). 7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 9. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day. 10. Calcium Citrate + D 315-200 mg-unit Tablet Sig: One (1) Tablet PO once a day. 11. Multi-Vitamin Hi-Po Tablet Sig: One (1) Tablet PO once a day. 12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 13. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day for 3 days. Discharge Disposition: Extended Care Facility: [**Hospital3 6560**] Care and Rehab center Discharge Diagnosis: Primary: - Community acquired pneumonia. - Bilateral lower ischemia. - UGIB: dieulafoy vs. duodenal ulcer. - Acute blood loss anemia. - Acute on chronic renal failure. - Atrial fibrillation. - Hematuria - Systolic heart failure - Aortic stenosis ([**Location (un) 109**] 1.1 cm2) - Dysphagia - MRSA - gout Secondary: - Left frontal CVA with hemiparesis. - Diabetes mellitus type II. - PVD s/p bilateral lower extremity fem-[**Doctor Last Name **] bypasses. - Hypertension. - Gout. - Benign prostatic hypertrophy. Discharge Condition: Mental Status:Confused - sometimes Level of Consciousness:Alert and interactive Activity Status:Out of Bed with assistance to chair or wheelchair Discharge Instructions: You were admitted with shortness of breath. You were originally in the intensive care unit, but improved and were transferred to the medicine floor. You were treated for influenzae and pneumonia. You also had a NSTEMI (otherwise known as a heart attack). You were medically managed for this per the cardiologists, or heart doctors. You were also found to have poor blood flow into your feet, so you were seen by the vascular surgeons. You were placed on heparin and warfarin, both blood thinners, for your extensive peripheral vascular disease. Your blood flow returned. You will continue these medications, and you will need to follow up with the vascular surgeons as an outpatient to continue to discuss possible surgical treatment. You also had atrial fibrillation, an arrhythmia, which was controlled with medications. Please continue your medications as prescribed. The following new medications have been prescribed: Simvastatin 40mg by mouth daily The following medications have been removed from your regimen: 1. Tricor 2. Nifedipine 3. Lipitor 4. Plavix Additionally, the dose of your lisinopril was increased and the dose of your Toprol was increased. Please keep all your medical appointments. Your INR (blood level of coumadin) was found to be elevated at 4.3. We would recommend that you do not take your dose of coumadin for 2 days, and then restart at 1 mg daily. You should have your INR checked regularly at the extended care facility. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD (Vascular Surgery) Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2129-2-4**] 11:30 MD: Dr. [**First Name (STitle) 2259**] [**Name (STitle) 12048**] [**Doctor Last Name **] and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Specialty: Primary Care Date/ Time: Thursday, [**2-25**] at 2:45pm Location: [**Hospital3 **], [**Location (un) **], [**Hospital Ward Name 23**] Bldg [**Location (un) 895**], [**Location (un) 86**], MA Phone number: [**Telephone/Fax (1) 250**] Special instructions for patient: Dr [**Last Name (STitle) **] is your new physician in [**Name9 (PRE) 191**] and Dr [**Last Name (STitle) **] works closely with Dr [**Last Name (STitle) **], [**First Name3 (LF) **] both will be involved in your care. For insurance purposes please indicate Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] as your Primary Care Physician MD: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Specialty: Cardiology Date/ Time: Tuesday, [**2-16**] at 9:00am Location: [**Location (un) **], [**Hospital Ward Name 23**] Bldg [**Location (un) **], [**Location (un) 86**], MA Phone number: [**Telephone/Fax (1) 62**] Provider: [**Name10 (NameIs) **] FELLOW ([**Doctor Last Name 12049**]) Phone:[**Telephone/Fax (1) 41**] Date/Time:[**2129-2-2**] 10:15 MD: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3748**] (Specialty: Urology) Phone number: ([**Telephone/Fax (1) 8791**] Special instructions for patient: Dr.[**Name (NI) 11306**] office will call you with an appt date and time. If you do not hear from the office by Wednesday, [**1-27**] please call above number. Completed by:[**2129-1-24**]

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55069

Discharge summary

report

Admission Date: [**2155-11-3**] Discharge Date: [**2155-11-12**] Date of Birth: [**2088-9-6**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2712**] Chief Complaint: fevers, respiratory distress Major Surgical or Invasive Procedure: - Intubation - Tracheostomy - Central venous line insertion History of Present Illness: Mr. [**Known lastname 4427**] is a 67M with history of alcohol abuse, BCC, fungal pericarditis, hypopharyngeal cancer currently undergoing XRT who presents with fevers, respiratory distress and transferred to the ICU for close monitoring. Pt went to rad/onc today for XRT and was found to be febrile to 101, and with increased work of breathing. In the ED, initial VS were: T 99.6 HR 115 BP 172/96 RR 30. He appeared ill, seemed to be in respiratory distress but thought to be mostly upper airway. He was self-suctioning CXR with possible vascular congestion and infiltrate on oxygen 4LNC, 94%. He was given cefepime and Vanc already given during the day. He was also given Decadron given laryngeal edema. Labs were notable for WBC 2.3 (baseline around [**3-7**]), Hct 25 (baseline 24-26), plts 64 (down from baseline 180-200). INR 1.5, Na 132 (baseline low 130s). UA was clean. Blood and urine cultures were sent and are pending. He is being transferred to the ICU for frequent suctioning, support, and for close monitoring. Cultures were sent and are pending. Pt was actually already on Vanc for unclear reasons per the [**Name (NI) **]. For access he has access R 20g in hand and port. On arrival to the MICU, patient's VS 104 144/91 23 93% on 4LNC. Pt was recently admitted from [**2155-8-22**] to [**2155-10-22**] with new diagnosis of squamous cell hypopharnygeal mass, complicated by respiratory distress from his mass, HCAP, intubated for prolonged period and extubated [**2155-10-8**], fungal pericarditis on fluconazole, and hypertensive urgency. Since discharge he has received chemo last on [**10-29**], and has continued to get XRT. Per the pt, his breathing has been difficult for the past week. It is otherwise difficult to get more history from him. Review of systems: somewhat limited given pt difficult to understand given secretions. Though pt denies fever, chills, sweats, chest pain, chest pressure, palpitations, abdominal pain, diarrhea, dark or bloody stools. Denies dysuria, frequency, or urgency. Past Medical History: -pyriform sinus tumor -basal cell carcinoma (nose) -hypothyroidism -h/o pneumonia -h/o alcohol withdrawl w/ seizures -anemia -etoh abuse -seizures -hyperlipidemia -L femur ORIf -bx pyriform sinus tumor -squamous cell hypopharyngeal tumor: ---> Patient underwent PET CT which revealed large FDG avid hypopharyngeal mass inseparable from esophagus and causing significant narrowing of the airway. Patient was transferred to the oncology service for induction chemotherapy. He received cycle 1 of TPF (docetaxel, cisplatin, 5-FU) on [**2155-9-8**]. Patient had subsequent anemia requiring transfusions [**9-14**] and [**9-17**], [**10-17**] thrombocytopenia (which resolved without necesitating platelet transfusion), and neutropenia (treated with neupogen earlier in admission). CT of neck and chest [**9-24**] showed significant improvement in disease burden and degree of airway narrowing. Pt restarted chemotherapy on [**2155-10-15**] and started day 1 of 30 of XRT on [**2155-10-14**]. Pt received chemotherapy on [**2155-10-22**] (day of discharge) and will continue chemo as outpatient on [**2155-10-29**]. - Radiation: pt to continue XRT for a total of 30 days. Day of discharge was day 8 of therapy therefore pt has 22 more sessions he will receive as outpatient. - Chemo: pt to contine chemotherapy, Paclitaxel and Carboplatin. Days 1, 8 already given on [**10-15**] and [**10-22**]. Pt to receive third dose on day 15, [**10-29**]. -fungal pericarditis s/p window -left humerus fracture Social History: currently residing at [**Hospital3 **]. Pt notes significant alcohol use and previous abuse. Denies history of tobacco use. No current IV or illegal substance use. Previous abuse of marijuana and psychedelic drugs. Family History: no history of head and neck cancer Physical Exam: Admission Physical: Vitals: HR 95 BP 177/100 RR 27 O2 sat 98% on 3LNC General: Alert, oriented, gurgling with secretions, no stridor HEENT: Sclera anicteric, dry MM, with thick secretions in orpharynx, difficult to examine posterior pharynx, EOMI Neck: thin, JVP not elevated, no LAD CV: tachycardic, regular rhythm, +S1, S2, no murmurs, rubs, gallops Lungs: no stridor, rhonchi throughout all lung fields, no wheezes Abdomen: + PEG tube in place with no surrounding erythema, soft, +BS, NTND, no HSM GU:+ foley Ext: Warm, thin, wasted musculature, 1+ pulses, + clubbing, no cyanosis or edema Neuro: CNII-XII grossly intact, moving all extremities, following simple commands, gait deferred Discharge physical exam: General: Trach in place. NAD HEENT: Sclera anicteric, dry MM Neck: thin, JVP not elevated, no LAD, LIJ in place, radiation changes on right side CV: RRR, S1/S2 normal, no murmurs, rubs, gallops Lungs: rhonchi throughout all lung fields, and diffuse transmitted upper airway sounds, no stridor, no wheezes Abdomen: + PEG tube in place with no surrounding erythema but no induration or pus, soft, +normoactive BS, NT/ND, no HSM GU:+ foley Ext: Warm, thin, wasted musculature, 2+ pulses, + clubbing, no cyanosis or edema Neuro: Awake, alert, moving all extremities, following commands, unable to speak, but will communicate through writing Pertinent Results: Admission labs: [**2155-11-3**] 03:50PM BLOOD WBC-2.3* RBC-2.81* Hgb-8.9* Hct-25.8* MCV-92 MCH-31.7 MCHC-34.5 RDW-18.0* Plt Ct-64*# [**2155-11-3**] 03:50PM BLOOD Neuts-79.1* Lymphs-14.6* Monos-5.0 Eos-1.0 Baso-0.3 [**2155-11-3**] 03:50PM BLOOD PT-15.8* PTT-35.4 INR(PT)-1.5* [**2155-11-3**] 03:50PM BLOOD Glucose-128* UreaN-19 Creat-0.5 Na-132* K-3.7 Cl-96 HCO3-29 AnGap-11 [**2155-11-4**] 01:21AM BLOOD Calcium-8.3* Phos-3.6 Mg-1.6 [**2155-11-4**] 03:31AM BLOOD Type-ART Temp-36.4 Rates-/22 FiO2-95 pO2-105 pCO2-54* pH-7.32* calTCO2-29 Base XS-0 AADO2-520 REQ O2-87 Intubat-NOT INTUBA Vent-SPONTANEOU Comment-HIGH FLOW [**2155-11-3**] 03:55PM BLOOD Lactate-1.0 Discharge labs: [**2155-11-12**] 04:17AM BLOOD WBC-1.3* RBC-3.00*# Hgb-9.4*# Hct-26.1*# MCV-87 MCH-31.2 MCHC-35.8* RDW-16.7* Plt Ct-28* [**2155-11-11**] 04:19AM BLOOD WBC-1.2* RBC-2.25* Hgb-6.9* Hct-20.1* MCV-89 MCH-30.7 MCHC-34.3 RDW-16.8* Plt Ct-34* [**2155-11-11**] 04:19AM BLOOD Neuts-60.7 Lymphs-32.5 Monos-4.5 Eos-1.9 Baso-0.4 [**2155-11-12**] 04:17AM BLOOD PT-13.7* PTT-33.7 INR(PT)-1.3* [**2155-11-11**] 04:19AM BLOOD Gran Ct-750* [**2155-11-12**] 04:17AM BLOOD Glucose-119* UreaN-21* Creat-0.5 Na-133 K-4.1 Cl-98 HCO3-30 AnGap-9 [**2155-11-12**] 04:17AM BLOOD Calcium-8.0* Phos-3.6 Mg-1.9 Microbiology: [**2155-11-5**] C. difficile: PENDING [**2155-11-4**] PICC LINE TIP-IV WOUND CULTURE: PENDING [**2155-11-4**] BLOOD CULTURE: PENDING [**2155-11-3**] MRSA SCREEN MRSA SCREEN-FINAL {POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS} [**2155-11-3**] BLOOD CULTURE: PENDING [**2155-11-3**] URINE URINE CULTURE-FINAL: no growth [**2155-11-3**] BLOOD CULTURE: PENDING Studies: [**2155-11-9**] CHEST PORT. LINE PLACEM A PICC line is present, overlying the soft tissues of the right axilla. It does not extend across the rib cage. The patient is status post tracheostomy. The cardiomediastinal silhouette is grossly unchanged. There is upper zone redistribution and mild vascular blurring. There is increased retrocardiac density, consistent with left lower lobe collapse and/or consolidation. A catheter or other tube overlies the left upper quadrant of the abdomen. No pneumothorax is detected. [**2155-11-8**] CHEST (PORTABLE AP) Tracheostomy is in place. A left IJ central line overlies the mid SVC. No pneumothorax is detected. Compared with [**2155-11-7**], there has been slight interval clearing at the left base laterally. Otherwise, no significant change is detected. There is persistent left lower lobe collapse and/or consolidation, with increased retrocardiac density and obscuration of the left hemidiaphragm. There is focal opacity in the right cardiophrenic region, raising question of a possible small hernia, unchanged. Tubing overlies the left upper quadrant. IMPRESSION: Paartial interval clearing at left base laterally. Otherwise, no significant change compared with [**2155-11-7**] at 8:18 a.m. [**2155-11-7**] CHEST (PORTABLE AP) In comparison with study of [**11-6**], there is little overall change. Monitoring and support devices remain in place. Continued enlargement of the cardiac silhouette with probable elevation of pulmonary venous pressure. Extensive retrocardiac opacification could reflect merely volume loss in the left lower lobe and pleural effusion. However, in the appropriate clinical setting, supervening pneumonia would have to be seriously considered. [**2155-11-6**] CHEST (PORTABLE AP) In comparison with the earlier study of this date, the endotracheal tube has been removed and replaced with a tracheostomy tube. No evidence of pneumothorax or pneumomediastinum. Continued enlargement of the cardiac silhouette with mild elevation of pulmonary venous pressure. Retrocardiac opacification may reflect merely volume loss in the left lower lobe and pleural effusion. In the appropriate clinical setting, supervening pneumonia would have to be considered. Fracture of the proximal humerus on the left is again seen. [**2155-11-6**] CHEST (PORTABLE AP) The ET tube tip is 5 cm above the carina. The left internal jugular line tip is at the level of mid SVC. Cardiomegaly is unchanged. Left retrocardiac consolidation is unchanged. The patient is in interstitial edema, unchanged in the short-term interval. No appreciable pneumothorax is seen. Right basal and left retrocardiac opacities can be also appreciated on the chest CT obtained on [**2155-11-4**] and are concerning for multifocal infection. [**2155-11-5**] CHEST (PORTABLE AP): Previous pulmonary edema on [**11-3**] has improved, but there is multifocal infection, demonstrated to better advantage on yesterday's chest CT scan concerning for pneumonia, with demonstration of heavy retained secretions in the airways, particularly the bronchus to the collapsed left lower lobe. Small bilateral pleural effusions are more obvious on the CT scan. Heart size is normal. ET tube is in standard placement. Left jugular line ends in the mid SVC. [**2155-11-4**] CT NECK W/CONTRAST: IMPRESSION: 1. Infiltrative tumor in the post-cricoid region involving the right hypopharynx, incompletely assessed in this CT study but appearing smaller compared to the recent study. Likely infiltrative process to the right thyroid cartilage. 2. Persistent edematous soft palate and edematous aryepiglottic fold. 3. Moderate retained fluid in the posterior oro- and nasopharynx, secondary to intubation. [**2155-11-4**] CT CHEST W/CONTRAST: IMPRESSION: 1. Heavy bronchial secretions occlude the left lower lobe bronchus and severely narrow the left upper. 2. Multifocal pneumonia, presumably related to difficulty clearing secretions. 3. Small-to-moderate bilateral pleural effusions layering nonhemorrhagic and decreased since [**9-24**]. 4. Progressive moderate cardiomegaly, predominantly left atrium and left ventricular. No pulmonary edema. 5. Severe T12 vertebral compression fracture, and multiple less severe thoracic vertebral compressions, all unchanged since [**Month (only) 216**]. T12 involvement could be malignant. Healed manubrium fracture. [**2155-11-4**] CT HEAD W/O CONTRAST: IMPRESSION: 1. No acute intracranial abnormality. Please note MRI is more sensitive for evaluation of intracranial metastasis. 2. Stable right frontal encephalomalacia. [**2155-11-4**] CHEST PORT. LINE PLACEM: AP semi-upright chest radiograph was obtained. Endotracheal tube terminates 5.9 cm above the carina. Left internal jugular catheter terminates in the mid SVC. Dense left lower lung atelectasis and effusion and right lower lung opacity consistent with aspiration are unchanged. No pneumothorax is seen with normal cardiac size and mediastinal contours. [**2155-11-4**] CHEST (PORTABLE AP): As compared to the previous radiograph, the patient has been intubated. The tip of the endotracheal tube projects 7 cm above the carina. If possible, the tube could be advanced by 1 to 2 cm. The known opacity at the right lung base, suggestive of aspiration pneumonia, is unchanged in extent and severity. Also unchanged is the left retrocardiac atelectasis and a minimal left pleural effusion. No evidence of complications, notably no pneumothorax. [**2155-11-4**] CHEST (PORTABLE AP): As compared to the previous radiograph, the size of the cardiac silhouette and the mild retrocardiac atelectasis are unchanged. There also is unchanged blunting of the costophrenic sinus on the left, suggesting presence of a small pleural effusion. On the right, the pre-existing opacities have slightly decreased in extent and severity and now more concentrated in the medial basal parts of the right lower lung. The location of these opacities suggests aspiration pneumonia rather than pulmonary edema. The right-sided PICC line is constant. [**2155-11-4**] ECHO: The left atrium is elongated. The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size is normal. with mild global free wall hypokinesis. There is abnormal septal motion suggestive of pericardial constriction. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is a very small pericardial effusion. The pericardium may be thickened. The septal motion, probable pericardial thickening, and mitral inflow pattern are all suggestive of pericardial constriction. Compared with the prior study (images reviewed) of [**2155-9-29**], the pericardial effusion is now smaller than it was in the last transthoracic echocardiogram and right ventricular free wall motion now appears slightly less vigorous. [**2155-11-3**] CHEST (PORTABLE AP) IMPRESSION: 1. Mild interstitial pulmonary edema. 2. Small left pleural effusion with retrocardiac opacity that likely represents compressive atelectasis. [**2155-11-3**] ECG Sinus tachycardia. Compared to the previous tracing of [**2155-10-10**] Q-T interval seems normal. Brief Hospital Course: Mr. [**Known lastname 4427**] is a 67M with history of alcohol abuse, BCC, fungal pericarditis, hypopharyngeal cancer currently undergoing XRT who presents with fevers, respiratory distress and transferred to the ICU for close monitoring, ultimately found to have aspiration pneumonia from difficult to manage secretions and was intubated for airway protection and is now s/p tracheostomy placement. # Respiratory distress, airway compromise: Likely secondary to difficult to manage secretions, hypopharyngeal mass and likely aspiration PNA. Pt had sufficient O2 sats on nasal cannula on admission, but was having difficulty clearing secretions. ENT was consulted given concern for airway edema and possible obstruction. On evaluation, he was not stridulous and his airways were patent on laryngoscopic evaluation. However, pt's mental status deteriorated. ABG showed slight hypercarbia but sufficient oxygenation. Given his clinical picture and difficult to manage secretions with evidence of possible aspiration pneumonia on CXR, he was intubated on HD#1 for airway protection with the fiberoptic scope. CT chest showed heavy bronchial secretions occluding the left lower lobe bronchus and severely narrow the left upper. There was also evidence of multifocal pneumonia. He was treated with vancomycin, cefepime, and flagyl for an 8 day total course ([**11-3**] - [**11-10**]) and continued on fluconazole which was started for fungal pericarditis (below) which should be continued through [**2155-11-26**]. ENT saw evidence of possible fungal laryngitis on laryngoscopic exam, and he will be sufficiently covered by his current fluconazole course. Given the likely need for prolonged intubation for airway protection in the setting of his progressive pharyngeal mass, the decision was made to proceed with tracheostomy which was performed by ENT on [**2155-11-6**]. He was weaned from the ventilator on [**11-8**] and has been breathing comfortably with sats in the high 90s on 40% trach mask. # Aspiration pneumonia: Patient presented with fevers to 101 at [**Hospital3 **] likely related to aspiration PNA vs HCAP. Most likely aspiration PNA given fevers, copious secretions, and difficulty protecting airway in the context of his pharyngeal mass and radiation treatment. CXR suggested possible infiltrate on admission and CT chest confirmed multifocal consolidations. Pt was started on IV Vanc/Zosyn at rehab on [**11-2**] and was transitioned to Vanc/Cefepime/Flagyl to cover for aspiration PNA and completed an 8 day total course ([**11-3**] - [**11-10**]). Blood cultures sent from [**Hospital1 1319**] grew MRSA and MRSA later grew in endotrachial sputum cultures. This was felt to be likely due to MRSA colonization. Blood cultures were sent on [**11-11**] after completing course of antibiotics, and these surveillance cultures should be followed to determine of there is a need to restart a longer course of vancomycin. He was also continued on fluconazole for fungal pericarditis (below), which will also cover for possible fungal laryngitis appreciated on ENT laryngoscopic exam (should continue taking through [**2155-11-26**]). He was intubated (above) for airway protection and ultimately had tracheostomy placement on [**11-6**] and weaned from the vent on [**11-8**]. # Encephalopathy, agitation, myoclonic jerks: On the evening of admission, pt became agitated and confused in the ICU. This was thought likely to be due to delirium given multiple factors including disturbance in sleep-wake cycle, infection, and concern for possible seizures given myoclonic movements. CT head revealed stable right frontal encephalomalacia from prior stroke. EEG was considered, though deferred given that these movements discontined once intubated. EEG was performed on previous admission which revealed generalized slowing, but no seizure activity. Multiple episodes of limb jerking were captured and there was no EEG correlate. His acute encephalopathy resolved and returned to baseline mental status which is alert and oriented x 3. # Hypopharyngeal SCC: Currently on XRT, though held on day of admission. He has received 14 of 30 planned fractions, most recently he received 3 dose of [**Doctor Last Name **]/taxol on [**2155-10-29**]. His primary oncologist and radiation/oncologist were notified of his admission. Goals of care discussion with his family was addressed at a family meeting, and decision was made to proceed with tracheostomy (above). He restarted XRT at [**Hospital1 18**] on [**11-11**] and received a total of 2 doses (#15 and #16 out of 30). In consultation with Dr. [**Last Name (STitle) **], the decision was made to hold off on additional chemotherapy due to pancytopenia. Chemo will resume when counts improve -- he has a total of 3 doses of [**Doctor Last Name **]/taxol remaining of his course. # Fungal pericarditis: Pleural effusion and pericardial tissue, but not pericardial effusion cultures from [**2155-9-29**] grew [**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) **] sensitive to fluconazole. He was started on fluconazole on prior admission with the intention of continuing through [**2155-11-26**]. Repeat TTE here showed findings consistent with constriction but only mild pericardial effusion. # MRSA bacteremia: Positive blood cultures at [**Hospital3 **], growing MRSA in 1 out of 4 bottles. Possible sources include multifocal pneumonia, osteomyelitis given prior humerus fracture, though these all seem unlikely. TTE was negative for vegetations and TEE deferred given low concern for endocarditis and negative surveillance cultures here. Likely colonized. He was treted for an 8 day course with HCAP (above) including 8 days of vancomycin. Surveillance blood cultures were drawn after stopping antibiotics and were pending at the time of discharge with no growth to date. # Pancytopenia: Most likely from recent chemo on [**2155-10-29**]. His counts trended down slowly requiring transfusion of 2 units pRBCs and 2 units of platelets during his admission. His hematocrit on discharge was 26 and platelets were 28. # Coagulopathy: INR 1.5 on admission, possibly [**3-6**] poor nutrition vs. recent abx. He was given a dose of Vitamin K and his INR improved slightly to 1.3 and remained stable throughout hospitalization without evidence of active bleeding. # Humerus fx: Felt to be a non-pathologic fracture in the setting of fall. Pt arrived with Lidoderm patch and MS contin and morphine IR for breakthrough. He was transitioned to fentanyl patch with breakthrough oxycodone given that he takes meds through his G tube and long acting morphine cannot be crushed. Pain control was titrated up and was adequate at the time of discharge. # Hyponatremia: Patient's sodium dropped from 137 to 126 during admission. Thought to be SIADH (from malignancy vs. pain with humerus fracture vs. recent tracheostomy) given that he was euvolemic on exam with good urine output, low serum osms, high urine osms, high urine sodium and improvement with free water restriction. Sodium improved to 133 by discharge. # DVT prophylaxis: Restarted heparin SC BID in house given high risk for clot given hypercoagulable state with malignancy, discharged on dalteparin. However, if pt has bleeding, would recheck platelets. Inactive issues: # Hypothyroidism: Continued levothyroxine # Hypertension: Hypertensive on admission. On prn IV anti-hypertensives while in the and should transition to home regimen on discharge. Transitional care: - CODE: FULL - Contact: Daughter [**Name (NI) **] (HCP), Sister [**Doctor First Name **] - Patient should continue fluconazole for fungal pericarditis and possible fungal laryngitis through [**2155-11-26**] - Multiple surveillance blood cultures pending at discharge - Please have speech and swallow evaluate for Passey Muir Valve Medications on Admission: Preadmissions medications listed are complete and require futher investigation. Information was obtained from webOMR. 1. Acetaminophen 325-650 mg PO Q6H:PRN pain 2. Bisacodyl 10 mg PR HS:PRN constipation 3. Docusate Sodium (Liquid) 100 mg PO BID constipation 4. Fluconazole 200 mg IV Q24H 5. Guaifenesin 10 mL PO Q6H:PRN Cough or Increased secretions 6. Labetalol 100 mg PO BID hold for SBP <95 or HR<55 7. Levothyroxine Sodium 100 mcg PO DAILY 8. Lidocaine 5% Patch 1 PTCH TD DAILY apply to left arm 9. Ondansetron 4 mg IV Q8H:PRN nausea 10. Polyethylene Glycol 17 g PO DAILY:PRN constipation 11. senna *NF* 8.8 mg/5 mL Oral [**Hospital1 **]:PRN constipation Reason for Ordering: Pt has cancer of larynx and unable to swallow pills 12. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain hold for oversedation 13. Morphine Sulfate IR 15 mg PO/NG Q4H:PRN pain 14. dalteparin (porcine) *NF* 5,000 unit/0.2 mL Subcutaneous daily Discharge Medications: 1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain, fever 2. senna *NF* 8.8 mg/5 mL Oral [**Hospital1 **]:PRN constipation Reason for Ordering: Pt has cancer of larynx and unable to swallow pills 3. Levothyroxine Sodium 100 mcg PO DAILY 4. Lidocaine 5% Patch 1 PTCH TD DAILY apply to left arm 5. Polyethylene Glycol 17 g PO DAILY:PRN constipation 6. Docusate Sodium (Liquid) 100 mg PO BID constipation\ 7. Bisacodyl 10 mg PR HS:PRN constipation 8. Albuterol Inhaler 6 PUFF IH Q4H:PRN Wheeze 9. Fentanyl Patch 25 mcg/h TP Q72H 10. Ibuprofen 600 mg PO Q6H 11. Lisinopril 10 mg PO HS please hold for SBP < 100 12. OxycoDONE Liquid 10-15 mg PO Q4H:PRN pain please hold for sedation or RR<10 13. Ondansetron 4 mg IV Q8H:PRN nausea 14. dalteparin (porcine) *NF* 5,000 unit/0.2 mL Subcutaneous daily 15. Fluconazole 200 mg PO Q24H Please continue through [**11-26**] Discharge Disposition: Extended Care Facility: [**Hospital1 **] [**Hospital1 8**] Discharge Diagnosis: Primary diagnoses: - Hypopharyngeal squamous cell cancer - Respiratory distress requiring intubation and tracheostomy placement - Health care associated pneumonia Discharge Condition: Mental Status: Clear and coherent, patient is unable to talk with trach in place, but is alert and oriented x 3 and can communicate by writing. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [**Known lastname 4427**], You were admitted to the hospital for respiratory distress in the setting of the cancer in your throat. You were intubated and you now have a tracheostomy tube to help you breathe. You were also treated with antibiotics for a pneumonia. You were seen by your oncologist Dr. [**Last Name (STitle) **] and you restarted your radiation treatments for the cancer in your neck, but your blood counts were too low to restart the chemotherapy at this time. You should follow up with Dr. [**Last Name (STitle) **] to determine when you are ready to restart the chemotherapy for the remainder of your course. You will have transportation arranged from [**Hospital1 **] for your radiation treatment. It was a pleasure taking care of you at the [**Hospital1 18**]! Followup Instructions: Department: ORTHOPEDICS When: THURSDAY [**2155-11-20**] at 8:40 AM With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: ORTHOPEDICS When: THURSDAY [**2155-11-20**] at 9:00 AM With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**] Building: [**Hospital6 29**] [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: FRIDAY [**2155-11-21**] at 1:15 PM With: CHECKIN HEM ONC CC9 [**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:[**2155-11-12**]

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icd9cm

[ [ [] ] ]

[ "38.93", "96.04", "31.42", "31.1", "96.6", "38.97", "96.72" ]

icd9pcs

[ [ [] ] ]

24696, 24757

15008, 22296

333, 395

24964, 24964

5654, 5654

26067, 26936

4227, 4264

23813, 24673

24778, 24943

22872, 23790

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4279, 4971

2216, 2456

265, 295

423, 2196

22313, 22846

5670, 6317

24979, 25225

2478, 3978

3994, 4211

4996, 5635

22,356

137,404

51136

Discharge summary

report

Admission Date: [**2156-7-15**] Discharge Date: [**2156-7-20**] Date of Birth: [**2095-10-5**] Sex: F Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2988**] Chief Complaint: Right hip pain Major Surgical or Invasive Procedure: s/p R THA [**2156-7-15**] History of Present Illness: 60 y.o F with longstanding hx of right hip pain. Conservative management without effect. Pt scheduled for Right THA on [**2156-7-15**]. Past Medical History: Arthritis Gout Hiatal hernia GERD Dysrhythmia Social History: Denies tobacco/ETOH use Lives with husband Family History: non-contributory Physical Exam: 60 y.o F, pleasant, in NAD AO x 3, AVSS R/R/R CTA Abd- soft, NT/ND Ext- No C/C/E, RLE- pain with passive/active ROM, sensation intact at DP/SP/T. + [**Last Name (un) 938**]/FHL/TA/GC. DP 1+ Pertinent Results: [**2156-7-20**] 06:30AM BLOOD WBC-6.4 RBC-3.33* Hgb-9.8* Hct-28.6* MCV-86 MCH-29.3 MCHC-34.1 RDW-14.5 Plt Ct-171 [**2156-7-19**] 06:40AM BLOOD WBC-7.4 RBC-3.32* Hgb-9.7* Hct-28.4* MCV-85 MCH-29.3 MCHC-34.4 RDW-14.0 Plt Ct-152 [**2156-7-17**] 06:00AM BLOOD WBC-9.0 RBC-2.67* Hgb-7.8* Hct-23.3* MCV-87 MCH-29.2 MCHC-33.5 RDW-14.0 Plt Ct-114* [**2156-7-15**] 04:39PM BLOOD WBC-18.8*# RBC-3.60* Hgb-10.4*# Hct-31.7* MCV-88 MCH-28.8 MCHC-32.7 RDW-13.7 Plt Ct-183 [**2156-7-20**] 06:30AM BLOOD PT-12.9 INR(PT)-1.1 [**2156-7-18**] 06:40AM BLOOD Plt Ct-126* [**2156-7-16**] 04:34AM BLOOD Plt Ct-163 [**2156-7-20**] 06:30AM BLOOD Glucose-89 UreaN-8 Creat-0.5 Na-140 K-3.3 Cl-106 HCO3-26 AnGap-11 [**2156-7-17**] 06:00AM BLOOD Glucose-109* UreaN-10 Creat-0.7 Na-139 K-3.7 Cl-106 HCO3-26 AnGap-11 Brief Hospital Course: Pt taken to OR on [**2156-7-15**] for R THA. Surgery went without incident. See Op note for further details. While in [**Name (NI) 13042**], pt has nausea and was given phenergan. Pt then became lethargic and was not responding. She was intubated, given Narcan/benadryl for anaphylactic reaction. Pt transferred to SICU for management. Pt responded well and was extubated [**2156-7-16**]. Pt remained AVSS while in house. She was given several units of PRBC's for HCT ~23-25. Pt responded well. SHe is PWB RLE(troch off precautions). COumadin for a/c. Goal INR 1.5-2.0 Her HCT on day of discharge is 28.6; U/A negative, Cx pending. SHe will be d/c'd to rehab for continued PT, management of a/c. Medications on Admission: Tylenol #3 Iron MVI Discharge Medications: 1. Insulin Regular Human 100 unit/mL Solution Sig: ASDIR 100u/ml Injection ASDIR (AS DIRECTED). 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for fever. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Warfarin Sodium 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) for 6 weeks: Goal INR 1.5-2.0 Have HO adjust as needed to meet goal. 5. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 7 days. 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Discharge Disposition: Extended Care Facility: [**Hospital3 1186**] - [**Location (un) 538**] Discharge Diagnosis: Right hip OA Discharge Condition: good Discharge Instructions: Partial weight bearing right lower extremity(troch off precautions). Continue Coumadin PO HS x 6 weeks for anticoagulation. Goal INR1.5-2.0 Please have HO adjust as needed to meet goal. Physical Therapy: Activity: Out of bed w/ assist Right lower extremity: Partial weight bearing PT: troch off precautions Treatments Frequency: Site: right hip Type: Surgical Dressing: Gauze - dry Change dressing: qd Comment: start [**2156-7-18**]. Initial change done on [**2156-7-17**]. Followup Instructions: f/u with Dr[**Name (NI) 2989**] office in 2 weeks. Phone # [**Telephone/Fax (1) 20921**] [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD, [**MD Number(3) 2991**] Completed by:[**2156-7-20**]

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icd9cm

[ [ [] ] ]

[ "81.51", "96.71", "96.04", "99.02", "99.04" ]

icd9pcs

[ [ [] ] ]

3120, 3193

1726, 2425

334, 362

3250, 3256

916, 1703

3791, 4020

672, 690

2495, 3097

3214, 3229

2451, 2472

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30770

Discharge summary

report

Admission Date: [**2156-6-4**] Discharge Date: [**2156-6-15**] Date of Birth: [**2131-9-5**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 148**] Chief Complaint: Acute pancreatitis. Presumed pancreatic injury from percutaneous biopsy. Major Surgical or Invasive Procedure: Exploratory Laparotomy, Wide drainage of pancreatic leak Placement of a combined gastrostomy/jejunostomy tube (MIC tube). History of Present Illness: This unfortunate 24-year-old lady had hepatitis B and was being worked up for this with a biopsy of her liver. It is uncertain to my why she required this biopsy. The patient had this done in the midline position 2 days prior to this procedure. In the interim, she became very sick and was treated at another hospital. She developed abdominal and went to NSMC-[**Hospital1 1281**] ED where workup was significant for lipase of [**2110**] and amylase of 1351. CT showed diffuse hypoattenuation of the liver, suggestive of infiltration, and small amount of ascites. She was admitted with a diagnosis of acute pancreatitits. On evening of [**6-3**], she became febrile and tachycardic. Repeat laboratories showed WBC 29.3 (from 20.0), amylase 3894 (from 1351), and lipase >2400 (from [**2110**]). Repeat CT showed increase in intraperitoneal fluid, pelvic fluid, and bilateral pleural effusions She was transferred to our facility the day of this operation. In the interim, she developed clear-cut acute pancreatitis and was gravely ill. We found her to be profoundly dehydrated with all the sequelae of raging acute pancreatitis. What was worrisome, however, was her abdominal exam which showed peritonitis. In reviewing the reports, there was apparently a percutaneous biopsy attempt of the left lateral sector of the liver. It was pretty clear that there was a traumatic injury to the pancreas through this biopsy precipitating acute pancreatitis. I was very concerned that there was a ductal leak injury given her clinical state with a rigid abdomen with peritoneal signs. Past Medical History: HBV x 5 years Social History: Has 2 young children. No EtOH or tobacco Physical Exam: Vitals - T 100.3, BP 139/64, HR 121, RR 18, O2 sat 98% 2L NC General - well-appearing female, speaking full sentences, no acute distress HEENT - PERRL, EOMI, OP clr, MMM, no LAD CV - RRR, [**3-16**] syst flow mur Chest - CTAB Abdomen - subxiphoid biopsy set dressed, c/d/i; abdomen diffusely tender with voluntary guarding Extremities - no edema Pertinent Results: [**6-6**] BCx-p [**6-5**] S/BCx-p; UCx-neg [**6-4**] UCx -> neg; Bld Cx -> pending; Bld fungal Cx -> pend; OR swab-GPC (broth only)-[**Last Name (un) **] pending . [**2156-6-4**] 07:24AM BLOOD WBC-28.1* RBC-3.91* Hgb-11.5* Hct-33.6* MCV-86 MCH-29.5 MCHC-34.3 RDW-14.8 Plt Ct-293 [**2156-6-9**] 06:30AM BLOOD WBC-13.3* RBC-3.41* Hgb-9.7* Hct-29.8* MCV-87 MCH-28.4 MCHC-32.5 RDW-14.8 Plt Ct-413 [**2156-6-9**] 06:30AM BLOOD Glucose-102 UreaN-5* Creat-0.4 Na-138 K-4.0 Cl-103 HCO3-28 AnGap-11 [**2156-6-9**] 06:30AM BLOOD ALT-25 AST-32 LD(LDH)-379* Amylase-170* TotBili-0.4 [**2156-6-4**] 07:24AM BLOOD ALT-35 AST-25 AlkPhos-49 Amylase-2045* TotBili-1.1 [**2156-6-4**] 07:24AM BLOOD Lipase-2662* [**2156-6-9**] 06:30AM BLOOD Lipase-190* [**2156-6-9**] 06:30AM BLOOD Calcium-7.5* Phos-2.6* Mg-2.6 . [**2156-6-15**] 05:50AM BLOOD WBC-14.9* RBC-3.27* Hgb-9.3* Hct-28.3* MCV-87 MCH-28.5 MCHC-32.9 RDW-15.3 Plt Ct-673* [**2156-6-14**] 05:05AM BLOOD Glucose-87 UreaN-10 Creat-0.7 Na-137 K-4.5 Cl-101 HCO3-26 AnGap-15 [**2156-6-15**] 05:50AM BLOOD ALT-72* AST-34 LD(LDH)-303* AlkPhos-99 Amylase-223* TotBili-0.4 [**2156-6-15**] 05:50AM BLOOD Lipase-286* [**2156-6-14**] 05:05AM BLOOD Calcium-8.7 Phos-4.1 Mg-2.7* [**2156-6-11**] 06:50AM BLOOD Albumin-3.0* . CT ABDOMEN W/CONTRAST [**2156-6-11**] 1:12 PM IMPRESSION: Marked improvement post-drainage of fluid collection in the abdomen. Decrease in amount of fluid seen in the pelvis as well. Tiny amount of fluid is seen near the pancreatic tail and lesser sac. The celiac, superior mesenteric, and inferior mesenteric arteries are patent. The portal vein, and superior mesenteric veins and splenic veins are patent. . [**2156-6-14**] ERCP Procedures: A plastic pancreatic stent was removed from the ampulla with a snare. Impression: PEG Stent in the major papilla A plastic pancreatic stent was removed from the ampulla with a snare. Otherwise normal ercp to second part of the duodenum . Brief Hospital Course: She was admitted on [**6-4**]//07 with a presumed pancreatic leak and peritoneal signs, fever, elevated WBC, tachycardic. # pancreatitis: She was NPO and started on IVF resuscitation. She was receiving Morphine for pain control. She went to the OR later that evening for Exploratory laparotomy; Wide drainage of pancreatic bed for pancreatic leak; Placement of a combined gastrostomy/jejunostomy tube (MIC tube). On POD 2, she was extubated. She continued to have fevers for several days post-op, with a Tm 103.4. Blood cultures were negative. She was found to be MRSA+, likely colonized. C.diff was negative. Urine grew out E.coli and she was started on Cipro for a UTI. She continued to have a WBC and intermittent fevers. She went for a ERCP for stent removal on [**2156-6-14**]. Her WBC trended down, she was not having fevers and clinically was stable. Her LFTs, Amylase and Lipase continued to trend down and did not bump with PO intake. Her pancreatitis seemed to resolve. #Abd/GI: She had 2 JP drains in place and a GJ feeding tube. Her midlin incision was C/D/I. The staples were removed on POD 11 and steri strips placed. The other drains will remain in place for now. # Tachycardia: Normal response to acute pancreatitis, improved with IVF resuscitation and as fevers trended down. . # Chronic HBV - monitor clinically . # FEN: She was NPO, IVF. She was started on trophic tubefeedings on POD 4 and started on clear liquids on POD 5. Her lytes were repleted PRN. Her diet was advanced over the next few days. She was able to tolerate food and her tubefeedings were discontined. . Proph - SQ heparin - PPI while NPO . Medications on Admission: none Discharge Medications: 1. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3-4H (Every 3 to 4 Hours) as needed for 2 weeks. Disp:*30 Tablet(s)* Refills:*0* 2. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 3 days. Disp:*6 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: Pancreatic leak Tachycardia Peritonitis Fever UTI Discharge Condition: Good Tolerating diet Abdomen soft Pain Controlled Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomitting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomitting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. = = = = = ================================================================ Please resume all regular home medications and take any new meds as ordered. You are being discharged on Cipro for a UTI. Please complete the full course of antibiotics. . Continue to ambulate several times per day. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] in 1 weeks. Call ([**Telephone/Fax (1) 15807**] to schedule an appointment. Completed by:[**2156-6-15**]

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Discharge summary

report

Admission Date: [**2165-6-4**] Discharge Date: [**2165-7-13**] Date of Birth: [**2099-2-19**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2279**] Chief Complaint: Coughing up blood Major Surgical or Invasive Procedure: [**2165-6-7**] - VATS for lung Bx [**2165-6-11**] - Renal Biopsy [**2165-6-29**] - L Renal Arteriogram History of Present Illness: 66F with history of HTN, CAD s/p CABG and mechanical [**Hospital3 9642**] aortic valve 20 years ago on coumadin, recent +PANCA, presented for admission for reversal of INR and observation for upcoming lung biopsy for workup of potential Wegners diagnosis. Patient was admitted on [**2165-6-5**] for complaints of a progressive severe cough for 2 months with three days of coughing up blood tinged mucus mixed in with some clots. OMR notes reveal anemia over past month with recent transfusion on Thursday prior to admission. . Per OMR notes she was undergoing routine echo of the heart when an increased dilation of the aorta was noted. A CT scan was ordered which revealed a 4.8 cm thoracic aortic aneurysm. However, in addition, bilateral lung nodules were seen. PET CT showed multiple bilateral FDG avid nodules. She was seen by thoracic surgery for consideration of EBUS versus open lung biopsy one month ago. In the interim, a pANCA level came back positive, along with an ESR of 115 and a newly discovered anemia of 8.0, and she was seen by Rheumatology, who facilitated elective admission to the hospital for further workup. . She was admitted to MICU for monitoring in setting of blood loss, CXR appearance showing diffuse opacities, and concern for hemoptysis. She was transfused two unit pRBC on [**6-5**] & [**6-7**] for decreasing HCT 21.1. Renal saw patient and noted: UA: 4+ blood, 2+ prot. Urine microscopy: >50 WBC/hpf. >50 RBC/hpf - isosormophic. ANCA +, ANTI-GBM pending. [**Doctor First Name **] +. Rhumatology saw patient and recommened 3 pulse doses before lung biopsy. On [**2165-6-7**], patient had video assisted thoracoscopic surgery, left upper lobe wedge resection, patient successfully extubated. Chest tube removed on [**6-8**] without complications. Patient was put on 60mg PO prednisone daily after VATS. Past Medical History: - Coronary Artery Disease with CABG in [**2143**] and additional placement of mechanical St. [**Male First Name (un) 1525**] aortic valve - Hypertension - Hyperlipidemia - Gout Social History: Ms. [**Known lastname 88713**] is originally from [**Country 1684**]. She worked as an aid for people with mental retardation in group home for many years. She has also worked for a few years at ITT doing a technology related role. Denies any respiratory occupational exposures to dust or other inhalation exposure. She does not drink alcohol, does not smoke and has never smoked and denies any drug use. She has three children. She is currently retired and lives with her son. Family History: There is no family history of autoimmune disease, lung or kidney disease. Physical Exam: On arrival to MICU: Vitals: 98.7, 73, 111/45, 96/RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated Lungs: scattered wheezes but good air movement. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . Discharged Exam: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: Supple, JVP not elevated Lungs: Bibasilar crackles, but other clear to auscultation bilaterally CV: Regular rate and rhythm, Mechanical Valve sounds at RUSB Abdomen: Soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: Deferred Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: On admission: [**2165-6-3**]: URINE: WBCCLUMP-MANY RBC-27* WBC-47* BACTERIA-FEW YEAST-NONE EPI-<1 URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-LG URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.005 PLT COUNT-406 NEUTS-86.0* LYMPHS-9.3* MONOS-3.1 EOS-1.4 BASOS-0.2 WBC-11.8* RBC-3.16* HGB-9.1* HCT-26.6* MCV-84 MCH-28.7 MCHC-34.0 RDW-15.3 ALBUMIN-3.9 ALT(SGPT)-34 AST(SGOT)-39 ALK PHOS-117* TOT BILI-1.8* URINE MUCOUS-RARE UREA N-28* CREAT-1.4* SODIUM-137 POTASSIUM-3.8 CHLORIDE-97 TOTAL CO2-26 ANION GAP-18 . Labs on Discharge: [**2165-7-13**]: BLOOD WBC-6.0 RBC-3.06* Hgb-9.0* Hct-26.2* MCV-85 MCH-29.3 MCHC-34.4 RDW-16.8* Plt Ct-195 BLOOD PT-24.9* PTT-24.4 INR(PT)-2.4* BLOOD Glucose-82 UreaN-31* Creat-0.8 Na-139 K-3.1* Cl-102 HCO3-29 AnGap-11 BLOOD Calcium-8.3* Phos-2.5* Mg-1.8 [**2165-6-28**]: BLOOD HBsAg-NEGATIVE [**2165-6-6**]: BLOOD ANCA-POSITIVE * . MICRO DATA: Blood Cultures, Urine Cultures negative. Renal and lung biopsy negative for infectious agents . [**6-4**]: Confirmed diagnosis of anti-[**Doctor Last Name **] antibody. [**Doctor Last Name **]-antigen is a member of the [**Doctor Last Name **] blood group system. Anti-[**Doctor Last Name **] antibody is clinically significant and capable of causing hemolytic transfusion reactions. In the future, the patient should continue to receive [**Doctor Last Name **]-antigen negative products for all red cell transfusions. Approximately 90% of ABO compatible blood will be [**Doctor Last Name **]-antigen negative. . [**6-4**] CXR: Bilateral ill-defined perihilar opacities, may represent alveolar hemorrhage. Differential considerations include a diffuse infectious process. . [**6-5**] Renal US: 1. Increased renal cortex echogenicity consistent with medical renal disease. 2. Moderately increased resistive indices. . [**6-6**] Echo: The left atrium is mildly dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 65%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. There are focal calcifications in the aortic arch. A bileaflet 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 (1+) mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. . [**6-6**] Chest CT w/o contrast: 1. Diffuse bilateral ground-glass opacities and consolidation are nonspecific. However, given the clinical and laboratory data for this patient, they are most consistent with widespread hemorrhage likely secondary to Wegener's granulomatosis or other vasculitis. The extent of involvement has increased since [**2165-5-8**], but the right lower lobe superior segment appears improved. 2. Prosthetic aortic valve with dilatation of the ascending aorta to 4.8 cm, unchanged from [**2165-4-25**]. 3. Possible calcified right renal artery pseudoaneurysm, less likely calcified lymph node anterior to the right kidney. . Wedge biopsies of lung, three (see note): . I. Left lower lobe segment superior segment: a) Lung tissue with recent hemorrhage and focal organizing alveolar fibrin. b) Focal capillaritis. c) Focal organizing pneumonitis. d) No large vessel vasculitis. . II. Anterior left upper lobe: a) Lung tissue with recent hemorrhage and focal organizing alveolar fibrin. b) Focal capillaritis. c) Focal organizing pneumonitis. d) No large vessel vasculitis. . III. Posterior segment, left upper lobe: a) Lung tissue with recent hemorrhage and focal organizing alveolar fibrin. b) Focal organizing pneumonitis. c) No large vessel vasculitis. . Note: Case was discussed with Dr. [**Last Name (STitle) **]. [**Doctor Last Name **] on [**2165-6-8**]. The findings are not specific. The typical findings of Wegener's granulomatosis are not seen. The diagnosis of Goodpasture syndrome should be considered. Clinical correlation is recommended. . [**6-12**] Renal Biopsy: Necrotizing extracapillary (crescentic) glomerulonephritis ,pauci-immune type consistent with glomerulonephritis of the ANCA-associated vasculitic syndromes (see note). . NOTE: Sections reveal fragments of renal parenchyma containing approximately 30 glomeruli, two of which are globally sclerotic. About 20% of the others show cellular/fibrocellular crescents of varying sizes and associated with fibrinoid necrosis (the extent of involvement by crescents varies greatly from level to level, up to 50%). Endocapillary proliferation is minimal. Mild interstitial fibrosis and tubular atrophy are noted accompanied by chronic inflammation. Focally the medulla shows an apparent capillaritis. Arterioles/small interlobular arteries show mild fibrotic changes. Larger arteries show focal /mild intimal fibroplasia. . Immunofluorescence studies reveal 8 glomeruli to be present. No staining is seen with immunoglobulin (IgA, IgG, IgM), kappa light chain, lambda light chain or C1q. C3 (+/-) stains vessels and tubular basement membranes. Trace fibrin is noted in a crescent. Albumin preparations are not contributory. Electron microscopy results pending. . [**2165-6-13**] Chest Radiograph: IMPRESSION: Minimal improvement in the extent of the confluent opacities in the perihilar and basilar regions, likely due to pulmonary hemorrhage in the setting of hemoptysis. . [**2165-6-17**] CT Abdomen and pelvis(Non-contrast): IMPRESSION: Slight increase to the right lung infiltrates. No intra-abdominal or retroperitoneal bleed. Right ovarian cyst which requires further assessment with ultrasound. . [**2165-6-19**] Right Upper Quadrant Ultrasound: 1. No evidence of focal or textural liver abnormalities. 2. Tiny cholesterol polyps are visualized; otherwise, the gallbladder is within normal limits. 3. Borderline enlarged spleen measuring 12.3 cm. . [**2165-6-21**]: CT Abdomen and pelvis without contrast. Interval large amount of hemorrhage in the left pararenal and perirenal spaces and subcapsular, with hematocrit effect and clot retraction, compatible with subacute hemorrhage. Fat stranding extends inferiorly from the left pararenal spaces to the left pelvis. . [**2165-6-22**]: Renal Ultrasound with Doppler 1. Left renal subcapsular hematoma and perinephric hematoma. 2. Echogenic kidneys suggesting medical renal disease. 3. Normal flow in bilateral main renal arteries and veins. 4. Elevated resistive indices bilaterally, which may be related to baseline medical renal disease. On the left, further increased resistive indices may be due to compression by hematomas. . [**2165-6-29**]: Left Renal Arteriogram 1. No evidence of active bleeding on left renal arteriogram including segmental selective injections to the interpolar branch and inferior polar branch. 2. No evidence of pseudoaneurysm, AV fistula, or free extravasation on left-sided lumbar arteriograms with selective injections of L2, L3 and L4 lumbar arteries. . [**2165-7-12**]: CT Abdomen and Pelvis without Contrast 1. Stable appearance of right perinephric and retroperitoneal hematoma without evidence of extension or new bleeding. 2. Right lower lobe 4-mm pulmonary nodule. If patient is low risk, no further followup is warranted. If the patient is high risk, then consider CT chest. Brief Hospital Course: 66yo woman with a h/o HTN, CAD s/p CABG and mechanical [**Hospital3 9642**] bileaflet aortic valve placed 20 years ago on coumadin, presented with hemoptysis, lung nodules, microscopic hematuria with positive P-ANCA, elevated ESR, CRP. Renal biopsy showed necrotizing extracapillary (crescentic) glomerulonephritis, pauci-immune type consistent with glomerulonephritis of the ANCA-associated vasculitic syndrome. [**Hospital **] hospital course was complicated by a post renal biopsy perinephric bleed and then a larger more expansive retroperitoneal bleed which ultimately self tamponaded with no need for open surgery or IR guided interventions. . # Hemoptysis/Microscopic hematuria: Patient presented with hemoptysis,lung nodules with +pANCA with working diagnosis of Wegener's granulomatosis/Microscopic Polyangiitis and admission was facilitated by outpatient rhuematology for INR reversal and lung biopsy. Due to worsening hemoptysis and anemia she was directly admittted to MICU. She had CT chest consistent with widespread hemorrhage thought to be secondary to Wegener's granulomatosis or other vasculitis given concurrent renal insufficiency and active urinary sediments. Following discussions with renal, IP, thoracics, and rheumatology, it was decided to proceed with a biospy of the lung. It was felt that given the intensity of immunosuppressive therapy for vasculitis, it would be best to confirm the diagnosis with biopsy. In the meantime, she was started on prednisone 60 mg PO. A complicating factor was her anticoagulation for her mechanical heart valve. Her coumadin was held before lung biopsy and she was given vitamin K to speed INR reversal. Lung biopsy results were non-diagnostic. She then had a renal biopsy on [**2165-6-11**] which confirmed diagnosis of ANCA associated vasculitis. She was started on monthly IV Cytoxan. Her course was complicated by an initial perinephric hematoma with bleeding and later by an expanding retroperotineal bleed after being re-bridged back to oral coumadin over a week after her surgery. Throughout the later half of her hospital course she continued to have hematuria on urine studies but no gross hematuria appreciated. She had no recurrent bouts of hemoptysis after initial few days in the hospital and this issue appeared to have stabilized by time of discharge. . # [**Last Name (un) **]/Microscopic hematuria: On UA patient had microscopic hematuria and proteinuria with active sediments with a large amount of WBC and RBC and fat bodies. Renal biopsy showed necrotizing extracapillary (crescentic) glomerulonephritis ,pauci-immune type consistent with glomerulonephritis of the ANCA-associated vasculitic syndromes. There was a maximum increase to Cr 1.5 during mid-[**Month (only) 205**] with potential pre-renal and intrinsic kidney damage to blame in the setting of known blood loss issues at that time. Fortunately, the patient's Cr remained stable and imroved down to 0.8-0.9 range at time of discharge which is essentially her normal Cr baseline. Of note, after she was started on IV cytoxan the first week in [**Month (only) 205**], it was noted that just after one week there was noticeable improvement in renal function as well as decrease in active urinary sediments. Thus, this confirmed most of her kidney dysfunction could be blamed on ANCA vasculitis. . # Perinephric and retroperitoneal bleeds: Two days after renal biopsy patient was started on heparin bridge to coumadin. 7 days later, while waiting for the INR to become therapuetic she developed severe abdmominal pain with CT scan showing perinephric and subcapsular hematoma. Her hematocrit intially dropped but then became stable after one unit of tranfusion. Her heparin and coumadin was discontinued. She was hemodynamically stable and therefore did not require any procedures. Three days after the bleed she was restarted on heparin bridge again. Two days after being put on heparin she again developed worsening abdominal pain with hemodynamic instability and was found to have a worsened retroperitoneal bleed. She was transferred to the ICU and received blood transfusions. She was taken to interventional radiology for embolization, but no active source of bleeding was found. After her hematocrit was stable for several days, she was restarted on heparin on [**6-30**]. On [**7-2**] she was restarted on coumadin since her hematocrit had remained stable. On [**7-6**] the patient was transferred out of the MICU. She remained stable while on the floor with hematocrits ranging from 24-26. She had a brief hematocrit drop on [**2165-7-11**] to 22.8, for which she was transfused an additional unit of blood and subsequently had a CT abdomen and pelvis which revealed no new bleeding source and stability of her perinephric bleed. Her hematocrit on discharge on [**2165-7-13**] was 26.2. Throughout her nearly 6 week hospital course, Ms. [**Known lastname 88713**] received a total of 18 blood transfusions. . # Anticoagulation: Ms. [**Known lastname 88713**] has an aortic mechanical AVR that was placed over 20 years ago at [**Location (un) 511**] [**Hospital **] Hospital. She has been on longstanding coumadin for her known mechanical valve. Per ECHO and patient's cardiologist she has bileaflet mechanical valve with normal EF, no history of afib, or additonal hypercoagulable conditions. As outlined above, she needed to interrupt her usual coumadin dosing to be briefly held and then re-bridged alongside heparin gtt. in the setting of a pulmonary biopsy, then later for her renal biopsy. After realizing active intra-abdominal/RP bleeding with dropping HCTs she also had her anticoagulation held in the ICU setting later in her hospital course. After a brief ICU stay in late [**Month (only) 205**] with clear evidence of stable HCTs for several days and stable vital signs her Coumadin was restarted at a lower cautious dose on [**7-2**]. Heparin was briefly stopped given a small hematocrit drop on [**7-6**] while INR was 1.8, but soon thereafter it was restarted with Coumadin. She was discharged on Coumadin dose of 4 mg/day and with an INR of 2.3. Close follow-up arranged with VNA and PCP for ongoing INR checks and HCT monitoring. . #Anemia: Patient became anemic one month prior to presentation most likely in the setting of hemoptysis and microscopic hematuria. Overall she received 18 units of pRBCs transfusion spaced out over the course of her hospitalization. Her reticulocyte was 1.3 on [**6-19**] possibly from bone marrow suppresion most likely from new meds e.g Cytoxan and Bactrim. After discontinuing Bactrim, her reticulocytes increased to around 5. However patient continued to be anemic. Patient's iron studies as well as B12, and folate as well as hemolysis labs were normal. 10 days after the renal biopsy patient developed a retropertotenial bleed further contributing to her anemia. Her Hct on discharge was 26.2. Plan at discharge was for VNA and PCP to help check her Hct within a few days of discharge to make sure it continued to remain stable. . # Elevated LFTs: During the hospital course patient had mild elevation in LFTs and increased in D-bili most likely cholestasis from Bactrim. RUQ Ultrasound did not show any biliary dilation. After discontinuing Bactrim patient's LFTs trended back to normal. . # Leukopenia: WBC trended down to 1.5 on [**2165-6-21**]. Most likely in the setting of Cytoxan related bone marrow suppression and immune suppression effects. Patient did not have any active signs or symptoms of infections. All blood and urine cultures during hospital course were unremarkable. Briefly placed on neutropenic precautions during her WBC nadir, while slowly resolved. Her WBC count returned to [**Location 213**] without any intervention by [**6-28**], and remained normal throughout the rest of her hospitalization. . # HTN: Blood pressure was initially on the low side and her captopril, lasix, spironolactone were held in the setting of low BP and RP/perinephric bleeding issues. Several days after her active bleed seemed to have stabilized in the ICU she had blood pressures adjusted again to include labetolol, TID captopril and amlodipine in order to ensure elevated blood pressures did not set off additional bleeding. Team tried to keep goal SBPs in the 120-140s range as much as possible, with several extra PRN IV hydralazine doses during her hospital stay. By time of discharge patient had been put on a stable combination of labetalol, captopril and amlodipine. Restarting of her Lasix or Spironolactone will be determined by her PCP at [**Name Initial (PRE) **] later date. . # CAD: Stable. Patient did not complain of any chest pain during hospital course. Aspirin was held in setting of numerous biopsies and then her bleeding complications. She was continued on usual home statin medication. . # Hyperlipidemia: Stable, patient continued on home pravastatin . # Gout: No acute flares of her known gout during hospital course. She was continued on home dose of allopurinol. . Transition of Care: PCP will consider need to continue holding vs. restart former diuretics ( spironolactone and lasix) if deemed necessary. Patient will follow up with her nephrologist Dr. [**First Name4 (NamePattern1) 429**] [**Last Name (NamePattern1) 118**] for her next planned IV Cytoxan therapy over the next few weeks Patient will have her INR monitored as outpatient by her PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4783**]. Medications on Admission: Codeine-guaifenesin 10 mg-100 mg/5 mL Oral Liquid [**12-9**] teaspoons by mouth at bedtime Pravastatin 40 mg Tab PO daily Allopurinol 300 mg Tab 1 Tablet(s) by mouth once a day Captopril 25 mg Tab 2 Tablet(s) by mouth twice a day Atenolol 50 mg Tab 1 Tablet(s) by mouth twice a day Furosemide 40 mg Tab 1 Tablet(s) by mouth Spironolactone 25 mg Tab 1 Tablet(s) by mouth twice a day Warfarin 4 mg Tab 1 Tablet(s) by mouth Discharge Medications: 1. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 2. Calcium 500 500 mg calcium (1,250 mg) Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*2* 3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 5. Outpatient Lab Work Please check potassium, hematocrit and INR within 2 days after discharge ( on [**Last Name (LF) 766**], [**2165-7-15**]) and have records sent to your physician [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 4597**] [**Last Name (NamePattern1) 5017**] (Fax #: [**Telephone/Fax (1) 88714**], Phone #: [**Telephone/Fax (1) 5424**]) so that your coumadin dose can be adjusted and labs can be monitored. 6. prednisone 20 mg Tablet Sig: Three (3) Tablet PO once a day. Disp:*90 Tablet(s)* Refills:*0* 7. labetalol 200 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*0* 8. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 9. atovaquone 750 mg/5 mL Suspension Sig: Two (2) PO once a day. Disp:*60 * Refills:*0* 10. allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day. 11. multivitamin Tablet Sig: One (1) Tablet PO once a day. 12. captopril 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* 13. warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Primary Diagnoses: ANCA-associated vasculitis, Anemia secondary to perinephric hematoma and retroperitoneal bleed Secondary Diagnoses: Hypertension, Coronary Artery Disease, Gout Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mrs. [**Known lastname 88713**], It was an absolute pleasure taking care of you during your hospitalization at [**Hospital3 **] [**Hospital 1225**] Medical Center. You were admitted to the hospital due to episodes of coughing up blood. You were directly admitted to the ICU where your symptoms and blood levels were closely monitored. You had a lung biopsy on [**6-7**] which was without clear diagnosis. Therefore, at the recommendations of our rheumatology and renal teams, you underwent a kidney biopsy on [**6-11**] which demonstrated inflammatory changes in your kidneys consistent with ANCA-associated vasculitis. After a multidisclplinary discussion between the renal, rheumatology, and medicine teams, you were started on cytoxan to treat your vasculitis. You received your first treatment of Cytoxan on [**2165-6-13**] without experiencing any decreased white blood cell counts. Your red blood cell counts decreased briefly, but returned back to their baseline levels. You were kept in the hospital to continue monitoring of your blood levels while waiting for your INR level to reach a therapeutic level. Unfortunately, your red blood cell levels (Hematocrit) decreased significantly due to a bleed around your kidneys which occurred after the renal biopsy. This bleeding complication was likely because your blood was thinned on recent anticoagulation medicine. This bleeding was in your abdomen and pelvic area (retroperitoneal space) and it was monitored on both abdominal ultrasounds and CT scans. Your anti-coagulation medication was stopped and later restarted once your bleeding appeared to have stopped. You received several blood transfusions, but ultimately you were transferred to the ICU for further management on [**2165-6-29**]. You eventually stabilized in the ICU, and you were then transferred back to the general medical floor on [**2165-7-6**] where you fortunately did not have any further bleeding complications until your discharge on [**2165-7-13**]. At that time, your red blood cell counts and INR had stabilized to appropriate levels. On discharge, you will follow-up with Dr. [**First Name4 (NamePattern1) 429**] [**Last Name (NamePattern1) 118**], your kidney doctor, on [**Last Name (LF) 766**], [**2165-7-15**]. He will be organizing your monthly Cytoxan therapy for your new diagnosis of ANCA-associated vasculitis. We also set up an appointment with your cardiologist Dr. [**First Name4 (NamePattern1) 4597**] [**Last Name (NamePattern1) 5017**] for Wednesday, [**7-17**], who will be continuing to help manage your anti-coagulation therapy and INR test results now that you have a history of a significant bleed. In addition, we changed your medications to allow for better control of your new ANCA-associated diagnosis and blood pressure. Those changes are listed below: We have made the following MEDICATION CHANGES: - STARTED Labetalol 200 MG twice a day - STARTED Amlodipine 10 MG once a day - STARTED Monthly IV Cytoxan - STARTED Prednisone 60 MG once a day - STARTED Atovaquone 1500 MG once a day - STARTED Calcium Carbonate 500 MG once a day - STARTED Vitamin D 400 Units once a day - STARTED Pantoprazole 40 MG once a day . - CONTINUE Pravastatin 40 MG once a day - CONTINUE Warfarin 3 MG once a day . - INCREASED Captopril to 75 MG three times a day . - DECREASED Allopurinol to 150 MG once a day . - STOPPED Lasix - STOPPED Spironolactone - STOPPED Codeine-Guaifenesin - STOPPED Atenolol . Followup Instructions: 1) [**7-15**] w/ Dr. [**First Name4 (NamePattern1) 429**] [**Last Name (NamePattern1) 118**] [**Location (un) **] [**Doctor Last Name **] 517 [**Location (un) 86**], [**Numeric Identifier 718**] Phone: ([**Telephone/Fax (1) 27787**] 2) [**7-17**] at 11:15 AM w/ Dr. [**First Name4 (NamePattern1) 4597**] [**Last Name (NamePattern1) 5017**] [**Street Address(2) **], [**Apartment Address(1) 83161**] [**Location (un) 7661**], MA Phone: [**Telephone/Fax (1) 5424**] Fax: [**Telephone/Fax (1) 88714**] . [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**] Completed by:[**2165-7-17**]

[ "V45.81", "417.8", "786.30", "V43.3", "401.1", "584.9", "599.72", "446.29", "568.81", "285.1", "274.9", "272.4", "441.2", "998.11", "E879.8", "583.4", "288.50", "782.4", "V58.61", "576.8", "E931.0" ]

icd9cm

[ [ [] ] ]

[ "32.20", "99.25", "55.23", "88.49", "88.45" ]

icd9pcs

[ [ [] ] ]

23151, 23200

11550, 21033

321, 425

23424, 23424

4083, 4083

27065, 27720

3014, 3090

21505, 23128

23221, 23336

21059, 21482

23575, 26440

3105, 4064

23357, 23403

26460, 27042

264, 283

4684, 11527

453, 2298

4097, 4665

23439, 23551

2320, 2498

2514, 2998

10,414

159,808

26039

Discharge summary

report

Admission Date: [**2113-5-31**] Discharge Date: [**2113-6-9**] Date of Birth: [**2052-11-5**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1384**] Chief Complaint: cc: acute renal failure in setting of ESLD Major Surgical or Invasive Procedure: orthotopic liver transplant [**2113-6-1**] History of Present Illness: HPI: 60 y/o M h/o ETOH cirrhosis, who presents with acute renal failure (Cr 1.0->3.4). He had blood drawn in clinic by Dr. [**Last Name (STitle) 497**] yesterday, and was subsequently called at home when his creatinine was found to be elevated. He has no associated symptoms of dysuria, hematuria, abd pains, nausea, vomiting, fever or chills. He does have h/o chronic low back pain x years, worse over past 1 week, and has been using tylenol for relief of symptoms, however specifically denies taking ibuprofen or other NSAIDs. . In ED, afebrile, BP 94/41, 99% RA. Labs notable for Creat 2.8, Na 126, K 4.9, Bicarb 22. Given 500cc NS bolus. Admitted to hepatology service. . Past Medical History: PMH: 1) ETOH cirrhosis: ESLD on transplant list; 2) h/o ascite 3) SBP on bactrim prophylaxis 4) hepatic encephalopathy 5) s/p umbilical hernia repair Social History: Lives w/ wife [**Name (NI) **] #[**Telephone/Fax (1) 64674**]. [**Name2 (NI) **] recent ETOH use-> quit in [**September 2112**] after h/o "heavy" use- won't quantify further Family History: Non-Contributory Physical Exam: Physical Exam: vitals: T 97.3, BP 104/60, HR 82, RR 20, 100% RA Gen- sleepy but arousable, NAD HEENT- EOMI. mild scleral icterus. OP clear CV- RRR. no m/r/g PULM- CTA b/l. no r/r/w abd- soft, dist abd w/ mild mid epigastric ttp w/o rebound or guarding. no fluid wave ext- 1+ pedal edema b/l. 2+ pulses. + asterixis b/l neuro- oriented x 3. CNII-XII intact. motor strength 5/5 upper/lower extremities Pertinent Results: Labs: [**2113-6-9**] Na 131 Cl 96 Bicarb 28 K 4.1 BUN 23 creat 0.8 gluc 90 ALT: 269 AP: 134 Tbili: 5.8 Alb: 2.5 AST: 46 WBC 12.6 Hgb 11.8 Hct 33.8 Plt 128 [**2113-5-31**] 10:25PM WBC-6.2 RBC-3.12* HGB-11.4* HCT-31.3* MCV-100* MCH-36.6* MCHC-36.5* RDW-14.6 [**2113-5-31**] 10:25PM FIBRINOGE-198# [**2113-5-31**] 06:30AM GLUCOSE-80 UREA N-48* CREAT-2.4* SODIUM-125* POTASSIUM-4.8 CHLORIDE-95* TOTAL CO2-20* ANION GAP-15 [**2113-5-31**] 06:30AM ALT(SGPT)-41* AST(SGOT)-62* ALK PHOS-166* AMYLASE-96 TOT BILI-5.3* [**2113-5-31**] 06:30AM LIPASE-57 [**2113-5-31**] 06:30AM ALBUMIN-2.8* CALCIUM-8.2* PHOSPHATE-3.8 MAGNESIUM-2.1 [**2113-5-31**] 06:30AM OSMOLAL-269* Brief Hospital Course: 60 y/o male with h/o ETOH cirrhosis with recent increase in creatinine on blood draws that was current on liver transplant list. Initial labs notable for creat of 2.8. Initial differential included pre-renal from volume depletion/diuresis, NSAID usage (denied by patient) and obstruction. Started on IVF for gentle hydration and admitted to hepatology service. Transplant workup was complete at time of admission. On [**6-1**] a liver became available and the OLT was performed on [**6-1**]. During Tx patient had cardiac arrest after the portal vein clamp was released and the liver began to perfuse. The etiology of this was unclear. The patient was quickly shocked in to a perfusing rhythm and regained blood pressure fairly quickly per op note. Post-op course has been uneventful and generally followed the pathway. Pt did have some confusion but was easily reoriented and this cleared over time. Pt followed by nutrition, PT, as well as transplant staff. Slight increase in liver enzymes POD 6 were remedied by uncapping the PTC. This will remain uncapped and followed at home with the help of VNA. Pt to return to clinic on Monday [**6-12**] for post op check. Medications on Admission: quinine sulfate 260 mg daily furosemide 80 mg [**Hospital1 **] lactulose 45 cc [**Hospital1 **] rifaxamin 400 mg [**Hospital1 **] Bactrim DS daily Aldactone 100 mg 2 tabd [**Hospital1 **] folic acid 1 mg daily MVI daily pantoprazole 40 mg [**Hospital1 **] CaCO3 500 mg [**Hospital1 **] Mag Ox 400 mg daily Discharge Medications: 1. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 2. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): follow taper. 3. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 8. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*1* 10. Tacrolimus 5 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet Sig: One (1) Packet PO TID (3 times a day). Disp:*30 Packet(s)* Refills:*1* 12. Insulin Regular Human 100 unit/mL Solution Sig: follow sliding scale Injection every six (6) hours: pre meals and bedtime. Disp:*1 * Refills:*1* 13. syringes low dose subcutaneous insulin syringes 1 month supply refill:1 14. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Transdermal once a day for 6 weeks. Disp:*42 * Refills:*0* 15. Nicotine 7 mg/24 hr Patch 24HR Sig: One (1) Transdermal once a day for 2 weeks. Disp:*14 * Refills:*0* 16. Midodrine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: VNA Southeastern MA Discharge Diagnosis: ESLD r/t etoh Discharge Condition: stable Discharge Instructions: Call [**Telephone/Fax (1) 673**] if fevers, chills, nausea, vomiting, inability to take meds, abdominal pain, jaundice, redness/bleeding/pus at incision or at old drain site, weight gain of 3 pounds in a day or malaise. Labs every Monday and Thursday for cbc, chem10, ast, alt, alk phos, t.bili, albumin, and trough prograf level. Fax results to [**Telephone/Fax (1) 697**] attn:[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13144**] No heavy lifting, no showering until incision healed. Empty JP and bile bag when half full. Record output and bring Followup Instructions: Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2113-6-15**] 10:40 Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2113-6-22**] 10:20 Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2113-6-29**] 10:40

[ "281.9", "303.90", "427.5", "570", "276.1", "789.5", "276.3", "572.3", "276.7", "584.9", "571.1", "293.9", "571.2", "724.5" ]

icd9cm

[ [ [] ] ]

[ "99.62", "99.07", "99.04", "38.93", "50.59", "00.93", "99.05", "51.79" ]

icd9pcs

[ [ [] ] ]

5794, 5844

2655, 3825

357, 402

5902, 5911

1946, 2632

6525, 6990

1491, 1509

4182, 5771

5865, 5881

3851, 4159

5935, 6502

1539, 1927

274, 319

430, 1108

1130, 1282

1298, 1475

7,618

144,210

14249

Discharge summary

report

Admission Date: [**2113-6-21**] Discharge Date: [**2113-6-25**] Date of Birth: [**2053-4-13**] Sex: M Service: MEDICINE Allergies: Atorvastatin Attending:[**First Name3 (LF) 443**] Chief Complaint: HA/difficult word finding Major Surgical or Invasive Procedure: Placement of left ICA stent History of Present Illness: Patient is a 60 yo M hx CAD s/p CABG ([**2103**] at [**Hospital1 112**]), DM II, hyperlipidemia, HTN recent admission 2 weeks prior for TIA sxs (right arm tingling, numbness, and difficulty making a fist), found to have 80-99% left carotid stenosis s/p stent. A self-expanding carotid stent was placed with 50% residual stenosis after stenting. 2 days prior to admission, patient developed transient episode of blurry vision and "speaking gibberish." He was initially admitted to the Neurology service then found to left caudate infarct and persistent stenosis of the ICA on CT neck and carotid ultrasound. He underwent repeat angiography and the self-expanding stent was in place but had expanded over the stenotic area. An additional stent was placed by Interventional Cardiology and he was transferred to the CCU for close hemodynamic monitoring. . Of note, patient also with known CAD with DOE over the past year and episodes of chest pain, had outpatient stress [**1-25**] with reported new inf/inf-lat wall motion abnormalities. Plan was for eventual revascularization after further work-up and stenting of carotids. . On review of symptoms, he has had prior TIA sxs as noted above. No deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. All of the other review of systems were negative. . *** Cardiac review of systems is notable for current absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. He has had DOE for the past year and plan for eventual cath, he has had exertional chest pain in the past. Past Medical History: - CAD s/p 2v CABG in [**2104-4-18**] (at [**Hospital1 112**] by Dr. [**Last Name (STitle) 1683**]; angina equivalent in the past: right arm pit discomfort; now SSCP - Stent to LAD in [**2103**] (at [**Hospital1 18**] cath with 90% mid-LAD and 89%diag lesion; EF 45%, apical hypokinesis; cath c/b dissection in distal LAD which was stable on re-cath); on ASA/Plavix since [**2103**] - HTN - Type II DM with neuropathy and retinopathy; since age 40; strong FHx; FS run in low 200s and HbA1c 8-9 per patient - s/p III degree burn on L foot [**1-20**] diabetic PNP (per pt) - s/p unnoticed fractures of R foot [**1-20**] diabetic PNP/charot's foot (per pt) - Hyperlipidemia - OSA - GERD Social History: lives with wife, daughter (33) and son (35), VP of sales, no tobacco, no EtOH Family History: Father died of malignant hypertension in 40s, father's brothers died of heart disease in 50s, mother died of aneurysm rupture at 76, several family members on mothers side with DM Physical Exam: VS: Temp afebrile HR 82 BP 198/92 RR 14 96RA Gen: Awake, alert and 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. no carotid bruit appreciated 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: soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: No c/c/e. Right groin sheath in place Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: 2+ DP Left: 2+ DP Pertinent Results: EKG: NSR, HR 68, Left axis, normal intervals. q waves III, aVF. TWIs I,aVL. poor R wave progression. . 2D-ECHOCARDIOGRAM performed onon [**2113-6-22**] demonstrated: Mildly dilated left atrium. No ASD or PFO. Mild symm LVH. The left ventricular cavity size is normal. EF 60%. Normal LV size and RV size with normal RV wall motion. No AS/AR. No MR. [**First Name (Titles) **] [**Last Name (Titles) 33904**]l effusion. . ETT performed on [**1-/2113**] demonstrated: done at outpt cardiologist's office. . CAROTID CATH performed on [**2113-6-23**] demonstrated: AO 207/94 mean 143 7.0 x 20mm acculink stent placed, residual proximal disease treated with additional overlapping 7.0 x 10mm x 40mm Acculink stent. Final angiography with normal flow, 10% residual thrombus and no residual filling defect. . MRA Brain/Neck [**2113-6-21**]: Apparent stenosis of the proximal left internal carotid may be artifactual secondary to susceptibility artifact from the stent; however, this is unclear without the administration of gadolinium. Repeat imaging with MRA with gadolinium or CTA can be pursued as clinically indicated. . Non-contrast Head CT [**2113-6-22**]: Subtle hypodensity within the left caudate head consistent with recent infarct noted on MR from a day prior which had a hemorrhagic component. . Carotid study [**2113-6-23**]: 1. Status post left ICA stent, intrastent stenosis of approximately 60% based on velocities. No evidence of intimal hyperplasia. 2. No change in essentially normal right-sided system (ICA stenosis graded as less than 40%). . CTA Neck [**2113-6-23**]: Findings of concern for lack of relief of stenosis of the left internal carotid artery by the stent device, as noted above, possibly with residual plaque at that locale . CT abdomen and pelvis s contrast [**2113-6-24**]: No evidence of intraperitoneal hemorrhage. . HEMODYNAMICS: . LABORATORY DATA: 143.|.109.|.15 162 --------------- 3.7.|.27.|.1.1 Ca: 8.8 Mg: 2.5 P: 2.7 . WBC 7.7 Hct 40.6 Plt 231 . [**2113-6-21**] FLP: LDL 82 HDL 26 TC 166, . Brief Hospital Course: A/P: 60 yo M hx CAD s/p CABG ([**2103**] at [**Hospital1 112**]), DM II, hyperlipidemia, HTN, recent Left carotid stent placed presented with TIA symptoms, and found to have reocclusion of left carotid stent. . # Carotid stenosis: second stent placed in left carotid with good effect. The patient was stable until the evening of [**6-23**]/7 when he had a vagal episode when his sheath was being pulled. His [**Date Range **] decreased to the 120s, and the patient began to have some difficulty with word-finding. Speech was noted to be slower than usual. The episode lasted ~2minutes with stable vital signs. Neurology was consulted felt that this may have been a re-expression of his existing left caudate infarct from low BP. They recommended no change in management. Throughout the admission the patient was maintained on ASA, plavix, niacin, and zetia. He was also started on simvastain 40mg despite history of myalgias for about 1 month until outpatient follow-up. Neurology continued to follow the patient throughout his hospital course and arranged for follow-up as an outpatient. . # HTN: the restenting procedure was complicated by acute evlevation in BP, so nipride and NTG gtt were started. These were weaned off and additional anti-hypertensives were held so that [**Date Range **] could be within goal of 145-180. Po metoprolol was restarted on [**6-25**]. -upon discharge, the patient was instructed to measure his BP twice daily and to follow-up with his doctor [**First Name (Titles) **] [**Last Name (Titles) **] is persistently < 130. - Additional andi-hypertensives are to be re-started as an outpatient. . # anemia: on [**2113-6-24**] the patient's hematocrit, which was previously stable around 40, dropped to 31.7. There was no evidence of hematoma on clinical exam. A CT of the abdomen and pelvis was done to r/o RP bleed and returned negative. Anemia resolved by [**6-25**] with a return to baseline ~40). . # DM: HgA1c A1c 8.6 (pt states lower than prior in the mid-9's). The patient was maintained on a RISS and his home NPH regimen when not NPO. . During the admission the patient was maintained on a cardiac, diabetic diet with a PPI and sc heparin for prophylaxis. He was discharged in good condition with VSS to home. Medications on Admission: 1. Amlodipine 2.5mg daily 2. insulin 70/30: 40 Uunits qam and 55 units qpm. 3. Clopidogrel 75 mg DAILY 4. Colesevelam 625 mg PO BID 5. Valsartan 160 mg PO DAILY 6. Fenofibrate Micronized 145 mg po daily 7. Ezetimibe 10 mg po daily 8. Lasix 20 mg po daily 9. Metoprolol Tartrate 50 mg po bid 10. Niacin 500 mg po daily 11. Vitamin E 400 unit po daily 12. Multi-Vitamin daily 13. Omeprazole 20 mg po daily 14. Aspirin 325 mg po daily Discharge Medications: 1. INSULIN Please resume your prior insulin regimen of 70/30 insulin, 40 U in the morning and 55 U in the evening. 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 4. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 6. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY (Daily). 7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 8. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 9. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed: max dose 4 g daily. Discharge Disposition: Home Discharge Diagnosis: Symptomatic carotid stenosis, now status post stenting of the left internal carotid artery Secondary: Coronary artery disease Hypertension Hyperlipidemia diabetes mellitus type 2 Gastroesophageal reflux disease Discharge Condition: afebrile, BPs 140s-160s, comfortable on room air, ambulating Discharge Instructions: Your have been evaluated for blockages to your carotid arteries, and you have undergone further stenting of the left carotid artery. You should monitor your blood pressures twice daily for the next two weeks. If you see blood pressures consistently < 130 systolic or > 170 systolic, please contact your cardiologist for further instructions. Please take all medications as prescribed otherwise. Contact your primary physician or return to the emergency room should you develop any of the following symptoms: slurred speech, facial asymmetry, weakness or numbness or either hand or leg, headache, neck pain, chest pain, difficulty breathing, pain in your groin, back pain, or any other concerns. Followup Instructions: Please follow up with your primary physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 20585**], in [**12-20**] weeks. Call [**Telephone/Fax (1) 20587**] for an appointment. Please follow up with your neurologist, Dr. [**Last Name (STitle) 656**], on [**2113-7-6**] at 9:30 am. Call [**Telephone/Fax (1) 1694**] if there is a problem with this appointment. Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], M.D. Phone:[**Telephone/Fax (1) 1694**] Date/Time:[**2113-7-6**] 9:30 Please follow up with your cardiologist, Dr. [**Last Name (STitle) 911**], in [**1-21**] weeks. Call ([**Telephone/Fax (1) 24798**] to make this appointment; we have let Dr.[**Name (NI) 5786**] team know that you have been discharged, so they may be calling you for an appointment.

[ "414.01", "357.2", "285.9", "250.50", "401.9", "V58.67", "362.01", "250.60", "530.81", "272.4", "433.11", "327.23", "V45.81" ]

icd9cm

[ [ [] ] ]

[ "00.40", "88.41", "00.61", "00.46", "00.63" ]

icd9pcs

[ [ [] ] ]

9571, 9577

5870, 8122

298, 328

9833, 9896

3806, 5847

10640, 11482

2892, 3073

8604, 9548

9598, 9812

8148, 8581

9920, 10617

3088, 3787

233, 260

356, 2073

2095, 2780

2796, 2876

28,476

104,222

12549

Discharge summary

report

Admission Date: [**2101-3-4**] Discharge Date: [**2101-3-10**] Date of Birth: [**2023-10-26**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: DOE Major Surgical or Invasive Procedure: CABG X 4 (LIMA >LAD, SVG>Diag, SVG>OM, SVG>PDA)([**2101-3-4**]) History of Present Illness: 77 yo M with DOE x 4-5 months, also occasional CP with exertion. + Stress test, cath with 3VD. Referred for surgery. Past Medical History: Hypertension "Borderline" Hypercholesterolemia Renal cell carcinoma s/p left nephrectomy in [**2098**] Right knee replacement Bilateral rotator cuff injury Partial colectomy for mass that was found to be benign Depression Social History: The patient lives with his girlfriend of 30 years in an apartment. He also has family in the area. He reports that he has 80 pack year smoking history, but quit 24 years ago. He does not drink alcohol. Family History: Father fatal MI age 55; mother died age 87; brother died age 82; another brother still alive age 85. Physical Exam: HR 46 RR 14 BP 121/59 NAD Lungs CTAB Heart RRR, No murmur Abdomen soft, NT. Well healed [**Doctor First Name **]. Extrem warm, no edema, spider veins at ankle. Pertinent Results: [**2101-3-10**] 05:55AM BLOOD WBC-8.2 RBC-3.31* Hgb-10.0* Hct-29.4* MCV-89 MCH-30.2 MCHC-34.0 RDW-15.1 Plt Ct-346# [**2101-3-10**] 05:55AM BLOOD Plt Ct-346# [**2101-3-10**] 05:55AM BLOOD Glucose-103 UreaN-35* Creat-1.3* Na-142 K-5.3* Cl-104 HCO3-31 AnGap-12 [**2101-3-8**] 11:06AM BLOOD Glucose-134* UreaN-33* Creat-1.2 Na-139 K-4.3 Cl-98 HCO3-33* AnGap-12 [**2101-3-8**] 03:46AM BLOOD Glucose-102 UreaN-29* Creat-1.3* Na-137 K-4.3 Cl-98 HCO3-30 AnGap-13 [**2101-3-8**] 01:00AM BLOOD Glucose-117* UreaN-30* Creat-1.4* Na-136 K-5.3* Cl-99 HCO3-30 AnGap-12 CHEST (PORTABLE AP) [**2101-3-8**] 7:30 AM CHEST (PORTABLE AP) Reason: evaluate ? effusion [**Hospital 93**] MEDICAL CONDITION: 77 year old man with s/p cabg REASON FOR THIS EXAMINATION: evaluate ? effusion HISTORY: Status post CABG. FINDINGS: In comparison with the study of [**3-7**], there is little overall change. Again, there is evidence of some bilateral pleural effusions with basilar atelectatic changes in a patient with intact sternal sutures. [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 38863**] (Complete) Done [**2101-3-4**] at 8:58:44 AM 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: [**2023-10-26**] Age (years): 77 M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Coronary artery disease. Left ventricular function. Preoperative assessment. ICD-9 Codes: 440.0 Test Information Date/Time: [**2101-3-4**] at 08:58 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 168**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2008AW2-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: >= 55% >= 55% Aorta - Annulus: 2.0 cm <= 3.0 cm Aorta - Sinus Level: *4.0 cm <= 3.6 cm Aorta - Sinotubular Ridge: 2.9 cm <= 3.0 cm Aorta - Ascending: 3.4 cm <= 3.4 cm Aorta - Descending Thoracic: 2.2 cm <= 2.5 cm Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness and cavity size. Overall normal LVEF (>55%). RIGHT VENTRICLE: Moderately dilated RV cavity. Normal RV systolic function. AORTA: Normal aortic diameter at the sinus level. Complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild thickening of mitral valve chordae. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. 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. Conclusions PREBYPASS No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is moderately dilated with normal free wall contractility. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. POSTBYPASS Preserved biventricular systolic function. The study is unchanged from the prebypass period. Brief Hospital Course: On [**2-/2022**] he underwent a CABG x 4. He was transferred to the ICU in stable condition on neo and propofol. He was extubated later that day. On [**3-7**] he was found on the floor after getting himself out of the chair, atrial wires were dc'd in the process, otherwise no signs of injury. He had some atrial fibrillation for which he was started on amiodarone and converted to NSR. He was transferred to the floor with a bedside sitter. He was transfused one unit. He otherwise did well postoperatively and was ready for discharge home on POD #6. Medications on Admission: Plavix 75', ASA 325', Toprol XL 50'(at home), Paxil 20', Lopressor 50(in hospital), Trazodone. Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 5. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. 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* 7. Zocor 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 8. Paxil 20 mg Tablet Sig: One (1) Tablet PO once a day. 9. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 1 weeks: then reassess need for diuresis. 11. Trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime. 12. Klonopin 1 mg Tablet Sig: One (1) Tablet PO at bedtime. Discharge Disposition: Extended Care Facility: Life Care Center of [**Location (un) 5165**] Discharge Diagnosis: CAD now s/p CABG HTN, depression, chronic shoulder pain, s/p L.nephrectomy (RCC) in [**2098**], s/p colon resection, s/p R TKR Discharge Condition: Good. 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. No lifting more than 10 pounds for 10 weeks from surgery. No driving until follow up with surgeon. Followup Instructions: Dr. [**Last Name (STitle) **] 2 weeks Dr. [**Last Name (STitle) **] 4 weeks Dr. [**Last Name (STitle) 7047**] 2 weeks Already scheduled appointments: Provider: [**Name10 (NameIs) 8741**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2101-8-12**] 11:15 Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7145**] ORTHOPEDIC PRIVATE PRACTICE Phone:[**Telephone/Fax (1) 11262**] Date/Time:[**2101-7-6**] 11:30 Completed by:[**2101-3-10**]

[ "E849.7", "413.9", "V15.82", "V10.52", "E878.2", "401.9", "997.1", "427.31", "V43.65", "311", "414.01", "V45.73" ]

icd9cm

[ [ [] ] ]

[ "39.63", "36.15", "88.72", "36.13" ]

icd9pcs

[ [ [] ] ]

7121, 7192

5289, 5843

325, 391

7363, 7371

1316, 1967

7684, 8224

1018, 1120

5988, 7098

2004, 2034

7213, 7342

5869, 5965

7395, 7661

1135, 1297

282, 287

2063, 5266

419, 537

559, 782

798, 1002

72,470

127,573

9242

Discharge summary

report

Admission Date: [**2161-4-23**] Discharge Date: [**2161-6-1**] Date of Birth: [**2125-2-2**] Sex: M Service: MEDICINE Allergies: Aspirin / Nsaids Attending:[**First Name3 (LF) 3913**] Chief Complaint: erythematous eyes, dysuria Major Surgical or Invasive Procedure: Flexible Sigmoidoscopy History of Present Illness: 36-year-old man with plasma cell leukemia, d+119 after ablative (flu/cy/TBI) cord SCT, complicated by skin and gut GVHD, now on velcade (C1D32) for persistent plasma cell dyscrasia in his bone marrow, presents with erythematous eyes and dysuria. Three days ago he started experiencing irritation in his eyes bilaterally. They felt dry and itchy. No visual changes, blurry vision or double vision. He reports some clear discharge. Two days ago he also develop severe dysuria without any hematuria, with the pain worst at the beginning and end of urination. No abdominal, back pain, nausea, or vomiting. No fever. No penile lesion or discharge. scharge. . He presented to clinic on [**2161-4-22**] with these symptoms, was diagnosed with possible ocular GVHD and UTI and was started on cyclosporine eye drops and levofloxacin. His urinalysis and urine culture came back negative. GC still pending. He re-presented to clinic on [**2161-4-23**] with persistent symptoms and was admitted. . Review of Systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies blurry vision, diplopia, loss of vision, photophobia. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pain or tightness, palpitations, lower extremity edema. Denies cough, shortness of breath, or wheezes. Denies nausea, vomiting, constipation, melena, hematemesis, hematochezia. Denies arthralgias or myalgias. Denies rashes or skin breakdown. No numbness/tingling in extremities. All other systems negative. Past Medical History: *[**6-/2159**] diagnosed with plasma cell leukemia, treated with 3 cycles of hyperCVAD part A and Velcade *[**2159-11-20**] autologous stem cell transplant, CR *[**5-/2160**] found to have brachial plexus involvement with plasma cell leukemia, BMbx shows relapse with 10-20% plasma cells. *[**2160-5-13**] Cytoxan, Velcade, dexamethasone x 1 cycle *[**2160-5-23**] XRT to brachial plexus, total dose 3600 cGy *[**2160-6-27**] IT MTX *[**2160-7-29**] hyperCVAD part A + Velcade *[**2160-8-26**] hyperCVAD part B *[**2160-9-12**] Velcade and Revlimid *[**9-/2160**] single [**Doctor Last Name 360**] Revlimid 15 mg/day x <1 cycle *[**11/2160**] Cytoxan/Velcade/Revlimid x 1 cycle for disease progression *[**11/2160**] Revlimid at 25 mg/day *[**2160-12-11**] continues 25 mg/day Revlimid with pulse dexamethasone of 20 mg x 4 days *[**2160-12-17**] last dose of Revlimid prior to transplant. *[**2160-12-25**] double cord blood transplant for plasma cell leukemia. Conditioning regimen was myeloblative using fludarabine, Cytoxan, and TBI. POST TRANSPLANT COMPLICATIONS: *Neutropenic fevers, ultimately resolved with removing tunnelled line *C.Diff *HHV6 viremia, not treated, followed by ID *DVT of right arm, not anticoagulated *Acute GVHD, grade 1 skin- treated with topical and systemic steroids. PMH: Plasma cell leukemia s/p transplant (as in HPI) Status post gunshot wound to left leg, status post bilateral knee surgeries. Social History: Lived alone prior to transplant, but since transplant, is staying with his mother. Currently unemployed but previously worked as a phlebotomist at [**Hospital1 2025**]. Social EtOH use. + marijuana use. He has 2 children. Family History: Mother and father are both alive and well. Mother's family has history of DM, HTN, and CAD. He doesn't know much about his father's side of the family. Possible history of cancer, but no history of leukemia or blood disorders. Pt has a sister and two children ages 16 and 8, all of whom are healthy. Physical Exam: ADMISSION EXAM: VS: T 97.2, BP 128/94, HR 88, RR 20, 100%RA GEN: Young man lying in bed in some discomfort from recent dysuria, in NAD, awake, alert HEENT: conjunctivae erythematous bilaterally with clear discharge, EOMI NECK: Supple, no JVD CV: Reg rate, normal S1, S2. No m/r/g. CHEST: Resp unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABD: Soft, NT, ND, no HSM, bowel sounds present MSK: normal muscle tone and bulk EXT: No c/c/e, 2+ DP/PT bilaterally Pertinent Results: ADMISSION LABS: [**2161-4-23**] 01:40PM UREA N-20 CREAT-1.0 SODIUM-138 POTASSIUM-4.5 CHLORIDE-101 TOTAL CO2-24 ANION GAP-18 [**2161-4-23**] 01:40PM ALT(SGPT)-50* AST(SGOT)-26 LD(LDH)-219 ALK PHOS-98 TOT BILI-0.4 [**2161-4-23**] 01:40PM ALBUMIN-4.1 CALCIUM-9.2 PHOSPHATE-3.2 MAGNESIUM-2.1 [**2161-4-23**] 01:40PM WBC-13.2* RBC-3.65* HGB-12.8* HCT-39.0* MCV-107* MCH-35.2* MCHC-32.9 RDW-18.7* [**2161-4-23**] 01:40PM NEUTS-76* BANDS-0 LYMPHS-8* MONOS-16* EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2161-4-23**] 01:40PM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-OCCASIONAL MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL [**2161-4-23**] 01:40PM PLT SMR-LOW PLT COUNT-107* DISCHARGE LABS: [**2161-6-1**] 12:00AM BLOOD WBC-6.2 RBC-2.39* Hgb-8.3* Hct-25.3* MCV-106* MCH-34.8* MCHC-32.8 RDW-25.1* Plt Ct-18* [**2161-6-1**] 12:00AM BLOOD Neuts-87* Bands-0 Lymphs-10* Monos-3 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2161-6-1**] 12:00AM BLOOD Glucose-185* UreaN-17 Creat-0.8 Na-137 K-4.0 Cl-104 HCO3-24 AnGap-13 [**2161-6-1**] 12:00AM BLOOD ALT-15 AST-15 LD(LDH)-643* AlkPhos-94 TotBili-0.6 IMAGING: GI Biopsies: Colonic mucosa with focal prominent apoptosis and focal cryptitis, crypt regenerative and degenerative changes, consistent with graft versus host disease (grade [**2-6**]) in the appropriate clinical setting. No definite viral inclusion seen. HSV and CMV immunostains are negative. [**4-29**] CT Abdomen/Pelvis: IMPRESSION: Persistent colonic wall thickening along the ascending and transverse portions, probably more so than distally, consistent with an inflammatory or infectious causes of colitis including potentially graft versus host disease. [**5-7**] ECHO: The left atrium is elongated. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. Regional left ventricular wall motion is normal. There is mild global left ventricular hypokinesis (LVEF = 45%). 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. No masses or vegetations are seen on the aortic valve. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: No valvular vegetations seen. Mildly dilated and hypokinetic left ventricle. Mild mitral regurgitation. Mild pulmonary hypertension. [**5-4**] CHEST CT: IMPRESSION: Multifocal bronchopneumonia, most severe in the right upper lobe. Though this is most likely bacterial in etiology, the nodular configuration of some of the opacities also raises the possibility of fungal organisms, especially if the patient is neutropenic. [**5-16**] CHEST CT: IMPRESSION: Resolving multifocal pneumonia with most marked improvement of the right upper lobe consolidation. However, area of persistent opacification within the right upper lobe now demonstrates cavitations with no clear fluid collection. Differential considerations include bacterial or fungal infection. [**5-19**] ECHO:The left atrium is normal in size. Color Doppler study suggests possible small interatrial shunt consistent with stretched patent foramen ovale or small atrial septal defect. (last beat of clip [**Clip Number (Radiology) **]). Left ventricular wall thicknesses are normal. The left ventricular cavity size is top normal/borderline dilated. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic arch is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. There may be trace aortic regurgitation (better seen on study of [**2161-5-7**]). The mitral valve leaflets are structurally normal. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. No vegetation seen (cannot definitively exclude). [**5-22**] CHEST CT:IMPRESSION: 1. Improving multifocal infection including decreased size of cavitary lesion in the right upper lobe. No new or worsening areas of lung or airways disease. 2. New small pericardial and trace pleural effusions. [**5-26**] U/S:IMPRESSION: Persistent thrombus in one of the right brachial veins. Brief Hospital Course: 36-year-old man with plasma cell leukemia, d+119 after ablative (flu/cy/TBI) cord SCT, complicated by skin and gut GVHD, now on velcade (C1D32) for persistent plasma cell dyscrasia in his bone marrow, presented with erythematous eyes and dysuria. . # Red eyes: Concerning for infection vs. ocular GVHD. He was treated empirically for chlamydia with azithromycin. Ophthalmology was consulted who felt that this was most likely [**2-4**] GVH. Symptomatically, he felt better about his eye discomfort by the time of discharge, and a f/u appointment was made with ophthalmology. Of note, Chlamydia was checked (as has GC) and both were negative. RPR was also NR. . # Dysuria: BK virus from the urine was positive, and so IVF were given for the patient to encourage urination and to avoid clot formation. Dysuria improved throughout hospitalization. . # BRBPR: Pt developed BRBPR during hospitalization, and out of concern for GVH, flex sig was done with bxs taken. No viral inclusions were seen on bx, and a CMV immunostain was done which was negative. CT abd/pelvis without contrast (gvien myeloma hx showed findings c/w GVH of the colon diffusely. The patient was initially made NPO with TPN but slowly weaned up to a full diet prior to discharge as steroids were added. He was discharged on Prednisone 20BID for his GVHD. He was also on CellCept 1000mg [**Hospital1 **] on discharge. Tacrolimus was stopped given concern for autonomic dysfunction and TTP. . # Plasma cell leukemia: We continued the pt's acyclovir and PO vanc for ppx. He refused many of these doses, however we encouraged him to take these medications. We also continued the MMF prednisone was changed as above. During the patient's treatment for GVHD his IgA level started to rise, peaking at 2072. He was treated with 2 doses of Velcade and 1 dose of Cytoxan. Soon after these doses he developed autonomic dysfunction (see below) and so further treatment was held. On D/C Ig A was 576. . # Bradycardia and Orthostatic Hypotension: During the course of his treatment for cavitary pneumonia (see below) and plasma cell leukemia with Velcade/Cytoxan, the patient suddenly developed bradycardia to the 30s and 40s with concomitant, symptomatic orthostatic hypotension. He was transferred to [**Hospital Unit Name 153**] for episodes of bradycardia, for which he was evaluated by cardiology service. Echocardiogram was done that showed no evidence of structural heart disease to explain ECG or telemetry findings and he had no evidence of conduction disease. He was also found to have orthostatic hypotension, with change in blood pressure from 195/105 when laying flat, with HR 40s, siting 139/103 HR 50-70, and standing 77/51 HR 122. The autonomics service was consulted and his dysautonomia was thought likely to be chronic with chemotherapy induced autonomic neuropathy with velcade being the most likely cause. Other potential causes were thought to be tacrolimus, which could cause bradycardia, or XRT effects on sympathetic nerve fibers. GVHD was considered as he has a history of GVHD in other systems, however was thought to be very unlikely. He was started on Midodrine in the ICU but this was discontinued after transfer back to the floor as the patient had supine hypertension. He should follow up with [**Hospital **] clinic for outpatient testing and in future a workup for paraneoplastic autonomic neuropathy could be considered, however this is unlikely. . # Hypertension: Metoprolol was discontinued given bradycardia, BP trended up to 200's and hydralazine was stared. He was transitioned to nifedipine with SBP in 150's, he will need follow up with repeat medication titration on discharge. . # Pneumonia: The patient developed a R sided PNA in the setting of a positive MRSA blood culture during this admission. He was treated with Vancomycin with initialy improvement, but developed cavitations in his PNA with fever and Cefepime was added. Cefepime was stopped when the patient developed TTP (see below) but the patient remained afebrile without respiratory compromise. ID was consulted and recommended a 6 week course of Vancomycin; he will be discharged with a PICC line to complete this course. . # TTP: After transfer from the [**Hospital Unit Name 153**] back to the BMT floor, with patient developed TTP with dropping platelets, schistocytes, low haptoglobin, rising LDH and dropping fibrinogen. The transfusion service was consulted and stated that plasma exchange was not an option given that this was unlikely to be an idiopathic antibody mediated TTP and instead more likely a result of his multiple medical problems or medications. Cefepime and Tacrolimus were D/Ced and his counts improved with supportive care. . # RUE Clot: Patient found to have RUE clot in R arm at the time of first PICC placement; this was persistent after PICC was removed; second PICC was placed in the same arm but a different brachial vein. The patient had some swelling in his R arm, possibly due to this clot, but was not treated with anti-coagulation due to multiple other medical issues. . # Prophylaxis: Acylovir, Voriconazole, PO Vanc, Bactrim. . Transitional Issues: - He was started on Nifedipine for hypertension and will need BP checks and dose titration - Patient will require two weeks of IV antibiotic therapy with Vancomycin (to complete [**6-16**]) - Patient will need follow up appointment with Dr. [**Last Name (STitle) 724**] in infectious disease before completion of vancomycin. He was discharged over the holiday weekend and this appointment could not be arranged. - Patient will need repeat RUE U/S in one month to make sure that clot has resolved. Medications on Admission: Medications - Prescription ACYCLOVIR - 400 mg Tablet - 1 Tablet(s) by mouth three times a day BUDESONIDE [ENTOCORT EC] - (Prescribed by Other Provider) - 3 mg Capsule, Ext Release 24 hr - 1 Capsule(s) by mouth three times a day CYCLOSPORINE [RESTASIS] - 0.05 % Dropperette - 1 drop OU Q12 hours Please place 1 drop in each eye every 12 hours. LEVOFLOXACIN [LEVAQUIN] - 750 mg Tablet - 1 Tablet(s) by mouth daily LORAZEPAM [ATIVAN] - (Prescribed by Other Provider) - 0.5 mg Tablet - 1 Tablet(s) by mouth every eight (8) hours as needed for nausea METOPROLOL TARTRATE - 25 mg Tablet - 0.5 (One half) Tablet(s) by mouth twice a day MORPHINE - 30 mg Tablet Extended Release - 1 Tablet(s) by mouth twice a day MYCOPHENOLATE MOFETIL - (Dose adjustment - no new Rx) - 500 mg Tablet - 1 Tablet(s) by mouth twice a day PENTAMIDINE [NEBUPENT] - (discharge med) - 300 mg Recon Soln - 1 Recon(s) inhaled MONTHLY Your doctor will help you to schedule for this medication. NEXT DOSE DUE [**2161-5-5**] PHENAZOPYRIDINE - 100 mg Tablet - 1 Tablet(s) by mouth three times a day For 2 days PREDNISONE - (Prescribed by Other Provider) - 5 mg Tablet - 4 Tablet(s) by mouth twice a day SULFAMETHOXAZOLE-TRIMETHOPRIM - (Prescribed by Other Provider) - 400 mg-80 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily) TACROLIMUS - (Prescribed by Other Provider) - 0.5 mg Capsule - 1 Capsule(s) by mouth once a day URSODIOL - 300 mg Capsule - 1 Capsule(s) by mouth q am, 2 capsules q pm VANCOMYCIN [VANCOCIN] - 125 mg Capsule - 1 Capsule(s) by mouth twice a day VORICONAZOLE [VFEND] - (On Hold from [**2161-3-30**] to unknown for elevated LFTs) - 200 mg Tablet - 1 Tablet(s) by mouth twice a day Discharge Medications: 1. acyclovir 400 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. Disp:*90 Tablet(s)* Refills:*0* 2. budesonide 3 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO TID (3 times a day). Disp:*90 Capsule, Ext Release 24 hr(s)* Refills:*0* 3. folic acid 1 mg Tablet Sig: Two (2) Tablet PO once a day. Disp:*60 Tablet(s)* Refills:*0* 4. lorazepam 1 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for anxiety or insomnia. Disp:*30 Tablet(s)* Refills:*0* 5. MS Contin 30 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO twice a day. Disp:*60 Tablet Extended Release(s)* Refills:*0* 6. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*0* 7. prednisone 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 8. voriconazole 200 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*0* 9. vancomycin 125 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*0* 10. vancomycin 1,000 mg Recon Soln Sig: 1000 (1000) mg Intravenous once a day for 10 days: Final day [**6-16**]. Disp:*10 grams* Refills:*0* 11. artificial tear ointment Ointment Sig: One (1) Appl Ophthalmic QHS (once a day (at bedtime)). Disp:*1 bottle* Refills:*0* 12. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**1-4**] Drops Ophthalmic TID (3 times a day). Disp:*1 bottle* Refills:*0* 13. Bactrim 400-80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 14. nifedipine 30 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO DAILY (Daily). Disp:*30 Tablet Extended Release(s)* Refills:*0* 15. Home infusion Supplies to administer vancomycin IV Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: Graft versus Host Disease . plasma cell leukemia Health care associated pneumonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname **], You were admitted to [**Hospital1 18**] with red eyes and pain when you urinated. We feel that your eyes are likely dry from GVH, and that your urination was painful because of a virus called BK. . While you were here you developed blood in the stool that was concerning for graft versus host disease (GVHD). For that reason, you had a flexible sigmoidoscopy and a CT scan which showed likely GVHD. Your hospitalization was complicated by a slow heart rate and variable blood pressure that we think was due to some of the chemotherapy that you received. . Finally, you were treated for a serious pneumonia while you were here. You will need to be on two weeks of IV antibiotics when you leave, with last day [**6-16**]. This means that you will need to go home with a PICC line in place and get home infusions daily. . We made many changes during your admission; please see the attached medication list to see what you should be taking. START Folic Acid 2 mg once daily START Nifedipine NOTE: You will also receive Vancomycin infusions once daily through your PICC line until [**6-16**]. START Artificial Tears Ointment at night; Artificial Tears Drops three times daily INCREASE Cellcept to 1000 mg twice daily STOP Restasis STOP Metoprolol STOP Ursodiol . Please follow up with your physicians as indicated below. Followup Instructions: 1. Appointments with Dr. [**Last Name (STitle) **]: Dr. [**Last Name (STitle) **] is on service next week so will see you on [**Hospital Ward Name 1826**]. You will have daily appointments for the first few days; you can then decide with Dr. [**Last Name (STitle) **] when to followup with him. Department: BMT/ONCOLOGY UNIT When: TUESDAY [**2161-6-2**] at 3:30 PM [**Telephone/Fax (1) 447**] Building: Fd [**Hospital Ward Name 1826**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3971**] Campus: EAST Best Parking: Main Garage Department: BMT/ONCOLOGY UNIT When: WEDNESDAY [**2161-6-3**] at 11:00 AM [**Telephone/Fax (1) 447**] Building: Fd [**Hospital Ward Name 1826**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3971**] Campus: EAST Best Parking: Main Garage Department: BMT/ONCOLOGY UNIT When: THURSDAY [**2161-6-4**] at 11:00 AM [**Telephone/Fax (1) 447**] Building: Fd [**Hospital Ward Name 1826**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3971**] Campus: EAST Best Parking: Main Garage 2. Appointment with Autonomic Neurology: This office will call you to schedule an appointment with Dr. [**Last Name (STitle) 1274**] or one of his associates. If you do not hear from them, you can call them at [**Telephone/Fax (1) 8139**]. 3. Appointment with Ophthalmology: Please go to the [**Hospital Ward Name 23**] Building on the Fifth Floor on [**6-3**] at 1PM to see Dr. [**Last Name (STitle) **]. 4. Appointment with Dr. [**Last Name (STitle) 724**] in [**Hospital **] Clinic: XXXXXXXXXXXXX

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icd9cm

[ [ [] ] ]

[ "45.25", "99.14", "38.97", "99.15" ]

icd9pcs

[ [ [] ] ]

18093, 18145

8936, 14073

302, 327

18270, 18270

4415, 4415

19790, 21463

3594, 3895

16316, 18070

18166, 18249

14619, 16293

18420, 19767

5112, 8913

3910, 4396

14094, 14592

1360, 1883

236, 264

355, 1341

4431, 5096

18285, 18396

1905, 3337

3353, 3578

10,067

160,442

25088

Discharge summary

report

Admission Date: [**2130-10-6**] Discharge Date: [**2130-10-6**] Date of Birth: [**2101-6-10**] Sex: Service: Trauma Surgery ADMISSION DIAGNOSIS: Status post motorcycle crash. DISCHARGE DIAGNOSIS: 1. Status post motorcycle crash, blunt trauma with massive liver laceration, probable closed head injury. 2. Laceration of small bowel mesentery. 3. Intraoperative death. HISTORY OF PRESENT ILLNESS: The patient is a 29-year-old male who reportedly struck a tree with his motorcycle. He was agonal at the scene and brought by EMS to the emergency department where extensive resuscitation was performed. The patient was hypoxic with agonal breathing and was emergently intubated. Bilateral chest tubes were placed in the emergency department. He did at some point have a cardiac arrest, and ATLS protocol was initiated. The patient was brought emergently to the operating room after chest x-ray revealed that the right chest tube appeared to be below the diaphragm. PHYSICAL EXAMINATION: The patient had a GCS of 5. He was confused. His lungs were clear to auscultation bilaterally. His abdomen was soft and distended. He had a gross deformity of his right lower extremity. HOSPITAL COURSE: The patient was seen and evaluated in the trauma bay. He was emergently intubated, and a large bore access was placed, as were bilateral chest tubes. Given the fact that the right chest tube appeared to be below the diaphragm, and the patient was actively coding, he was resuscitated and brought emergently to the operating room. Exploratory laparotomy was performed with a repair of a liver laceration. He also had a laceration of the small bowel mesentery. The abdomen was packed. He was resuscitated, massively receiving 15 units of blood in the operating room. The patient continued to be unstable throughout the procedure dropping his blood pressure. We decided to do a transabdominal pericardiotomy to ensure that there was no tamponade, which there was not. The aorta was cross-clamped and held to maintain his blood pressure; however, the patient continued to be intermittently bradycardic and hypotensive and finally sustained a cardiac arrest which he could not be resuscitated. CONDITION ON DISCHARGE: Death. DISCHARGE DIAGNOSIS: 1. Status post motorcycle crash with blunt trauma, massive liver laceration and probable closed head injury. 2. Laceration of small bowel mesentery. 3. Blood loss anemia. 4. Intraoperative death. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**MD Number(2) 62938**] Dictated By:[**Last Name (NamePattern1) 56208**] MEDQUIST36 D: [**2131-1-12**] 09:26:05 T: [**2131-1-12**] 09:42:44 Job#: [**Job Number 62939**]

[ "863.89", "958.4", "736.89", "864.04", "E823.2", "427.5", "285.1", "850.4" ]

icd9cm

[ [ [] ] ]

[ "96.04", "37.12", "99.04", "99.60", "96.71", "50.61", "34.04" ]

icd9pcs

[ [ [] ] ]

2266, 2744

1220, 2212

1015, 1202

165, 196

425, 992

2237, 2245

31,332

149,438

30286

Discharge summary

report

Admission Date: [**2119-8-28**] Discharge Date: [**2119-9-8**] Date of Birth: [**2055-4-28**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2969**] Chief Complaint: Carcinoma of the distal esophagus. Major Surgical or Invasive Procedure: Bronchoscopy. Transthoracic esophagectomy History of Present Illness: Mr. [**Known lastname 72100**] is a 64-year-old gentleman with locally advanced biopsy-proven carcinoma of the distal esophagus. He has completed induction chemoradiotherapy with no evidence for disease progression. He is admitted today for transthoracic esophagectomy with a right thoracotomy, laparotomy and left neck anastomosis. Past Medical History: Esophageal Cancer Hypertension Hypercholesterolemia Myocardial Infarction [**2109**] Chronic Right Shoulder Pain Social History: He is married. He has four children in their 20s. He lives in [**Location 5110**] with his wife. [**Name (NI) **] is retired from the meat cutting industry. He does not smoke cigarettes nor has he in the past. He drinks alcohol rarely about a six-pack per summer. Family History: His mother is alive at age 88 with breathing difficulties and memory loss and heart problems. His father is alive at age [**Age over 90 **] and was just recently diagnosed with gastric cancer. He has a sister who died at age 61 of pancreatic cancer and a sister who is alive at age 54. There is no other family history of breast, ovarian, uterine, or colon cancer. Physical Exam: General - alert and oriented, no acute distress CV - regular rate and rhythm Pulm - Mild bilateral rhonchi Abd - S/NT/ND, J-tube in place, incision c/d/i Ext - 1+ bilateral pedal edema Pertinent Results: [**2119-8-28**] 03:13PM BLOOD WBC-4.6 RBC-3.39* Hgb-10.7* Hct-30.1* MCV-89 MCH-31.7 MCHC-35.7* RDW-17.2* Plt Ct-146* [**2119-8-28**] 08:50PM BLOOD WBC-5.8 RBC-3.64* Hgb-11.9* Hct-33.5* MCV-92 MCH-32.6* MCHC-35.4* RDW-17.3* Plt Ct-176 [**2119-9-8**] 06:00AM BLOOD WBC-10.8 RBC-2.85* Hgb-8.9* Hct-26.9* MCV-95 MCH-31.2 MCHC-33.0 RDW-16.3* Plt Ct-339# [**2119-8-28**] 03:13PM BLOOD Glucose-137* UreaN-14 Creat-0.6 Na-139 K-3.9 Cl-111* HCO3-22 AnGap-10 [**2119-8-28**] 08:50PM BLOOD Glucose-155* UreaN-12 Creat-0.6 Na-136 K-3.9 Cl-108 HCO3-19* AnGap-13 [**2119-9-8**] 06:00AM BLOOD Glucose-139* UreaN-16 Creat-0.6 Na-137 K-4.3 Cl-102 HCO3-27 AnGap-12 [**2119-8-28**] 03:13PM BLOOD Calcium-7.8* Phos-4.4 Mg-1.3* [**2119-8-28**] 08:50PM BLOOD Calcium-7.6* Phos-4.1 Mg-1.9 [**2119-9-8**] 06:00AM BLOOD Calcium-7.9* Phos-3.5 Mg-2.2 [**9-6**] CXR: Port-A-Cath tip remains in the right atrium. Interval removal of a mediastinal drain. Cardiomediastinal contours are stable. Persistent small bilateral effusions with associated atelectasis. A very small left apical pneumothorax persists. A small amount of subcutaneous emphysema in the left chest. Path: Microscopic foci of degenerated carcinoma cells and calcification in the muscularis propria and adventitia. Regional lymph nodes: No tumor (0/16). Lymph nodes, left gastric: lymph node: No tumor (0/4). Lymph nodes, level 8: Lymph node: No tumor (0/1). Cultures: [**9-4**] BCx: P [**9-3**] UCX (F): Neg [**9-3**] BCX: P Brief Hospital Course: Patient arrived the day of surgery on [**2119-8-28**] and underwent an uncomplicated 3 hole transthoracic esophagectomy with left cervical esophagogastrostomy and bronchoscopy. Patient was transferred to the ICU intubated, on neo, cerivcal drain and a right chest tube in place. Upon transfer to the ICU a left sided chest tube was placed secondary to a plueral effusion found on postop CXR. Patient was extubated and weaned of Neo on POD#1. Patient was able to move to a chair on POD#2 and tube feeds were started on POD#3. Patient was transfered to the floor on POD#3 in stable condition. Upon arriving to the floor overnight the patient pulled out his NGT after becoming disoriented and was placed on aspiration precautions. Right chest tube was D/C'd on POD#5 and left chest tube was D/C'd on POD#6 with no evidence of PTX on follow up CXR. Pt became febrile to 101.8 on POD#6, urine culture and cxr were negative and blood cultures have had no growth to date. Pt underwent a grape juice challenge on POD#8 to assess for leaks which were not present and the pt was advanced to clears ad lib. The cervical JP drain was DC'd on POD#9 and was advanced to full liquid diet which the patient tolerated. Pt continued to be diuresed and ambulated well throughout the hospital course. Pt was deemed to be ready for rehab on POD#11 in good condition. Medications on Admission: Lipitor 20, Metoprolol XL 50, Lisinopril 10 Discharge Medications: 1. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2* 2. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Last Name (STitle) **]: 5-10 MLs PO Q4H (every 4 hours) as needed. Disp:*500 ML(s)* Refills:*0* 3. Lopressor 50 mg Tablet [**Last Name (STitle) **]: [**1-31**] Tablet PO three times a day. Disp:*60 Tablet(s)* Refills:*2* 4. Furosemide 10 mg/mL Solution [**Month/Day (2) **]: Twenty (20) mg Injection twice a day for 5 days: Please hold if there are signs of hypotension . mg 5. Potassium Chloride 20 mEq Packet [**Month/Day (2) **]: One (1) Packet PO ONCE (Once) for 5 days: Please mix with 10cc of fluid before administering. Disp:*5 Packet(s)* Refills:*0* 6. Flagyl 500 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO three times a day for 7 days. Disp:*21 Tablet(s)* Refills:*0* 7. Portacath Flush Per protocol Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Location (un) 701**] Discharge Diagnosis: HTN, Hyperchol, Esophageal CA, MI [**09**], chronic right shoulder pain PSH: [**5-31**] - Port-a-cath and Feeding J placement transhiatal esophagectomy Discharge Condition: deconditioned Discharge Instructions: Call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 170**] if you experience chest pain, shortness of breath, fever, chills, nausea, vomiting, diarrhea, or abd pain. If your feeding tube sutures become loose or break, please tape tube securely and call the office [**Telephone/Fax (1) 170**]. If your feeding tube falls out, save the tube, call the office immediately [**Telephone/Fax (1) 170**]. The tube needs to be replaced in a timely manner because the tract will close within a few hours. Do not put any medication down the tube unless they are in liquid form. Flush your feeding tube with 50cc every 8 hours if not in use and before and after every feeding. You may shower. pat the area around the feeding tube and your incision site dry. Followup Instructions: you have a follow up appointment with Dr. [**Last Name (STitle) **] on [**2119-10-5**] at 10:30 AM in the [**Hospital Ward Name **] [**Hospital Ward Name 23**] clinical center [**Location (un) **]. Please arrive 45 minutes prior to you appointment and report to the [**Location (un) **] radiology for a Chest XRAY.

[ "272.0", "401.9", "511.9", "530.85", "V45.82", "719.41", "412", "E878.2", "150.5" ]

icd9cm

[ [ [] ] ]

[ "99.04", "03.90", "34.04", "33.23", "42.52", "96.6", "42.41" ]

icd9pcs

[ [ [] ] ]

5713, 5795

3277, 4624

356, 399

5992, 6007

1786, 3254

6817, 7135

1199, 1566

4718, 5690

5816, 5971

4650, 4695

6032, 6794

1581, 1767

281, 318

427, 761

783, 897

913, 1183

11,242

177,353

54193

Discharge summary

report

Admission Date: [**2156-11-17**] Discharge Date: [**2156-11-20**] Date of Birth: [**2108-7-29**] Sex: F Service: MEDICINE Allergies: acetaminophen-codeine Attending:[**First Name3 (LF) 1115**] Chief Complaint: hyperglycemia Major Surgical or Invasive Procedure: None History of Present Illness: 48 yo female history poorly controlled DM1 (last A1C [**10-2**]) and med noncompliance presented to her PCP's office with 1 day N/V and mild crampy abdominal discomfort found to have critically high BS. She denies any hematemesis. She reports that she has been taking her insulin as scheduled, and last took it twice this morning with BS in the 100's. She checks her FS QID at home. However, in the past she has noted that she often misses not infrequently. She denies chest pain and denies urinary symptoms beyond polyuria. Notes initial SOB upon arrival to her clinic appointment. Notes increaseing fatigue and decreased exercise tolerance recently. She notes subjective F/C, but was afebrile in clinic and in the ED. Also notes diffuse abdominal pain which is worse with vomiting, but is improving. At clinic her VS were T 98.1 BP 138/70 P 120, critically high BS. She received 14 units of humalog in clinic, but her repeat BS was still critically high. Her clinic urine dip showed glucose >160 mg/dL, neg nitrites and neg leuk est. Urine HCG was also negative. . In the ED, initial Vitals were 97.9,126,127/57,16,100/ra. Labs revealed an wbc 19.5 left shift, Na 135, Cl 99, HCO3 8, AG 28. UA was within normal limits. CXR done. She was given 1L NS, 1L LR, and 10U regular insulin SQ. She was started on an insulin drip at 10U/hr. One PIV placed. . In the [**Hospital Unit Name 153**], she is feeling better with no further nausea or vomiting. She notes improved abdominal pain from prior. Past Medical History: DM1, dx [**2144**], poorly controlled with last A1C [**10-2**] HTN HL anemia, baseline hct 30 cardiomyopathy, nonischemic mild [**Last Name (LF) 19874**], [**First Name3 (LF) **] 40-45%,(-) cath in [**2149**] hx Pancreatitis GERD Social History: Lives with fiance and three children in [**Location (un) 686**]. Works as a legal secretary. Denies tobacco, EtOH, drug use. Family History: Mother had DM. Physical Exam: Admission Physical Exam: VS: Temp: 98.9 BP: 129/68 HR: 115 RR: 24 O2sat 99% on RA GEN: pleasant, comfortable, NAD HEENT: PERRL, [**Location (un) 3899**], anicteric, MMM, op without lesions, no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules RESP: CTA b/l with good air movement throughout CV: tachycardic, S1 and S2 wnl, no m/r/g ABD: nd, +bs, soft, nt, nd, 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. Pertinent Results: Labs on Admission: [**2156-11-17**] 08:45PM GLUCOSE-556* UREA N-15 CREAT-1.1 SODIUM-135 POTASSIUM-4.9 CHLORIDE-99 TOTAL CO2-8* ANION GAP-33* [**2156-11-17**] 08:45PM estGFR-Using this [**2156-11-17**] 08:45PM ALT(SGPT)-16 AST(SGOT)-18 CK(CPK)-72 ALK PHOS-113* TOT BILI-0.2 [**2156-11-17**] 08:45PM LIPASE-15 [**2156-11-17**] 08:45PM CK-MB-2 cTropnT-<0.01 [**2156-11-17**] 08:45PM ALBUMIN-4.6 [**2156-11-17**] 08:45PM %HbA1c-11.3* eAG-278* [**2156-11-17**] 08:45PM ACETONE-MODERATE OSMOLAL-320* [**2156-11-17**] 08:45PM URINE HOURS-RANDOM [**2156-11-17**] 08:45PM URINE GR HOLD-HOLD [**2156-11-17**] 08:45PM WBC-19.3*# RBC-4.46 HGB-12.8 HCT-39.3 MCV-88 MCH-28.8 MCHC-32.7 RDW-13.0 [**2156-11-17**] 08:45PM NEUTS-92.9* LYMPHS-5.4* MONOS-1.1* EOS-0.5 BASOS-0.1 [**2156-11-17**] 08:45PM PLT COUNT-348 [**2156-11-17**] 08:45PM PT-13.3 PTT-17.6* INR(PT)-1.1 [**2156-11-17**] 08:45PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.027 [**2156-11-17**] 08:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-1000 KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2156-11-17**] 08:45PM URINE RBC-0-2 WBC-0 BACTERIA-OCC YEAST-NONE EPI-[**1-22**] Labs on Discharge: [**2156-11-20**] 07:15AM BLOOD WBC-7.6 RBC-4.14* Hgb-11.6* Hct-34.4* MCV-83 MCH-28.0 MCHC-33.7 RDW-13.1 Plt Ct-289 [**2156-11-20**] 07:15AM BLOOD Glucose-77 UreaN-6 Creat-0.5 Na-142 K-3.5 Cl-106 HCO3-26 AnGap-14 [**2156-11-20**] 07:15AM BLOOD Calcium-9.2 Phos-4.2 Mg-1.7 Imaging: CHEST (PA & LAT) Study Date of [**2156-11-17**] 10:21 PM IMPRESSION: No acute cardiopulmonary process. Brief Hospital Course: 48 yo female history poorly controlled DM1, HTN, HL, and cardiomyopathy presents with N/V/D in DKA. . #DKA: The patient presented with hyperglycemia and DKA with an anion gap of 28. The patient was started on IVF with potassium, as well as an insulin gtt. We awaited closure of the patient's AG, after which point SC insulin was started (home regimen of lantus 60 plus humalog sliding scale). [**Last Name (un) **] was consulted. The patient's DKA was felt likely secondary to insulin non-compliance, as she did not have any active signs or cultures indicative of infection, though it is possible that she had a mild viral gastroenteritis as a trigger. A normal EKG made ACS unlikely. We aggressively repleted her potassium. Extensive diabetes education was done by MDs and RNs. She will follow up closely with her PCP, [**Name10 (NameIs) **] [**First Name (STitle) 31365**]. . #leukocytosis: Pt WBC count was initally 20 on arrival to the ED, which trended down to 12 the next day in the ICU, then normalized. Urine cx and CXR were unremarkable, and did not reveal any source of infection; this was likely a stress response from DKA. . #tachycardia: likely [**12-22**] to dehydration in the setting of DKA. Abdominal pain improving. The patient's tachycardia resolved after administration of IV fluids. . # she was continued on her home medications for hypertension and hyperlipidemia. Medications on Admission: insulin glargine [Lantus] 60 UNITS SC qpm insulin lispro [Humalog] 14 units tid with meals lisinopril-hydrochlorothiazide 40 mg-25 mg daily simvastatin 80 mg Tablet by mouth qhs aspirin 81 mg Tablet daily Discharge Medications: 1. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 3. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Insulin Glargine: 60 units at bedtime Humalog: Per sliding scale (attached) Discharge Disposition: Home Discharge Diagnosis: Diabetic Ketoacidosis Type 1 Diabetes, uncontrolled with complications Hypertension gerd cardiomyopathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with diabetic ketoacidosis. This is a life threatening complication of your diabetes. You were treated in the intensive care unit and improved. It is critically important for you to follow a diabetic diet, to to take your insulin as scheduled, to check your fingersticks 4x / daily, and to contact your PCP with any worrisome glucose readings. Followup Instructions: Follow up with your PCP, [**Name10 (NameIs) **] [**First Name (STitle) 31365**], this week. Please call her office to schedule an apppointment: [**Telephone/Fax (1) 7976**]

[ "428.0", "577.1", "401.9", "428.20", "250.13", "425.4", "530.81" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6604, 6610

4516, 5908

298, 304

6758, 6758

2900, 2905

7298, 7476

2240, 2256

6164, 6581

6631, 6737

5934, 6141

6909, 7275

2296, 2881

245, 260

4107, 4493

332, 1827

2919, 4088

6773, 6885

1849, 2080

2096, 2224

77,413

149,155

36256

Discharge summary

report

Admission Date: [**2136-6-20**] Discharge Date: [**2136-6-29**] Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3227**] Chief Complaint: Increase size of subdural hematoma Major Surgical or Invasive Procedure: Left sided craniotomy History of Present Illness: [**Age over 90 **] year-old male with DMII, dementia who sustained an unwitnessed fall at nursing home down approximately five stairs in [**2136-4-27**] resulting in a large SDH, rib fracture and scapula fracture. He was treated without operative management and discharged to [**Hospital **] Rehab. Pre report, his mental status has not been the same since his fall and reportedly has been was conbative with an altered mental status while on a course of Cipro for a UTI. His sons report he has been eating poorly with cloudy sensorium. Past Medical History: 1. Hypertension 2. Dementia 3. DM 4. Intermittent Atrial Fibrillation 5. Tachycardia Social History: Social History: resides in nursing home until just recently was living at home doing own ADLS with wife until fall in [**Month (only) 116**]. Son [**Name (NI) **] is HCP Family History: n/c Physical Exam: On Admission: O: T:96.7 BP:208/51 HR:48 RR:13 O2Sats:100% on room air Gen: WD/WN, comfortable, NAD. HEENT: Pupils: 3mm bilateral, EOMs intact, mild right lip droop Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person only Language: Speech fluent Right facial droop Full motor strength L pupil [**4-29**] and R pupil [**4-30**] _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ________________________________________________________________ On Discharge: Gen: HEENT: Pupils: Neck: Lungs: Cardiac: Abdomen: Extremity: Neuro: Menttal Status: Orientation: Language/Speech: Facial Symmetry: Motor: Cerebellar: Pertinent Results: [**2136-6-21**] 05:32AM BLOOD WBC-7.0 RBC-3.48* Hgb-10.8* Hct-32.0* MCV-92 MCH-31.0 MCHC-33.7 RDW-13.4 Plt Ct-279 [**2136-6-20**] Neuts-70.8* Lymphs-18.8 Monos-7.2 Eos-2.9 Baso-0.2 Plts-279 Phenyto-0.9* [**2136-6-22**] BLOOD WBC-8.5 RBC-3.43* Hgb-10.4* Hct-31.0* MCV-91 MCH-30.5 MCHC-33.6 RDW-13.4 Plt Ct-287 [**2136-6-23**] BLOOD WBC-14.9* RBC-2.53* Hgb-7.8* Hct-23.0* MCV-91 MCH-31.0 MCHC-34.1 RDW-14.0 Plt Ct-143* [**2136-6-24**] WBC-28.6* RBC-3.83* Hgb-11.6* Hct-32.7* MCV-86 MCH-30.4 MCHC-35.5* RDW-16.8* Plt Ct-121* [**2136-6-27**] WBC-6.3 RBC-3.86* Hgb-11.3* Hct-33.5* MCV-87 MCH-29.3 MCHC-33.9 RDW-16.0* Plt Ct-86* [**2136-6-29**] 08:40AM BLOOD WBC-8.7 RBC-3.52* Hgb-10.4* Hct-30.3* MCV-86 MCH-29.7 MCHC-34.5 RDW-15.4 Plt Ct-127* [**2136-6-29**] 08:40AM BLOOD Plt Ct-127* [**2136-6-29**] 08:40AM BLOOD Calcium-7.7* Phos-2.5* Mg-1.5* (repleted) Brief Hospital Course: Mr [**Name13 (STitle) **] was admitted to the SICU for close neurological observation. During his first overnight he went into an atrial fibrillation with rapid ventricular rate. He was placed on cardiazem drip and converted via medicine. He had a repeat CT on his first hospital day which was unchanged showing large acute on chronic subdural hematoma. On his first hospital day he pulled out his foley causing significant trauma, Urology recommended. He was taken to the OR on [**6-22**] for a left sided craniotomy for SDH evacuation. Post operatively he was monitored in the ICU where he was extubated. His neurologic examination improved subsequently to the point where he was following simple commands consistently and MA4E purposefully. On initial presentation [**2136-6-20**], coags were PT 15.0, PTT 22.7, INR 1.3. The coag's gradually trended up to PT 29.1, PTT 40.2, INR 2.9 on [**6-23**]. No history of systemic anticoagulation, other than heparin SC for DVT prophylaxis on [**6-20**] and [**6-21**]. Of note, during his last hospitalization, he was given vitamin K ([**2136-5-17**]) for INR of 1.6 (PT was 17.7, PTT 27.3). Hematology was consulted they were initially concerned that the patient had developed DIC, however they felt malnutrition might play more of a role in his coagulopathy. He was treated with Vitamin K X2 days. On [**6-25**] his INR was 1.3. Mr. [**Known lastname 22956**] was noted to have an episode of pulmonary edema on [**6-25**] which was responsive to diuresis.He had intermittent rapid ventricular rate with his atrial fibrillation which was treated with titration of lopressor (PO) and cardiazem (PO) He was evaluated by speech and swallow and on [**6-28**] he was found to have a swallowing pattern correlates to a Dysphagia Outcome Severity Scale (DOSS) rating of 2, partial PO only. They recommended a PO diet of thin liquids and puree solids, Strict 1:1 supervision, Meds via non-oral means for reliable source (NGT, IV, other). Based on PT/OT evaluation, the patient was discharged to rehabilitation. Medications on Admission: lisinopril 30', osteo [**Hospital1 **]-flex, metformin 500", Aricept 5', donepezil 5', dorzolamide", latanoprost', Depakote 125", Colace 100 Discharge Medications: 1. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain or fever >101.4. 4. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: 2.5 Tablets PO DAILY (Daily). 9. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 12. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 13. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Risperidone 0.5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO TID (3 times a day) as needed for agitation. 15. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 16. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 17. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. Discharge Disposition: Extended Care Facility: [**Hospital **] Medical Center - [**Hospital1 3597**] Discharge Diagnosis: Left sided subdural Hematoma New onset atrial fibrillation with rapid ventricular rate Discharge Condition: Neurologically stable Discharge Instructions: ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and/or staples have been removed. If your wound closure uses dissolvable sutures, you must keep that area dry for 10 days. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**First Name (STitle) **] in 6 weeks with a head CT; Your sutures will dissolve on their own. Please see your primary care in 3 weeks to discuss starting some type of anticoagulation for your atrial fibrillation. Must wait one month from surgery Completed by:[**2136-6-29**]

[ "867.0", "E880.9", "290.3", "852.20", "427.31", "263.9", "E928.9", "276.0", "431", "348.4", "287.5", "250.00", "514", "276.2", "401.9" ]

icd9cm

[ [ [] ] ]

[ "01.31", "96.6", "38.93" ]

icd9pcs

[ [ [] ] ]

6664, 6744

2887, 4941

301, 325

6875, 6899

2005, 2864

8459, 8814

1206, 1211

5132, 6641

6765, 6854

4967, 5109

6923, 8436

1226, 1226

1832, 1986

227, 263

353, 893

1241, 1508

1523, 1818

915, 1002

1034, 1190

25,073

178,386

20583+20620+20621

Discharge summary

report+report+report

Admission Date: [**2163-2-2**] Discharge Date: [**2163-2-17**] Date of Birth: [**2085-4-10**] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 77-year-old female with a history of chronic obstructive pulmonary disease with recent right total knee replacement in [**2162-11-25**]. Rehabilitation stay complicated by a left hip fracture. Status post open reduction/internal fixation in [**2162-12-26**]. Her surgeries were performed in [**State 531**], and she was initially in rehabilitation there, but she was later transferred to [**Hospital6 85**] in [**Location (un) 86**] because this facility is closer to her family. At [**Hospital3 **], she was found to have a temperature of 102.5 degrees Fahrenheit as well as a desaturation to 89% on room air and 95% on 2 liters with decreased breath sounds at both bases. The patient was transferred to [**Hospital1 188**] for was of the fevers. Blood cultures were drawn at rehabilitation, and she received 1 gram of cefepime intravenously en route. On arrival in the Emergency Department, the patient complained of low back pain that was related to position, and she stated this had been going on for weeks. She also complained about two days of abdominal pain. She denied nausea, vomiting, diarrhea, or constipation. She also reported about one week of a cough productive of yellow and green sputum with no hemoptysis. She reported worsening dyspnea above her baseline. She denied headache, chest pain, melena, bright red blood per rectum, dysuria, or any new rashes. Urinalysis was consistent with a urinary tract infection. An abdominal computed tomography showed no diverticulitis but a question of left lower lobe consolidation. She was started on levofloxacin and metronidazole. She also received hydrocortisone 100 mg intravenously times one because she takes steroids chronically, and it was felt she may need stress-dose steroids. PAST MEDICAL HISTORY: 1. Chronic obstructive pulmonary disease and asthma. 2. Diabetes mellitus (on insulin). 3. Total knee replacement on the right on [**2162-12-17**]. 4. Left hip fracture; status post pinning in [**2162-11-25**]. 5. Hypertension. 6. Diverticulitis. 7. Chronic renal insufficiency (with an unknown baseline creatinine). 8. History of urinary tract infection. 9. Remote thyroidectomy; now hypothyroid. 10. Depression. MEDICATIONS ON ADMISSION: 1. Prednisone 5 mg by mouth once per day. 2. Zocor 40 mg by mouth once per day. 3. Lantus insulin 20 units subcutaneously at hour of sleep. 4. Toprol-XL 25 mg by mouth once per day. 6. Multivitamin one tablet by mouth once per day. 7. Iron sulfate 325 mg by mouth twice per day. 8. Lisinopril 20 mg by mouth once per day. 9. Clonidine 0.1 mg by mouth twice per day. 10. Synthroid 50 mcg by mouth once per day 11. Advair 1 puff inhaled once per day. 12. Protonix 40 mg by mouth once per day. 13. Ritalin 2.5 mg by mouth in the morning. ALLERGIES: She has an allergy to SULFA. SOCIAL HISTORY: No tobacco. No alcohol. She lives in [**State 16269**] with her husband. REVIEW OF SYSTEMS: Positive for heartburn. PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed her temperature was 103.8 degrees Fahrenheit, her blood pressure was 146/80, her pulse was 136, her respiratory rate was initially 34 and later 16, her oxygen saturation was 98% on room air. In general, she was an upset female in no acute distress. She was complaining of back pain. Head, eyes, ears, nose, and throat examination revealed the mucous membranes were slightly dry. The neck was supple. There was no lymphadenopathy. The lungs had diffuse scattered rhonchi, and there were decreased breath sounds at both bases. Cardiovascular examination revealed a regular rate and rhythm. No murmurs. The abdomen was obese. Slight bilateral left quadrant tenderness. There was no rebound or guarding. There were normal active bowel sounds. Extremity examination revealed no clubbing, cyanosis, or edema. Dorsalis pedis pulses were 1 to 2+ bilaterally. On neurologic examination, she was alert and oriented times three with no focal signs. Back revealed no costovertebral angle tenderness. PERTINENT LABORATORY VALUES ON PRESENTATION: Complete blood count revealed her white blood cell count was 19.8 (with 90% neutrophils and 5% lymphocytes), her hematocrit was 33.9, and her platelets were 432. Chemistry-7 revealed sodium was 135, potassium was 5.1, chloride was 101, bicarbonate was 22, blood urea nitrogen was 20, creatinine was 1.2, and blood glucose was 186. Aspartate aminotransferase was 32, her alanine-aminotransferase was 15, her alkaline phosphatase was 117, and her total bilirubin was 0.4. Her lipase was 14 and amylase was 17. Albumin was 2.6. Lactate was 2.8. Urinalysis revealed a specific gravity of 1.018, large blood, nitrite positive, moderate leukocyte esterase, 500 protein, trace ketones, more than 50 red blood cells, and more than 50 white blood cells. PERTINENT RADIOLOGY/IMAGING: A computed tomography of the abdomen revealed no appendicitis. There was sigmoid diverticulosis with no diverticulitis. There were hyperdense right renal cysts. There was a left lower lobe consolidation thought to represent atelectasis versus pneumonia. A chest x-ray showed a right lower lobe consolidation. IMPRESSION: The patient is a 77-year-old woman with diabetes, chronic obstructive pulmonary disease, and recent orthopaedic procedures who presented from rehabilitation with fever, back pain, and hypoxia. SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: 1. FEVER ISSUES: The patient's blood cultures from [**Hospital6 85**] grew methicillin-resistant Staphylococcus aureus. The patient was started on vancomycin with gentamicin added for synergy. Sources were felt to be either the patient's newly installed prostheses, her heart, or her back. Plain films of the prostheses were unremarkable, and there was no significant pain upon moving her right knee or left hip. She did not have effusions on examination, nor were the joints warm or tender. Attention was next turned to the possibility of endocarditis. A transesophageal echocardiogram was planned for [**2-7**], but it could not be performed because of lack intravenous access and the patient's confusion. Therefore, a transthoracic echocardiogram was performed on [**2-9**] which showed global left ventricular hypokinesis with an ejection fraction of 25%; most consistent with multivessel coronary artery disease. There was 1 to 2+ tricuspid regurgitation with a right atrium to right ventricular gradient to 36 mmHg. There was 2+ mitral regurgitation. No vegetations were seen. The possibility of an infectious focus in the patient's back was evaluated. A magnetic resonance imaging of the lumbar spine was a poor study because of motion artifact that showed abnormal signal from L1 to L5 with probable epidural abscess, osteomyelitis, and L5-S1 discitis. It was unclear how this abscess developed. On [**2-17**], the patient was placed under general anesthesia and had a repeat magnetic resonance imaging to further delineate the focus of infection. This clearly demonstrated an L5-S1 discitis with an epidural abscess and osteomyelitis. The patient was taken to the operating room, and the area was debrided by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1338**] of Neurosurgery. The remainder of the postoperative course will be dictated in an Addendum. 2. BACTEREMIA ISSUES: As mentioned, the patient had blood cultures positive for methicillin-resistant Staphylococcus aureus. These remained positive despite vancomycin and gentamicin therapy from [**2-2**] through [**2-7**]. From [**2-8**] through [**2-11**], repeat blood cultures were sterile. On [**2-15**], gentamicin was discontinued because her creatinine increased to 1.6. There was concern for gentamicin toxicity. The patient was afebrile from [**2-3**] through the time of this dictation ([**2-17**]). 3. QUESTION OF ASPIRATION PNEUMONIA ISSUES: The patient was noted to have increasing oxygen requirements with thick secretions. Given the patient's depressed mental status (see below), there was concern for aspiration pneumonia. A chest x-ray showed bibasilar atelectasis that had increased on the right along with a right-sided effusion. Her oxygen saturation was 98% on a 35% face mask. She was started on piperacillin tazobactam for broad coverage of nosocomial pathogens. A sputum culture grew methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa that was resistant to levofloxacin and sensitive to piperacillin tazobactam. The patient's oxygen saturation improved, and on [**2-14**] was up to 99% on 1 to 2 liters. Her secretions improved on [**2-14**] and were essentially resolved by [**2-15**]. She did not spike a temperature. On [**2-17**], the piperacillin tazobactam was discontinued because of a concern of acute interstitial nephritis. 4. CHANGE IN MENTAL STATUS ISSUES: Over the first week of the hospitalization, the patient's mental status deteriorated. She became confused, disoriented, unable to follow commands, and pulled at her tubes and lines. This was felt to be secondary to delirium from infection. When studies needed to be performed, she was given Haldol intermittently with moderate-to-good affect. 5. ATRIAL FIBRILLATION ISSUES: The patient was briefly in atrial fibrillation with a rapid ventricular response. She did not have a known history of atrial fibrillation. Her ventricular rate was in the 150s, but she was not hemodynamically unstable. She was briefly on a diltiazem drip with good control, and she ultimately spontaneously converted to a normal sinus rhythm. The diltiazem was discontinued, and she was loaded on amiodarone 400 mg by mouth twice per day which should be halved in one week. 6. CONGESTIVE HEART FAILURE ISSUES: The patient was found to have an ejection fraction of 25% and 2+ mitral regurgitation. There was no known prior history of congestive heart failure. It was unclear when the patient developed systolic dysfunction. It was presumed that she had multivessel coronary artery disease from the multifocal wall motion abnormalities noted on echocardiogram. The patient was continued on beta blockade, and ACE inhibitor and furosemide was started to decrease preload and afterload. However, when the patient's renal function worsened the ACE inhibitor and Lasix were discontinued. She was not felt to be in any significant amount of pulmonary edema at any time up to the point of this dictation. 7. ACUTE RENAL FAILURE ISSUES: The patient had deteriorating renal function from [**2-13**] when her creatinine was 1.1 to [**2-17**] when it was 2.1. The urine was evaluated by the Nephrology team and felt to be bland sediment. Urine eosinophils were positive but rare. Because of the possibility of acute interstitial nephritis, piperacillin was discontinued. Gentamicin-induced acute tubular necrosis remained a possibility. Her fractional secretion of sodium was 6.9%, so a prerenal problem was unlikely. 8. ANEMIA ISSUES: The patient had an anemia that was of unclear etiology. She was transfused 2 units of packed red blood cells on [**2-8**] when her hematocrit was 27.5. Her hematocrit increased appropriately with the transfusion. It remained stable at approximately 30. 9. ORAL HERPES SIMPLEX VIRUS ISSUES: The patient developed oral lesions that were felt to be consistent with herpes simplex virus. These were cultured, and at the time of this dictation there had been virus isolated. However, she was empirically started on acyclovir due to the high likelihood of this being herpes. 10. CHRONIC OBSTRUCTIVE PULMONARY DISEASE/ASTHMA ISSUES: The patient has been on prednisone 5 mg by mouth once per day for a long time, and this was continued. She was given stress-dose steroids immediately prior to surgery. 11. HYPOTHYROIDISM ISSUES: The patient was continued on Synthroid 50 mcg by mouth once per day. 12. ACCESS ISSUES: On [**2-7**], the patient was without peripheral access, and multiple attempts were unsuccessful to achieve access. A right subclavian line was placed on [**2-7**] and was removed on [**2-17**]. A right internal jugular line was planned for intraoperative placement. 13. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The patient was evaluated by the Swallow Service who felt that she was a high aspiration risk due to impaired swallow function. An nasogastric tube was placed, and she received approximately three days of full-strength tube feeds prior to proceeding to the operating room for epidural abscess debridement. The Swallow Service recommended percutaneous endoscopic gastrostomy tube placement in the event her swallowing function does not recover following the operation. 14. COAGULOPATHY ISSUES: The patient had an INR of approximately 2 for the first and second weeks of her hospitalization which was likely secondary to malnutrition and vitamin K deficiency in her diet. She was given vitamin K and the coagulopathy resolved. 15. PROPHYLAXIS ISSUES: The patient was maintained on heparin subcutaneously for deep venous thrombosis prophylaxis. 16. CODE STATUS: Full. NOTE: The remainder of the hospital stay will be dictated in an Addendum. [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**], M.D. [**MD Number(1) 736**] Dictated By:[**Name8 (MD) 2734**] MEDQUIST36 D: [**2163-2-17**] 17:57 T: [**2163-2-17**] 19:38 JOB#: [**Job Number 55039**] Admission Date: [**2163-2-3**] Discharge Date: [**2163-2-27**] Date of Birth: [**2085-4-10**] Sex: F Service: Medical Intensive Care Unit This patient was initially admitted on [**2163-2-3**] to the Surgical Intensive Care Unit and subsequent transferred to the Medical Intensive Care Unit Team after several days in the hospital on [**2163-2-17**] at which point the intern dictating this addendum discharge summary took care of this patient. Reason for transfer is postoperative for L5-S1 epidural abscess in the setting of previous Methicillin-resistant Staphylococcus aureus bacteremia. HISTORY OF PRESENT ILLNESS: This is a 77 year old female with a history of hypertension, diabetes mellitus, status post recent total knee replacement and hip fracture in [**2162-11-25**], chronic renal insufficiency, coronary artery disease status post myocardial infarction, asthma, chronic obstructive pulmonary disease who initially presented from rehabilitation on [**2-3**] with fevers to 102 and hypoxia at 89% in the setting of oxygen saturations of 89% on room air. During this subsequent hospital course, the patient was found to have a urinary tract infection and a questionable right lower lobe infiltrate, and blood cultures were positive for gram positive cocci in pairs and clusters which subsequently grew out Methicillin-resistant Staphylococcus aureus and the patient had five days of Methicillin-resistant Staphylococcus aureus bacteremia from [**2-2**] to [**2-7**] at which point the patient was treated initially with Vancomycin and Gentamicin. In summary, the patient was initially on the Medical Service prior to [**2-17**] and subsequently the patient was taken to the Operating Room on [**2163-2-17**] for an L5-S1 debridement. There was on blood loss and the patient tolerated the procedure well. In the Operating Room the patient has had an intraoperative transesophageal echocardiogram to further evaluate the cardiomyopathy and showed no valvular vegetation, moderate mitral regurgitation, no aortic insufficiency and ejection fraction greater than or equal to 45%. The Swan-Ganz catheter was also placed which revealed the central venous pressure of 9, PA pressure of 49/20, cardiac output of 5.12. The patient was subsequently taken postoperatively to the Post Anesthesia Care Unit and vent set on AC 600 by 14 with positive end-expiratory pressure of 5 and FIO2 of 40%. The patient was subsequently transferred to the Medical Intensive Care Unit while intubated for further hospital course. PAST MEDICAL HISTORY: Please refer to the previously dictated discharge summary dictated on [**2163-2-17**] for the previous hospital course and past medical history, medications, social history and relative family history. HOSPITAL COURSE: 1. Epidural abscess, status post debridement. The patient returned to the Medical Intensive Care Unit after epidural abscess debridement. Subsequent pathology showed acute osteomyelitis as the source. The patient was maintained on Vancomycin dose by level and subsequent cultures from the tissue grew out Methicillin-resistant Staphylococcus aureus and the patient was maintained on Vancomycin dose by level given her creatinine that had continued to rise. Infectious disease was initially consulted and under their care as the patient was maintained as a consult throughout the course. They recommended continued coverage with Vancomycin, and Neurosurgery continued to follow the patient who recommended following the patient's mental status and neurological examination as the sedation from the ventilation was weaned off. The patient was subsequently extubated on [**2163-2-24**]. That was uncomplicated with successful wean to pressure support. The patient was initially thought to require tracheostomy, however, after improvement of her respiratory status she no longer needed a tracheostomy. Bronchoscopy prior to extubation revealed a large plug that was removed from the left lobe which subsequently improved her breathing status. 2. Bacteremia - The patient was dosed by level, given her creatinine with Vancomycin. The patient had subsequent blood cultures that were resent giving the rising white count of 12 on [**2-23**] and the surveillance cultures have shown no growth to date. 3. Aspiration pneumonia - The patient had a history of Pseudomonas in her sputum. She was initially started on Zosyn but given the creatinine rise and positive eosinophils in her urine this was changed to Aztreonam for a total 14 day course which ended on [**2163-2-26**], as per infectious disease records. 4. Respiratory status - The patient was intubated post surgery, likely from pulmonary edema and aspiration pneumonia. The patient was continued on AC and was subsequently weaned and extubated on [**2-24**] as detailed above with improved oxygenation saturations, as the patient was tolerating 2 liters of nasal cannula on discharge from the Medical Intensive Care Unit. 5. Atrial fibrillation - The patient was in normal sinus rhythm throughout her course in the Medical Intensive Care Unit. She was initially loaded on Amiodarone prior to transfer and maintained on Lopressor. Amiodarone was decreased on [**2-21**], given the loading taper and the patient initially had a long QT, documented to be 490. Subsequent decrease of the Amiodarone showed that her QTC had resolved. This was also multifactorial in the face of having received Haldol during the course. 6. Coronary - The patient was maintained on Aspirin per Neurosurgery and Cardiology recommendations and beta blocker as tolerated for her blood pressure. 7. Pump - Congestive heart failure, the patient had an ejection fraction of 20% per surface echocardiogram. A transesophageal echocardiogram intraoperatively showed an ejection fraction of about 30 to 40%. Cardiac monitoring with PA pressures showed a cardiac output of 6 and a pulmonary capillary wedge pressure of 18, likely due to elevated filling pressures. The patient was initially diuresed. Swan was discontinued on [**2-20**] and the Lasix drip was started with a goal of negative 1 liter out. The patient remained total body water overloaded likely with anasarca likely due to low albumin state, and the patient was subsequently diuresed to the point where she became a little more alkalotic and she required more fluid. On the day of discharge she still continues to have 2+ edema peripherally likely due to hyperalbuminemic state. 8. Renal - The patient presented with acute and chronic renal failure. Initial FENA was 6.5 with positive eosinophils on urine smear, prior to transfer to Medicine Intensive Care Unit. Initial concern was gentamicin toxicity or acute interstitial nephritis due to Zosyn. The patient's creatinine continued to rise. Renal was involved and they recommended that the patient likely needed higher pressures at the level of the kidney to produce urine with an aim of a systolic blood pressure in the 130s to 140s. The Propofol for sedation was weaned off and the patient was subsequently taken off of beta blockade from a hypotension and increasing of creatinine. The patient was also placed on a Lasix drip for further diuresis which improved her creatinine slightly but after overdiuresis her creatinine continued to rise but plateaued until the day of this dictation. Repeat urine eosinophil smear was negative. 9. Herpes simplex virus labialis - The patient was treated with Acyclovir which was discontinued on [**2-23**]. 10. Endocrine - The patient was maintained on an insulin drip which was discontinued on [**2-23**] and tapered fingerstick blood glucose. The patient maintained normal glycemia on this. Hydrocortisone was initially given at stress doses given her chronic Prednisone which was subsequently being tapered off for chronic obstructive pulmonary disease treatment. 11. Chronic obstructive pulmonary disease - The patient was maintained on Flovent, metered dose inhaler, inhaled, and subsequently started on steroid taper. 12. Delta MS - The patient had laughing mania delirium prior to transfer and on arrival to the Medical Intensive Care Unit she was intubated and sedated. As she was weaned off of her intubation as the patient was lightened. Magnetic resonance imaging scan was obtained which showed no acute process and she was initially started on Haldol which was subsequently discontinued given her prolonged QTC syndrome in favor of uveitis. 13. Gastrointestinal bleed - On [**2-25**], the patient had a hematocrit drop with some gross melena, however, given her current medical condition, gastrointestinal workup was deferred until the patient was more medically stable. Will likely need further gastrointestinal follow up and colonoscopy in the future for evaluation of melena. She responded with 2 units of packed red cells without any further hematocrit drop. 14. Fluids, electrolytes and nutrition - The patient was subsequently maintained on tube feeds while she was intubated and planned post extubation with placement of percutaneous endoscopic gastrostomy tube for tube feeds. 15. Access - The patient initially had a right Swan from her operation on [**2-17**] that was subsequently discontinued, given a fever spike and replaced with a triple lumen catheter. CODE: The patient was full code during this hospital stay. Please refer to the remainder of the hospital course which will be dictated by the next intern receiving the care of this patient. [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7585**] Dictated By:[**Last Name (NamePattern1) 5227**] MEDQUIST36 D: [**2163-2-27**] 15:31 T: [**2163-2-27**] 15:14 JOB#: [**Job Number 55113**] Admission Date: [**2163-2-3**] Discharge Date: [**2163-3-8**] Date of Birth: [**2085-4-10**] Sex: F Service: RESIDENT ONLY MEDICINE ADDENDUM: This is an addendum to a previous dictation of [**2163-2-27**]. Please see the previously dictated discharge summary dated [**2163-2-27**] and [**2163-2-17**] for complete hospitalization course of this patient. The following dictation will recount the events and plan since [**2163-2-27**]. In summary, this is a 77-year-old female who is status post recent total knee replacement and hip fracture in [**2163-2-24**] who was admitted from [**Hospital3 **] with fever on [**2163-2-3**]. She was found to have MRSA bacteremia and epidural abscess, status post debridement on [**2163-2-17**] in the Operating Room by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1338**]. Her postoperative course was notable for intubation, aspiration pneumonia. She continues on IV vancomycin for the MRSA bacteremia and the epidural abscess and has been recovering on the floor since then. HOSPITAL COURSE: 1. METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS BACTEREMIA/EPIDURAL ABSCESS: Mrs. [**Known lastname **] is currently on day number 19 of vancomycin since her OR debridement on [**2163-2-17**] and she will need to complete a total of [**9-6**] weeks of treatment by levels per the Infectious Disease specialist. Surveillance blood cultures on [**2163-3-3**] were negative and the patient has been afebrile without leukocytosis since [**2163-2-27**]. She will need her vancomycin levels checked three times per week and to dose vancomycin 1 gram IV for a level of less than or equal to 15. 2. ASPIRATION PNEUMONIA: Mrs. [**Known lastname **] is status post a 14 day course of vancomycin/Zosyn which was later changed to vancomycin/aztreonam (she had elevated creatinine on Zosyn). She is status post percutaneous endoscopic gastrostomy tube and a follow-up failed speech and swallow test on [**2163-3-4**] for all consistencies occurred. She remained n.p.o. until she is able to pass a speech and swallow test. 3. OXYGEN REQUIREMENT: This has been improving. A chest x-ray on [**2163-3-7**] demonstrated an improvement and perihilar haziness but continued upper zone vascular redistribution. She continues to have small bilateral pleural effusions and a left retrocardiac opacity but these are unchanged compared with previous chest x-rays. She is also noted to have increased opacity in her right middle and right lower lobes consistent with atelectasis or possible infection. As of [**2163-3-8**], she is saturating 98% on 1.5 liters and this will be weaned off as tolerated. 4. CONGESTIVE HEART FAILURE: An echocardiogram on [**2163-2-21**] demonstrated an ejection fraction of 50%. Chest x-rays in early [**Month (only) 547**] demonstrated significant fluid overload which was confirmed on examination with 2+ pitting edema and increased oxygen requirement. She has been diuresed 1-2 liters daily since early [**Month (only) 547**] with improvement of signs of CHF on chest x-ray. Lasix diuresis will be continued with a dose of 40 mg IV b.i.d. until this total body fluid overload is improved. This will be done with caution to her renal function. 5. DIABETES/HYPERGLYCEMIA: Despite increasing levels of Glargine, the patient continued to have elevated glucose levels during the daytime. [**Last Name (un) **] Diabetes Center was consulted and has devised a regimen of 30 units of Lantus in the evening and a Humalog scale q. four hours which will be enclosed with her discharge summary. Her blood sugars remain below 200 on this regimen. 6. RENAL: Mrs. [**Known lastname **] is status post ATN from gentamicin toxicity which has been fully resolving with a steadily improving creatinine daily. Her creatinine has steadily improved despite Lasix 40 mg IV b.i.d. An extra dose of Lasix was given on [**2163-3-6**] with a bump in her creatinine the next day from 2.8 to 3.0. However, without extra Lasix diuresis her creatinine continues to come down. Free water boluses have been given through her PEG tube as needed for hypernatremia. 7. MENTAL STATUS: The patient had some delirium and continues to have some waxing and [**Doctor Last Name 688**] mental status but this has been improving daily with resolution of her medical issues. 8. PSYCHIATRY: The patient is depressed. Social Work has been involved and psychiatric evaluation has been considered. Also, treated with SSRI has been considered but has been delayed awaiting improved mental status. 9. HYPERTENSION: Metoprolol was increased to 150 mg b.i.d. but persistent systolic blood pressure remained elevated on this to approximately 160s. Additional antihypertensives will be added and will be included in the discharge summary. 10. PAROXYSMAL ATRIAL FIBRILLATION: The patient has been in normal sinus rhythm for approximately one week on Amiodarone and beta blocker. Anticoagulation had been discussed but was decided against given her tenuous condition and her need for significant physical therapy and balance issues at this point. 11. CANDIDURIA: The patient had urine cultures in early [**Month (only) 547**] positive for [**Female First Name (un) 564**]. This was resolved after a seven day course of fluconazole IV and a urine culture on [**2163-3-4**] was negative for [**Female First Name (un) 564**]. 12. FLUIDS, ELECTROLYTES, AND NUTRITION: The patient has had goal tube feeds with .................... at 45 cc per hour and has required daily phosphate repletion secondary to her renal failure. 13. ANEMIA: The patient has required several blood transfusions but her hematocrit has been stable at 30 or over for over one week now. Iron studies and B12 and folate were within normal limits but demonstrated an anemia of chronic disease. 14. ACCESS: The patient has a right PICC in place. 15. COMMUNICATION: The patient's communication has been with the patient and her husband as well as other members of the family. 16. CODE STATUS: The patient's code status is DNR/DNI. 17. DISPOSITION: To rehabilitation pending. DISCHARGE MEDICATIONS: 1. Lantus 30 units subcutaneously q.h.s. plus sliding scale Humalog which will be enclosed. 2. Metoprolol 150 mg p.o. b.i.d., hold for systolic blood pressure less than 120 or heart rate less than 50. 3. Albuterol nebulizers one nebulizer q. 8-12 hours. 4. Atrovent nebulizer one nebulizer q. 8-12 hours. 5. Lasix 40 mg IV b.i.d. 6. Lansoprazole oral suspension 30 mg per NG tube/PEG tube q.d. 7. Heparin 5,000 units subcutaneously q. eight hours. 8. Prednisone 5 mg p.o. q.d. 9. Amiodarone 200 mg p.o. q.d. 10. Olanzapine 5 mg p.o. q.d. agitation. 11. Miconazole powder 2% one application TP p.r.n. 12. Levothyroxine 50 micrograms p.o. q.d. per NG/PEG tube. 13. Simvastatin 40 mg p.o. q.d. per PEG tube. 14. Nystatin ointment one application TP q.i.d. p.r.n. 15. Flovent 110 micrograms two puffs inhaled b.i.d. CONDITION ON DISCHARGE: Fair. DISCHARGE STATUS: The patient is discharged to a rehabilitation facility. DISCHARGE INSTRUCTIONS: The patient should follow-up with Nephrology at the [**Hospital6 256**] as an outpatient if her creatinine does not improve to her baseline of 0.9 in the next month. She may call [**Telephone/Fax (1) 60**] to make an appointment at the clinic. DISCHARGE DIAGNOSIS: 1. Methicillin-resistant Staphylococcus aureus bacteremia. 2. Epidural abscess. 3. Aspiration pneumonia. 4. Depression. 5. Hypertension. 6. Diabetes mellitus with hyperglycemia. 7. Paroxysmal atrial fibrillation. 8. Candiduria with chronic indwelling Foley catheter. 9. Gentamicin-induced acute tubular necrosis. 10. Hypophosphatemia. 11. Anemia. 12. Congestive heart failure, ejection fraction 50%. [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**], M.D. [**MD Number(1) 736**] Dictated By:[**Last Name (NamePattern1) 55114**] MEDQUIST36 D: [**2163-3-8**] 09:51 T: [**2163-3-8**] 09:56 JOB#: [**Job Number 55115**] cc:[**Hospital3 19740**]

[ "730.08", "790.7", "599.0", "424.0", "324.1", "397.0", "428.21", "427.31", "493.20" ]

icd9cm

[ [ [] ] ]

[ "38.93", "00.13", "43.11", "45.13", "03.4", "96.6", "99.04", "96.56", "33.22" ]

icd9pcs

[ [ [] ] ]

29574, 30396

30796, 31510

2420, 3017

24491, 27565

30529, 30775

5614, 14268

3131, 5579

14297, 16199

27581, 29551

16222, 16425

3034, 3110

30421, 30504

8,222

178,669

4069+4096

Discharge summary

report+report

Admission Date: [**2198-12-13**] Discharge Date: [**2198-12-23**] Service: CHIEF COMPLAINT: Abdominal pain. HISTORY OF PRESENT ILLNESS: This is an 86 year old man with a history of coronary artery disease, myelodysplastic syndrome, aortic stenosis, aortic regurgitation, who presents with acute onset of midepigastric pain without radiation to his back. The pain was constant and ten out of ten. The patient came to the Emergency Department for further evaluation and he had dry heaves but without vomiting. He denies fever or chills at home. He has no history of postprandial pain. No recent changes in his medications. The patient denies chest pain and currently he has no palpitations. PAST MEDICAL HISTORY: 1. Coronary artery disease, status post coronary artery bypass graft of four vessels in [**2189**], at [**Hospital6 2121**]. 2. Hypertension. 3. Myelodysplastic syndrome with thrombocytopenia. 4. Gout. 5. Basal cell carcinoma. 6. History of dysplastic colonic polyps. 7. Glaucoma. 8. Cataract. 9. Anxiety. 10. Degenerative joint disease with disc herniation at L4-L5. 11. Parkinson's disease. 12. Aortic stenosis with moderate aortic insufficiency. Echocardiogram in [**2196**], demonstrated an ejection fraction of greater than 55% with aortic valve of 1.0 square centimeters and moderate aortic stenosis and moderate to severe aortic regurgitation. MEDICATIONS ON ADMISSION: 1. Isosorbide 20 mg once daily. 2. Potassium Chloride 20 meq once daily. 3. Lasix 40 mg twice a day. 4. Tricor 60 once daily. 5. Allopurinol 300 mg once daily. 6. Paxil 20 mg once daily. 7. Sinemet one tablet twice a day. 8. Protonix 40 mg once daily. ALLERGIES: The patient is allergic to Ciprofloxacin, Morphine, Demerol that causes nausea and vomiting. FAMILY HISTORY: Brother with muscular dystrophy. SOCIAL HISTORY: He is a retired fireman who lives alone in a duplex with his daughter living nearby. PHYSICAL EXAMINATION: Vital signs revealed temperature 102, blood pressure 148/80, heart rate 106, respiratory rate 24, oxygen saturation 87% in room air and 90% on two liters oxygen. In general, the patient is an elderly man, slightly uncomfortable. Head, eyes, ears, nose and throat - Extraocular movements are intact. The left pupil is surgical. No jugular venous distention. Mucous membranes are dry. Cardiovascular - S1 and S2 irregularly irregular and are obscured by systolic ejection murmur at the right upper sternal border that is III/VI. The lungs are clear to auscultation bilaterally. Abdomen is soft, nondistended with decreased bowel sounds and midepigastric tenderness. No rebound or guarding. There is no costovertebral angle tenderness. Rectal examination is guaiac negative per Emergency Department. Extremities are without edema. Neurologically, there is no gross deficit. LABORATORY DATA: On admission, white blood cell count 9.1, hematocrit 44.1, baseline around 37.0, platelet count 55,000, MCV 101. Blood urea nitrogen 22 and creatinine 1.9. ALT was 11, AST 131, LDH 293, amylase 287, lipase [**2211**], total bilirubin 3.1, alkaline phosphatase 69, CK 67, troponin 0.09. Right upper quadrant ultrasound showed common bile duct of [**9-16**] millimeter diameter and gallbladder containing gallstones. There was moderate gallbladder distention but no wall edema. No pericholecystic fluid. There was also fatty infiltration of the liver and some splenomegaly. HOSPITAL COURSE: Following the results of the right upper quadrant ultrasound, it was felt that the patient had a dilated common bile duct secondary to obstruction by gallstone and the patient was treated with Ampicillin, Ceftriaxone and Flagyl and given intravenous fluids. An endoscopic retrograde cholangiopancreatography was attempted but cannulation of the biliary duct was unsuccessful despite multiple attempts because the patient became very agitated and uncooperative and therefore, the procedure was aborted. It was decided to attempt another endoscopic retrograde cholangiopancreatography, this time under anesthesia. However, in the meantime, the patient was found to have rising troponin T which gradually reached the 0.6 level. Original impression was that this elevated troponin represented demand ischemia imposed on the heart by the pancreatitis and the cholestatic picture in the setting of aortic stenosis/aortic regurgitation. Given the rising trend in the troponin, as well as need for general anesthesia to perform the endoscopic retrograde cholangiopancreatography, it was decided that the patient should be evaluated by cardiac catheterization. The cardiac catheterization showed severe native three vessel coronary artery disease, as was known from before. Severe but not critical aortic stenosis with moderate aortic regurgitation, severe pulmonary arterial hypertension, systemic systolic arterial hypertension, severe left ventricular diastolic heart failure, patent left internal mammary artery - left anterior descending, patent saphenous vein graft OM and saphenous vein graft posterior descending artery, presumed occluded saphenous vein graft - diagonal and severe disease in unusual OM4 to AV groove with complex OM lesion arising from bifurcation and distal lesion with limited runoff. It was decided that most of the perioperative cardiac risk is related to the severe aortic stenosis/aortic regurgitation and diastolic heart failure. Stenting of the OM4 would be associated with increase of stent thrombosis given poor runoff. It is doubtful that balloon angioplasty of this OM which supplies only a small area of myocardium would significantly improve his perioperative risk of cardiac events. Decision first was made to defer PCI on this OM. These results confirmed the results of a transthoracic echocardiogram that had been done on [**2198-12-14**], and had shown an aortic valve area of 0.7 square centimeters, left ventricular ejection fraction of 40% and symmetric left ventricular hypertrophy. Following these results, it was decided that the patient could have the endoscopic retrograde cholangiopancreatography and as of the time of this dictation, the patient is scheduled for an endoscopic retrograde cholangiopancreatography in the morning of [**2198-12-24**]. As of [**2198-12-23**], the pancreatic enzyme levels as well as the total bilirubin level have returned towards normalization, and the patient is free of abdominal pain. However, a MRCP demonstrated persistence of gallstones in the common bile duct, necessitating an endoscopic retrograde cholangiopancreatography procedure and sphincterotomy. During the hospitalization and at the time that the patient was in a pancreatitis abdominal pain picture, intravenous fluids were given resulting in an increase in total body weight and fluid retention. The patient is recommended to be gently diuresed following the next few days, to remove a goal of ten pounds in fluid. This diuresis is complicated by the elevated creatinine which currently is 1.8 as of [**2198-12-23**]. Hematology - The patient has an underlying myelodysplastic syndrome which manifests with chronic thrombocytopenia. The patient's platelet count on admission was 55,000 and remained in the 40,000 to 50,000 range until the patient was transfused platelets prior to the endoscopic retrograde cholangiopancreatography procedure. DI[**Last Name (STitle) 408**]E INSTRUCTIONS: The patient as of [**2198-12-23**], is expected to be discharged to home pending endoscopic retrograde cholangiopancreatography on [**2198-12-24**], and with recommended follow-up by primary care physician as well as by his primary cardiologist, Dr. [**First Name4 (NamePattern1) 1399**] [**Last Name (NamePattern1) 17915**] and it has been recommended that he follow-up with Dr. [**Last Name (Prefixes) **] of cardiothoracic surgery for an outpatient evaluation and potential consideration of an aortic valve repair. Also during this hospitalization and while the patient was on telemetry, he demonstrated frequent premature ventricular contractions as well as runs of ventricular tachycardia. It is recommended that the patient's primary care physician consider [**Name9 (PRE) 702**] with an Electrophysiology specialist. Medications and discharge information will be dictated by the intern taking over the service on [**2198-12-24**]. Again, the finalization of this discharge summary will be done through an addendum by the intern taking over the service on [**2198-12-24**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**] Dictated By:[**Last Name (NamePattern1) 17916**] MEDQUIST36 D: [**2198-12-23**] 14:39 T: [**2198-12-23**] 15:09 JOB#: [**Job Number 17917**] Admission Date: [**2198-12-13**] Discharge Date: [**2198-12-26**] Service: DISCHARGE SUMMARY ADDENDUM: This dictation records the events from [**12-24**] to [**12-26**]. The patient proceeded to endoscopic retrograde cholangiopancreatography on [**2198-12-24**]. This procedure was done in the Operating Room under general anesthesia. Several round stones ranging from 4 mm to 10 mm causing partial obstruction was seen in the common bile duct. There was post obstructive dilation. Gallstones were also visualized in the gallbladder. There was noted to be a distal pancreatic duct. A biliary sphincterotomy was performed at the 12:00 position and the stones were extracted successfully using a 12 mm balloon. After the procedure the patient did well postoperatively. He did not have any further episodes of chest pain or shortness of breath. He continued to diuresed with Lasix 40 mg po b.i.d. His diet was advanced on [**12-26**] without any further incidence of abdominal pain. In[**Last Name (STitle) 17997**] of his aortic valve repair, he will be seen by Dr. [**Last Name (Prefixes) **] in two to three weeks as an outpatient. DISCHARGE DIAGNOSES: 1. Gallstone pancreatitis status post endoscopic retrograde cholangiopancreatography done under general anesthesia with extraction of stones. 2. Non ST elevation myocardial infarction secondary to severe aortic stenosis and demand ischemia. 3. Coronary artery disease. 4. Severe aortic stenosis with a valve area of .6 status post cardiac catheterization. 5. Myelodysplastic syndrome with thrombocytopenia status post platelet transfusions preprocedure. 6. Chronic renal insufficiency. 7. Cholangitis. 8. Congestive heart failure secondary to severe aortic stenosis. 9. Atrial fibrillation. CONDITION ON DISCHARGE: The patient will be discharged to [**Hospital3 **]. He is currently in good condition. DISCHARGE MEDICATIONS: 1. Sinemet 25/100 mg tabs one tab po b.i.d. 2. Epogen 20,000 units one injection q week every Friday. 3. Lantanoprost .005% drops one drop q.h.s. 4. Bromindione .15% drops one to two drops q 8 hours. 5. Albuterol inhalers one to two puffs q 4 to 6 hours. 6. Ativan .5 mg tab po q 4 to 6 hours. 7. Ambien one tab po q.h.s. prn. 8. Colace 100 mg po b.i.d. 9. Protonix 40 mg po q day. 10. Coumadin 2 mg tablet po q day. 11. Levaquin 500 mg tablet one tab po q day for four more days. 12. Lasix 40 mg one tab po b.i.d. 13. Lopressor 25 mg po b.i.d. hold for heart rate less then 60 or SBP less then 100. 14. Zofran 2 mg intravenously q 6 hours prn. FO[**Last Name (STitle) 996**]P: The patient will follow up with his primary care physician in two to three weeks and had an appointment with Dr. [**Last Name (Prefixes) **] cardiothoracic surgeon in two weeks. He is also to follow up with his outpatient cardiologist Dr. [**Last Name (STitle) 17915**] who is affiliated with [**Hospital1 2025**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**] Dictated By:[**Last Name (NamePattern1) 218**] MEDQUIST36 D: [**2198-12-26**] 10:01 T: [**2198-12-26**] 10:24 JOB#: [**Job Number 17998**]

[ "287.5", "416.0", "574.50", "428.0", "585", "584.9", "410.91", "577.0", "424.1" ]

icd9cm

[ [ [] ] ]

[ "88.56", "37.23", "51.10", "51.85", "88.42", "51.88" ]

icd9pcs

[ [ [] ] ]

1802, 1836

9958, 10559

10696, 11989

1418, 1785

3461, 9937

1962, 3443

104, 121

150, 709

731, 1392

1853, 1939

10584, 10673

832

181,423

4880

Discharge summary

report

Admission Date: [**2166-10-29**] Discharge Date: [**2166-11-1**] Service: MEDICINE Allergies: Penicillins Attending:[**Location (un) 1279**] Chief Complaint: Renal artery stenosis Major Surgical or Invasive Procedure: Renal artery stent History of Present Illness: 82 yo F with prior hx of HTN, hyperlipidemia, bilateral carotid artery stenosis who was diagnosed with bilateral RAS by MRA 1 month prior to rising Cr. An MRA showed bilateral RAS with L>R. The left-sided plaque is contiguous with an ulcerated plaque in the aorta. Given the severity of her renal artery stenosis, the patient was admitted for stenting. She has been feeling increasing shortness of breath since stopping her diovan and lasix and more severe SOB over the past 2 days. The patient also reports no appetite and just eating to "stay alive." She also has nearly no urine output. She denies any constipation/diarrhea/abdominal pain, fevers, chills, cough. Past Medical History: 1. HTN 2. bilateral renal artery stenosis 3. hyperlipidemia 4. prosthetic right eye 5. hx of Sjogren's syndrome 6. bilateral carotid artery stenosis s/p CEA Social History: Professor [**First Name (Titles) **] [**Last Name (Titles) 20367**] and experimental psychology. Lives alone, no husband, no children. HCP is [**Name2 (NI) 20368**] [**Name (NI) **] [**Name (NI) 20369**]. Living will indicated does not want excessive or life-prolonging measures. No tobacco, EtOH. Family History: Mother and father with CAD. No renal disease. Physical Exam: 96.5, 96, 260/90, 22, 93-96% on 2L NC Gen- frail, elderly female; tachypneic, sitting at 90 degrees speaking short sentences HEENT- PEERL, OP clear, upper dentures in place NECK- no JVP CV- RR, no M Chest- bilateral crackles [**3-27**] way up bilaterally Abd- soft, NT/ND, +BS, no abdominal/renal bruits appreciated Ext- 1+ edema bilaterally, warm extremities Pertinent Results: [**2166-10-29**] 07:19PM GLUCOSE-177* UREA N-60* CREAT-4.0*# SODIUM-137 POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-21* ANION GAP-18 [**2166-10-29**] 07:19PM CALCIUM-8.3* PHOSPHATE-4.6*# MAGNESIUM-1.8 [**2166-10-29**] 07:19PM WBC-7.8 RBC-3.37*# HGB-10.0*# HCT-30.3* MCV-90 MCH-29.6 MCHC-33.0 RDW-15.4 [**2166-10-29**] 07:19PM NEUTS-85.5* LYMPHS-8.9* MONOS-3.5 EOS-1.3 BASOS-0.8 [**2166-10-29**] 07:19PM HYPOCHROM-1+ [**2166-10-29**] 07:19PM PLT COUNT-142* [**2166-10-29**] 07:19PM PT-13.1 PTT-24.7 INR(PT)-1.1 Brief Hospital Course: Pt is an 82 yo F with PVD and severe bilateral renal artery stenosis, severe HTN secondary to RAS, and [**Doctor First Name 48**] who was admitted for renal artery stenting secondary to recent admission for poorly controlled hypertension and CHF. During her hospital stay, she developed hypertensive emergency requiring transfer to the CCU with SBP 260 and flash pulmonary edema. She was started on a labetalol drip and diuresed with IV lasix. The renal team agreed with managment. She underwent right renal artery stent x 1 as a salvage attempt for her renal failure. However, this salvage attempt failed and she returned in cardiogenic shock and was made CMO. Her code status was determined with the patient and her PCP as the patient expressed that she would never want hemodialysis. All of her lines were removed and she remained unresponsive with 100% NRB and passed away peacefully on [**11-1**] while on a morphine drip. Medications on Admission: Atenolol 12.5 mg po qd Zocor 40 mg po qd ASA 81 mg po qd Discharge Medications: PASSED AWAY Discharge Disposition: Expired Discharge Diagnosis: Renal Artery Stenosis Diastolic CHF Hypertensive emergency Death Discharge Condition: CMO and died during this admission. Discharge Instructions: NONE Followup Instructions: NONE Completed by:[**2167-1-26**]

[ "405.01", "584.9", "440.1", "428.0", "428.32", "786.6", "272.4", "585", "433.30" ]

icd9cm

[ [ [] ] ]

[ "39.90", "39.50" ]

icd9pcs

[ [ [] ] ]

3521, 3530

2449, 3378

239, 259

3638, 3675

1908, 2426

3728, 3763

1466, 1513

3485, 3498

3551, 3617

3404, 3462

3699, 3705

1528, 1889

178, 201

287, 954

976, 1135

1151, 1450

23,262

122,821

48313

Discharge summary

report

Admission Date: [**2188-10-21**] Discharge Date: [**2188-10-31**] Date of Birth: [**2134-8-19**] Sex: M Service: SURGERY Allergies: Tetracycline Attending:[**First Name3 (LF) 668**] Chief Complaint: ESLD due to HCV cirrhosis ESRD due to HCV cryoglobulemia, MPGN Major Surgical or Invasive Procedure: s/p simultaneous OLT and CRT [**2188-10-21**] History of Present Illness: Pt is 54M with ESLD due to HCV cirrhosis and ESRD due to HCV cryglobulemia/MPGN who presented for simultaneous OLT and CRT on [**2188-10-21**]. Past Medical History: ESLD due to HCV cirrhosis ascites ESRD due to HCV cryglobulemia/MPGN Congenital L anephrosis s/p L AVF x 3 nephrolithiasis s/p kidney stone retrieval & stent [**1-2**] anemia CHF endocarditis HTN Social History: Hx of IVDU in [**2153**] EtOH use, quit 3 yrs ago Smoking 80 pk-yr, quit 3 yrs ago Family History: Mom - AAA rupture Dad - lung ca, MI Physical Exam: AVSS icteric jaundiced RR S1 S2 no murmur CTA b/l mildly dist NT abdomen no edema Pertinent Results: [**2188-10-21**] 01:40PM WBC-6.0 RBC-4.64 HGB-15.0 HCT-43.1 MCV-93 MCH-32.4* MCHC-34.8 RDW-16.4* [**2188-10-21**] 01:40PM PLT COUNT-213 [**2188-10-21**] 01:40PM PT-13.1 PTT-30.8 INR(PT)-1.1 [**2188-10-21**] 01:40PM GLUCOSE-86 UREA N-50* CREAT-9.3* SODIUM-138 POTASSIUM-5.4* CHLORIDE-95* TOTAL CO2-28 ANION GAP-20 [**2188-10-21**] 01:40PM CALCIUM-10.0 PHOSPHATE-5.9*# MAGNESIUM-1.8 [**2188-10-21**] 01:40PM ALT(SGPT)-49* AST(SGOT)-31 ALK PHOS-207* TOT BILI-0.5 [**2188-10-21**] 01:40PM BLOOD Glucose-86 UreaN-50* Creat-9.3* Na-138 K-5.4* Cl-95* HCO3-28 AnGap-20 [**2188-10-22**] 02:20AM BLOOD Glucose-148* UreaN-46* Creat-6.4*# Na-141 K-6.1* Cl-94* HCO3-21* AnGap-32* [**2188-10-23**] 04:17AM BLOOD Glucose-106* UreaN-44* Creat-3.0* Na-138 K-3.9 Cl-101 HCO3-24 AnGap-17 [**2188-10-24**] 08:40AM BLOOD Glucose-140* UreaN-40* Creat-1.7*# Na-139 K-4.1 Cl-106 HCO3-26 AnGap-11 [**2188-10-25**] 07:41AM BLOOD Glucose-140* UreaN-36* Creat-1.4* Na-140 K-3.8 Cl-107 HCO3-25 AnGap-12 [**2188-10-26**] 09:00AM BLOOD Glucose-125* UreaN-36* Creat-1.3* Na-141 K-3.9 Cl-108 HCO3-24 AnGap-13 [**2188-10-27**] 08:20AM BLOOD Glucose-77 UreaN-31* Creat-1.3* Na-141 K-3.9 Cl-109* HCO3-24 AnGap-12 [**2188-10-28**] 08:20AM BLOOD Glucose-87 UreaN-25* Creat-1.2 Na-134 K-4.0 Cl-103 HCO3-25 AnGap-10 [**2188-10-29**] 09:00AM BLOOD Glucose-153* UreaN-21* Creat-1.1 Na-136 K-3.2* Cl-103 HCO3-25 AnGap-11 [**2188-10-30**] 09:30AM BLOOD Glucose-235* UreaN-20 Creat-1.2 Na-135 K-3.6 Cl-103 HCO3-22 AnGap-14 [**2188-10-31**] 10:15AM BLOOD Glucose-204* UreaN-24* Creat-1.2 Na-136 K-4.0 Cl-101 HCO3-25 AnGap-14 [**2188-10-22**] 02:20AM BLOOD ALT-1258* AST-3015* AlkPhos-187* Amylase-106* TotBili-5.9* DirBili-3.7* IndBili-2.2 [**2188-10-23**] 04:17AM BLOOD ALT-481* AST-515* AlkPhos-124* TotBili-0.9 [**2188-10-24**] 08:40AM BLOOD ALT-332* AST-225* AlkPhos-147* Amylase-60 TotBili-1.7* [**2188-10-25**] 07:41AM BLOOD ALT-288* AST-179* AlkPhos-152* TotBili-4.6* [**2188-10-26**] 09:00AM BLOOD ALT-309* AST-184* AlkPhos-145* TotBili-4.8* DirBili-3.3* IndBili-1.5 [**2188-10-27**] 08:20AM BLOOD ALT-241* AST-103* AlkPhos-133* TotBili-2.4* [**2188-10-29**] 09:00AM BLOOD ALT-307* AST-125* AlkPhos-171* TotBili-3.0* [**2188-10-30**] 09:30AM BLOOD ALT-213* AST-62* AlkPhos-158* TotBili-2.0* [**2188-10-31**] 10:15AM BLOOD ALT-187* AST-60* AlkPhos-174* TotBili-2.1* [**2188-10-23**] 04:17AM BLOOD Cyclspr-113 [**2188-10-24**] 08:40AM BLOOD Cyclspr-485* [**2188-10-25**] 07:41AM BLOOD Cyclspr-1043* [**2188-10-26**] 09:00AM BLOOD Cyclspr-567* [**2188-10-27**] 08:20AM BLOOD Cyclspr-573* [**2188-10-28**] 08:20AM BLOOD Cyclspr-805* [**2188-10-29**] 09:00AM BLOOD Cyclspr-1209* [**2188-10-30**] 09:30AM BLOOD Cyclspr-1345* [**2188-10-31**] 10:15AM BLOOD Cyclspr-708* [**2188-10-22**] Abd US / Renal US - 1. Unremarkable transplanted liver with patent hepatic and portal vessels. 2. Unremarkable transplanted kidney with no hydronephrosis, perirenal fluid, or evidence of rejection. [**2188-10-25**] Abd US - IMPRESSION: Appropriate direction and appearance of waveforms of vascular flow within the hepatic veins, hepatic arteries, and portal veins. No biliary ductal dilatation. [**2188-10-27**] Tube Cholangiogram - IMPRESSION: 1. There is no evidence of leak or biliary obstructions. 2. Mild stenosis of the distal common bile duct near the papilla. [**2188-10-28**] Abd US - IMPRESSION: Portal veins and hepatic arteries are patent and demonstrate appropriate waveforms. Dampening of hepatic venous waveforms, unchanged from the previous exam, of uncertain clinical significance. No biliary ductal dilatation. Brief Hospital Course: Pt presented for simultaneous OLT & CRT on [**2188-10-22**]. Please see Op Note for details. Briefly, pt tolerated the procedure well. He was extubated on POD#1. Routine Abd US and Renal Tx US was WNL. Pt was transferred to floor on POD#2. On POD#3, pt was found to have elevated TBili to 4.6 - however, rest of the LFT's were normalizing. Coags were WNL. Repeat US of the liver did not show significant change in vascular flow into and from the liver. Pt underwent Tube Cholangiogram which only showed mild distal CBD stenosis. Bilirubin declined w/o further intervention. Renal function dramatically improved after CRT, with normalization of Cr. Pt's immunosuppression induction was per protocol. He received SoluMedrol 1gm IV on induction and was tapered per protocol to Prednisone 20mg po daily. He received MMF 1gm q12h. He received Simulect 20mg IV on induction and on POD#4. He was started on Cyclosporine and was discharged on therapeutic level. Medications on Admission: Norvasc 10mg po daily Epoetin 6000units qWeekly Allopurinol 100mg po BID Isordil 90mg po BID Cyclobenzapine 10mg po daily Toprol XL 50mg daily Neurontin 300mg daily MVI Iron Nephrocaps VitB12 Mg Oxide Discharge Medications: 1. Cyclosporine Modified 25 mg Capsule Sig: Six (6) Capsule PO Q12H (every 12 hours) for 2 doses: take as instructed by Transplant Center. 2. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 6. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 8. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Valganciclovir HCl 450 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 capsules* Refills:*0* 11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 12. Lasix 20 mg Tablet Sig: 0.5 Tablet PO once a day for 30 days: take as instructed by Transplant Center. Disp:*30 Tablet(s)* Refills:*0* 13. Outpatient Lab Work CBC, Chem7, Ca, Mg, Phos, AST, ALT, AlkPhos, TBili, albumin, Cyclosporine level (2hrs AFTER AM dose) qMon and qThur - fax results to Transplant Center [**Telephone/Fax (1) 697**] Discharge Disposition: Home Discharge Diagnosis: HCV cirrhosis ESRD - HRS vs HCV cryoglobulinemia s/p simultaneous OLT and CRT [**2188-10-21**] hx of CHF anemia hx of endocarditis mild pulmonary htxn Discharge Condition: good Discharge Instructions: Do NOT lift heavy objects > 10 lbs. Do NOT bathe. You can shower. If you have fever, chills, nausea, vomiting, please call the Transplant office ASAP. Please do dry dressing change on the wound as needed. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Where: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2188-11-6**] 8:45 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Where: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2188-11-13**] 8:45 Provider: [**Name10 (NameIs) 1344**] [**Last Name (NamePattern4) 3125**], MD Where: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2188-11-20**] 9:00 Completed by:[**2188-12-8**]

[ "782.4", "070.70", "403.91", "571.5", "285.9" ]

icd9cm

[ [ [] ] ]

[ "50.59", "55.69", "87.54", "50.4", "38.95" ]

icd9pcs

[ [ [] ] ]

7294, 7300

4661, 5619

336, 384

7496, 7502

1046, 4638

7755, 8373

892, 929

5870, 7271

7321, 7475

5645, 5847

7526, 7732

944, 1027

234, 298

412, 557

579, 776

792, 876

83,347

151,010

35783

Discharge summary

report

Admission Date: [**2167-6-25**] Discharge Date: [**2167-6-29**] Date of Birth: [**2084-3-15**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2290**] Chief Complaint: Nausea/vomiting, labs concerning for cholangitis, hypotension s/p ERCP Major Surgical or Invasive Procedure: ERCP with stent placement in right intrahepatic biliary system History of Present Illness: Ms. [**Known lastname 37682**] is an 83 year old woman with a PMHx significant for breast and ovarian cancer and stricture of the CBD who presented to the GI service on [**2167-6-25**] for ERCP. She is followed at [**Hospital1 46**] in [**Location (un) 3320**] for all of her care and is treated at [**Hospital1 18**] only for a stricture of the CBD. Stricture was initially discovered in [**2165**] and was stented at [**Hospital1 18**]. Stent was not removed until [**2167-5-3**] by Dr. [**Last Name (STitle) 63421**]. Several weeks following this removal, Ms. [**Known lastname 37682**] began to experience worsening nausea and weakness with dark urine and light stools. In [**Month (only) **] it was noted at [**Hospital1 46**] that she had a tbili of 10.1 CT at [**Hospital1 46**] also noted a infiltrative process in the liver. ERCP was scheduled for [**Hospital1 18**]. During ERCP on [**2167-6-25**], several stone fragments and a moderate amount of pus were found in the biliary tree. A 9cm 10FR stent was placed with immediate drainage of pus and bile. Pt was started on Ampicillin 2g IV x1, Vancomycin 1gm IVx1, Gentamycin 60mg IV x1 for presumed cholangitis. In the PACU, Ms. [**Known lastname 37682**] was found to be hypotensive to 70/43, but recovered to 90s-100s/46-53 after a 1L NS bolus. . On the floor, Ms [**Known lastname 37682**] has been stable with SBP ranging from 91-104. She was conversant and denied confusion/HA/dizziness or pain. Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. . Past Medical History: Breast Cancer s/p R mastectomy and XRT to L s/p chemotherapy with taxol, carboplatin, w/ concurrent tamoxifen Ovarian Cancer s/p chemotherapy in [**2164**] Osteoporosis GERD Social History: Lives alone in [**Location (un) 3320**], MA. Denies tobacco (remote use), EtOH, drug use Family History: Mother (died 62 yo) and 2 sisters with breast cancer, no family history of ovarian cancer. Father with prostate/bladder cancer (died 82 yo). Physical Exam: General: Alert, oriented, no acute distress HEENT: icteric sclera, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: ERCP The major papilla was protuberant and fleshy- likely representing hyperplastic response from prior long-term plastic CBD stent. We did not biopsy this area given other ERCP evidence concerning for cholangitis. Cannulation of the biliary duct was successful and deep with a sphincterotome using a free-hand technique. Contrast medium was injected resulting in complete opacification. There was evidence of pus drainage shortly after introduction of the sphincterotome. There was a stricture involving the common hepatic duct and bifurcation. There was severe upstream dilation in the right intrahepatic system, with filling defects suggestive of stones. There was signficant irregular stricturing throughout the visualized left intrahepatic system. The common bile duct appeared normal, although contrast opacification was limited given evidence of cholangitis. Several stone fragments and a moderate amount of pus was extracted successfully using a balloon. A 9cm by 10FR biliary biliary stent was placed successfully, entering the right intrahepatic system, with immediate drainage of pus and bile. Otherwise normal ERCP to 3rd portion of the duodenum . Blood cultures X2 ([**2167-6-26**]) NGTD . [**2167-6-29**] 04:05AM BLOOD WBC-6.5 RBC-2.83* Hgb-9.6* Hct-28.3* MCV-100* MCH-33.9* MCHC-33.9 RDW-13.5 Plt Ct-269 [**2167-6-28**] 05:07AM BLOOD PT-15.4* PTT-40.2* INR(PT)-1.3* [**2167-6-29**] 04:05AM BLOOD Glucose-95 UreaN-6 Creat-0.6 Na-136 K-3.9 Cl-102 HCO3-27 AnGap-11 [**2167-6-29**] 04:05AM BLOOD ALT-53* AST-84* AlkPhos-430* TotBili-5.7* [**2167-6-29**] 04:05AM BLOOD Calcium-8.2* Mg-1.6 Brief Hospital Course: Ms. [**Known lastname 37682**] is an 83 year old woman with a PMHx significant for breast/ovarian cancer and biliary stricture who presents with cholangitis and hypotension following placement of a biliary stent. . # Cholangitis: Given pus observed on ERCP, cholangitis was felt likely. Stent placed and stones removed on ERCP. She was started on Zosyn by ERCP team for a ten day course, and broadened to Vancomycin in the setting of hypotension. Once the stent was placed, her TBili did down trend relatively quickly, from 10s to 8s. She had received ampicillin, vancomycin, gentamicin post-ERCP. Her diet was advanced and she tolerated this well. She will need follow in eight weeks for stent removal via repeat ERCP. Her antibiotics were transitioned to ciprofloxacin and flagyl. She was monitored for 24 hours after the change without fevers, changes in symptoms or any other complaints. . # Hypotension: Following placement of biliary stent, felt likely due to the significant instrumentation and transient bacteremia. The patient was also likely hypovolemic, dehydrated from generally not feeling well (nausea, weakness). Likely early sepsis vs. SIRS. Patient remained borderline hypotensive with BP ~100/50 but responded to fluid boluses and resuscitation. Her infectious causes were treated per above. . # H/O Breast Cancer - Continued on tamoxifen . FEN: replete electrolytes, regular diet - Continue outpatient magnesium and potassium supplementation . Prophylaxis: Subcutaneous heparin . Access: peripherals . Code: Full . Communication: Patient Medications on Admission: Tamoxifen 20mg daily, potassium 20 mEq [**Hospital1 **], omeprazole 20 mg daily, magnesium 1200 mg daily, Fosamax 70 mg once a week. . Discharge Medications: 1. tamoxifen 10 mg Tablet Sig: Two (2) Tablet PO Q 24H (Every 24 Hours). 2. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 6 days. Disp:*12 Tablet(s)* Refills:*0* 3. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 6 days. Disp:*18 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Cholangitis status-post ERCP Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital for a ERCP and after the ERCP your blood pressure dropped. You were treated with antibotics and intravenous fluids and your blood pressure improved. You were doing well at the time of discharge. You will need to take your antibiotics to complete a 10-day course, which will be done on [**7-4**]. **** MEDICATION CHANGES: - START ciprofloxacin twice daily through [**2167-7-4**] - START flagyl three times daily through [**2167-7-4**] Followup Instructions: Name:[**Name6 (MD) 251**] [**Last Name (NamePattern4) 81372**],MD Specialty: Primary Care Address: [**Apartment Address(1) 81373**], [**Location (un) **],[**Numeric Identifier 40624**] Phone: [**Telephone/Fax (1) 26647**] When: Wednesday, [**7-8**] at 1:30pm

[ "V45.71", "733.00", "574.50", "174.9", "576.1", "V10.43", "790.7", "576.2", "530.81" ]

icd9cm

[ [ [] ] ]

[ "51.87", "51.88" ]

icd9pcs

[ [ [] ] ]

7001, 7072

4919, 6479

375, 439

7145, 7145

3295, 4896

7791, 8053

2651, 2795

6665, 6978

7093, 7124

6505, 6642

7296, 7634

2810, 3276

7654, 7768

265, 337

1946, 2328

467, 1928

7160, 7272

2350, 2526

2542, 2634

83,151

189,935

44758

Discharge summary

report

Admission Date: [**2106-1-16**] Discharge Date: [**2106-1-19**] Date of Birth: [**2021-5-20**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3984**] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: none History of Present Illness: 84F h/o COPD, DM-2, HTN, CVA (details unknown), hyperlipidemia, CAD, depression, CHF, PVD presents with altered mental status and fever from [**Hospital3 537**] nursing home. Grand-daughter states that four days prior to admission, Ms. [**Known lastname **] became confused and slow to answer. The patient is usually oriented and able to carry out a normal conversation. Her Tm at [**Hospital3 **] was 102.5. This morning her grand daughter states that the patient was much less responsive than days earlier. She may have had a right facial droop this morning, but she was slouched to her right side in bed and the grand daughter was not sure. Her oxygen saturations dropped to the 80s and this incited a hospital transfer. . In the ED, initial VS were unrecorded in triage presumably due to the need for immediate bipap. T 104.6, HR 84, BP 89/47, RR 19 Sat 100 ?CPAP. FS 444. Recieved levofloaxacin 500mg iv, vancomycin 1g iv, ctx 1g iv (had gotten another gram at NH). A CXR showed left base opacity c/f atelectasis (cannot rule out infiltrate). CT head showed small hyperdensity in left thalamus c/w hemorrhage/cavernoma/cancer. Due to this finding, an LP was not done. Neurosurgical c/s revealed no surgical interventions. Vitals upon transfer to MICU were vitals 101, 112/46, 73, rr 23, 100%. . OSH record review shows CXR [**2105-1-15**] showing no acute pathology, EKG with SR 79 w/ nonspecific st/t changes. UA with trace glucose, negative ketones, 1+ protein. K 3.8, CO2 38, BUN 41, Cr 0.9, Na 155, glucose 307, Ca 9.3, WBC 12.7, Hct 45.2, Plt 237. On [**2105-12-18**] labs indicated wbc 9.5, Na 141, K 4.5, Cl 95, CO2 40, Cr 0.5, BUN 16, glucose 117, Ca 9.0, Cholesterol 164, HDL 50, LDL 71, Hgb A1C 7.1. . On arrival to the MICU, BiPAP mask taken off and she was put on high flow face mask w/ 80% oxygen/15L which took her saturation from 88 to 100% over several minutes. She was non-verbal. She nodded appropriately. . Review of systems: unable to obtain Past Medical History: COPD, DM-2, HTN, CVA, hyperlipidemia, CAD, depression, CHF, uterine prolapse, PVD, osteoarthritis, and had an appendectomy in the distant past. Social History: Currently resides at [**Hospital3 537**]. Family History: Non-contributory Physical Exam: Admission PE: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact . Discharge PE: expired Pertinent Results: Admission Labs [**2106-1-16**] 07:55PM URINE HOURS-RANDOM [**2106-1-16**] 07:55PM URINE GR HOLD-HOLD [**2106-1-16**] 07:55PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.024 [**2106-1-16**] 07:55PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [**2106-1-16**] 07:55PM URINE RBC-8* WBC-1 BACTERIA-MANY YEAST-NONE EPI-<1 [**2106-1-16**] 07:55PM URINE HYALINE-1* [**2106-1-16**] 07:45PM LACTATE-3.0* [**2106-1-16**] 07:45PM LACTATE-3.0* [**2106-1-16**] 07:45PM O2 SAT-59 [**2106-1-16**] 07:35PM GLUCOSE-384* UREA N-62* CREAT-1.6*# SODIUM-157* POTASSIUM-4.2 CHLORIDE-109* TOTAL CO2-35* ANION GAP-17 [**2106-1-16**] 07:35PM estGFR-Using this [**2106-1-16**] 07:35PM ALT(SGPT)-87* AST(SGOT)-53* ALK PHOS-61 TOT BILI-0.4 [**2106-1-16**] 07:35PM LIPASE-53 [**2106-1-16**] 07:35PM cTropnT-0.07* [**2106-1-16**] 07:35PM proBNP-1542* [**2106-1-16**] 07:35PM proBNP-1542* [**2106-1-16**] 07:35PM NEUTS-52 BANDS-28* LYMPHS-12* MONOS-7 EOS-0 BASOS-0 ATYPS-1* METAS-0 MYELOS-0 [**2106-1-16**] 07:35PM PLT SMR-NORMAL PLT COUNT-206 [**2106-1-16**] 07:35PM PT-12.9* PTT-24.6* INR(PT)-1.2* [**2106-1-16**] 07:24PM LACTATE-3.2* [**2106-1-16**] 07:13PM VoidSpec-QNS . Discharge Labs : expired Brief Hospital Course: 84F h/o COPD, DM-2, HTN, CVA (details unknown), hyperlipidemia, CAD, depression, CHF, PVD presents with altered mental status and fever from [**Hospital3 537**] nursing home. . # toxic metabolic encephalopathy: The patient's altered mental status was attributed to toxic-metabolic encephaolpathy in the setting of sepsis, although additional concerns included new stroke, bacterial or viral meningitis, or hypercarbia. The patient was initially started on empiric antibiotic treatment for possible meningitis. A CT head was done showing a hyperattenuating focus involving the left thalamus, that could represent parenchymal hemorrahage vs. neoplam. There was also evidence of small vessel ischemic diease and multiple remote infarctions. Neurosurgey evaluated the patient and it was decided that no surgical intervention was indicated at the time. The patient's mental status did not improve during the hospitalization, and a family meeting with the grand-daughter (HCP) was held, and the patient's focus of care was CMO. . With the assistance of Palliative Care consult team, pt was transfered to the the general medicine floor, continued on morphine and prn lorazepam for comfort. She quietly expired during the evening, and, as per her grand daughter's request, an autopsy will be done. . # Dyspnea/respiratory status: The patient has a history of COPD with 100 pack year history; possible that this is related to COPD exacerbation; other differentials include pneumonia versus CHF exacerbation. CXR with evidence of possible L basilar infiltrate versus atelectasis. The patient was on antibiotic coverage initially, however, after she was made CMO, as antibiotics were discontinued. . On transfer to the general medicine floor, the patient was on nebs for comfort and breathing comfortably on nasal cannula. She passed during the night. . # Fevers: The etiology of the patient's fevers has broad differential, including pneumonia, UTI, or meningitis. The patient was initially on broad spectrum abx, but since being made CMO, all abx have been d/ced and her vitals were no longer being checked. . # Hyperattenuating lesion in L thalamus: Possibly hemorrhagic stroke versus neoplasm. Neurosurg was following patient, and decided that there was no need for surgical intervention at this time. Possible that this lesion could have explained the patient's acute change in altered mental status, as well. . # COPD: The patient had oxygen requirement during this hospitalization, which could have represented COPD excacerbation versus underlying pneumonia. The patient was initially on antibiotics; however, these were later discontinued when she was made CMO. Nebulizers were continued for patient comfort. . Chronic Issues: # HTN/hyperlipidemia: The patient was initially continued on her home anti-hypertensives and hyperlipidemia medications. However, as she was made CMO, these home medications were held. . #depression/dementia: The patient's home medications were also held when she was made CMO. Medications on Admission: bisacodyl fleet enema prn milk of mag prn ipratropium/albuterol q6hrs nebs prn tramadol 50mg q6hrs prn CTX 1g times one tylenol prn spiriva 1cap daily docusate memantine/namenda 10mg [**Hospital1 **] mirtazapine 15mg qhs simvastatin 20mg qhs donepezil 10mg qhs ASA 325mg daily atenolol 75mg daily bupropion 150mg qAM lisinopril 10mg daily Discharge Medications: expired. Discharge Disposition: Expired Discharge Diagnosis: immediate cause of death: pneumonia (days) secondary cause of death: COPD, stroke (years) Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**] Completed by:[**2106-1-19**]

[ "V12.54", "496", "518.81", "V66.7", "443.9", "349.82", "486", "294.20", "V49.86", "272.4", "276.0", "584.9", "311", "250.00", "V49.75", "401.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8015, 8024

4571, 7293

327, 333

8157, 8166

3260, 4547

8222, 8386

2576, 2594

7982, 7992

8045, 8136

7618, 7959

8190, 8199

2609, 3218

2313, 2332

3232, 3241

265, 289

361, 2293

7309, 7592

2354, 2500

2516, 2560

24,149

132,161

13932

Discharge summary

report

Admission Date: [**2176-11-26**] Discharge Date: [**2176-12-4**] Service: VSU CHIEF COMPLAINT: Abdominal aortic aneurysm. HISTORY OF PRESENT ILLNESS: This is an 85-year-old gentleman with known history of hypertension, hyperlipidemia, diabetes, and former tobacco abuse with known coronary artery disease status post CABG in [**2165**] who presents with an abdominal aortic aneurysm for elective repair. ALLERGIES: Penicillin, codeine, and Keflex. Manifestations: Not documented. PAST MEDICAL HISTORY: Illnesses include hypertension, hyperlipidemia, type 2 diabetes, history of coronary artery disease with myocardial infarction, status post CABG x3 in [**2165**] that was a LIMA to the LAD, a saphenous vein graft to the ramus, obtuse marginal I, and right acute marginal, and to the right PDA, sternal wound infection status post debridement, sick sinus syndrome status post pacemaker implant with recent generator change on [**2176-4-18**]. Patient is AV paced. History of CVA without residual in [**2160**], history of GERD on Protonix, history of gout on colchicine, history of prostate carcinoma status post prostatectomy, history of cholelithiasis, history of cranial bleed in the [**2150**] with clipping, history of skin cancer status post excision, history of inguinal hernia repair. MEDICATIONS ON ADMISSION: Prilosec 20 mg daily, glyburide 1.25 mg daily, Plavix 75 mg daily, Toprol 100 mg b.i.d., Lescol 40 mg at bedtime, captopril 12..5 mg t.i.d., colchicine 0.6 mg at bedtime, aspirin 325 mg daily, Xalatan eye drops 1 both eyes at bedtime, Imdur 60 mg daily, multivitamin tablet. FAMILY HISTORY: Is negative for premature coronary artery disease or AAA. SOCIAL HISTORY: Patient is married. Has 7 children. His daughter-in-law, [**Name (NI) **], is involved with his care. He works as a nurse at [**State 20192**] Center. PHYSICAL EXAM: Temperature is 94.8, heart rate 70, AV paced, blood pressure 120/51, respiratory rate 14, O2 saturation 100%, CVP was [**3-19**], PAP was 22/10, cardiac output was 3.5, index is 1.75. Neurologically, the patient is intubated and sedated. HEENT exam is unremarkable. Heart is a regular rate and rhythm without murmurs, gallops, or rubs. Respiratory: Lungs are clear to auscultation bilaterally. Abdominal exam is soft, nontender, nondistended with bowel sounds. Extremities are with 1+ edema. Pulse exam shows pedal pulses on the right, absent DP with a monophasic dopplerable PT and on the left, the DP and PT are biphasic dopplerable signals. HOSPITAL COURSE: Patient was admitted to the preoperative holding area on [**2176-11-26**]. He underwent an open abdominal aortic repair with a tube graft. He tolerated the procedure well. Was transferred to the SICU intubated in stable condition. Postoperatively, the patient was monitored by the anesthesia acute pain service secondary to his epidural. Patient was also evaluated by the electrophysiology service to check pacer. The pacer mode was set at a DDD at 60- 120. It was sensing and pacing AV. The P-R interval was adjusted to allow for sinus rhythm instead of V-pacing. Postoperative day 1 overnight events, the patient had 3 episodes of hypotension requiring 4 units of FFP, 4 units of pack red blood cells, and 5 liters of lactated Ringer. The epidural was held secondary to the hypotension. Postoperative hematocrit was 31.1 with a white count of 18.3, platelets 54 K. BUN 23, creatinine 1.0. Postoperative day 2, the epidural was instituted with morphine sulfate as analgesic [**Doctor Last Name 360**]. A HIT panel was sent secondary to persistent low platelet count, and he continued with aggressive fluid boluses. His troponin was 0.11. His pulse exam remained unchanged. He remained on ventilator support. Postoperative day 4, the patient was extubated. His Swan catheter was replaced with a triple lumen. His Lopressor was increased for rate control. His white count which peaked at 21.5 showed a decreasing count of 16.4, hematocrit remains stable at 30.7. BUN and creatinine were stable at 32 and 0.9. Patient was neurologically intact and oriented x3. He continued to remain NPO. Patient did have bowel sounds, but had not passed flatus. Patient's intrathecal catheter was discontinued. His HIT panel was negative. His platelet count continued to show improvement. Patient was transferred to the VICU for continued monitoring and care. On postoperative day 5, patient had bowel sounds, but no flatus. His diet was advanced. NG tube was removed. He was evaluated by physical therapy who felt that he would benefit from rehab when medically stable for discharge. The patient continued to progress. Postoperative day 7, the Foley was removed. The patient failed to void. A Foley was replaced. An informal consult with urology service determined that the patient should maintain the catheter until he is transferred to rehab, and then they can begin a q.6h. intermittent straight catheterization. Patient then should follow up with the urology clinic and call for an appointment. Patient's remaining hospital course was unremarkable. Patient continued to do well. He was transferred to rehab on [**2176-12-4**] in stable condition, tolerating POs. DISCHARGE MEDICATIONS: Latanoprost 0.005% drops 1 both eyes at bedtime, acetaminophen tablets 325 [**12-17**] q.4-6h. p.r.n., oxycodone/acetaminophen 5/325 tablets [**12-17**] q.4-6h. p.r.n., Protonix 40 mg daily, Colace 100 mg b.i.d., colchicine 0.6 mg daily, indomethacin 50 mg t.i.d., glyburide 2.5 mg b.i.d., Plavix 75 mg daily, Lopressor 100 mg b.i.d., pravastatin 20 mg daily, captopril 12.5 mg t.i.d., isosorbide mononitrate 60 mg q.24h., milk of magnesia 30 cc q.6h. p.r.n. as needed, Dulcolax suppository tablets 1 or 2 tablets as needed. DISCHARGE DIAGNOSES: Abdominal aortic aneurysm status post open abdominal aortic repair with tube graft on [**2176-11-26**], type 2 diabetes controlled, postoperative urinary retention, postoperative blood loss anemia transfused corrected, history of coronary artery disease status post myocardial infarction, status post coronary artery bypass graft x3 in [**2165**] stable, history sick sinus syndrome, status post pacemaker implant with adjustment postoperatively [**2176-11-14**], history of prostate carcinoma with prostatectomy, history of gastroesophageal reflux disease, history of gout, history of cerebrovascular accident, history of glaucoma. DISCHARGE INSTRUCTIONS: Patient's Foley will be continued until after transfer to rehab. It should then be discontinued and q.6h. straight catheterization should be done. This should be continued until the patient is seen in followup in 1 week with the urology clinic. They can call for an appointment at [**Telephone/Fax (1) 164**]. Follow up with Dr. [**Last Name (STitle) 1391**] in 2 weeks' time. Please call for an appointment at [**Telephone/Fax (1) 1393**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**] Dictated By:[**Last Name (NamePattern1) 2382**] MEDQUIST36 D: [**2176-12-4**] 11:37:45 T: [**2176-12-4**] 12:03:00 Job#: [**Job Number 41685**]

[ "788.20", "441.4", "280.0", "414.00", "V45.01", "V45.81", "V10.46", "250.00", "997.5" ]

icd9cm

[ [ [] ] ]

[ "38.44", "38.93", "99.04" ]

icd9pcs

[ [ [] ] ]

1634, 1693

5771, 6405

5223, 5749

1341, 1617

2541, 5199

6430, 7143

1878, 2523

108, 136

165, 498

521, 1314

1710, 1862

62,466

109,721

34914

Discharge summary

report

Admission Date: [**2107-10-24**] Discharge Date: [**2107-11-9**] Date of Birth: [**2025-11-13**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 13565**] Chief Complaint: Falls - found to have R cerebellar hemorrhage at OSH Major Surgical or Invasive Procedure: None History of Present Illness: Mr [**Known lastname 61509**] is a LHM, and is a retired printer (former veteran), who normally does cross-word puzzles, Sodoku and plays Game Boy. He was in his usual state of health until 3 am on [**10-24**]. His step-son, [**Name (NI) **] [**Name (NI) 36913**], whom he lives with, found him sitting by the front door, drenched in blood, and trying to get out. Mr [**Name13 (STitle) 36913**] cleaned his step-father up, and noticed that he had hit the right side of his forehead and right forearm. Mr [**Name13 (STitle) 36913**] took his father back to bed, at around 4 am. Mr [**Known lastname 61509**] [**Last Name (Titles) **] up around 6:30 am, and had breakfast around 7 am which consisted of his usual bowl of cereal and two cups of coffee. Mr [**Known lastname 79898**] daughter-in-law [**Doctor First Name **] noticed that he had made a mess in the kitchen earlier that morning, taken the kitchen rug and tried to wrap the table in it. However, both Mr and Mrs [**Last Name (STitle) 36913**] left for work, requesting their daughter ([**Name (NI) **]) to look in on Mr [**Name (NI) 61509**]. [**Doctor First Name **] came by to give Mr [**Known lastname 61509**] lunch, and found that there was more blood in the house, in addition, he had vomited his breakfast up on the living room sofa. She noticed that while he was eating his bowl of soup, his soup spoon kept missing his mouth. In addition, she noticed that her grand-father's speech was slurred. [**Doctor First Name **] took her Grand-father to the [**Hospital3 **] [**Name (NI) **]. He had a CT of his brain which showed a right cerebellar hemorrhagic lesion with vasogenic edema and some compression of the fourth ventricle, so he was transferred to [**Hospital1 18**] ED. At the ED he was reviewed by Neurosurgery. Review of systems: Apart from headache, the rest of his systems review was apparently negative. Past Medical History: 1. Asthma 2. Osteoporosis 3. Osteoarthritis 4. s/p bilateral catarect surgery Social History: Lives with his step-son who is his only child and his HCP, his name is [**Name (NI) **] [**Name (NI) 36913**] and his cell phone number is: [**Telephone/Fax (1) 79899**]. According to Mr [**Last Name (Titles) 36913**], his step-father is DNR/DNI. His PCP is Dr [**Last Name (STitle) 27542**] at [**Location (un) **]. He is an ex-smoker, smoking up to two packs per day (not known over the number of years). Mr [**Known lastname 61509**] does not drink alcohol. His bedroom is on the [**Location (un) 1773**], and he normally manages his ADLs. Family History: Not known Physical Exam: Vitals: T99, HR 40, BP 157/60, RR 16, SpO2 96% on room air General: right forehead and right arm bruises noted. HEENT: complained that it tickled when trying to examine the cervical lymph nodes. Resp: Poor air entry in the right middle zone CVS: difficult to hear the heart sounds clearly, as he would not stop talking GI: Soft, non-tender with normal bowel sounds. Neurological Examination Mental status: Awake and alert, multiple promptings for the exam. Oriented to person, [**Location (un) 86**] and [**2107**]. Normal repetition; no anomia. Moderate dysarthria. Registers 0/3,recalls 0/3 in 5 minutes. Right-left confusion. Cranial Nerves: Fundoscopic examination kept closing his eyes tightly. Pupils equally round and reactive to light, 3 to 2 mmbilaterally. Visual fields appear to be full to confrontation, but he is easily distractible. Extraocular movements intact bilaterally with nystagmus to the right. Sensation appears to beintact V1-V3. Facial movements are symmetric. Palate elevationsymmetric. Sternocleidomastoid and trapezius full strength bilaterally. Tongue midline. Motor: Decreased bulk diffusely but normal tone bilaterally. No observed myoclonus, asterixis, or tremor. No pronator drift. Full strength in all muscles tested. Sensory testing was totally unreliable. Reflexes: 2+ and symmetric throughout. Positive Babinski on the right. Coordination: Normal finger-nose-finger, heel to shin, and fine finger movements. Gait: Unsafe on his feet very unsteady Pertinent Results: [**2107-10-24**] 03:55PM BLOOD WBC-8.6 RBC-3.82* Hgb-11.9* Hct-34.0* MCV-89 MCH-31.2 MCHC-35.1* RDW-13.7 Plt Ct-278 [**2107-10-24**] 03:55PM BLOOD Glucose-92 UreaN-20 Creat-0.9 Na-143 K-4.1 Cl-109* HCO3-23 AnGap-15 [**2107-10-25**] 02:43AM BLOOD ALT-11 AST-18 AlkPhos-92 TotBili-1.0 [**2107-10-24**] 03:55PM BLOOD CK-MB-4 [**2107-10-25**] 02:43AM BLOOD Calcium-8.9 Phos-2.3* Mg-2.1 [**2107-10-24**] 03:55PM BLOOD TotProt-6.5 EKG [**10-24**]: Sinus bradycardi. Left bundle branch block CT head: 1. 1.5 cm hyperdense lesion in the right cerebellar hemisphere, with surrounding edema, and mild effacement of the fourth ventricle. Differential considerations include hyperdense or hemorrhagic metastasis, versus vascular malformation, or other source of hemorrhage, including hypertensive bleed. MRI with contrast is recommended for further evaluation. 2. 1.3 cm probable small calcified meningioma right middle cranial fossa. This could also be more definitively characterized by MRI. 3. Vascular calcifications, and bilateral basal ganglia chronic lacunar infarcts, and right frontal chronic infarction. MR head: Approximately 1.5-cm lesion in the right cerebellar hemisphere with surrounding edema most consistent with a hemorrhagic tumor. Adjacent enhancement in the cerebellar sulci may be leptomeningeal seeding from a tumor. These findings are most consistent with a malignant hemorrhagic tumor. [**2107-11-8**] 11:20AM BLOOD WBC-22.7* RBC-4.08* Hgb-12.7* Hct-37.4* MCV-92 MCH-31.1 MCHC-33.9 RDW-13.9 Plt Ct-373 [**2107-11-5**] 07:20AM BLOOD Neuts-94.3* Lymphs-3.9* Monos-1.8* Eos-0 Baso-0 [**2107-11-2**] 09:10AM BLOOD PT-13.0 PTT-28.1 INR(PT)-1.1 [**2107-11-8**] 11:20AM BLOOD Glucose-166* UreaN-38* Creat-1.0 Na-136 K-4.3 Cl-96 HCO3-26 AnGap-18 [**2107-11-5**] 07:20AM BLOOD Glucose-125* UreaN-32* Creat-0.8 Na-139 K-4.2 Cl-100 HCO3-28 AnGap-15 [**2107-11-3**] 06:20AM BLOOD Glucose-107* UreaN-34* Creat-0.8 Na-138 K-4.5 Cl-103 HCO3-24 AnGap-16 [**2107-11-5**] 07:20AM BLOOD ALT-24 AST-17 LD(LDH)-282* AlkPhos-74 Amylase-65 TotBili-0.8 [**2107-11-5**] 07:20AM BLOOD Albumin-3.6 Calcium-9.0 Phos-4.8* Mg-2.4 [**2107-11-5**] 01:43AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG MRI Brain [**10-24**]: FINDINGS: There is a well-defined hyperintense lesion within the right cerebellar hemisphere, measuring approximately 15 x 12 mm. T1-weighted imaging shows inhomogeneous signal with a surrounding dark ring. Gradient-echo sequence shows the lesion to be hypointense. There is a large area of surrounding edema. On post-contrast images, there is uniform enhancement of the dura. There is also enhancement of the cerebellar sulci which could signify leptomeningeal seeding from a tumor. IMPRESSION: Approximately 1.5-cm lesion in the right cerebellar hemisphere with surrounding edema most consistent with a hemorrhagic tumor. Adjacent enhancement in the cerebellar sulci may be leptomeningeal seeding from a tumor. These findings are most consistent with a malignant hemorrhagic tumor. MRI Brain [**11-7**]: Prelim read: Large decrease in mass effect of right cerebellar mass on fourth ventricle since MR [**First Name (Titles) **] [**10-24**] with small improvement in mass effect seen since head CT of [**11-4**]. Brief Hospital Course: Patient is a 81 year old LHM with a h/o smoking presents with recent multiple falls with possible loss of balance per patient. He also developed nausea and vomitting plus bifrontal headache. Patient was found to have 1.5cm R cerebellar hemorrhage with significant vesogenic edema and some effacement of 4th ventricle. He was started on Decadron and initially admitted to ICU where he remained stable with little neurological findings. Neurosurgery and neuro-oncology were consulted given the high index of suspicion for either primary CNS or metastatic tumor. CT of thorax also performed given hx of smoking and possbile primary etiology being lung, thyroid, GI and renal which was unremarkable. While in the ICU, patient also had moderate/severe sundowning. He was given Seroquel as needed. On HD #3, he was transferred to general service. On the general service he had a fairly uneventful course. His major issue initially was significant sun-downing which improved with a regemin of scheduled seroquel and trazadone. Lately he has been much improved without significant trouble, although he does have some confusion worse at night and early morning. He has had significant improvement in his dysarthria as well. Over the past week he was noted to have a persistent elevated WBC count. An exhaustive work-up was done including several negative blood and urine cultures, chest-xray and lower extremity dopplers. This leukocytosis is likely due to steroids and not an acute infection. He has been afebrile throuhgout the hospital course. Recently his biopsy results returned as inconclusive. He had a repeat MRI which showed stable lesion with decreased swelling. He was discussed at tumor board and it was decided to wean the steroids and have a follow-up MRI in [**1-12**] months to evaluate progression. He will follow-up in Brain [**Hospital 341**] Clinic as scheduled. It should be noted that he had evidence of a right subdural hygroma on his initial and follow-up scans, deemed incidental to his presentation. His exam upon discharge is significant for oriented to person and year, often not to place. He is mildly dysarthric. He has surgical pupils bilateral. EOMI are full with few beats of nystagmus on right end gaze. Face is symmetric. He has full strength throuhgout. He has slight asterixis L>R. His right sided is mildly dysmetric with finger-nose-finger and he has slight overshoot on rapid actions. He has a steady gait with assistance. Medications on Admission: Fosamax Advair Serevent Albuterol as needed Discharge Medications: 1. Dexamethasone 2 mg Tablet Sig: as directed Tablet PO three times a day for 2 days: From [**Date range (1) 68310**], take 8mg in the morning, 6mg in the afternoon, and 8mg at night. Disp:*qs Tablet(s)* Refills:*0* 2. Dexamethasone 2 mg Tablet Sig: as directed Tablet PO three times a day for 2 days: From [**Date range (1) **], take 8mg in the morning, 6mg in the afternoon and 6mg at night. Disp:*qs Tablet(s)* Refills:*0* 3. Dexamethasone 2 mg Tablet Sig: as directed Tablet PO three times a day for 2 days: From [**Date range (1) 79900**], take 6mg three times a day. Disp:*qs Tablet(s)* Refills:*0* 4. Dexamethasone 2 mg Tablet Sig: as dir Tablet PO three times a day for 2 days: From [**Date range (1) 25351**], take 6mg in the morning, 4mg in the afternoon, and 6mg at night. Disp:*qs Tablet(s)* Refills:*0* 5. Dexamethasone 2 mg Tablet Sig: Two (2) Tablet PO three times a day for 2 days: From 11/6-7, take 6mg in the morning and 4mg in the afternoon and at night. Tablet(s) 6. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO three times a day for 2 days: From [**Date range (1) 21385**], take 4mg TID. 7. Dexamethasone 2 mg Tablet Sig: 1-2 Tablets PO three times a day for 2 days: From [**2110-11-20**], take 4mg in the morning, 2mg in the afternoon, 4mg at night. 8. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO twice a day for 2 days: Take from [**2112-11-22**]. 9. Dexamethasone 2 mg Tablet Sig: 1-2 Tablets PO twice a day for 2 days: Take 4mg in the morning and 2mg at night from [**2014-11-23**]. 10. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO twice a day for 2 days: Take from [**2016-11-25**]. 11. Dexamethasone 1 mg Tablet Sig: Two (2) Tablet PO twice a day for 2 days: Take from [**2018-11-27**]. 12. Dexamethasone 1 mg Tablet Sig: One (1) Tablet PO once a day for 2 days: Take from [**2020-11-29**] then discontinue dexamethasone. 13. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 15. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 16. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 17. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 18. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 19. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 20. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 21. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 22. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1) Injection Q8H (every 8 hours) as needed. 23. Nystatin 50,000,000 unit Powder Sig: One (1) PO five times a day: swish and swallow. Discharge Disposition: Extended Care Facility: [**Hospital6 25759**] & Rehab Center - [**Location (un) **] Discharge Diagnosis: Cerebellar hemorrhage Discharge Condition: Stable Discharge Instructions: You were admitted to the hospital with a cerebellar bleed. Brain biopsy failed to reveal a diagnosis, which may be tumor or amyloid angiopathy. You will be sent to rehab and return for follow-up. Followup Instructions: Provider: [**Name10 (NameIs) 5005**] [**Last Name (NamePattern4) 5342**], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2107-12-19**] 1:00 Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2107-12-19**] 11:15

[ "431", "V12.54", "V15.82", "784.5", "427.89", "E884.4", "715.90", "288.60", "237.5", "E932.0", "733.00", "780.1", "787.23", "426.13", "348.4", "781.2", "781.3", "493.90" ]

icd9cm

[ [ [] ] ]

[ "01.13", "93.59", "87.03" ]

icd9pcs

[ [ [] ] ]

13388, 13474

7819, 10302

372, 378

13540, 13549

4507, 4995

13793, 14045

2969, 2980

10396, 13365

13495, 13519

10328, 10373

13573, 13770

2995, 3387

2213, 2291

280, 334

406, 2194

3642, 4488

5004, 7796

3402, 3626

2313, 2392

2408, 2953

67,505

133,051

13011

Discharge summary

report

Admission Date: [**2193-11-16**] Discharge Date: [**2193-12-2**] Date of Birth: [**2129-2-23**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 78**] Chief Complaint: I have the chills and I can't stop shaking. Major Surgical or Invasive Procedure: None History of Present Illness: HPI:Asked to eval this 64 year old white male who fell off a ladder approx 10 ft this afternoon for bifrontal contusions and left frontal SDH. Pt reports he was on a ladder that slipped out from under him because it was on ice. He does not recall what time he fell. ER states pt reported LOC for unknown period of time. BIBA. Upon this examiners arrival he started to vomit. Per nursing this was the second time. He currently admits to headache, nausea, vomiting. He denies salty taste down the back of his throat. Past Medical History: PMHx: HTN Bipolor disorder no surgeries or overnight hospitalizations Social History: Social Hx: lives with girlfirend, admits to cocaine use about 48 hours prior to admission Family History: non contrib Physical Exam: PHYSICAL EXAM: O: T: af BP: 170 / 102 HR: 73 / was in afib on ekg not currently R 20 O2Sats100 on NC Gen: WD/WN, appears uncomfortable. HEENT:No CSF rhinorrhea/otorrhea, no hemotympanum / Pupils: 4-2mm bilaterally EOMI Neck: Supple. / collar off / cleared by ortho Neuro: Mental status: Awakens to voice, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date (thought is was 12th 13th or 14th). Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria, + paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 4 to 2 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 full power [**4-9**] throughout. No pronator drift Sensation: Intact to light touch no clonus ON DISCHARGE: A and O x 3, impulsive, MAE, PERRL 4mm to 2mm, otherwise nonfocal Pertinent Results: [**11-16**] Head CT IMPRESSION: 1. Bilateral frontal and left anterior temporal intraparenchymal hematomas/contusions with associated subarachnoid blood, most prominent overlying the left frontal lobe extending towards the vertex. Small bilateral acute subdural hematomas. Effacement of the overlying sulci but no midline shift. 2. No depressed skull fracture. Minimal diastasis of the right occipital mastoid suture. [**11-17**] Head CT IMPRESSION: 1. Diffuse subarachnoid hemorrhage, bifrontal and left temporal hemorrhagic contusions as described above. This is grossly stable to possibly slightly increased when compared to most recent prior exam. Continued close interval followup is recommended. 2. No evidence of hydrocephalus or shift of normally midline structures. [**11-22**] Head CT IMPRESSION: 1. Bifrontal hemorrhagic contusion appears stable compared to most recent prior with slightly increased vasogenic edema surrounding the left frontal contusion. Left temporal hemorrhagic contusion stable in size and appearance. 2. Subdural hematoma is noted layering over the left temporal lobe and within the left falx. 3. Subarachnoid hemorrhage is noted within the left frontal region. 4. No shift of normally midline structures. -[**2193-11-28**] 04:55AM BLOOD WBC-15.6* RBC-5.05 Hgb-14.8 Hct-44.2 MCV-88 MCH-29.3 MCHC-33.5 RDW-12.6 Plt Ct-470* -[**2193-11-25**] 06:05AM BLOOD PT-14.4* PTT-25.0 INR(PT)-1.2* -[**2193-11-28**] 04:55AM BLOOD Glucose-94 UreaN-20 Creat-1.2 Na-134 K-4.2 Cl-101 HCO3-22 AnGap-15 -[**2193-11-28**] 04:55AM BLOOD Calcium-9.1 Phos-3.9 Mg-2.3 Brief Hospital Course: Pt was BIBA to [**Hospital1 18**] ER s/p fall off of ladder with LOC. He was admitted to the trauma team for the first 24 hours. He was then taken over by the neurosurgery service as he was an isolated head injury. CT scan in the ED revealed bifrontal contusions with left sdh. He was given a six pack of plts in the ED as he was taking asa 325mg daily. He was also loaded with Dilantin for sz prophylaxis. On arrival it was also noted that he had afib/aflutter with RVR. This continued intermittently throughout his hospital stay, requiring cardiology consult. He required ICU care for titration of Diltiazem and Amiodarone drip. His rate was eventually controlled with Amiodarone 400 mg PO and Diltiazem 60 mg PO. An echo showed mild pulm artery systolic HTN with R ventricular/R+L atrial enlargement. Mr [**Known lastname 39859**] should follow up with Cardiology in 2 weeks for ablation. On trauma evaluation a CT scan of the chest was performed. The findings indicate that the pt has a pulmonary nodule that requires outpt follow up. On [**11-19**] patient was to be transferred to the step down unit with a 1:1 sitter; however, patient went We requested psychiatry due to his impulsive behavior. Psychiatry they titrated his Lithium dose for his known bipolar disorder. . We have also discussed this with his psychiatrist, Dr [**Last Name (STitle) **] at [**Hospital 1191**] hospital who stated patient has dx of atypical bipolar and does not need the Lithium with his current head injury but should resume after he has recovered from these injuries. His mental status, behavior issues and appetite improved on daily basis. PT and OT recommended acute rehabilitation for the patient. On [**12-2**] pt was neurologically stable and was transferred to [**Hospital1 **]. Medications on Admission: Medications prior to admission: Atenolol 50mg po daily asa 325 po daily lisinopril 5mg po daily Discharge Medications: 1. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily). 7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 9. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Olanzapine 10 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO QHS (once a day (at bedtime)) as needed for anxiety. 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). 14. Ondansetron 4 mg IV Q8H:PRN nausea 15. Metoprolol Tartrate 5 mg IV Q3H:PRN SBP>160 or hr>100 Hold for SBP<100, hr<60 16. HYDROmorphone (Dilaudid) 0.5-2 mg IV Q3H:PRN breakthrough pain 17. Lithium Carbonate 300 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO BID (2 times a day): please note: this medication was re-started today....he has not yet received a dose. . Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: TRAUMATIC BRAIN INJURY BIFRONTAL CONTUSIONS LEFT FRONTAL SUBDURAL HEMATOMA DIASTHESIS OF RIGHT OCCIPITAL MASTOID SUTURE ATRIAL FIBRILLATION Discharge Condition: Mental Status:Confused - sometimes Level of Consciousness:Alert and interactive Activity Status:Ambulatory - requires assistance or aid (walker or cane) 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, or Ibuprofen etc. ?????? If you have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion, lethargy 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. ?????? New onset of the loss of function, or decrease of function on one whole side of your body. Followup Instructions: **** YOU NEED TO FOLLOW UP WITH YOUR PRIMARY CARE PHYSICIAN WITHIN TWO WEEKS OF YOUR ARRIVAL HOME / TO BE DISCUSSED - PULMONARY NODULES THAT NEED RADIOGRAPHIC FOLLOW UP IN THREE MONTHS - ATRIAL FIBRILLATION - CONTROL OF YOUR BLOOD PRESSURE - FOLLOW UP OF ECHOCARDIOGRAM - FOLLOW UP OF ADRENAL GLANDS / NOTED ON CT CHEST/ABD Follow-Up Appointment Instructions ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**First Name (STitle) **], to be seen in 4 weeks. ??????You will need a CT scan of the brain without contrast prior to your appointment. This can be scheduled when you call to make your office visit appointment. Please follow up with cardiology in [**12-7**] weeks to discuss ablation. Call [**Telephone/Fax (1) 62**]. Per Dr. [**Known firstname **] [**Last Name (NamePattern1) 349**] - Follow up with your psychiatrist [**Telephone/Fax (1) 39860**] Dr [**Last Name (STitle) 39339**] to discuss resuming Lithium or page through [**Hospital 1191**] Hospital [**0-0-**]. Completed by:[**2193-12-2**]

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icd9cm

[ [ [] ] ]

[ "38.91", "38.93" ]

icd9pcs

[ [ [] ] ]

7541, 7611

4088, 5874

363, 370

7795, 7795

2480, 4065

9049, 10095

1140, 1153

6021, 7518

7632, 7774

5900, 5900

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2394, 2461

279, 325

398, 922

1746, 2380

7809, 7950

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1032, 1124

79,687

141,557

48790

Discharge summary

report

Admission Date: [**2150-6-8**] Discharge Date: [**2150-6-12**] Date of Birth: [**2078-5-22**] Sex: F Service: MEDICINE Allergies: Plavix / Diovan Attending:[**First Name3 (LF) 2387**] Chief Complaint: melena Major Surgical or Invasive Procedure: Gastric endoscopy Cardioversion History of Present Illness: This is a 72 year old female with history of coronary artery disease with multiple stents most recently at OSH in [**Doctor Last Name 13548**]2 months ago, on ticlopidine for stents and warfarin for atrial fibrilllation, now presenting with single noted episode of melena on day of presentation. Over the course of the week prior to hospitalization, Ms [**Known lastname **] experienced increasing light-headedness, dizziness, and fatigue. Ordinarily is a functional, active woman; however over the past week her fatigue has limited her usual activities. Over the past three days she has also endorsed shortness of breath on exertion but no cough, orthopnea, PND, or lower extremity edema. On day of admission she had loose stools in the morning with dark stool but no bright red blood per rectum. She denied any abdominal pain, nausea, vomiting, hematemesis. No fevers, chills, syncope, chest pain/pressure. Review of systems otherwise negative. She presented to the emergency department for these complaints and was found to have an INR of 2.8 and Hct 21. She was started on IV PPI and given 10 mg PO Vit K. NG lavage was deferred. She was hemodynamically stable. She was transferred to the CCU for further workup. Past Medical History: CAD, s/p multiple PCI's and MI x 2, recent NSTEMI summer [**2148**], s/p STEMI and mid-LAD stent [**2140**] and distal LAD angioplasty, s/p RCA stent and large D1 stent [**4-/2146**]; also supposedly has stents placed ealier this spring in [**State 792**]hospital 3. OTHER PAST MEDICAL HISTORY: STEMI [**2140**] s/p stent to mid-LAD [**2140**], and RCA, large D1 [**2145**] [**Hospital 792**]hospital stent: [**Telephone/Fax (1) 102531**] Atrial fibrillation on Tikosyn [**4-/2147**] for failred cardioversion Congestive heart failure Rheumatic mitral valve disease with 2-3+ MR b/l Renal artery stenosis Abnormal LFT??????s, ?pericholangitis Mild obstructive lung disease Thyroid disease (not currently on medicine) Remote surgery for a blocked left breast duct Prior TIA's- last episode was at least 5 years ago Right leg varicose vein surgery Removal of a benign colon polyp Constipation GERD Social History: -Tobacco history: Patient smoked 1 pack a day for approximately 35 years, quitting 16 years ago -ETOH: social -Illicit drugs: Denies. -Formerly worked as telephone operator/receptionist, currently retired -Exercises swim 3x/wk, walks without getting SOB Family History: Father died of CAD at 58. Mother had a pacemaker, died of ?MI in 70's. Daughter died of lung CA. Sister had two prior [**Name (NI) 27141**], first in her 50's, also with h/o Rheumatic fever and MI. Physical Exam: VS: HR 68 sinus, 96/56, afebrile, RR 12 GEN: Sitting up in bed in NAD HEENT: Anicteric Cardiac: RRR, systolic murmur loudest at left lower sternal border Resp: lungs clear bilaterally Abd: soft NT ND Ext: no edema noted Pertinent Results: Admission labs: [**2150-6-8**] 01:30PM BLOOD WBC-6.1 RBC-2.35*# Hgb-6.8*# Hct-21.3*# MCV-91 MCH-29.0 MCHC-32.0 RDW-16.2* Plt Ct-231 [**2150-6-8**] 01:30PM BLOOD PT-28.3* PTT-28.9 INR(PT)-2.8* [**2150-6-8**] 01:30PM BLOOD Glucose-140* UreaN-27* Creat-1.2* Na-136 K-3.9 Cl-106 HCO3-20* AnGap-14 [**2150-6-8**] 01:30PM BLOOD ALT-108* AST-75* LD(LDH)-159 AlkPhos-147* TotBili-0.2 . Discharge labs: [**2150-6-12**] 07:40AM BLOOD WBC-4.4 RBC-3.05* Hgb-9.2* Hct-28.6* MCV-94 MCH-30.3 MCHC-32.3 RDW-16.9* Plt Ct-156 [**2150-6-12**] 12:40PM BLOOD PT-14.2* INR(PT)-1.2* [**2150-6-12**] 07:40AM BLOOD Glucose-98 UreaN-18 Creat-1.1 Na-140 K-4.5 Cl-109* HCO3-22 AnGap-14 . [**2150-6-9**] H.pylori antibody negative . [**2150-6-8**] CXR: There may be a new small left pleural effusion. Heart size top normal, has increased, and vascular engorgement of both hila is longstanding. There is no pulmonary edema or pneumonia. . [**2150-6-9**] EKG: Atrial fibrillation with a rapid ventricular response, new as compared with prior tracing of [**2150-6-8**]. . [**2150-6-9**] EGD: Impression: Erythema, congestion and erosion in the antrum compatible with gastritis Small hiatal hernia Otherwise normal EGD to third part of the duodenum Recommendations: please check HP Abs. Brief Hospital Course: This is a 72 year old female with a history of coronary artery disease s/p multiple PCIs most recently 2 months ago at OSH, now presenting with anemia with HCT of 21 and melena on day of admission with symptoms of lightheadedness and fatigue extended back the week prior to admission. . # Anemia: In the setting of dark stool, likely melena from upper GI source. Patient had EGD that showed gastritis. Patient was also transfused several units of blood. HCT was stable prior to discharge. Patient to have colonoscopy and capusule study as outpatient. Patient's coumadin was held and she was restarted on coumdain at discharge . # Coronary artery disease - History of multiple stents and PCI in the past; would continue on aspirin, statin, and metoprolol. Due to bleed, ASA was decreased to 81mg po qday . # Atrial fibrillation - Paroxysmal, anticoagulated with warfarin. Patient had episode of atrial fibrillation while hospitalized. She had cardioversion. She was continued on coumadin after EGD and remained on dofetalide. . # Congestive Heart failure - Echo per [**2148**] has depressed EF to 45% likely in setting of multivessel CAD; also has MR likely secondary to rheumatic mitral valve history. Patient to continue on lasix as outpatient. Lisinopril was temporarily held [**1-27**] low blood pressures. Her cardiology, Dr. [**Last Name (STitle) **], [**First Name3 (LF) **] restart lisinopril when indicated. . # TIAs - Continue ticlodipine . # Pericholangitis - Continue ursodiol Medications on Admission: -aspirin 325 mg daily -Ursodiol 300 mg Cap TID -Lisinopril 2.5 mg daily -Lipitor 80 mg Tab daily -Tikosyn 500 mcg Cap [**Hospital1 **] -Calcium Carbonate-Vitamin D3 500 mg (1,500)-200 unit Tab daily -Multivitamin qAM -Metoprolol Tartrate 25 mg Po twice daily -Furosemide 20 mg Tab MWF -Nitrostat 0.4 mg Sublingual Tab PRN -Colace 100 mg Cap [**Hospital1 **] -Warfarin 4 mg Tab 1-1.5 Tablet(s) by mouth on tues, Wed, Fri, Sat and Sun. Warfarin 2mg on Mon and thurs. -Ticlodipine 250 mg [**Hospital1 **] Discharge Medications: 1. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Calcium 600 + D(3) 600 mg(1,500mg) -200 unit Tablet Sig: One (1) Tablet PO once a day. 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Multivitamin Capsule Sig: One (1) Capsule PO once a day. 6. 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* 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO MWF (Monday-Wednesday-Friday). 8. Nitrostat 0.4 mg Tablet, Sublingual Sig: One (1) tablet Sublingual as directed as needed for chest pain. 9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 10. Outpatient Lab Work Please check CBC and INR on [**2150-6-15**] and call results to Dr. [**Last Name (LF) 102532**],[**First Name3 (LF) **] M. at [**Telephone/Fax (1) 20306**] 11. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 13. Ticlopidine 250 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) packet PO DAILY (Daily) as needed for constipation. 15. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice a day. 16. Ferrous Sulfate 325 mg (65 mg Iron) Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day. 17. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: Take 2 tablets (4mg total) on Mon and thursday. 18. Dofetilide 500 mcg Capsule Sig: One (1) Capsule PO twice a day. Discharge Disposition: Home With Service Facility: Community VNA, [**Location (un) 8545**] Discharge Diagnosis: Gastritis Gastrointestinal Bleeding Coronary Artery Disease chronic systolic congestive Heart Failure Atrial fibrillation: currently in normal sinus rhythm Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You had some bleeding from your gastrointestinal tract. It has stopped but we were not able to tell exactly where the bleeding was coming from. Therefore, you will need to see a gastroenterologist soon to discuss further testing. You should also watch your stools and call your primary care doctor if you notice that your stools are dark black, loose or if they have blood. Please also call for increasing fatigue or trouble breathing like you had before you were admitted. WE restarted your coumadin at you home dose. Please get your INR checked on Monday [**6-15**]. Weigh yourself every morning, call Dr. [**Last Name (STitle) **] if weight goes up more than 3 lbs in 1 day or 6 pounds in 3 days. . Medication changes: 1.Start pantoprazole twice daily to help to heal the erosions in your stomach 2. Start folic acid, ferrous sulfate (Iron) and vitamin C to help your body make more red blood cells. 3. Decrease the aspirin to 81 mg daily 4. continue on your home dosing of Warfarin. Your INR on [**6-12**] was 1.2. 5. stop Lisinopril for now because your blood pressures have been low. Dr. [**Last Name (STitle) **] can restart this in a few weeks. . Please talk to Dr. [**Name (NI) **]_Bensson about a gastroenterologist to see for the colonoscopy and capsule endoscopy. You may have to return to [**Hospital1 18**] for the capsule endoscopy if that is not available in your area. Followup Instructions: Gastroenterology: Will need colonoscopy and capsule endoscopy as outpatient. . Liver Center: When: THURSDAY [**2150-7-9**] at 8:00 AM With: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 3688**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2422**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage . Vascular: Department: VASCULAR SURGERY When: MONDAY [**2151-3-29**] at 9:30 AM With: VASCULAR LAB [**Telephone/Fax (1) 1237**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage AND Department: VASCULAR SURGERY When: MONDAY [**2151-3-29**] at 10:50 AM With: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD [**Telephone/Fax (1) 1237**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage . Primary Care: Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 102533**],MD When: Friday [**6-19**] at 11:30am Location: [**Hospital **] MEDICAL ASSOCIATES Address: [**Street Address(2) 57526**], [**Location (un) **],[**Numeric Identifier 14085**] Phone: [**Telephone/Fax (1) 20306**] Please talk to Dr. [**Doctor Last Name **] about a gastroenterologist to see for the colonoscopy and capsule endoscopy. You may have to return to [**Hospital1 18**] for the capsule endoscopy if that is not available in your area. . Cardiology: Name: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Specialty: Cardiology When: Monday [**7-13**] at 10:45am Location: [**Location (un) 10877**], [**Street Address(1) **], MA Phone: [**Telephone/Fax (1) 7960**] Completed by:[**2150-6-12**]

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icd9cm

[ [ [] ] ]

[ "99.61", "45.13" ]

icd9pcs

[ [ [] ] ]

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282, 316

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3246, 3246

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2788, 2989

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Discharge summary

report

Admission Date: [**2124-3-29**] Discharge Date: [**2124-4-8**] Date of Birth: [**2063-8-7**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4765**] Chief Complaint: Syncope. Major Surgical or Invasive Procedure: Percutaneous transvenous clot extraction from pulmonary artery. Removal of internal cardioverter difibrillator. Removal of PICC line with placement of Swan-Ganz catheter to prevent further pulmonary embolism. New PICC line placement because nafcillin cannot be used by midline. History of Present Illness: Mr. [**Known lastname **] is a 60-year-old man with dilated non-ischemic cardiomyopathy (clean cath.; LVEF 15%), with ICD placement and removal after complication by MSSA endocarditis, undergoing antibiotic therapy at rehabilitation, presenting to [**Hospital1 18**] after a syncopal episode. Mr. [**Known lastname **] has been at [**Hospital3 **] for about one week, where he has been receiving oxacillin for his endocarditis. Just after lunch today, Mr. [**Known lastname **] was watching television with family when his 'eyes rolled back in his head' and he lost consciousness. Staff described him as [**Doctor Last Name 352**] with agonal breathing and pinpoint pupils. He was placed on a non-rebreather. Blood sugar was 111. Tele strips at the time demonstrate AFib with HR about 38. Documentation of the event varies. [**Name6 (MD) **] the MD note, he regained consciousness and was coherent within 60 seconds. Per the nursing staff, he gained awareness within 10 minutes but could not recall what had happened. BP immediately after event was 80/40 with pulse 70-90. He was given 500cc NS bolus and a dose of 2g IV cefepime. Upon arrival to the ED, initial vitals were 98.0 101/67 100 18 100% NRB. He was given flagyl 500mg IV and zosyn 4.5g IV. He became hypotensive to 88/61 and received 1L of IVF and was started on a levophed gtt. A left groin CVL was placed. Work-up revealed a right central PE with concern for wedge infarct. Given that his INR was elevated at 5, he was not considered a candidate for thrombolysis. He was therefore transferred to the cath lab for possible thrombectomy. In the cath lab, a right heart cath showed pulmonary HTN and pulmonary angiogram was done, demonstrating embolic occlusion of subsegmental branch in the right middle lobe. A thrombectomy was performed with restoration of blood flow. The team then placed a retrievable IVC filter (although there was no visible clot in the right iliac vein). Upon arrival to the CCU, Mr. [**Known lastname **] [**Last Name (Titles) **] chest pain, shortness of breath, or cough. Apart from being quite sweaty, he feels like his normal self. Past Medical History: 1. Non-ischemic cardiomyopathy - Diffuse, global hypokinesis, LVEF 15% on [**2-/2124**] TTE - Cardiac catheterization in [**2118**] wnl. - s/p dual chamber guidant ICD implanted [**2120-3-25**] by [**Last Name (un) 31148**] Koplan at [**Hospital3 **]; s/p lead extraction on [**2124-3-22**] (given endocarditis/lead infection)/ 2. Endocarditis: TEE on [**2124-3-13**] showed vegetations on the tricuspid valve (1.3cm) and ICD wire (1.2). There was also concern for < 1cm echodensity on aortic valve. 3. Atrial fibrillation, on coumadin 4. h/o NSVT 5. Embolic event to right lower extremity in [**12/2123**] 6. Non-insulin dependent diabetes mellitus -- patient [**Year (4 digits) **] 7. h/o diverticulitis complicated by peri-colonic abscess ([**2-/2124**]) - drained by IR [**3-9**], drain removed [**3-17**] - Cx grew [**Female First Name (un) **] albicans, and he was treated w/ fluconazole [**Date range (1) 60921**] 8. Hyperlipidemia 9. Hypertension 10. GERD 11. Anxiety Social History: Patient used to be a PE teacher for an elementary school in [**Hospital1 8**]. He has been married for 39 years and has 6 grandchildren. He never smoked and drinks ~5 bottles of beer/week. Family History: Mother with DM, alive at age 85. Father died of lung CA. No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: VS: 97.3 90/62 93 26 96% 2L GENERAL: Overweight man who is smiling but profusely sweaty. HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of [**6-6**] cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. Irregularly irregular. Soft systolic murmur at LLSB. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Obese. Wound dressing at prior drain site in LLQ. Bowel sounds present. Soft and not tender. No mass appreciated. EXTREMITIES: +pitting LE edema b/l. PULSES: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ On the day of discharge, vital signs were: 97.6 (max. 97.9) F, 108/78 (91/74 - 116/81) mmHg, 100 (artifactually low [**Location (un) 1131**] of 41 in context of ectopy - 100) BPM, RR of 22 (minimum 20) and 94 % hemoglobin saturation on room air. Telemetry revealed two runs of ventricular tachycardia of 30 beats, both near 5 p.m. last night. Physical exam findings were essentially unchanged, but for transmitted upper airway sounds of loose mucus. No consolidation or other signs of infection. Pertinent Results: ADMISSION: [**2124-3-29**] 02:40PM BLOOD WBC-14.2* RBC-3.29* Hgb-10.2* Hct-32.2* MCV-98 MCH-31.0 MCHC-31.7 RDW-15.6* Plt Ct-249# [**2124-3-29**] 02:40PM BLOOD Neuts-88.1* Lymphs-6.8* Monos-4.7 Eos-0.2 Baso-0.2 [**2124-3-29**] 04:30PM BLOOD PT-49.9* PTT-40.3* INR(PT)-5.5* [**2124-3-29**] 02:40PM BLOOD Glucose-105* UreaN-9 Creat-0.9 Na-135 K-4.2 Cl-98 HCO3-29 AnGap-12 [**2124-3-30**] 03:08AM BLOOD ALT-25 AST-18 LD(LDH)-249 CK(CPK)-9* AlkPhos-98 TotBili-0.7 [**2124-3-30**] 03:08AM BLOOD Calcium-7.7* Phos-3.3 Mg-1.7 [**2124-3-30**] 03:18AM BLOOD %HbA1c-6.9* eAG-151* [**2124-3-29**] 03:10PM BLOOD Lactate-1.3 [**2124-3-29**] 03:10PM BLOOD Lactate-1.3 DISCHARGE: [**2124-4-8**] 06:00AM BLOOD WBC-10.4 RBC-3.83* Hgb-11.6* Hct-38.1* MCV-100* MCH-30.3 MCHC-30.5* RDW-17.7* Plt Ct-345 [**2124-4-7**] 07:20AM BLOOD PT-19.6* PTT-58.8* INR(PT)-1.8* [**2124-4-7**] 07:20AM BLOOD Glucose-114* UreaN-6 Creat-0.9 Na-140 K-4.4 Cl-103 HCO3-29 AnGap-12 [**2124-3-29**] 02:40PM BLOOD cTropnT-0.02* [**2124-3-30**] 03:08AM BLOOD CK-MB-NotDone cTropnT-0.02* REPORTS: CTA CHEST [**2124-3-29**]: 1. Large pulmonary embolism involving distal right main pulmonary artery extending into all lobes of the right lung. Occlusion is complete in the right upper lobe posterior segment, and partially elsewhere. Wedge posterior right upper lobe parenchymal abnormality suggestive of pulmonary infarct. No CT evidence of right ventricular heart strain. 2. No acute aortic pathology. 3. Bilateral pleural effusions with overlying atelectasis. 4. Left upper lobe consolidation. Other pulmonary nodular opacities as above, measure up to 7 mm. Findings could be infectious, but recommend short-term followup in three-to-six months after appropriate treatment to assess for stability/resolution and exclude neoplastic process. 5. Possible trace perisplenic fluid, not well or fully assessed. CARDIAC CATH [**2124-3-29**]: 1. Access was obtained at the left femoral vein using an 8 Fr short sheath. 2. Right pulmonary angiography was performed through a 5 Fr JR4 catheter. This showed an occlusive embolus in a right subsegmental branch. We exchanged the catheter to a 6 Fr MPA1 guide catheter and attempted to aspirate material. Aspirate was sent for microbiologic culture. Partial restoration of flow occurred. We next advanced a Prowater wire across the embolus and activated an Export AP aspiration thrombectomy catheter over several passes. Flow to the pulmonary segment improved substantially and the residual embolic material was left. 3. Venography performed via the left femoral vein sheath showed no apparent thrombus in the left iliac vein, proximal right iliac vein, or IVC. 4. An Optease Vena Cava filter was deployed in the IVC below the renal veins. FINAL DIAGNOSIS: 1. Pulmonary embolus. 2. Partial embolectomy performed. 3. Placement of an IVC filter. CT ABDOMEN [**2124-3-30**]: 1. Inflammatory changes surrounding sigmoid colon, consistent with acute diverticulitis. 2.9 cm intramural loculated air collection, some of which may be extraluminal. As this is surrounded by small bowel loops, this is not amendable to percutaneous drainage. 2. Findings that are consistent with third spacing, including anasarca, ascites, retroperitoneal fluid and effusions. 3. Gallbladder wall thickening is presumed to be related to the same process, however, further evaluation with son[**Name (NI) **] followup is recommended. 4. Bladder wall thickening, in part related to decompressed bladder state. Correlate with urinalysis. BL LE U/S [**2124-3-30**]: FINDINGS: Grayscale, color and Doppler images were obtained of bilateral common femoral, superficial femoral, popliteal and tibial veins. There is normal flow, compression and augmentation seen in all of the vessels. IMPRESSION: No evidence of deep vein thrombosis in either leg. BL UE U/S [**2124-3-30**]: IMPRESSION: Extensive thrombus surrounding the IV line within the left arm extending from the antecubital fossa to the left axillary vein. No other deep vein thrombosis seen in the right arm. ECHO [**2124-3-31**]: The left atrium is moderately dilated. The right atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is severe global left ventricular hypokinesis (LVEF = 15-20%). The right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. No masses or vegetations are seen on the aortic valve. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. There is a large (3.0 x 1.3 cm) highly-mobile verrucous tricuspid valve vegetation. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. No vegetation/mass is seen on the pulmonic valve. There is a small pericardial effusion. IMPRESSION: Large tricuspid valve vegetations. Moderate to severe tricuspid regurgitation. Dilated left ventricle with severe global systolic dysfunction. Moderate global right ventricular systolic dysfunction. Moderate pulmonary hypertension. CARDIAC CATH [**2124-4-3**]: 1. Access was obtained at the right femoral vein. A 5 Fr 55cm [**Last Name (un) **] sheath was advanced. An Amplatz Gooseneck snare was advanced and used to capture the Optease IVC filter without difficulties. 2. We next turned our attention to removing the PICC from the right brachial vein. Through the [**Last Name (un) **] sheath in the right femoral vein, we advanced a 4 Fr JR4 catheter over a wire to the right subclavian vein. Venography with partial retrograde filling revealed thrombus. We then inserted an 0.032" wire through the PICC lumen and removed the PICC. A 4 Fr short sheath was inserted over this wire. Venography through this sheath also showed extensive thrombus from the brachial to axillary. There was a long segment of occlusion with a large collateral vein bypassing it. We exchanged the brachial sheath to a 5 Fr 45cm [**Doctor Last Name **] 0 over a Choice PT ES wire to perform Angiojet thrombectomy. Via the right femoral vein sheath, we advanced a [**Doctor Last Name 4726**] Flow reversal balloon tipped catheter to the subclavian and inflated the balloon until cessation of flow occurred. We then performed Angiojet thrombectomy using a XVG catheter. Mild improvement in flow occurred. However, large thrombi remained. We performed balloon dilations of the occlusive segment using a 4.0x120mm Aphirion balloon at 8 atms and a 5.0x120mm Submarine balloon at 4 atms and a 6.0x120mm Submarine balloon at 3 atms. Venography showed a stenosis in the subclavian vein that we dilated using an 8x40mm Admiral balloon at 3 atms. Final venography showed persistent thrombi and slow flow in the previously occluded segment. Flow through the collateral vein was preserved. FINAL DIAGNOSIS: 1. IVC filter retrieval. 2. PICC removal. 3. Right upper extremity deep venous thrombosis. CTA CHEST [**2124-4-5**]: Overall little interval change since [**2124-3-30**]. 1. Inflammatory changes about the sigmoid colon with colonic wall thickening and air collection in the region of the proximal sigmoid colon which may be intramural/extramural is consistent with diverticulitis and is unchanged since [**2124-3-30**]. 2. Bilateral pleural effusions right greater than left unchanged since [**2124-3-30**]. 3. Ascites and retroperitoneal stranding is unchanged since [**2124-3-30**]. CXR [**2124-4-7**]: CHEST, AP: A new left PICC terminates 1-2 cm beyond the cavoatrial junction. There is no pneumothorax. Left lower lobe atelectasis has worsened, and a loculated right effusion is increased. Multiple pulmonary nodules are present. Moderate cardiomegaly is unchanged. IMPRESSION: Left PICC 1-2 cm beyond cavoatrial junction. Increased left lower lobe atelectasis and right effusion. Brief Hospital Course: Mr [**Known lastname **] is a 62-year-old man w/ alcoholic CHF, AICD placement, c/b endocarditis, AICD removed, PICC line placed for Rx, with subsequent clot around PICC, despite anticoagulation, who presented with dyspnea, hypotension, atrial fibrillation and was found to have a PE. Right PICC removed and intravenous heparin treatment commenced. Pulmonary embolism/DVT He presented with a PE in the setting of a supratherapeutic INR. He underwent thrombectomy and was started on a heparin drip, and an IVC filter was placed prophylactically. His PE was thought to be embolic from fibrous material on his mitral valve from his endocarditis. However, PICC line-associated DVT was also noted and may be a more likely source of emboli. His PICC was removed in the cath lab with use of a Swan-Ganz catheter and clot retrieval to reduce further pulmonary thromboembolism. However, a second PICC was placed on the contralateral side prior to discharge for continuation of nafcillin for his MSSA endocarditis. The IVC filter was removed after lower extremity ultrasound did not reveal thrombus. Coumadin was restarted after these procedures and when his INR was again just below 2, restarted on [**2124-4-7**]. Hem.-Onc. recommended a hypercoagulability workup if ever he is not anticoagulated. Given recurrent thrombosis, he ought be treated with coumadin life-long, also indicated by atrial fibrillation in this patient. Therefore, this will only be important for the purpose of determining genetic risk. More importantly, he will need age-appropriate cancer screening, including colonoscopy and PSA. CT torso did not reveal evident neoplasia. Endocarditis This developed in the context of AICD placement given dilated cardiomyopathy and depressed ejection fraction for primary prevention of serious arhythmia. The AICD was removed on [**3-20**] and the endocarditis was complicated by valvular incompetentence/destruction. He was initially on broad spectrum antibiotics but eventually put on nafcillin. A repeat cardiac echo demonstrated enlargement of vegetations and cardiothoracic surgery was consulted but felt that he was not a candidate for valvular revision or debridement. ID recommended continuing nafcillin until [**4-18**] and he will follow-up with the [**Hospital **] clinic on [**2124-5-5**]. Diverticulosis This was seen on abdominal CT and he was briefly given levofloxacin and flagyl. A repeat abdominal CT demonstrated no significant changes and his antibiotics were stopped. He had no abdominal pain. Systolic Heart Failure/NSVT He has chronic systolic heart failure with an LVEF 15-20%. He was continued on metoprolol and lisinopril, and his ICD was removed as above. He was seen by the electrophysiology service and they recommended that he must wear a lifevest at rehab, and that he does not need to be followed on telemetry provided he is wearing his lifevest. Given the possible expense of the life-vest, often not covered by insurance in acute settings, such as LTAC, this may be revisited by LTAC physicians, in conjunction with electrophysiology and the patient. We would only recommend that this continue where there is not continuously monitored telemetry. Electrolytes, particularly potassium and magnesium should be followed closely, daily initially, to insure that his chances of ventricular arhythmia are reduced. Atrial Flutter He was continued on metoprolol and anticoagulated. Dyslipidemia Continued simvastatin. Medications on Admission: Warfarin Lisinopril 2.5mg daily (although unclear if 1.25mg) Carvedilol 25mg [**Hospital1 **] (was 25mg in AM and 50mg in PM at dc) Digoxin 125mcg daily Furosemide 20mg daily Simvastatin 40mg QHS Lansoprazole 30mg daily Glipizide 2.5mg daily (was not on this at dc) Docusate 100mg [**Hospital1 **] Magnesium oxide 400mg [**Hospital1 **] MVI with minerals daily Niacin 500mg QHS Trazodone 25mg QHS prn Oxycodone 2.5mg prior to PT/OT (not being given) Tylenol 650mg Q4H prn Lorazepam 0.5mg Q9H prn Lidoderm patch 5% daily (new) Oxacillin 2g IV Q4H (this had been given in rehab. but there was some initial concern that this had not been given) Discharge Medications: 1. Digoxin 125 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 2. Simvastatin 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at bedtime). 3. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 4. Nafcillin in D2.4W 2 gram/100 mL Piggyback [**Last Name (STitle) **]: Two (2) GM Intravenous Q4H (every 4 hours): Last dose [**2124-4-18**] or until ID recommends otherwise . 5. 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. 6. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 7. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and PRN. 8. 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. Warfarin 1 mg Tablet [**Month/Day/Year **]: Three (3) Tablet PO Once Daily at 4 PM. 10. Niacin 500 mg Capsule, Sustained Release [**Month/Day/Year **]: One (1) Capsule, Sustained Release PO HS (at bedtime). 11. Multivitamin,Tx-Minerals Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY (Daily). 12. Trazodone 50 mg Tablet [**Month/Day/Year **]: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 13. Aspirin 81 mg Tablet, Chewable [**Month/Day/Year **]: One (1) Tablet, Chewable PO DAILY (Daily). 14. Acetaminophen 325 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 15. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Month/Day/Year **]: One (1) Inhalation Q6H (every 6 hours) as needed for congestion. 16. Ipratropium Bromide 0.02 % Solution [**Month/Day/Year **]: One (1) Inhalation Q6H (every 6 hours) as needed for congestion. 17. Lisinopril 5 mg Tablet [**Month/Day/Year **]: 0.5 Tablet PO DAILY (Daily). 18. Lorazepam 0.5 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. 19. Loperamide 2 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO QID (4 times a day) as needed for after each loose stool. 20. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup [**Month/Day/Year **]: Five (5) ML PO Q6H (every 6 hours) as needed for cough. 21. Metoprolol Tartrate 50 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO BID (2 times a day). 22. Insulin Lispro 100 unit/mL Solution [**Month/Day/Year **]: One (1) Subcutaneous ASDIR (AS DIRECTED): Sliding scale. 23. Ondansetron 4 mg Tablet, Rapid Dissolve [**Month/Day/Year **]: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for Nausea. 24. Heparin (Porcine) in NS 10 unit/mL Kit [**Month/Day/Year **]: One (1) Intravenous Continuous: To treat PE. Goal PTT 60-100. Today's PTT ([**2124-4-8**]) is 98. . Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital- [**Hospital1 8**] Discharge Diagnosis: Pulmonary Embolus Deep venous thrombosis Line infection Infectious endocarditis Ventricular tachycardia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure to take care of you here at [**Hospital1 18**]. You were admitted to the hospital for a pulmonary embolus, or blood clot in your lung. This was thought to be due to a piece of the infection on your heart valve breaking off and blocking the arteries to the lungs. This clot was removed during a cardiac catheterization. There was also an infection of your PICC line. You will need to be on blood thinners for the rest of your life. It is critical to your health to wear your lifevest at all times. We have made the following changes to your medications: STOP taking carvedilol START taking metoprolol START albuterol and ipratropium nebulizers as needed for shortness of breath START taking a daily baby aspirin START ativan as needed for anxiety Continue nafcillin until [**2124-4-18**] Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs in 1 day or 6 pounds in 3 days. Followup Instructions: Infectious Disease: Provider: [**First Name8 (NamePattern2) 4021**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2124-5-5**] 10:00 . Primary Care: [**Last Name (LF) **],[**First Name3 (LF) **] M. Phone: [**Telephone/Fax (1) 26774**] Date/time: . Elecrophysiology: [**First Name8 (NamePattern2) **] [**Known firstname **], MD [**First Name (Titles) **] [**Hospital3 2568**]. Phone: Date/time:

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icd9cm

[ [ [] ] ]

[ "88.67", "38.7", "88.63", "37.21", "88.43", "39.79", "88.51" ]

icd9pcs

[ [ [] ] ]

20640, 20710

13490, 16958

322, 601

20858, 20858

5444, 8185

21962, 22387

3992, 4166

17651, 20617

20731, 20837

16984, 17628

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4181, 5425

21583, 21939

274, 284

631, 2767

20873, 20985

2789, 3767

3783, 3976

80,688

113,630

54085

Discharge summary

report

Admission Date: [**2185-3-24**] Discharge Date: [**2185-3-27**] Date of Birth: [**2162-10-4**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1390**] Chief Complaint: trauma, MVC Major Surgical or Invasive Procedure: [**2185-3-24**] - Closed reduction and maxillomandibular fixation of Right angle left body mandibular fractures History of Present Illness: 22M s/p unrestrained MVC at approx 20MPH car vs siderail. Hit head against steering column and knee against dash. No loss of consciousness. ? etoh. Ambulatory at the scene. Patient reports pain in jaw, over the left lateral aspect of his foot and left knee. Past Medical History: PMH: NONE PSH: left wrist ORIF Social History: + etoh, + tobacco, denies illicts Family History: N/C Physical Exam: Admission exam: (see admission trauma sheet for further details) HEENT: significant mandible pain with palpation. moderate bilateral facial edema. blood in nares. CV: tachy, regular rhythm Resp: CTAB, no crepitus Abd: S/NT/ND. pelvis stable Ext: Left lower extremity with bruising and tenderness over lateral aspect of foot over the base of the 5th metatarsal. Some associated edema. No erythema, induration. able to extend knee against gravity, but does have tenderness to palp directly over patella, and a bulge of his quadriceps. . On discharge: T98.7F HR94 BP 160/100 RR18 Sat98RA GEN: NAD CV: RRR PULM: CTAB LE: LLE in brace. no edema or erythema Pertinent Results: [**2185-3-24**] 05:05AM WBC-14.8* RBC-4.76 HGB-16.7 HCT-47.9 MCV-101* MCH-35.1* MCHC-34.9 RDW-12.1 [**2185-3-24**] 05:05AM PLT COUNT-230 [**2185-3-24**] 05:05AM GLUCOSE-120* UREA N-12 CREAT-0.9 SODIUM-140 POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-20* ANION GAP-21* [**2185-3-24**] 05:05AM LIPASE-27 [**2185-3-24**] 05:20AM PT-12.9* PTT-24.7* INR(PT)-1.2* [**2185-3-24**] CT Head OSH Read: No ICH, no fracture [**2185-3-24**] CT Face OSH Read: acute right and left mandibular fx [**2185-3-24**] CT CSpine OSH Read: no fracture [**2185-3-24**] CT Chest OSH Read: No intrathoracic injury [**2185-3-24**] CT Abd OSH Read: No pelvic or abdominal injury [**2185-3-24**] Plain film L foot: Distracted fracture of the fifth metatarsal base. . [**2185-3-24**] Mandib plain film: There is a fracture through the angle of the right mandible with approximately 8 mm of lateral displacement and mild overriding. Per report, there is also a fracture of the left mandible as well. A nasotracheal tube is noted. Brief Hospital Course: Mr [**Known lastname 64592**] was transferred from OSH after an MVC with a mandibular fracture. Patient was initially admitted to the surgical floor on nasal cannula, managing his own secretions without difficulty. He was doing well for several hours on the floor, but mid-morning, he complained of increased facial/throat tightness. Given concern for airway compromise he was transferred to the Trauma ICU for urgent intubation. An awake, [**Last Name (un) **]-tracheal intubation was performed at the bedside in the ICU. Patient was taken to the OR with OMFS for bilateral mandible fracture repair. His mandible was wired closed and he was transferred back to the ICU intubated. On POD 1, his edema was significantly reduced and he was extubated. He tolerated this well, with O2 saturations of 99% on 2L nasal cannula. He was persistently tachycardic, though with a normal hematocrit this was considered likely from a pain and anxiety. On POD 2 the tachycardia resolved and he was transferred to the surgical floor and transitioned to all oral medications (liquid formulation) and tolerating a liquid diet. Patient will follow-up with OMFS in 4 days. Patient was also found to have a 5th metatarsal tuberosity fracture & likely partial quadriceps tendon tear. The orthopedic surgery evaluated him and recommended an air cast boot for the metatarsal fracture and knee immobilizer for partial quadriceps tear. Patient was discharged home with crutches after physical therapy evaluation and recommendations. Medications on Admission: none Discharge Medications: 1. chlorhexidine gluconate 0.12 % Mouthwash Sig: Five (5) ML Mucous membrane [**Hospital1 **] (2 times a day). Disp:*300 ML(s)* Refills:*2* 2. acetaminophen 650 mg/20.3 mL Solution Sig: Twenty (20) mL PO Q6H (every 6 hours) as needed for pain. Disp:*300 mL* Refills:*0* 3. oxycodone-acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4H (every 4 hours) as needed for pain. Disp:*300 ML(s)* Refills:*0* 4. amoxicillin-pot clavulanate 250-62.5 mg/5 mL Suspension for Reconstitution Sig: Ten (10) mL PO Q12H (every 12 hours) for 5 days. Disp:*100 mL* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Poly-Trauma: Bilateral mandible fractures Left 5th metatarsal fx Left partial quad tear Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for evaluation and treatment of your jaw (mandibular) fracture after a car collision. Because of the significant swelling in your jaw, you had to get a breathing tube . Your jaw was repaired and the breathing tube removed Keep wire cutters available at all times to release jaw wires in case of emergency. Please call your doctor or nurse practitioner if you experience the following: *New chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *Vomiting and cannot keep down fluids or your medications. *Dehydration due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *Blood or dark/black material when you vomit or have a bowel movement. *Burning when you urinate, blood in your urine, or urinary discharge. *Your pain doesn't improve in [**7-17**] hours or is not gone within 24 hours. Call or return immediately if your pain becomes severe, changes location or moves to your chest or back. *Shaking chills or fever greater than 101.5F or 38C. *An acute change in your symptoms, or new symptoms that concern you. *Increased pain, swelling, redness, or drainage from any incisions you may have. *Any of the warning signs listed below. Followup Instructions: OMFS follow-up: [**3-31**] 2:30pm at [**Hospital1 2177**]. [**Last Name (NamePattern1) **], [**Location (un) 6332**]. Yawkey ACC BLDG - [**Telephone/Fax (1) 28910**] Completed by:[**2185-3-27**]

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icd9cm

[ [ [] ] ]

[ "76.75", "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

4711, 4717

2557, 4067

315, 428

4849, 4849

1529, 2533

6329, 6526

837, 842

4122, 4688

4738, 4828

4093, 4099

4999, 6306

857, 1392

1406, 1510

264, 277

456, 715

4864, 4975

737, 770

786, 821

24,163

152,448

4534

Discharge summary

report

Admission Date: [**2159-12-16**] Discharge Date: [**2159-12-26**] Date of Birth: [**2083-8-18**] Sex: F Service: MEDICINE Allergies: Codeine / Heparin Agents / Ciprofloxacin / Keflex / Ranitidine / Gadolinium-Containing Agents / Amoxicillin / Vancomycin And Derivatives / Dilantin / Iodine; Iodine Containing / Clindamycin Attending:[**First Name3 (LF) 6195**] Chief Complaint: Abdominal pain, bloating. Major Surgical or Invasive Procedure: EGD with biopsy of duodenal mass CT guided biopsy of duodenal mass History of Present Illness: Ms. [**Known lastname 19314**] is a 76 year-old female with metastatic breast cancer on Femara and Megace, with a known duodenal mass followed with serial CT scans status post non-diagnostic endoscopic biopsy in [**2155**], who presents with a 5-day history of worsening abdominal pain and bloating. * She describes vague abdominal discomfort worsening over the past few days. She also describes associated bloating, and mild nausea now resolved. She denies emesis, no change in bowel habits. She has been able to eat over the past few days, albeit with somewhat decreased appetite. No complaint of early satiety, but overall mild anorexia. No fever or chills at home. She notes some weight gain over the past few months, attributed to Megace therapy. Of note, she was recently admitted for breast cellulitis, resolved on Clindamycin therapy. * In ED, T 99.3, HR 91, BP 148/62, RR 18, Sat 95% on RA. CT scan was remarkable for increase in duodenal mass, with ? hemorrhage. She was seen by surgery, with impression of GIST with hemorragic transformation versus metastatic breast cancer. Past Medical History: 1. Metastatic breast cancer. - Infiltrating mucinous carcinoma ER positive, HER2/neu negative, no lymphatic invasion, status post lumpectomy in [**2136**] (right breast) and XRT. - Status post lumpectomy in [**2154**] (left breast) and XRT. - Metastatic disease diagnosed in [**2157**], placed on Femara and Megace. 2. Duodenal mass, status post non-diagnostic endoscopic biopsy in [**2155**], followed with serial CT scans. Slow increase in size over the years. 3. Meningioma, status post excision X2 4. Dural AV fistula, status post coiling and multiple embolizations. 5. Mild chronic renal insufficiency 6. Status post cholecystectomy in [**2155**] 7. Status post TAH/BSO 8. History of seizure disorder 9. History of HIT 10. Paget's disease. Social History: Lives with her husband at home. Has no VNA but is interested in home PT. Children and grandchildren live nearby.Ex-smoker, she quit >20 years ago. No EtOH. Family History: -Father (d 60yo) - lung cancer, smoker, ?stroke -Mother (d [**Age over 90 **]yo) - unclear etiology of death -No other history of cancer; no FHx of diabetes, HTN, seizures Physical Exam: (at admission) VITALS: Tm 99.3, HR 86, BP 143/56, RR 24, Sat 96% on RA. GEN: Obese Caucasian female, in NAD. HEENT: Anicteric. MMM. NECK: JVP does not appear elevated. RESP: CTAB, with few bibasilar crackles. CVS: RRR. Normal S1, S2, No S3, S4. GI: Obese abdomen. BS present. Fullness in epigastrium, with mild diffuse tenderness, without rebound or guarding. DRE: Performed by ED resident, stools g-. EXT: Trace edema (upon transfer to Medicine service [**12-21**]) 97.9 80-118 102-135/56-83 RR 15-40 1605/700 Gen: lying in bed, pleasant, optimistic, somewhat tachypneic iwth talking HEENT: no LAD, MMM, NCAT Cor: s1s2, I/VI systolic murmur heard best at LUSB nonradiating Pulm: CTA R, mild wheeze on L [**12-3**] way up from base Abd: distended, high pitched BS, tender to palpation Ext: no c/c/e skin: no rash Pertinent Results: admission labs: GLUCOSE-119* UREA N-19 CREAT-1.1 SODIUM-137 POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-22 ALT(SGPT)-38 AST(SGOT)-39 ALK PHOS-221* AMYLASE-97 TOT BILI-0.9 LIPASE-140* ALBUMIN-3.8 WBC-10.1 RBC-3.76* HGB-11.6* HCT-32.8* MCV-87 MCH-30.8 MCHC-35.3* RDW-16.0* PLT COUNT-350# - NEUTS-70.9* LYMPHS-20.8 MONOS-4.4 EOS-3.7 BASOS-0.2 UA: WBC 371, neg nitrites, mod leuks. mod bact. U cx: contaminated [**2159-12-16**] CT ABD: 1. Large mass arising from the third portion of the duodenum with cystic and solid components has increased in size since the prior exam. In addition, there is new stranding around the mass and stranding extending into the paracolic gutters bilaterally, right greater than left. The appearance is suspicious for new hemorrhage into the mass. Edema is also a possibility, though less likely. 2. Extensive metastatic disease within the liver, which appears to be worsened compared to the prior exam. Comparison is limited, however, given the lack of IV contrast. 3. Coronary artery calcifications. 4. [**1-4**] mm right lower lobe nodule. [**12-18**] CXR: Persistent elevation of the right hemidiaphragm, with retrocardiac atelectasis vs. early pneumonia. [**12-18**] ECHO: The left atrium is mildly dilated. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. EGD biopsy of submucosal duodenal mass: nondiagnostic CT-guided bx: nondiagnostic, blood only Brief Hospital Course: Ms. [**Known lastname 19314**] is a 76 year-old female with metastatic breast cancer treated with Femara and Megace, with known duodenal and liver masses, who presented with abdominal pain/bloating, and CT showed increased size of duodenal mass with hemorrhagic appearance. On hospital day two she had new onset more severe abdominal pain and was admitted to the surgical service, however pain resolved, and she was not deemed to have a surgical abdomen. EGD was undertaken to perform biopsy of the submucosal duodenal mass, which was nondiagnostic. We then performed CT-guided biopsy of the mass, the result of which was pending when the patient was discharged but has since returned nondiagnostic and blood only. DIfferential diagnosis includes gastrointestinal stromal tumor, metastatic breast cancer, versus other malignancy. Ms. [**Known lastname 19323**] hematocrit was stable throughout her hospital stay. Her abdominal pain was well controlled with 5-10 mg of liquid oxycodone every 6 hours. She was found to have increasing edema and shortness of breath responsive to lasix with oxygen saturations in the low 90s on room air. She was believed to be retianing water secondary to her megace, which was subsequently discontinued. She was maintained on lasix 40mg PO qam and 20mg qafternoon. Towards the end of her stay her subjective dyspnea did not correlate to any decrease in oxygen saturation and her ambulatory sat was consistently 94%. On the last day of hospitalization the patient complained of dysuria. UA was consistent with UTI, and the patient was discharged with 5 days of Bactrim therapy. Urine culture was pending at the time of discharge but has since returned consistent with contamination. We avoided heparin products given the patient's history of HIT and kept the patient on pneumoboots. She ate a regular low salt diet throughout her stay. We kept her on a bowel regimen given her narcotics, and she frequently required bisacodyl suppositories. The patient was discharged to home with outpatient follow up with Dr. [**First Name (STitle) **] and Dr. [**Last Name (STitle) 19324**]. She will continue femara as well as her other medications and will stop megace. Medications on Admission: Femara 2.5 mg PO QD Megace 40 mg PO BID Lasix 20 mg PO BID Calcium MVI daily Ambien 5 mg PO QHS:PRN Discharge Medications: 1. Oxycodone 5 mg/5 mL Solution Sig: [**12-3**] teaspoons (5-10mL) PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:*500 mL* Refills:*0* 2. Letrozole 2.5 mg Tablet Sig: One (1) Tablet PO qd () as needed for breast CA. 3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). Disp:*30 Tablet(s)* Refills:*2* 4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 5 days. Disp:*10 Tablet(s)* Refills:*0* 6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal once a day as needed for constipation. Disp:*30 Suppository(s)* Refills:*0* 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 8. 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* 9. Multivitamin Capsule Sig: One (1) Capsule PO once a day. 10. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: primary: metastatic breast cancer duodenal mass liver masses UTI Discharge Condition: stable. O2 sat 93% RA. resting sat 95% RA. pain well controlled with oxycodone. Has UTI. Discharge Instructions: Please take your medications as directed. 1. Please STOP taking your megace. 2. Please take your antibiotic for urine infection one pill twice per day for the next 5 days. 3. Please continue your other medications, as well as Lasix 40mg in the morning and 20mg after lunch time, and oxycodone every 4-6 hours when needed for pain. 4. Please use colace (docusate) twice per day to prevent constipation and bisacodyl suppositories daily when needed for constipation. Please go to your follow up appointment with Dr. [**First Name (STitle) **] on [**1-17**] at 10:20am. Please call Dr. [**Last Name (STitle) 19324**] for a follow up appointment and for your biopsy results in the next two weeks. [**Telephone/Fax (1) 19325**] If you have increased abdominal pain, fever over 100.5, chills or other concerning symptoms please call Dr. [**First Name (STitle) **] or come to the emergency department. Followup Instructions: 1.Please call Dr. [**Last Name (STitle) 19324**] for a follow up appointment in the next 2 weeks. [**Telephone/Fax (1) 19325**] 2. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2160-1-17**] 10:20 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6198**] MD, [**MD Number(3) 6199**] Completed by:[**2159-12-28**]

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icd9cm

[ [ [] ] ]

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icd9pcs

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38813

Discharge summary

report

Admission Date: [**2159-3-19**] Discharge Date: [**2159-4-3**] Date of Birth: [**2110-5-1**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 78**] Chief Complaint: Headache Major Surgical or Invasive Procedure: Cerebral Angiogram [**2159-3-20**] Cerebral angiogram [**2159-3-26**] History of Present Illness: This is a 48 year old white male who was transferred from an OSH for SAH. The patient reports that he was having intercourse with his wife this am the day of admit and then had sudden onset headache. It was accompanied by nausea and vomiting. He denied LOC or seizure activity. He received dilantin and nimodipine at the OSH. By med flight report the patient had increased somnolence over transport. He received fentanyl for pain. He was intubated in our ED for somnolence. Past Medical History: none per outside hospital records. Social History: No tobacco, occ EtOH, no drugs, lives with wife. Family History: NC Physical Exam: On admission: O: T: AF BP: 150 /99 HR: 71 R18 O2Sats100% Gen: WD/WN, NAD. HEENT: NCAT Pupils:[**1-30**] bilaterally / roving gaze / disconjugate at times / no eye contact EOM appear intact / pt difficulty following commands at time/ Neck: appears to have difficulty with chin to chest Extrem: Warm and well-perfused. Neuro: Mental status: Opens eyes to voice/noxious, attempts to cooperate with exam. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light,3 to 2 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements grossly intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**4-4**] throughout. No pronator drift sensation grossly intact On Discharge NON FOCAL Pertinent Results: CTA head [**3-19**]: prelim CT Head: SAH in the left Sylvian fissure, along the anterior falx, perimesencephalic and premedullary cisterns with effacement of sulci in left cerebral convexity. Small amount of hemorrhage in the b/l occipital horns, ? third ventricle. Mass effect on the 4th ventricle. No shift of normally midline structures, e/o tonsillar herniation or overt hydrocephalus. CTA: no flow limiting stenosis, large aneurysm or e/o dissection. Final read pending recons. Cerebral Angiogram [**3-19**]: FINDINGS: Right vertebral artery arteriogram shows fairly large caliber right vertebral artery with normal filling of the right PICA. The basilar artery fills well along with its branches. Both PCAs are seen well with no evidence of aneurysm or vasculitis. Very prominent dural branch was seen with no evidence of dural AV fistula. Multiple muscular branches are seen in the neck, and the anterior spinal artery is seen originating at the junction of the vertebral and basilar. Left internal carotid artery arteriogram shows normal filling of the left internal carotid artery and its branches. The left internal carotid artery fills well along the cervical, petrous, cavernous and supraclinoid portion. Both anterior and middle cerebral arteries are seen well with no evidence of aneurysms, arteriovenous malformations or AV fistula. Left common carotid artery arteriogram shows normal carotid bifurcation with no evidence of stenosis. Left external carotid artery arteriogram shows no evidence of dural AV fistula or AVMs. Left vertebral artery arteriogram shows normal filling of the left vertebral artery. The left PICA artery is seen normally. There is some tortuosity at the origin of the left PICA artery. The basilar artery fills well along with its branches. Right internal carotid artery arteriogram shows normal filling of the right internal carotid artery; the A1 is noted to be hypoplastic. There is a very prominent superior hypophyseal artery with filling of the pituitary gland, however, no dural AV fistula is seen. There is some early venous drainage from this pituitary area. There is a prominent branch of the right cavernous carotid possibly supplying the meninges in the middle fossa. However, no AVMs are seen. Right external carotid artery arteriogram shows normal filling of the right external carotid artery and its branches with no evidence of dural AV fistula. Right common femoral artery arteriogram shows normal filling of the right common femoral artery with no evidence of stenosis. IMPRESSION: [**Known firstname **] [**Known lastname **] underwent cerebral arteriography which failed to reveal a source of his subarachnoid hemorrhage; specifically no aneurysms, AVMs or dural AV fistula was noted. There was a prominent right superior hypophyseal artery with early venous drainage from the pituitary fossa, however, this was not really consistent with a dural AV fistula. A prominent branch was also seen in the right cavernous carotid area. The patient will be brought back for angiography in one week's time. [**Last Name (un) **] DUP EXTEXT BIL (MAP/DVT) Study Date of [**2159-3-27**] 9:55 AM FINDINGS: There is normal spontaneous phasic flow, compressibility and augmentation, without evidence of intraluminal filling defect. IMPRESSION: No evidence of DVT. CT BRAIN PERFUSION Study Date of [**2159-3-28**] 11:30 AM Final Report HISTORY: 48-year-old male with subarachnoid hemorrhage. Evaluate for vasospasm. COMPARISON: CT perfusion, [**2159-3-23**] and cerebral angiograms, [**2159-3-26**] and [**2159-3-19**]. TECHNIQUE: Non-contrast imaging was performed from the foramen magnum to the cranial vertex. Following the uneventful administration of IV contrast, CTA was performed through the head, and CT perfusion was also performed. Multiplanar reformations were provided. NON-CONTRAST HEAD CT: As expected, there has been progressive decrease in the conspicuity and quantity of subarachnoid hemorrhage, with small foci of persistent blood products seen interdigitating in the sulci in the left frontoparietal region (2:21). There is also decrease in conspicuity of tiny amount of intraventricular hemorrhage layering posteriorly in the lateral ventricles (2:18). No new site of hemorrhage is seen. There has been no development of hydrocephalus. There is no evidence of major vascular territory infarction. The right maxillary sinus demonstrates partial opacification with air-fluid level, and the left maxillary sinus mucus retention cyst is partially imaged (2:1). CTA HEAD: There has been progression of development of vasospasm involving the posterior circulation, with the basilar artery both narrowed in caliber and quite irregular distally, well seen on axial source images, and well demonstrated on curved reformation images. This is new since the CT perfusion study [**2159-3-23**], and increased since the cerebral angiogram of [**2159-3-26**] which demonstrated slight irregularity of the basilar artery, but essentially normal caliber at that time. There is no vascular occlusion or aneurysm. The previously described early draining vein from the sellar/pituitary region is not seen, although venous contamination limits that assessment. The anterior circulation demonstrates maintenance of normal caliber, without evidence of vasospasm. CT PERFUSION: There is no regional abnormality of mean transit time or cerebral blood flow, and the cerebral blood volume appears symmetric. IMPRESSION: 1. Significant vasospasm limited to the posterior circulation, as described. 2. Decreased conspicuity and amount of left subarachnoid hemorrhage. 3. No evidence of acute ischemia. Dr. [**Last Name (STitle) **] discussed the findings with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **], and Dr. [**First Name (STitle) **] discussed with [**First Name4 (NamePattern1) 6177**] [**Last Name (NamePattern1) 86146**], N.P. at 1:40 p.m. on [**2159-3-28**]. [**Known lastname **],[**Known firstname 1730**] E [**Age over 90 86147**] M 48 [**2110-5-1**] CT BRAIN PERFUSION Study Date of [**2159-3-30**] 10:23 AM FINDINGS: HEAD CT: Again prominence of the ventricles seen with temporal [**Doctor Last Name 534**] prominence and small amount of blood within the occipital horns, unchanged from previous study. No evidence of loss of [**Doctor Last Name 352**]-white matter differentiation seen or no new hemorrhage identified. CT PERFUSION: CT perfusion demonstrates no territorial areas of abnormal perfusion. CT ANGIOGRAPHY HEAD: CT angiography of the head again demonstrates diminished caliber of the basilar artery compared to the examination of [**2159-3-19**]. However, this has not significantly changed since the examination of [**2159-3-28**]. Within the anterior circulation, no evidence of vascular occlusion is identified. There remains hypoplastic A1 segment of the right anterior cerebral artery which is unchanged. There is no evidence of occlusive vasospasm seen in the anterior circulation. No definite aneurysm is identified. IMPRESSION: 1. Head CT shows slight prominence of ventricles with a small amount of blood in the ventricles. No new hemorrhage. 2. CT perfusion of the head demonstrates no evidence of asymmetric perfusion or large territorial area of perfusion abnormality. 3. CT angiography of the head demonstrates vasospasm involving the basilar artery which is unchanged from [**2159-3-28**] but new since [**2159-3-19**]. No evidence of vasospasm seen in the anterior circulation. Brief Hospital Course: Mr. [**Known lastname **] was admitted to [**Hospital1 18**] on [**2159-3-19**]. He had a CTA and angiogram with Dr. [**First Name (STitle) **]. There was no aneurysm detected. He was extubated after his angiogram. He had some nausea. He was on Q1 hr neruo checks. He was neurologically intact. MRA brain, cspine, tspine was ordered to rule out AVM. He was getting Prednisone daily for headaches: 60 x2 days, 40 x2, 20 x2, 10 x2. On [**3-21**], patient remains nonfocal with a mild [**2-7**] headache. He will continue to be observed in the ICU for a week, then will have a repeat angiogram to rule out aneurysm. He was seen by the pain service and placed on a dilaudid PCA and topomax. He had a repeat angiogram on [**2159-3-26**] which was negative for aneurysm. He was transferred to the floor and seen by PT. Patient continues to have a headache, but will be transitioned to PO meds. He remains nonfocal and a CTA was oredered to access for vasospasm. PT has cleared the patient safe to return home. CTA showed vasospam of basilar and bilateral PCAs. He was transferred to ICU and given fluids at 150cc/hr and Q1H neuro checks. Exam remained stable through [**3-30**], and on [**3-31**], he was transferred out of the ICU to the floor. His blood pressure parameters were liberalized to 160, and his fluids were brought down to 100cc/hour. He remained on nimodipine for spasm prophylaxis. [**Date range (1) 25246**] he remained stable but continued to report headaches. He was cleared by PT for home and with his headaches greatly improved - he agrees with this plan. He will complete his course of nimodipine (5 days remaining) and follow up in one month without imaging. Medications on Admission: none Discharge Medications: . 1. Nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4 hours) as needed for hold for sbp < 110 for 5 days. Disp:*60 Capsule(s)* Refills:*0* 2. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [**12-2**] Tablets PO Q6H (every 6 hours) as needed for HA: do not drive while taking this medication. Disp:*40 Tablet(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Subarachnoid hemorrhage Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. 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, or Ibuprofen etc. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion, lethargy 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. ?????? New onset of the loss of function, or decrease of function on one whole side of your body. Followup Instructions: Follow-Up Appointment Instructions You have an appointment to see Dr. [**First Name (STitle) **] on [**5-3**] at 11am - please call [**Telephone/Fax (1) **] if you need to change or cancel this appointment. Please call the Pain Management Center to see Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) **] for an appointment for headache management if you feel this is necessary. Completed by:[**2159-4-3**]

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icd9cm

[ [ [] ] ]

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icd9pcs

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Discharge summary

report

Admission Date: [**2177-3-14**] Discharge Date: [**2177-3-25**] Date of Birth: [**2111-11-23**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4691**] Chief Complaint: Transfer from OSH, s/p MVC with cardioversion for suspected Vtach en route and intubated for expanding neck hematoma. Major Surgical or Invasive Procedure: Central venous line x 2 Arterial line Orogastric tube PICC line History of Present Illness: 65yo M transfer from OSH s/p high speed MVC, cardioverted en route for V tach and intubated for expanding neck hematoma. Past Medical History: CAD s/p CABG x 2, cirrhosis, Chronic renal insufficiency Social History: Patient reports history of extensive ETOH intake. Family History: Non-contributory Physical Exam: T 97.8 HR 120 BP 101/60 RR 13 Gen: sedated, intubated HEENT: Large L neck hematoma with tracheal deviation. Intubated. Chest: BS bilaterally, Large hematoma over L pectoralis. Cardio: tachycardic Abd:soft, RUQ eccymoses. Ext: 2+ pulses throughout. skin: + seatbelt sign. Neuro: sedated. Pertinent Results: [**2177-3-14**] 01:21PM BLOOD WBC-8.6 RBC-3.20* Hgb-11.1* Hct-33.3* MCV-104* MCH-34.6* MCHC-33.2 RDW-16.9* Plt Ct-90* [**2177-3-18**] 03:14AM BLOOD WBC-2.6* RBC-1.99* Hgb-6.5* Hct-19.9* MCV-100* MCH-32.8* MCHC-32.7 RDW-18.4* Plt Ct-66* [**2177-3-19**] 01:37AM BLOOD WBC-3.7* RBC-2.58*# Hgb-8.3*# Hct-25.4* MCV-98 MCH-32.0 MCHC-32.6 RDW-18.6* Plt Ct-84* [**2177-3-21**] 01:57AM BLOOD WBC-6.9# RBC-2.70* Hgb-8.6* Hct-26.3* MCV-98 MCH-31.9 MCHC-32.7 RDW-18.2* Plt Ct-130* [**2177-3-14**] 01:21PM BLOOD PT-16.1* PTT-28.9 INR(PT)-1.4* [**2177-3-14**] 01:21PM BLOOD Plt Smr-LOW Plt Ct-90* [**2177-3-21**] 01:57AM BLOOD Plt Ct-130* [**2177-3-14**] 01:21PM BLOOD Fibrino-383 [**2177-3-14**] 04:26PM BLOOD Glucose-188* UreaN-18 Creat-1.1 Na-138 K-3.0* Cl-101 HCO3-22 AnGap-18 [**2177-3-21**] 01:57AM BLOOD Glucose-104 UreaN-20 Creat-1.0 Na-141 K-3.5 Cl-106 HCO3-23 AnGap-16 [**2177-3-14**] 01:21PM BLOOD CK(CPK)-250* Amylase-95 [**2177-3-14**] 01:21PM BLOOD ALT-43* AST-143* AlkPhos-158* Amylase-96 TotBili-3.9* [**2177-3-18**] 08:42AM BLOOD ALT-27 AST-66* CK(CPK)-144 AlkPhos-104 Amylase-42 TotBili-2.5* [**2177-3-14**] 01:21PM BLOOD Lipase-42 [**2177-3-18**] 08:42AM BLOOD Lipase-14 [**2177-3-14**] 01:21PM BLOOD CK-MB-8 cTropnT-0.05* [**2177-3-18**] 04:04PM BLOOD CK-MB-3 cTropnT-0.02* [**2177-3-14**] 01:21PM BLOOD [**Year/Month/Day **]-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**3-14**]: CT C-spine: 1. No fracture. 2. Large soft tissue hematoma centered on the left sternocleidomastoid muscle. A vascular injury is suspected - please correlate with CTA neck obtained concurrently. 3. Multilevel degenerative disease. [**3-14**] CTA neck/chest/abd: 1. Large right chest wall hematoma due to active bleeding likely from small artery branch. Given the superficial nature, external compression will likely be of therapeutic benefit. There is no significant intrinsic mass effect on intrathoracic structures. 2. Large soft tissue hematoma along the course of the left sternocleidomastoid muscle. Given the imaging features, traumatic venous injury is highly suspect with most likely the left external jugular vessel of the culprit structure. There is minimal mass effect on the tracheal structures. The patient is intubated and a nasogastric tube is in place. 3. No traumatic intrathoracic or intraperitoneal injury noted. 4. Please note incidentally seen but not mentioned above, there is an approximately 3.4-cm infrarenal abdominal aortic aneurysm with no signs of acute traumatic injury, rupture, or dissection. 5. Question possible nondisplaced fracture of the right manubrium as detailed above. There may be a small associated retrosternal anterior mediastinal hematoma. [**3-14**] CT Head: 1. No evidence of intracranial hemorrhage or edema. 2. Bilateral proptosis with prominent intraorbital fat and without evidence of orbital abnormality or retrobulbar hematoma. [**3-18**] Xray R Knee: No gross fracture detected. However, minimal irregularity along posterior and lateral tibia raises the question of a subtle fracture versus overlying artifact. If clinically indicated, CT could be used for more detailed assessment. [**3-20**] CXR: The right central line was removed in the meantime interval. The cardiomegaly is unchanged including the post-CABG changes. There is no change in bilateral perihilar opacities, continuing towards the lower lobes consistent with mild pulmonary edema. Brief Hospital Course: Mr. [**Name13 (STitle) 57920**] was admitted to TSICU, intubated for expanding neck hematoma. Imaging results are noted above. Electrophysiology was consulted for episode of suspected VTach s/p shock en route to hospital as well as a brief (seconds) episode of wide complex tachycardia during RIJ placement. EP reviewed and sees no sign of Vtach, more likely sinus tach. Determined that no anti-arrythmics needed and recommended a follow up echo. Early morning [**2177-3-18**], patient became hypotensive and was resuscitated with 2u PRBC as well as pressors. Cultures were sent and he was started on Vancomycin and Zosyn for empiric coverage. Central line was re-sited. He weaned from pressors over weaned from pressors in less than 24 hours and cultures grew as follows: sputum- group B strep, enterobacter, MSSA. Blood- group B strep, enterobacter. Urine- Strep viridans. Catheter tip- negative. He was extubated later that day on [**2177-3-18**]. Also received a R knee plain film on [**3-18**] for eccymoses R knee. That film was negative for fracture. On [**2177-3-21**] patient was transferred to the floor. His central line was removed and he received 2 peripheral IV's. On the floor, he received physical therapy and a follow up echocardiogram to rule out vegetation. On [**3-22**], patient's antibiotics were switched to PO augmentin. Diet was advanced. Transthoracic echo was negative on [**3-25**]. Physical therapy cleared patient for rehabilitation facility. Patient was maintained on sliding scale insulin thoughout stay. Since transfer to floor, patient has remained hemodynamically stable without oxygen requirement. Neck hematoma has been followed and is spontaneously resolving. Social work was consulted re: ETOH history. He is discharged to rehab in good condition and is to follow up in clinic with Dr. [**Last Name (STitle) **] in [**2-12**] weeks. Medications on Admission: lasix 40mg qd, simvastatin 20mg [**Last Name (LF) **], [**First Name3 (LF) **] 81mg qd, levitra Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 1 weeks. 7. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 2 days. 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 13. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for SOB. 14. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for SOB. Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 731**] - [**Location (un) 3320**] Discharge Diagnosis: Neck hematoma Rib fracture C7 transverse process fracture Right pulmonary contusion Discharge Condition: stable Discharge Instructions: You were admitted to the hospital after a motor vehicle accident. You were given a breathing tube due to an injury in your neck. You also had a broken rib, a bruise on your lung and a broken bone in your spine. With improvement you were removed from the breathing tube, however, you contracted an infection in the hospital for which you were treated with antibiotics. Continue the antibiotics for 2 more days to complete a 10 day course. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] in trauma surgery clinic in 2 weeks by calling [**Telephone/Fax (1) 6429**] for an appointment. Completed by:[**2177-4-7**]

[ "519.19", "922.1", "V45.81", "V43.64", "585.9", "E815.0", "414.00", "807.00", "920", "571.5", "861.21", "805.07" ]

icd9cm

[ [ [] ] ]

[ "96.6", "38.93" ]

icd9pcs

[ [ [] ] ]

7819, 7941

4589, 6473

433, 499

8069, 8078

1153, 3857

8565, 8743

812, 830

6619, 7796

7962, 8048

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113,002

26235

Discharge summary

report

Admission Date: [**2131-9-18**] Discharge Date: [**2131-9-19**] Date of Birth: [**2047-6-10**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3984**] Chief Complaint: Transfer for ERCP Major Surgical or Invasive Procedure: ERCP [**2131-9-18**] History of Present Illness: 84 year old male with a history of of coronary artery disease, sick sinus syndrome s/p pacemaker, chronic kidney disease and recent prolonged hospitalization for gangrenous cholecystitis s/p open cholecystectomy complicated by bile leak requiring external drainage in [**2131-8-1**]. The initial surgery was performed on [**2131-8-11**]. On entering the abdomen he was noted to have gangrenous cholecystitis. He had extensive adhesions and it was difficult to dissect the fascial planes. It was not possible to remove the entire gallbladder and the gallbladder was instead divided 1 cm above the takeoff of the cystic duct. He was ultimately discharged to Blueberry [**Doctor Last Name **] nursing home on [**2131-8-24**]. Per notes his subhepatic drain was removed on [**2131-9-14**]. . He represented to [**Hospital **] hospital on [**2131-9-16**] with right upper quadrant pain and chills. On arrival to [**Hospital **] hospital he was afebrile with a HR of 78, BP of 98/57, O2 saturation 95% on RA. WBC count on presentation was 20.4 with normal transaminases. CT scan done on admission showed a distended gallbladder with irregular contour and thickened wall and pericholecystic inflammatory changes suspicious for acute cholecytsitits with possible track from the gallbladder to the skin. He was started on IV antibiotics initially with Unasyn and then Zosyn. He underwent drainage of subhepatic fluid collection on [**2131-9-17**] with removal of 50mL thicky cloudy bile and a 12 F catheter was placed. He was transferred to this hospital for ERCP and internalization of his biliary drain. . He was transferred to the ERCP suite. He was intubated periprocedure. The procedure was technically uncomplicated and he had two plastic stents placed. During the procedure his blood pressure was labile ranging from the 60s to 130s systolic. He required treatment with neosynephrine at 0.5 mcg/kg. He received 1.5 L IVF and made 120 cc urine. There was minimal blood loss. He was extubated in the PACU and transferred to the medical ICU ([**Hospital Ward Name 332**]). Neosynephrine was turned off on arrival to the [**Hospital Unit Name 153**] with blood pressures in the 120s to 130s systolic. In the [**Hospital Unit Name 153**], he currently had no complaints. He denied fevers, chills, nausea, vomiting, diarrhea, constipation, dysuria, hematuria, leg pain or swelling. He continued to endorse abdominal pain, worst in the right upper quadrant. Past Medical History: Open cholecystectomy for gangrenous cholecystitis [**2131-8-11**] Coronary artery disease s/p anterior MI in [**2126**] Cardiomyopathy with congestive heart failure (EF 45-50% in [**1-6**]) Sick sinus syndrome s/p biventriuclar pacemaker in [**2121**] Stage IV Chronic Kidney Disease (baseline creatinine 2.0) Cervical spinal fracture with cord compression in [**2127**] complicated by three month hospitalization with tracheostomy and PEG placement Gastroesophageal Reflux Disease Hypogonadism Hypopituitarism (on 5 mg hydrocortisone at home) Hyperlipidemia Hypertension History of orthostatic hypotension BPH s/p TURP Left pulmonary granuloma History of diverticulosis and diverticulitis Osteoarthritis History of reflux sympathetic dystrophy of left hand Type II Diabetes History of MRSA Social History: Lives with his son in [**Name (NI) **] but now coming from rehab. Remote history of smoking (quit 20+ years ago). No current alcohol use but previously drank one per day. No illicit drug use. Retired electrician. Family History: Father died at age 83 of throat cancer. Mother died at age 80 of coronary artery disease. 1 sister died of leukemia. 1 living brother and 2 living sisters. Physical Exam: PE at admission to [**Hospital Unit Name 153**] [**2131-9-18**]: Vitals: T: 97.6 BP: 123/66 P: 117 R: 18 O2: 97% on 3L General: Alert, oriented to person, [**Month (only) 216**], not place or season, no acute distress HEENT: Sclera anicteric, MM dry, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Trace crackles at bases, poor inspiratory effort, no wheezes or ronchi CV: Tachycardic, regular rhythm, normal s1 and s2, II/VI HSM at LLSB, no rubs or gallops Abdomen: soft, tender in RUQ, mildly distended, bowel sounds present, positive guarding, no rebound, cholecystecomy scars well healing, drain in place with green bile, previous g-tube site well healed, no organomegaly GU: Foley with clear yellow urine Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . PE at transfer back to [**Hospital1 **] [**2131-9-19**]: Tmax: 99.4 ??????F Tc: 99.4 ??????F HR: 106 BP:136/56(75) RR: 17 SpO2: 94% NC 4L General: Alert, oriented to person, [**Month (only) 216**], not place or season, no acute distress Lungs: Trace crackles at bases, poor inspiratory effort, no wheezes or rhonchi CV: Tachycardic, regular rhythm, normal s1 and s2, II/VI HSM at LLSB, no rubs or gallops Abdomen: soft, tender in RUQ, mildly distended, bowel sounds present, positive guarding, no rebound, cholecystecomy scars well healing, drain in place with green bile, previous g-tube site well healed, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Labs on admission [**2131-9-18**]: Urinalysis [**2131-9-16**]: Negative Chemistries [**2131-9-17**]: Na 141, K 4.8, Cl 108, CO2: 20, BUN: 31, Creatinine 1.9, TBili 0.5, Lipase 138, AP 54, AST 20, ALT 26 INR 1.25 WBC: 14.5 (from 20.4 with 84% PNS), Hct: 36.2, Plts 155 . Labs on transfer to [**Hospital1 **] [**2131-9-19**]: WBC-12.0* RBC-3.73* Hgb-11.2* Hct-34.4* MCV-92 MCH-30.1 MCHC-32.6 RDW-16.0* Plt Ct-191 Neuts-79.8* Lymphs-16.0* Monos-2.5 Eos-1.2 Baso-0.4 PT-13.9* PTT-31.2 INR(PT)-1.2* Glucose-57* UreaN-22* Creat-1.6* Na-142 K-4.1 Cl-111* HCO3-18* AnGap-17 ALT-12 AST-13 AlkPhos-47 TotBili-0.7 Calcium-8.4 Phos-3.3 Mg-2.0 Lactate-0.7 . Micro [**9-18**] BCx - pending at time of transfer . Imaging: CXR [**2131-9-18**]: Extremely low lung volumes may account for much of the prominence of the transverse diameter of the heart. Bibasilar atelectatic change without definite acute focal pneumonia. Pacemaker device is in place. No evidence of intubation on this study. Of incidental note is an apparent tube in the right mid abdomen laterally. . ERCP [**2131-9-18**]: Findings: Esophagus: Limited exam of the esophagus was normal Stomach: Limited exam of the stomach was normal Duodenum: Limited exam of the duodenum was normal Major Papilla: Normal major papilla Cannulation: Cannulation of the biliary duct was successful and deep with a Autotome 44 using a free-hand technique. Contrast medium was injected resulting in partial opacification. . Biliary Tree: Extravasation of dye was noted at the gallbladder. No filling defects were seen in the CBD. A biliary sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. Two 10FR by 9cm Cotton [**Doctor Last Name **] biliary stents were placed in tandem successfully using a Microvasive 10FR stent introducer kit. . Impression: Cannulation of the biliary duct was successful and deep with a Autotome 44 using a free-hand technique. Extravasation of dye was noted at the gallbladder. No filling defects were seen in the CBD. A biliary sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. Two 10FR by 9cm Cotton [**Doctor Last Name **] biliary stents were placed in tandem successfully using a Microvasive 10FR stent introducer kit. Brief Hospital Course: [**Hospital Unit Name 153**] Course [**Date range (3) 29787**]: Assessment and Plan: 84 year old male with a history of of coronary artery disease, sick sinus syndrome s/p pacemaker, chronic kidney disease and gangrenous cholecystitis now presenting with fevers, leukocytosis and right upper quadrant pain transferred for ERCP. . Biliary Sepsis: Patient with known bile leak from previous cholecystectomy. On presentation to [**Hospital1 **] he was afebrile but with leukocytosis, tachycardia and mild hypotension. He had significant clinical improvement with IV antibiotics and drain placement and is now s/p ERCP with stents with ultimate hope to internalize drain. He was mildly tachycardic but with stable blood pressures. Pt was NPO post procedure, advanced to clears which the patient tolerated well. Carvediolol was restarted but other anti-hypertensives were held and not re-initiated before transfer. Continued zosyn for broad spectrum coverage of biliary pathogens. Pain not adequately controlled with morphine and pt had increased O2 requirement, so changed mediation to dilaudid for better pain management and decreased splinting with improved pain control. . Hypoxia: Patient with 3-4L oxygen requirement post-procedure. Lung exam significant for crackles. Patient does have a history of cardiomyopathy with mildly decreased ejection fraction. Also may have a component of atelectasis and is an aspiration risk. Pt was also splinting due to pain and pain control increased with dilaudid 0.5mg q4h: PRN. . Coronary artery disease: s/p anterior MI in [**2126**]. No chest pain after procedure. Coreg and Zestril were initially held. Coreg restarted prior to transfer with stable SBP 100s. Statin and fibrate were contrinued. Aspirin was held peri-procedure and continues to be held for 72 post procedure. . Cardiomyopathy: Last ejection fraction 45-50% in [**2128**]. Currently with new oxygen requirement. No pulmonary edema on CXR although pt had low lung volumes. Carvedilol restarted once BP stable. Zestril continued to be held. . Stage IV Chronic Kidney Disease: Baseline creatinine 2.0. At baseline at the time of transfer from OSH. Cr on transfer back to [**Hospital1 **] was 1.6. Zestril held and not re-initiated prior to transfer back to OSH. . Hypopituitarism: Per notes, post-traumatic, on hydrocortisone at home, on transfer on both hydrocortisone and fludricortisone. Will continue with plans to taper if remains at this facility. Continued hydrocortisone 15 mg PO daily, 10 mg at 3 PM. Continued fludrocortisone 0.1 mg PO BID. . Gastroesophageal Reflux Disease: continued PPI . Hyperlipidemia: continued statin and fibrate . Hypertension: Coreg re-initiated prior to transfer. Zestril held. . Benign Prostatic Hypertrophy: Floxmax held given foley . Type II Diabetes: Currently diet controlled but was on sliding scale at rehab. Insulin sliding scale was held. . Prophylaxis: Subutaneous heparin . Code: DNR not DNI (discussed with health care proxy) . Communication: Patient, son [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 64992**], [**First Name5 (NamePattern1) 553**] [**Last Name (NamePattern1) 64993**] [**Telephone/Fax (1) 64994**] (cell) . Disposition: Transfer back to [**Hospital **] Hospital ICU Medications on Admission: Medications from Rehab: Coreg 6.25 mg Po BID Prenisone 10 mg (taper) Flomax 0.5 mg PO daily Omeprazole 20 mg PO daily Multivitamin daily Vitamin D 800 IU daily Aspirin 81 mg PO daily Megestrol Acetate 800 mg PO BId Oxycodone 5 mg PO Q4h:PRN Tylenol PRN Insulin sliding sale Milk of Magnesia Dulcolax Fleets enemas . Medications on Transfer from [**Hospital **] Hospital [**2131-9-18**]: Zosyn 3.375 IV Q6H Coreg 6.25 mg [**Hospital1 **] Flomax 0.4 mg PO HS Prilosec 20 mg PO daily Hydrocortisone 15 mg PO daily, 10 mg at 3 PM Fludrocortisone 0.1 mg PO BID Zocor 40 mg PO daily Tricor 145 mg PO daily Zestril 5 mg PO daily Tylenol 650 mg PO Q6H:PRN Dilaudid 1 mg SC Q2H:PRN Vicodin 1 mg PO Q4H:PRN Discharge Medications: 1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 2. Hydrocortisone 5 mg Tablet Sig: Three (3) Tablet PO QAM (once a day (in the morning)). 3. Hydrocortisone 5 mg Tablet Sig: Two (2) Tablet PO QPM (once a day (in the evening)). 4. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 7. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for pain, fever. 8. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Hold for SBP<100 or HR<60 . 9. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: 2.25 g Intravenous Q6H (every 6 hours). 10. Hydromorphone (PF) 1 mg/mL Syringe Sig: 0.5 mg Injection q4H: PRN as needed for pain. 11. Insulin Sliding Scale - Per Rehab sliding scale Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital - [**Hospital1 **] Discharge Diagnosis: 1. Biliary sepsis . 2. Hypoxia . 3. CAD, Cardiomyopathy, CKD, Hypopituitarism Discharge Condition: Stable, to [**Hospital **] Hospital ICU for further care. Discharge Instructions: You were transferred to [**Hospital1 18**] for endoscopic study of your biliary tract and pancreas (ERCP) and internalization of your biliary drain. You were intubated peri-procedure. The ERCP was technically uncomplicated and you had two plastic stents placed. During the procedure your blood pressure was labile and you required medicine to maintain an adequte blood pressure to perfuse your organs. You received fluids and there was minimal blood loss. You were extubated after the procedure and transfered to the intensive care unit for further monitoring of your blood pressure. Your blood pressures were stable but you did require increased oxygen to maintain oxygen saturation. This was attributed to atelectasis (collapsed lung, often seen after a procedure) and pain. Your pain was controlled with dilaudid and incentive spirometry was recommended. You were transferred back to [**Hospital **] Hospital for further care. Followup Instructions: ERCP Recommendations: -Follow-up with Dr. [**First Name (STitle) **] [**Name (STitle) **] any problems- please call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 1983**]. -No aspirin, plavix, NSAIDS, coumadin for 72 hours. -Follow for response and complications. If any abdominal pain, fever, jaundice, gastrointestinal bleeding please call ERCP fellow on call ([**Hospital1 **] [**Telephone/Fax (1) 64995**], pager [**Numeric Identifier **]) -Repeat ERCP in 6 weeks for evaluation and stent pull. -Follow drainage from percutaneous drain and GB fossa. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]

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icd9cm

[ [ [] ] ]

[ "51.87", "51.85" ]

icd9pcs

[ [ [] ] ]

12921, 12991

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333, 355

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111,668

25223

Discharge summary

report

Admission Date: [**2187-9-17**] Discharge Date: [**2187-9-29**] Date of Birth: [**2112-9-3**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: [**2187-9-21**] Five vessel coronary artery bypass grafting - left internal mammary to left anterior descending, vein graft to first obtuse marginal, vein graft to second obtuse marginal, vein graft to diagonal, vein graft to PDA. History of Present Illness: This is a 75 year old male with ESRD, on dialysis for the last 18 months. In [**2187-8-20**], he was admitted with CHF and found to have severe three vessel coronary disease. ECHO at that time showed severely depressed LV function with an EF 20-25% and only 1+MR. [**Name13 (STitle) **] was concomitantly treated with antibiotics for a pneumonia. He was not an ideal surgical candidate at that time and was eventually discharged on medical therapy. On day prior to admission, he presented to OSH in pulmonary edema. He ruled in for an acute MI with elevated troponins. He was treated with Nitro and Lasix with improvement in symptoms. He was subsequently transferred to the [**Hospital1 18**] for further evaluation and treatment. On admission, his shortness of breath improved. He denied chest pain, nausea, vomiting, orthopnea, PND and palpitations. Past Medical History: Coronary artery disease, ESRD on dialysis for past 18 months, Hypercholesterolemia, Hypertension, Heart Block - s/p PPM placement, Neuropathy, Retinopathy, Anemia Social History: Lives with wife. [**Name (NI) **] 3 children. Never smoked. Occasional ETOH. Family History: Non-contributory, no premature coronary disease Physical Exam: Vitals: T 98 BP 150/75 P 81 RR 22 O2sat 100%4L General: Elderly male lying in bed in no acute distress HEENT: PERRL, EOMI, NECK: Supple, JVP ~12cm CV: Regular rate with ectopy, normal s1s2, no murmur or rub Chest: Decreased breath sounds bilaterally up to mid lungs, minimal crackles. Abd: Soft, NT, ND. Normoactive bowel sounds Ext: 1+ dp/pt pulses bilaterally Neuro: Non-focal Brief Hospital Course: On admission, cardiac enzymes remained flat. Cardiac surgery was consulted for surgical revascularization as multivessel PCI was not an option. Antiplatelet therapy was therefore discontinued and Warfarin was reversed with Vitamin K and FFP. He was subsequently started on IV Heparin. Once his prothrombin time improved, it was decided to proceed with surgical revascularization. He otherwise remained pain free on medical therapy and continued on his routine dialysis schedule. On [**2187-9-21**], Dr. [**Last Name (STitle) **] performed coronary artery bypass grafting. Following the operation, he was brought to the CSRU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated without incident. He initially required inotropes for blood pressure support. By POD #2, he weaned from intravenous therapy. He maintained stable hemodynamics and transferred to the SDU on POD #3. He experienced bouts of paroxsymal atrial fibrillation. Warfarin therapy was eventually resumed Medications on Admission: 1. Calcium Acetate 667 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 4. Losartan Potassium 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*0* 6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Sertraline 50 mg Tablet Sig: One (1) Tablet PO once a day. 8. Insulin Glargine 100 unit/mL Solution Sig: Twenty One (21) units Subcutaneous at bedtime. 9. Insulin Aspart 100 unit/mL Solution Sig: Five (5) units Subcutaneous every 6-8 hours: afternoon dose. 10. Insulin Aspart 100 unit/mL Solution Sig: Thirteen (13) units Subcutaneous Sun, mon, wed, fri: Take as you do usually. 11. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 12. Famotidine 20 mg Tablet Sig: One (1) Tablet PO once a day. 13. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five (5) ML PO Q6H (every 6 hours) as needed. 14. Cefpodoxime Proxetil 200 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 3 days: To complete a 10 day course. Disp:*8 Tablet(s)* Refills:*0* 15. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*1* . Discharge Disposition: Extended Care Facility: [**Hospital3 **] Hosptial Discharge Diagnosis: CAD - s/p CABG, CHF, HTN, ESRD, PAF, Hyperlipidemia, Diabetes mellitus, Anemia, History of 2nd and 3rd heart block - s/p PPM placement, Neuropathy, Retinopathy Discharge Condition: Good Discharge Instructions: Patient may shower. No baths. No lotions or creams to incisions. No driving for one month. No lifting more than 10 lbs for 10 weeks. Followup Instructions: Dr. [**Last Name (STitle) **] in 4 weeks Dr. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **] in [**2-22**] weeks Dr. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **] in [**2-22**] weeks Completed by:[**2187-9-29**]

[ "V45.01", "293.0", "250.40", "410.71", "285.29", "V10.46", "403.91", "272.0", "414.01", "428.0" ]

icd9cm

[ [ [] ] ]

[ "99.07", "36.14", "36.15", "39.61", "39.95", "99.04" ]

icd9pcs

[ [ [] ] ]

4797, 4849

2233, 3243

340, 574

5053, 5060

5241, 5499

1753, 1802

4870, 5032

3269, 4774

5084, 5218

1817, 2210

281, 302

602, 1456

1478, 1642

1658, 1737

43,481

158,224

19608

Discharge summary

report

Admission Date: [**2164-12-21**] Discharge Date: [**2164-12-25**] Date of Birth: [**2089-8-4**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2569**] Chief Complaint: Headache and unsteady gait. Major Surgical or Invasive Procedure: None. History of Present Illness: Patient is a 75 year old right handed man with a history of prostate cancer who presents with headaches since Monday, lethargy since Tuesday and unsteady gait. According to his wife [**Name (NI) **] and his son [**Name (NI) **] who were with him in the ER, he has been progressively getting worse. Today, his PCP had organized an MRI of his brain at [**Hospital 246**] Hospital, which showed a right intraparenchymal hemorrhage, so he was sent in for further evaluation. Of note the patient takes ASA 81 mg at home, and he has had some higher SBP readings at home and in the doctor's office. The headache started on Monday night, it came on gradually [**11-25**] intensity, and has been constant since then. When the patient was requested to localize the headache, he stated that it was "all over my head", and then he pointed to his forehead on the left and right. He said that coughing exacerbated the headache, however, positional factors did not change the character of the headache. On Monday night when the headache started, his wife gave him a total of 4 baby aspirins (2 and then another 2, 4h later). He normally never gets headaches. He has managed to sleep through the pain. Both the patient's wife and his son mentioned that the patient is not as sharp as he normally is, and has been lethargic since Tuesday. In the ER, he continued to have a [**11-25**] headache, so he was given morphine prior to the neurology consult, and he was placed on a labetalol drip as his systolic BPs kept going as high as the 200 mmHg range. ROS: the patient and the patient's family, have not noticed any weakness such as hemiparetic symptoms, word finding difficulties, seizures, dysphagia, nausea, vomiting, photophobia, tinnitus, phonophobia, dyspnea, although he does have a cough, no palpitations, no chest pain, no abdominal pain or dysuria. Past Medical History: 1. HTN 2. Prostate cancer - transrectal ultrasound-guided biopsy on [**7-6**], [**2164**], revealing [**3-30**] cores positive for [**Doctor Last Name **] 3+3=6 disease with up to 40% of core length involved - there is a question of starting brachytherapy 3. GERD 4. OSA on BiPAP 5. fungal infection on the toe nails Social History: He is married and has two grown children. He retired ten years ago after working as an electrical engineer. He never smoked and only rarely drinks alcohol. He has never used recreational drugs. His wife who has breast ca is his HCP, her name is [**Name (NI) **] cell: [**Telephone/Fax (1) 53150**]. Family History: He reports a family history of oral cancer in his father diagnosed at the age of 70. Physical Exam: T-98.8 HR-74 BP-180/80 RR-16 SpO2-99% Gen: Lying in bed, no bruising noted over the head HEENT: NC/AT, moist oral mucosa Neck: No tenderness to palpation, normal ROM, supple, no carotid or vertebral bruit Back: No point tenderness or erythema CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally Abd: +BS, soft, nontender Ext: No edema Neurologic examination: Mental status: General: alert, awake, lethargic (received morphine) Orientation: oriented to person, place, but not date, keeps saying 11, 11, 11. Attention:Able to go backwards with DOW until Tuesday, then keeps on repeating Tuesday, and falling asleep Executivefunction: *Follows simple axial and appendicular commands: closes and opens his eyes, shows me his tongue. Memory: *Cannot register [**4-18**], therefore recall not checked. Speech/Language: Extremely hypophonic but non-dysarthric speech. Fluent w/o paraphasic (phonemic or semantic) errors; comprehension, repetition, naming (high frequency objects): normal. He found low frequency words difficult, but according to his son, this may be his baseline because his main language in Armenian. Prosody: normal. Able to read. Cranial Nerves: II: Pupils 2 mm bilaterally but reactive. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V1-3: Sensation intact V1-V3. VII: Mild L facial droop with slightly large palpebral fissure on the L. VIII: Hearing intact to finger rub bilaterally. IX & X: Palate elevation symmetric. Uvula is midline. Gives a good cough. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius full strength bilaterally. XII: Good bulk. No fasciculations. Tongue midline, movements intact. Motor: Normal bulk bilaterally. Tone normal. No observed myoclonus or tremor His left arm drifts down slightly with possible pronation. He appears to have full strength in his arms and legs - possible 4s in FEs but bilateral. Sensation: Intact to light touch. No extinction to DSS. Rest of the exam not attempted due to inattention Reflexes: 2 and symmetric throughout. Toes downgoing bilaterally Coordination: finger-nose-finger normal, heel to shin normal, RAMs slower with the left hand than the right. Gait: Wide-based and unsteady. Pertinent Results: [**2164-12-23**] 02:37AM BLOOD WBC-12.3* RBC-4.55* Hgb-13.2* Hct-38.3* MCV-84 MCH-29.1 MCHC-34.5 RDW-13.2 Plt Ct-215 [**2164-12-21**] 03:15PM BLOOD Neuts-77.8* Lymphs-14.8* Monos-6.0 Eos-0.9 Baso-0.5 [**2164-12-23**] 02:37AM BLOOD PT-13.5* PTT-25.7 INR(PT)-1.2* [**2164-12-20**] 04:15PM BLOOD ESR-17* [**2164-12-23**] 02:37AM BLOOD Glucose-101* UreaN-23* Creat-1.1 Na-136 K-3.7 Cl-104 HCO3-23 AnGap-13 [**2164-12-22**] 02:12AM BLOOD ALT-20 AST-25 AlkPhos-74 [**2164-12-23**] 02:37AM BLOOD Calcium-8.5 Phos-3.7 Mg-2.0 EKG Sinus rhythm. Leftward axis. Voltage criteria for left ventricular hypertrophy. No previous tracing available for comparison. Rate PR QRS QT/QTc P QRS T 74 194 86 366/390 31 -26 21 CT head and CTA neck [**2164-12-21**] CT head demonstrates right basal ganglia hemorrhage with extension to the lateral ventricles without hydrocephalus. CT angiography of the head and neck are normal. CXR Cardiac size is top normal. The aorta is tortuous. The right hilum is prominent. This finding should be evaluated with a regular PA and lateral views of the chest when possible to exclude hilar or lung abnormality. Otherwise, the lungs are clear. There is no pneumothorax or pleural effusion. Repeat NCHCT [**2164-12-22**] Similar appearance of right basal ganglia hemorrhage with intraventricular extension, but increased lateral ventricle caliber as compared to eight hours ago, suggestive of a developing mild hydrocephalus. MRI Head (with and without contrast: 1. Somewhat limited study due to motion. Right-sided basal ganglia hemorrhage identified with surrounding edema and extension to the ventricle. 2. There is some enhancement surrounding the hematoma on the post gadolinium images. Brief Hospital Course: Patient is a 75yo RHM with a h/o HTN, OSA on BiPAP and prostate cancer hx on ASA daily who started to have a HA that was refractory to Tylenol. He had no prior hx of headaches and he also felt more fatigued. He denied any other associated symptoms but given the worsening headache, he went to an outside hospital where he was found to have R IPH hence transferred here for further care. There is no report of any trauma but he does report that he has had elevated BP in the past but has been under good control for the past few years. He was hypertensive in the ED. Given the hemorrhage, he was initially admitted to the ICU but given stable imaging and exam, he was transferred to the floor. He underwent repeat head CT and MRI with and without contrast to further evaluate for possible underlying pathology. However, there was no evidence of tumor or aneurysm/AVM. Given the location and the risk factors (hypertension), this was felt to be likely hypertensive in etiology. Patient's exam is reassuring. He has extremely hypophonic speech with some L facial droop and possible, mild L arm weakness. He still suffers from HA that is mostly frontal. Most likely secondary to hemorrhage but may be exacerbated by the fact that he was not using BiPAP during this admission. 1. R caudate hemorrhage - likely hypertensive in origin. BP control and HCTZ started during this admission. Will need follow-up with PCP once discharged from rehab and [**First Name8 (NamePattern2) **] [**Last Name (un) 6550**] 2nd [**Doctor Last Name 360**] such as ACEI if BP not well controlled. We have discontinued to ASA 81mg daily during this admission and we do not recommend restarting the ASA. 2. OSA - patient needs to use BiPAP at bedtime. Patient has follow-up appointments scheduled with both Dr. [**First Name8 (NamePattern2) 2530**] [**Name (STitle) **] (neurologist who oversaw his care during this admission) and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] who follows up with him for his sleep apnea. Patient needs to schedule follow-up with Dr. [**Last Name (STitle) 838**] as outpatient once discharged from the rehab facility. Medications on Admission: ASA 81mg daily MVI daily Discharge Medications: 1. multivitamin with minerals Capsule Sig: One (1) Capsule PO once a day. 2. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: Primary Intracerebral hemorrhage likely due to hypertension Secondary Ostructive Sleep Apnea Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Very soft speech with mild L facial droop and slight L arm weakness. Complains of bifrontal headache which is likely multifactorial including not being on BiPAP during this admission and the brain hemorrhage. Discharge Instructions: You came to the hospital after bleeding in your brain. You were admitted to the hospital for evaluation of the cause and management of this intracerebral hemorrhage. We think that your bleed was a consequence of mild hypertension and aging of small vessels of your brain given that no underlying lesion was noted on MRI scan of your brain. It will be important to have this imaging repeated in about six weeks to evaluate this further. You were started on hydrochlorothiazide for blood pressure control. You will need close follow-up with your blood pressure and likely titration of this med and possible addition of another medication (i.e. ACE inhibitor) if needed. Please be sure to use BiPAP at bedtime for your sleep apnea. Followup Instructions: Please follow-up with your medical care providers as scheduled below. Additionally, please scheduled follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 838**] for follow-up within two weeks of discharge from the rehab: Dr. [**First Name (STitle) **] was the neurologist/attending you oversaw your care during this admission: Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2165-1-15**] 8:00 [**Hospital Ward Name 23**] Building, [**Location (un) **] Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6855**], M.D. Phone:[**Telephone/Fax (1) 6856**] Date/Time:[**2165-11-18**] 9:00 [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**] Completed by:[**2164-12-25**]

[ "530.81", "784.59", "348.4", "401.9", "431", "728.87", "327.23", "185", "348.5", "781.94" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9459, 9531

7037, 9203

345, 352

9668, 9668

5304, 7014

10785, 11639

2899, 2985

9278, 9436

9552, 9647

9229, 9255

10029, 10762

3000, 3372

278, 307

380, 2225

4202, 5285

9683, 10005

3396, 3396

2247, 2566

2582, 2883

938

118,519

14737+56573

Discharge summary

report+addendum

Admission Date: [**2120-7-9**] Discharge Date: [**2120-8-9**] Date of Birth: [**2067-1-15**] Sex: F Service: [**Location (un) 259**] CHIEF COMPLAINT: Elective surgery for kyphoscoliosis HISTORY OF PRESENT ILLNESS: This is a 53-year-old woman without significant past medical history, who was in her usual state of health until about two months ago. On [**2120-5-31**], she suffered an L1 burst fracture and left rib fracture secondary to a fall from a ten foot ladder (per patient) or from a second-floor window (per patient's daughter) at home. She was initially seen at an outside hospital two days later, after the incident. She was transferred to [**Hospital1 69**] immediately for surgical intervention. She had a relatively uneventful perioperative course except for one unit of packed red blood cell transfusion postoperatively. She had a total L1 vertebrectomy, fusion and segmental instrumentation of T12 to L3, cage placement at L1, and autograft during the first surgery. She was evaluated by Psychiatry at that time for possible paranoia and questionable suicidal ideation postoperatively. Medical workup at that time included a negative RPR, normal thyroid function tests, and a head MRI showing possible chronic microvascular ischemia. She was sent to a rehabilitation facility on [**2120-6-7**], in stable condition. About one month later, on [**2120-7-9**], she was readmitted for elective second operation to correct kyphoscoliosis. Again she had an uneventful operative course. The second operation included a posterior fusion of T9 to L3, multiple thoracolumbar laminectomies, segmental instrumentation of T9 to L3, and right iliac crest graft. Postoperatively, however, she suddenly decompensated in the Post-Anesthesia Care Unit while she was receiving a transfusion of one unit of packed red blood cells. She complained of sudden onset of chest pain and shortness of breath with oxygen saturations dropping to 70%, blood pressure dropping to 70/40. She was intubated immediately, and transferred to the Surgical Intensive Care Unit for further management. Progressive loss of bilateral translucency on chest x-ray and positive anti-HLA and anti-granulocyte antibodies on hematological workup were all consistent with TRALI (transfusion-associated lung injury). While in the Surgical Intensive Care Unit, her postoperative course was further complicated with methicillin-sensitive staphylococcus aureus bacteremia, pneumonia, and wound infection (which were documented with positive cultures on [**7-17**]). These events eventually led to a prolonged intubation. After she was started on intravenous oxacillin on [**7-20**], she had very good response, with decreased fever and decreased white blood cell count, as well as clearing of bacteremia which was documented by several blood cultures drawn on later days. She also underwent incision and drainage of posterior wounds on [**7-23**]. Wound cultures showed decreased colonization of methicillin-sensitive staphylococcus aureus and rare colonies of E. coli. She also had a diagnostic pleural tap on [**7-26**] for persistent left pleural effusion. The final culture was negative. She had repeated TTE on [**7-22**] which showed no vegetation and left ventricular ejection fraction greater than 55%. She also had a CT of the chest, abdomen and pelvis on [**7-25**], which showed improving effusion and normal bowels with old splenic infarct. CT angio was also performed, which showed improving atelectasis and effusion without evidence of pulmonary emboli. She was extubated on [**7-28**], and transferred to Medicine on [**7-30**] in stable condition. MEDICATIONS: Oxacillin, Lopressor, subcutaneous heparin, Zantac, Ativan, Haldol, Colace, Epogen, vitamin D, nasogastric tube feeds ALLERGIES: No known drug allergies. SOCIAL HISTORY: Works full-time as an insurance underwriter. Lives alone. Questionable alcohol. FAMILY HISTORY: Schizophrenia PAST MEDICAL HISTORY: Uterine fibroids REVIEW OF SYSTEMS: Unavailable PHYSICAL EXAMINATION: Temperature 100.9, blood pressure 132/80, pulse 122, respirations 16, oxygen saturation 94% on room air. General: Thin, middle-aged woman, lying in bed, with thoracolumbar brace in place. A little confused, able to follow simple commands, answering simple questions. Alert and oriented x 1 (person). No apparent distress. Head and neck: Normocephalic, atraumatic, anicteric, pupils equal, round and reactive to light. Neck supple. Chest: Well-healed left lateral posterior surgical scar, nontender, no erythema. Cardiovascular: Normal S1 and S2, no murmurs, rubs or gallops. Lungs: Clear to auscultation bilaterally (anterior and lateral). Abdomen: Soft, nontender, nondistended. Extremities: Warm to touch, no edema or cyanosis. Distal pulses 2+ bilaterally. No calf tenderness. On Venodynes. Neurological: Cranial nerves II through XII intact, strength equal bilaterally, sensory intact. Psychiatric: Appeared disoriented and paranoid. Skin intact, no rashes. LABORATORY DATA: White cell count 17.9, hematocrit 34.1, platelets 509. Differential: 71% neutrophils, 19% lymphocytes, 8% monocytes, 2% eosinophils. Sodium 138, potassium 3.8, chloride 104, bicarbonate 24, BUN 7, creatinine .3, glucose 76. Calcium 8.2, phosphorus 3.6, magnesium 1.6. PT 13.0, PTT 30.4, INR 1.2. Liver function tests: AST 82, ALT 52, LD 319, alkaline phosphatase 201, amylase 29, lipase 22. Two recent blood cultures on [**7-22**] and [**7-27**] were negative. Urine culture on [**7-22**] and [**7-27**] were negative. Wound culture on [**7-23**] showed decreased methicillin-sensitive staphylococcus aureus. Stool cultures were negative for C. difficile. Catheter tip culture on [**7-25**] was negative. Chest x-ray on [**7-26**] showed decreased left pleural effusion without pneumothorax, decreased congestive heart failure, persistent left basilar atelectasis. CT on [**7-25**] showed an old splenic infarct, no abnormal bowel or liver or fluid collection. CT angio showed no evidence of pulmonary emboli, increased left pleural effusion, ground-glass attenuation consistent with volume overload. TTE: Left ventricular ejection fraction greater than 55%, small pericardial effusion. Pleural tap showed no malignant cells. HOSPITAL COURSE: While on the Medical service, she was continued on oxacillin and showed improvement with decreased white blood cell count and decreased temperature. Six weeks of intravenous oxacillin was recommended by Infectious Disease consult, given the patient's high risk of relapse due to the hardware placed inside the originally-infected wound. A PICC line has been placed for the long course of intravenous antibiotic treatment. So far, all blood cultures drawn after starting oxacillin were negative to date. Her initial symptoms of tachycardia have also resolved, likely due to a combination of measures including intravenous hydration, improved pulmonary function with incentive spirometer. Repeated chest x-ray showed improving atelectasis. Repeated CTA revealed no evidence of pulmonary emboli. After she was medically stabilized and weaned off all sedatives including Haldol, Ativan, Zantac, her mental status improved dramatically. Signs of underlying psychiatric disorder became more obvious. She appeared paranoid and delusional at times, and seemed lacking of insight into her disease. Given her questionable history of alcohol abuse and poor nutritional status currently, vitamin B12 and folate and thiamine and a multivitamin were given as supplements. A head CT revealed age-inappropriate atrophy such as seen in increased risk for dementia. Psychiatry recommended restarting on Haldol to control psychotic symptoms and continue one-to-one sitter until the patient was no longer at high risk of eloping from the hospital. The patient's psychotic symptoms improved with gradually increased doses of Haldol. Now the patient has been doing well without a one-to-one sitter for more than 24 hours. DISCHARGE CONDITION: Stable DISCHARGE STATUS: Rehabilitation facility DISCHARGE DIAGNOSIS: 1. L1 burst fracture and left rib fracture status post L9 to T3 fusion 2. Methicillin-sensitive staphylococcus aureus wound infection 3. Methicillin-sensitive staphylococcus aureus pneumonia 4. Methicillin-sensitive staphylococcus aureus bacteremia 5. Psychotic disorder, unspecified DISCHARGE INSTRUCTIONS: Wear thoracolumbar brace for three months when out of bed. Activities as tolerated. DISCHARGE MEDICATIONS: Oxacillin 2 grams every four hours intravenously for a total of six weeks (until [**8-31**]), Haldol 2 mg every morning and 2 mg daily at bedtime, Trazodone 50 mg daily at bedtime, Lopressor 100 mg twice a day and hold for systolic pressure less than 100 or heart rate less than 60, multivitamin one tablet once daily. [**First Name11 (Name Pattern1) 312**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 313**], M.D. [**MD Number(1) 314**] Dictated By:[**Last Name (NamePattern4) 43363**] MEDQUIST36 D: [**2120-8-9**] 01:50 T: [**2120-8-9**] 01:59 JOB#: [**Job Number 43364**] Name: [**Known lastname 7908**], [**Known firstname **] Unit No: [**Numeric Identifier 7909**] Admission Date: [**2120-7-9**] Discharge Date: [**2120-8-9**] Date of Birth: [**2067-1-15**] Sex: F Service: DISCHARGE SUMMARY ADDENDUM: Since the patient developed low grade fever in the two days prior to discharge, a CT scan of chest, abdomen and pelvis were performed on the date of discharge. There is a small fluid collection which measures 2.7 by 1.4 cm in the region of prior debridement but no gas in subcutaneous tissues. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] the patient's orthopedic surgeon was asked to review the film and evaluate the patient. Dr. [**Last Name (STitle) **] however feels there is nothing to be concerned at this time since the wound appears to be healing well without any palpable abnormality or focal tenderness. However the patient should be followed up in the office by Dr. [**Last Name (STitle) **] in two to three weeks for postoperative evaluation. The phone number is 617-667-BACK. If the patient spikes a fever or develops any focal tenderness of drainage at the wound site Dr. [**Last Name (STitle) **] should be informed immediately. Dr. [**Last Name (STitle) **] was also informed and agreed with the discharge plan. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 166**] Dictated By:[**Last Name (NamePattern5) 975**] MEDQUIST36 D: [**2120-8-12**] 14:05 T: [**2120-8-19**] 08:43 JOB#: [**Job Number 7910**]

[ "482.41", "737.30", "790.7", "999.8", "998.3", "998.59", "298.9" ]

icd9cm

[ [ [] ] ]

[ "96.6", "96.04", "38.91", "96.72", "77.69", "77.79", "81.08" ]

icd9pcs

[ [ [] ] ]

8076, 8128

3963, 3978

8574, 10833

8149, 8439

6340, 8054

8464, 8550

4075, 6322

4039, 4052

172, 209

239, 3847

4001, 4019

3864, 3946

1,594

151,808

11835

Discharge summary

report

Admission Date: [**2118-12-21**] Discharge Date: [**2118-12-27**] Date of Birth: [**2060-2-14**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Abdominal pain, SOB Major Surgical or Invasive Procedure: None History of Present Illness: 58 M with h/o metastatic rectal cancer to liver, lungs, and brain who presents with 3d of SOB, abd pain, CP, diarrhea, found to have pancreatitis, increased mets in liver and lung, sepsis. Patient was initially diagnosed with rectal CA in [**2115**], has had resection of the primary and numerous attempts at chemo and radiation for metastatic disease (see below). Most recent chemo cycle finished in [**6-4**]. Disease has progressed despite these treatments. . Patients reports that he was in his USOH until 3-4d ago, when he developed diffuse abdominal pains, as well as pains in his lower chest bilaterally. These pains were constant and came on at rest, and have become progressively more severe over the last 24 hours. He also notes the onset of dyspnea to the point of not being able to walk over the past 3d, with no cough or wheezing. He reports no palpitations, no change in his LE edema. Reports recent diarrhea and loss of appetite, with no vomiting, no BRBPR or melena. Urine has become more dark. . Today, he kept his first appointment at the [**Hospital **] Clinic to be evaluated for his diabetes, and he was found to be in respiratory distress and unable to stand because of dyspnea and chest pain. He was sent to the [**Hospital1 18**] ER for evaluation. On presentation to the ED, his VS were: T 102.1, HR 140, BP 160/90, RR 33-36, Sat 93% on ??. He complained of [**7-9**] pain in his belly, desaturating with exertion. VBG 7.49/38/30 on suplemental oxygen, with lactate 4.7, LFTs, amylase, lipase elevated, resulting in concern for pancreatitis. . Code Sepsis called, pt received a Precept catheter showing CVP=4 SVO2 83 BP 142/90 HR 111 RR 40 95% on ??. He got 7.6 L IVF, with VS= 97.7 106 26 SvO2 70 UOP 1610 since admission, with CVP=11. Imaging included CT chest/abd/pelvis, as well as RUQ USN (see results below). Pt was transferred to [**Hospital Unit Name 153**] for further evaluation and monitoring. Gen [**Doctor First Name **] consult evaluated patient in the [**Hospital Unit Name 153**]. . Past Medical History: 1. carcinoma of the rectosigmoid junction and rectum - s/p low anterior resection in [**2115**] - Neo adjuvant chemo radiation ([**2115**]) - Six cycles of CPT-11, 5-FU and leucovorin ([**2116**]) - Ostomy reversal ([**2116**]) - seven cycles of the [**Doctor Last Name **] regimen with Avastin ([**2116**]) - 6 week cycles of FLOX chemotherapy ([**2118**]) - VP shunt placed by neurosurgery ([**9-/2118**]) 2. hypertension 3. diabetes Social History: The patient is originally from the [**Country 13622**] Republic, speaks excellent English, and prefes to read Spanish. He lives with his cousin [**Street Address(1) 4184**]. His mother and his 3 children are in [**State 531**] City. He does not smoke. He used to drink alcohol on weekends but stopped completely. He previously worked 2 jobs, one as a shuttle driver and another in maintenance. Family History: Noncontributory; no cancer. Father with diabetes Physical Exam: VS: T 98.2, HR 100, BP 131/80, CVP 6, RR 27, Sat 96% on 4L at rest, Wt 92 kg GEN: ill-appearing, uncomfortable, jaundiced man, breathing rapidly and speaking in short sentences [**3-3**] dyspnea HEENT: EOMI, OP clear, MMM, JVP flat CV: tachy, regular, nl s1, s2, +s4, no murmur PULM: decreased BS throughout left side, rales in bottom [**Date range (1) 5082**] ABD: midline well-healed scars with no herniation; increased BS of normal pitch; tender in RUQ, epigastrium, LLQ; no rebound, no guarding; negative Murphys RECTAL: deferred, though guaiac neg by [**Doctor First Name **] exam EXT: warm, 2+ dp pulses BL, 1+ pitting edema bilaterally to calf NEURO: alert & oriented x 3; [**5-4**] hip flexors bilaterally, [**6-3**] dorsi- and plantar-flexion; symmetric 1+ patellar bilaterally; 1 beat of clonus of L ankle Pertinent Results: . [**2118-12-21**] CXR: Again demonstrated innumerable nodular densities throughout both lung fields representing advanced metastatic disease. No definite areas of consolidation are identified. A right subclavian central venous catheter is in unchanged position. There is also note of a ventriculoperitoneal shunt. . [**2118-12-21**] CT CHEST/ABD 1. Interval progression of metastatic disease in the lungs and liver. There is progression of innumerable lung metastases with notable conglomerate masses in the right lower lobe, measuring 3.6 x 2.3 cm, previously 2.5 x 1.7 cm. 2. No evidence of pulmonary embolism. 3. Interval increase in left-sided pleural effusion. 4. Interval development of gallbladder wall edema. This could suggest cholecystitis. There is apparent gallbladder wall edema. There is peripancreatic stranding and stranding and small fluid tracking in the left and right anterior pararenal spaces. 5. Peripancreatic stranding with stranding and small fluid tracking along the right and left anterior pararenal spaces consistent with pancreatitis. 6. New right adrenal nodule and interval enlargement in a left upper pole renal lesion. . [**2118-12-21**] RUQ USN: gallbladder wall thickened though with no edema or hyperemia to suggest cholecystitis. No stones or sludge. No ductal dilitation. Portal vein patent. . [**11-4**] MRI BRAIN: A right frontal approach ventriculostomy drainage catheter remains unchanged in position. Three cerebellar enhancing metastatic lesions are identified, two in the left cerebellar hemisphere and one in the right. . Brief Hospital Course: . A/P: 58yo man with h/o met rectal CA to liver, lungs, brain, now p/w 3d of fatigue, SOB, abd pain, CP, diarrhea, found to have pancreatitis, increased mets in liver and lung, sepsis. . [**Hospital Unit Name 153**] Course: Patient was admitted to [**Hospital Unit Name 153**] for concern for sepsis. He was started on broad spectrum antibiotics (Vancomycin, Zosyn, Flagyl) for concern for pancreatitis/ascending cholangitis. The Flagyl was subsequently discontinued. Blood, urine, sputum and stool cultures were sent and are currently no growth to date. His hypoxia was thought to be secondary to his multiple pulmonary metastases as well as worsening left pleural effusion. He was started on a Morphine PCA for both his severe abdominal pain as well as symptom management of his severe dyspnea. His elevated LFTs were thought to be [**3-3**] to his liver metastases. General surgery was consulted but felt there was no further need for surgical intervention and the patient would not likely benefit from a percutaneous biliary drain. Pain and palliative care was consulted for assistance with pain control, and symptom management as well as possible discussion of hospice/palliation. The patient's primary oncologist, Dr. [**Last Name (STitle) **], was notified. Vanco/Zosyn were d/c'd after further discussion with pt and his family resulted in change of goals of care to CMO. Pt was started on morphine gtt for comfort on [**12-25**], as he continued to have considerable pain with morphine PCA. He expired on [**12-27**] at 2:50 AM, surrounded by family members. Medications on Admission: dexamethasone 4mg po q8h pantoprazole 40mg po qdaily metoprolol 25mg po bid glargine 60U SC QHS HISS keppra 1000mg po bid Discharge Disposition: Expired Discharge Diagnosis: rectal CA Discharge Condition: expired Discharge Instructions: none Followup Instructions: none [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

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